Epidemiological and statistical research on health problems of low and middle-income countries: MRC Tropical Epidemiology Group (TEG)

The mission of the MRC Tropical Epidemiology Group (TEG) is to help improve health in low- and middle-income countries (LMICs), by conducting research that identifies and evaluates effective interventions.

Infectious diseases, including malaria, HIV, tuberculosis (TB) and neglected tropical diseases (NTDs), remain a main focus of our research, as they are the leading causes of ill-health in Africa. In the next grant period, we will expand our research on emerging diseases, adolescent health and non-communicable diseases - particularly hypertension, diabetes and chronic obstructive pulmonary disease, which are major disease problems in LMICs. Our research focuses on conditions that are major causes of ill-health, and for which improved prevention or treatment leads directly to improved economic and social outcomes. The importance of these issues to the UK is highlighted in the 2015 Government strategy for overseas aid, on tackling global challenges in the national interest.

The scale-up of malaria control tools, primarily long-lasting insecticidal nets, and effective combination therapies, has prevented an estimated 663 million clinical malaria cases in sub-Saharan Africa since 2000, and has made malaria elimination an achievable goal in some countries. However, these gains may be threatened by insecticide resistance, drug-resistance, and resource-constraints. Within the next grant period, our focus will be on evaluating new tools, combining new and existing control strategies, and investigating sustainable and more effective deployment of these strategies.

For HIV, we focus on the goal that 90% of those living with HIV know their status, 90% of known HIV-positive individuals receive sustained ART, and 90% of individuals on ART have durable viral suppression. For example, we are leading a major trial in South Africa and Zambia to evaluate the impact of a combination prevention intervention on new cases of HIV in the community. The intervention includes household-based HIV testing and linkage-to-health services by community care providers, and immediate initiation of treatment delivered through routine healthcare services.

TEG research on TB includes studies to evaluate improved TB treatment strategies, improved diagnosis, prevention and control of drug-resistant TB, improved TB case finding and prevention, and evaluation of structural interventions (social support and monetary incentives) to control TB. For example, we are working on a trial to evaluate an improved electronic medication device for TB patients to reduce treatment failure and subsequent recurrence/retreatment in the absence of directly observed treatment.

We will continue our long-standing work on intervention strategies for the control and elimination of NTDs, and our more recent involvement in the control of outbreaks such as the Ebola and Zika virus outbreaks. We will also continue our work on the effectiveness of lay-health worker interventions to treat common mental disorders (depression and anxiety), focusing particularly on treatment of these conditions among adolescents, in whom over half of mental health disorders start.

Through the MRC Programme Grant, we leverage additional funding for research projects and support salaries for around 30 statisticians and epidemiologists, based at LSHTM. The grant is critical to enable us to recruit and retain these scientists, who have disease and methodological expertise in the design and analysis of epidemiological studies in LMICs. We collaborate with the MRC Units in The Gambia and Uganda, and over 50 other research institutes in LMICs. We will continue our initiatives to increase capacity in medical statistics in sub-Saharan Africa, for example by expanding the MRC TEG Fellowship scheme, which to date has trained 17 medical statisticians through a Masters in Medical Statistics at LSHTM, followed by a placement year. All are now working as medical statisticians in Africa.

The aim of TEG is to conduct cutting-edge epidemiological studies on health problems of low- and middle-income countries (LMICs). TEG will continue to have a major focus on the epidemiology and control of infectious diseases, with increased emphasis on evaluating delivery strategies for interventions of proven effectiveness. We will expand our research on emerging infectious diseases, adolescent health, non-communicable diseases and applied epidemiological methods. We will also expand our capacity building initiatives, including the TEG Fellowship scheme to train African statisticians. These issues are critical to the UK Government strategy for overseas aid, as indicated by the £1.5 billion Global Challenges Research Fund to support challenges in LMICs.

TEG malaria research includes assessing the scale-up and combination of malaria control tools, e.g. investigating sustainable and more effective deployment of long-lasting insecticidal nets, and effective combination therapies. For HIV, we focus on community-based approaches to improving HIV testing and linkage-to-care in sub-Saharan Africa, and interventions for key populations in high-incidence settings. Our TB research includes studies to evaluate improved TB treatment strategies, improved diagnosis, prevention and control of drug-resistant TB, improved case finding and prevention, and structural interventions. We will continue research on the control and elimination of NTDs, including the Ebola and Zika virus outbreaks. Finally, we conduct applied methodological work to advance the design and analysis of epidemiological studies in LMICs.

Through the Programme Grant, we will continue to leverage funding to recruit and retain a critical mass of scientists who have expertise in design and analysis of epidemiological studies in LMICs, and relevant disease-specific expertise. We collaborate closely with the African MRC Units and many other institutes in LMICs, with whom we published 700 papers in the past 5 year

Beneficiaries of our research include i) populations in low- and middle-income countries (LMICs) affected by the diseases which we research, ii) local and national stakeholders; iii) national and international policy makers; iv) scientists within TEG; v) our collaborators in LMICs; and vi) the wider academic community of global health researchers.

i) The diseases we focus on are malaria, HIV, TB, emerging and neglected diseases - including mental health, eye health and non-communicable diseases. Each of these disproportionately affect the poorest in resource-poor countries, and those marginalised from society. These diseases also have a substantial impact on national socio-economic development. By reducing the rates of important causes of ill health, we have the potential to alleviate poverty as well as improving life expectancy. Many of the studies we undertake involve community-based interventions focused on overcoming barriers to health service access and to minimize stigma and discrimination. This is a common issue for many of the diseases we work on, and particularly for HIV and mental health, and among some of the key populations that we focus on, including adolescents and high-risk groups.

ii) We engage with local and national stakeholders, as described in the Pathways to Impact statement, and they benefit directly, for example, from our studies to evaluate optimal strategies for delivery of interventions of known effectiveness (for example on integrating HIV and non-communicable disease treatment and care); or to improve efficiency or cost of interventions (for example the first trial of reduced dose human papillomavirus (HPV) vaccine in Tanzania, or the planned trial of fractional dose pneumococcal vaccine in Kenya).

iii) We are able to ensure that results from our research and other important studies help to inform new policies and guidelines, through our role on national and international advisory committees, including as Chair of the WHO Joint Technical Expert Group on Malaria Vaccines in Pivotal Phase 3 Trials & Beyond; and members of the UNAIDS Scientific Expert Panel, the scientific advisory committees of EDCTP and CEPI (Coalition for Epidemic Preparedness, Innovations), the WHO Technical Advisory Committee on Safe Male Circumcision, the WHO Evidence Review Group on Malaria in Pregnancy, the WHO Global Malaria Programme, Surveillance Monitoring and Evaluation Technical Advisory Group, and WHO Expert Working Groups on Lassa fever, Nipah virus and MERS Co-V vaccine Target Product Profiles.

iv) The Programme Grant enables us to sustain a strong critical mass of experienced statistical epidemiologists and to provide an actively supportive academic environment and mentorship for all our staff. We regularly review and encourage career development, support the development of Fellowship and research grant applications, and provide funds for training courses and conference attendance.

v) Our collaborators benefit directly from our research (see Letters of Support), as the Programme Grant enables us to provide consistent and continuous, disease-specific, statistical and epidemiological expertise that is in short supply in global health research. This leads to high-quality scientific outputs and new grant applications, which lead to population health benefits. We also have an impact on the careers of the MSc, PhD and post-doctoral students who we teach, supervise and mentor, both at LSHTM, through our Fellowship scheme and collaborative links, as described in the Case for Support and Academic Beneficiaries sections.

vi) We produce around 120 papers annually, and disseminate findings at international conferences in order to benefit to the wider academic community working on global health. This includes clinical epidemiologists, social scientists and laboratory scientists. In March 2021 we plan to hold a two-day symposium to increase the impact and reach of our research findings.