Prospective study of factors associated with asthma attack recurrence (ATTACK) in children from three Ecuadorian cities during COVID-19: a study protocol.

INTRODUCTION: Asthma is a growing health problem in children in marginalised urban settings in low-income and middle-income countries. Asthma attacks are an important cause of emergency care attendance and long-term morbidity. We designed a prospective study, the Asthma Attacks study, to identify factors associated with recurrence of asthma attacks (or exacerbations) among children and adolescents attending emergency care in three Ecuadorian cities. METHODS AND ANALYSIS: Prospective cohort study designed to identify risk factors associated with recurrence of asthma attacks in 450 children and adolescents aged 5-17 years attending emergency care in public hospitals in three Ecuadorian cities (Quito, Cuenca and Portoviejo). The primary outcome will be rate of asthma attack recurrence during up to 12 months of follow-up. Data are being collected at baseline and during follow-up by questionnaire: sociodemographic data, asthma history and management (baseline only); recurrence of asthma symptoms and attacks (monthly); economic costs of asthma to family; Asthma Control Test; Pediatric Asthma Quality of life Questionnaire; and Newcastle Asthma Knowledge Questionnaire (baseline only). In addition, the following are being measured at baseline and during follow-up: lung function and reversibility by spirometry before and after salbutamol; fractional exhaled nitric oxide (FeNO); and presence of IgG antibodies to SARS-CoV-2 in blood. Recruitment started in 2019 but because of severe disruption to emergency services caused by the COVID-19 pandemic, eligibility criteria were modified to include asthmatic children with uncontrolled symptoms and registered with collaborating hospitals. Data will be analysed using logistic regression and survival analyses. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Hospital General Docente de Calderon (CEISH-HGDC 2019-001) and Ecuadorian Ministry of Public Health (MSP-CGDES-2021-0041-O N° 096-2021). The study results will be disseminated through presentations at conferences and to key stakeholder groups including policy-makers, postgraduate theses, peer-review publications and a study website. Participants gave informed consent to participate in the study before taking part.

Deaths in people from Black, Asian and minority ethnic communities from both COVID-19 and non-COVID causes in the first weeks of the pandemic in London: a hospital case note review.

OBJECTIVE: To undertake a case review of deaths in a 6-week period during the COVID-19 pandemic commencing with the first death in the hospital from COVID-19 on 12th of March 2020 and contrast this with the same period in 2019. SETTING: A large London teaching hospital. PARTICIPANTS: Three groups were compared: group 1-COVID-19-associated deaths in the 6-week period (n=243), group 2-non-COVID deaths in the same period (n=136) and group 3-all deaths in a comparison period of the same 6 weeks in 2019 (n=194). PRIMARY AND SECONDARY OUTCOME MEASURES: This was a descriptive analysis of death case series review and as such no primary or secondary outcomes were pre-stipulated. RESULTS: Deaths in patients from the Black, Asian and minority ethnic (BAME) communities in the pandemic period significantly increased both in the COVID-19 group (OR=2.43, 95% CI=1.60-3.68, p<0.001) and the non-COVID group (OR=1.76, 95% CI=1.09-2.83, p=0.02) during this time period and the increase was independent of differences in comorbidities, sex, age or deprivation. While the absolute number of deaths increased in 2020 compared with 2019, across all three groups the distribution of deaths by age was very similar. Our analyses confirm major risk factors for COVID-19 mortality including male sex, diabetes, having multiple comorbidities and background from the BAME communities. CONCLUSIONS: There was no evidence of COVID-19 deaths occurring disproportionately in the elderly compared with non-COVID deaths in this period in 2020 and 2019. Deaths in the BAME communities were over-represented in both COVID-19 and non-COVID groups, highlighting the need for detailed research in order to fully understand the influence of ethnicity on susceptibility to illness, mortality and health-seeking behaviour during the pandemic.

Lack of uniformity in the investigation and management of suspected ß-lactam allergy in children.

BACKGROUND: Beta-lactam allergy is commonly suspected in childhood with health implications for the individual and wider public. Diagnostic modalities include skin prick tests (SPT), specific immunoglobulin-E (sp-IgE) tests, intradermal tests (IDT) and drug provocation challenges (DPC). The aim of this research was to establish whether variation exists around the world in the investigation and management of beta-lactam allergy. METHODS: Anonymized electronic questionnaire surveys were distributed over 3 months through International Allergy Societies for completion by clinicians who investigate drug allergy in children. RESULTS: Eighty-one clinicians, practising in 16 countries, completed the questionnaire. There is variability in the selection of diagnostic tests used by clinicians around the world and poor agreement on positive cut-off values (sp-IgE, SPT and IDT) and practical techniques used to measure SPT or IDT wheal diameters. DPC were considered the gold standard investigation with 94% of respondents undertaking DPC over the last 12 months; 64% of respondents considered DPC extremely useful for both exclusion and confirmation of beta-lactam allergy. However, there is a lack of consensus on when and how DPC should be performed. Overall, DPC are safe - only 3% of our respondents had patients who required intramuscular adrenaline and none had patients requiring admission to intensive care. CONCLUSIONS: There is lack of consistency amongst clinicians in different countries in the diagnosis and management of suspected beta-lactam allergy. The development of a standardized approach is a priority.