Many countries are now suffering after years of insufficient attention to warnings about the need for improved pandemic preparedness. The WHO has declared COVID-19 a pandemic, but its underlying factors, vulnerabilities and impacts go far beyond the health sector, and in Sri Lanka, it is overwhelming government and response agencies. This study will address two, inter-related challenges: How will countries cope if a major natural hazard occurs while the COVID-19 pandemic is ongoing? How can pandemic preparedness make use of the existing infrastructure for tackling other hazards? The project team will attempt to understand the potential impact of a pandemic-natural hazard hybrid scenario. It will also seek to improve early warning and preparedness for such an event, as well as the availability of and access to multi-hazard early warning systems (MHEW) and disaster risk information that include pandemic/biological hazards, which is also Target G of the SFDRR [1]. We will address these challenges by examining how public health actors be better included within a MHEW environment and how pandemic threats are integrated within national and local DRR strategies. We will explore the impact of COVID-19 on the response capabilities for other hazards, either multiple simultaneous events, or cascading impacts, and consider how COVID-19 and public health surveillance can be synergised with "the last mile" of MHEW. Pandemic is global, but the preparedness and response is local, and that response is very dependent on governance, laws, culture, risk perception and citizen behaviour. The study has been designed in close collaboration with Sri Lankan health and DRR agencies who identified the key gaps that need exploring. The team will develop and disseminate guidance to better incorporate pandemics and other biological hazards into national and local DRR preparedness and response

Malnutrition in all its forms broadly includes undernutrition (e.g. underweight and lack of certain key nutrients) and overnutrition (e.g. obesity and related chronic non-communicable diseases, such as type 2 diabetes). Malnutrition in all its forms is the largest cause of disease and premature death globally and in South-East Asia (SEA). Its health impacts are twice as high as that of tobacco use and high blood pressure. This public health challenge is also associated with heavy social and economic burdens. Different forms of malnutrition share common causes, especially within food systems that are promoting these various forms of malnutrition, which can co-occur in the same individual, household or country at the same time. Locally relevant solutions will need to be generated in relation to people's eating habits and food cultures (e.g. the local food systems) as well as general living environments. Therefore, the seemingly different nutrition problems can be improved through common solutions targeting the wider systems of people's daily lives. Current approaches to interventions are not reducing undernutrition fast enough and have failed to control the rise of obesity and related chronic diseases. These problems have rarely been considered and managed together in an integrated way. To effectively combat this largely preventable public health challenge, we need a new way of working that recognises the connections between different forms and causes of malnutrition within a wider context and creates double-duty actions to address them together. We aim to develop public health interventions in Chinese and SEA cities that are: 1) jointly enacted by multiple sectors, 2) aimed to improve multiple forms of malnutrition, and 3) expected to benefit everyone living in these cities. We will do this collectively with local policy makers from different departments and sectors as well as community representatives (e.g. those who have delivered or received existing services or programmes aimed to improve nutrition status) over three project phases using a contemporary research method called the Group Model Building (GMB). GMB is a useful tool to develop a shared understanding of complex, inter-related issues and to facilitate coordinated actions among different people. It has been successfully used by members of this research team for developing systemic-level obesity interventions in developed countries. The proposed project (phase 1) will provide a strong foundation for subsequent project phases by: 1) co-developing systems interventions through GMB and forming intervention delivery Action Groups with local decision makers and community representatives in an Asian city; and gaining practical insights into this new intervention development method for application in other Asian cities, 2) identifying strategies to recruit SEA cities to join the project, and 3) providing information needed to support the development of an internationally comparable and sustainable tools to monitor and assess impacts of developed interventions. In the subsequent, phase 2 project, we will 1) support the Action Groups to deliver the interventions developed in phase 1, and measure early impacts of the interventions in the first Asian city using monitoring systems informed by phase 1; and 2) recruit SEA cities, develop interventions in these cities using the GMB process and form Action Groups. This will be the first research project to use GMB to develop malnutrition interventions in developing, Asian countries. Our findings will importantly advance the work on the Decade of Action on Nutrition towards achieving the United Nations' Sustainable Development Goals and contribute to method development and impacts of this new way of working on public health promotion globally.

There is an epidemic of primarily tubular-interstitial chronic kidney disease (CKD) clustering in agricultural communities in low-and-middle income countries (LMICs). Although it is currently unclear whether there is a common underlying cause, these conditions have been collectively termed CKD of unknown cause (CKDu). CKDu is estimated to have led to the premature deaths of tens to hundreds of thousands of young adults in LMICs over the last two decades. Thus, there is an urgent need to understand the aetiology and pathophysiology of these condition(s) and to develop preventive interventions. We have now established that CKDu exists in Central America (Nicaragua) and South Asia (India, Sri Lanka), but not in some other tropical countries (Malawi, Peru). It is not clear yet whether the epidemics in Central America and South Asia have common causes or different causes, which is why is it important to conduct research using the same protocols and methods in these different regions. Together with colleagues we have established prospective studies in affected communities in Nicaragua, South India, Sri Lanka to investigate the causes of the epidemics of CKDu, and factors which affect prognosis. We already have published striking findings from Nicaragua, where 10% of the community, who were apparently healthy when we started following them, have lost one-third of their kidney function in two years of follow-up - so something very alarming and striking is occurring. The underlying hypothesis is that CKDu is caused by unknown factors to which the populations have become exposed due to the changes in agricultural practice, or other environmental changes (e.g. water supply), over recent decades. The objectives of the proposed Programme Grant research are to investigate the environmental causes of renal decline in these high-risk populations, using both standardised instruments capturing occupational and environmental exposures. We will address four proposed causes of CKDu: (i) metals and metaloids; (ii) agrochemicals; (iii) infections by organisms that affect the kidney; and (iv) heat/dehydration. To achieve these objectives we aim to: (i) extend the follow-up to at least four years in each of the three studies (Nicaragua, India, Sri Lanka); (ii) expand each prospective study to a total of 1000 participants to increase the power of the primary analyses; (iii) use standardized questionnaires to capture self-reported exposures; (iv) directly measure exposures to metals, agrochemicals, infections and heat/dehydration; (v) identify potential biomarkers of early disease; and (vi) identify genetic factors which affect decline in kidney function.