Health data research in the UK is rapidly evolving, with new capabilities emerging through the rise of hybrid engagement and the accelerated adoption of digital technologies.
At the height of the COVID-19 pandemic, these capabilities were put to the test, being used to compare hospital caseloads to research activity in real-time and enabling COVID-19 clinical trials to rapidly recruit participants across the UK.
Having demonstrated the possibilities when multiple agencies work together towards the same single goal – solving a pandemic – one disease/virus, researchers have an understanding of how this model could work. However, expanding that model to cover all data in all disease areas is a monumental and highly ambitious task.
In the UK, research organisations and pharma companies are working to find ways to reach this goal, using data to inform commercial clinical research now, and how this foundation can be built upon in the future. This was the focus of a recent pharmaphorum webinar, held in association with the National Institute of Health and Care Research (NIHR) where experts from the NIHR and Roche discussed the potential of healthcare data in commercial clinical research.
While data is an asset across the research landscape, speakers spotlighted site selection as an area where data can be particularly valuable.
“This is about doing research in the right place at the right time,” explained Professor Caroline Wroe “We know that there is an inverse care law, the people that need our help the most are the least likely to access it.”
“It would be fantastic if we could shift that paradigm when we are talking about research. If we can put that resource where it is most beneficial then that is a really good starting point.”
Why is data important?
In the early stages of planning a clinical trial, one of the most important considerations is site selection. Identifying the best location for a particular trial can have a direct impact on the development of a study as it progresses, but there are a number of variables that have to be assessed to ensure that the right study is placed at the right site, at the right time.
“Data is becoming an essential element in early decision making around clinical trials both in terms of the countries that are selected to take part but also sites that take part,” explained Roche’s therapy relationship manager, oncology, Ed Merivale. “It provides great insight into where our trials may be most successful, which patient groups have the most clinical need and the best ways for us to design and deliver those studies.”
Historically, site selection was often influenced by experience and relationships between pharma companies and researchers. According to the head of business intelligence for the NIHR’s Clinical Research Network, Stephen Lock, this is an understandable approach, as prior knowledge of a sites working patterns and experience can be an asset, allowing companies to focus on meeting specific trial goals and timelines. However, as noted, this may have also biased companies against exploring more suitable partnerships:
“With all those pressures we can become a little bit blind to some of the other choices that are available to us, and that’s where data can really help.”
Using site selection data, researchers are empowered to plan clinical research in locations that offer the best resources, access to patient groups, and expertise for that particular study.
Lock highlighted the NIHR’s work with data in diabetes as a notable example of how data can be used to inform site selection. “We have worked a lot with data that comes from public health England, which could show the prevalence of diabetes across the country. What we can do is take that data and we can contrast that with patterns of recruitment into diabetes studies.”
Moreover, the panel noted that pharma companies can use data to identify sites that are not already taking part in studies. By utilising these sites, researchers open up trial access to a wider pool of participants, who may have been unable to take part in previous studies due to personal, distance or time restraints. As these areas are unlikely to be saturated, their inclusion offers enhanced recruitment potential.
The current data landscape in commercial clinical research
Although data is one of multiple considerations that companies assess when planning commercial clinical research, as the data matures and becomes more accessible, companies have a wealth of valuable information to draw from. Within the UK, sources can provide detailed information about factors, such as disease epidemiology and population level data that can impact how and where clinical research takes place.
“There is a huge amount of publicly available data, but it needs reformatting, presenting, and interpreting to highlight where in the UK we should focus our recruitment efforts,” explained Merivale. “It’s not just about placing the site in the right places, sometimes we can’t do that, but also how we tailor the recruitment efforts in and around the sites that we do have. All with the ambition to ensure that we are enabling representative enrolment.”
Building upon this, Merivale noted that using data to model historical recruitment by ethnicity vs catchment area could potentially produce a profile model, which companies could use to predict the diversity profile of new studies.
In the UK, the NIHR has also witnessed the growing importance of data in the research space. As Lock highlighted, while the NIHR’s Clinical Research Network is predominantly responsible for the delivery of research, there has been an increasing interest in using the network’s knowledge and data to help advise upstream.
“We have a lot of data on what has and hasn’t worked historically, and there is a lot that we can infer from that data,” explains Lock. “With that we can really help the company to understand that they may want to consider somewhere like Blackpool in addition to Oxford or Cambridge.”
To illustrate how the Clinical Research Network can support a study, Wroe spotlighted the recent RELIEVE IBS-D trial. In this example, data played a significant role in identifying where irritable bowel syndrome with diarrhoea patients were located and how to access potential participants.
“We worked with the chief investigator to facilitate data searches in primary care so that we get really good feasibility and that means that you can pick sites where you have high numbers of patients and will likely have a high success rate in terms of recruitment.”
Additionally, Wroe explained that this information about the patient population offered insights into potential barriers and facilitators – both of which could be planned for in advance.
What’s next for healthcare data in commercial clinical research?
Although COVID-19 disrupted the status-quo of commercial research in the UK, panel members agreed that the pandemic demonstrated the potential of data and digital in clinical studies. The situation was certainly a unique one, with the majority of research efforts directed at one specific disease, however there are a number of lessons learned over the past two years about how companies identify and support site selection and trial recruitment that can be applied to smaller studies across multiple areas.
For Wroe, the NIHR-funded Platform Adaptive trial of NOvel antiviRals for eArly treatMent of COVID-19 In the Community (PANORAMIC) study is a notable example of how digitally enabled feasibility and recruitment can be effectively used to drive clinical research. With nearly 17,000 participants recruited over a three-month period, in early 2022 the study became the UK’s fastest ever recruiting interventional clinical trial to be delivered through primary care.
Digital literacy was also highlighted as an important element as pharma companies look ahead to future commercial clinical research. As Wroe noted during the webinar, “There is something that is so important about digital literacy, that we learn how to use this data comfortably and understand how we interact with our commercial partners to make best use of data.”
Another area where data has gained significant recognition is in precision targeting of rare disease patients. According to Merivale, there are many opportunities for development in this space, particularly in terms of connectivity at the point of identification and trial matching. Building on the progress of genomic lab hubs and with the right resources in place, he explained that researchers may reach a point in the future where data flow highlights mutations in real time.
Creating a foundation for future developments
While there are many areas where data can be used to improve the success of research, both the connectivity and application needs to be further developed to ensure that data can be readily translated into insights to improve commercial research delivery.
Optimising the data available for commercial clinical research is not something that will happen overnight. This is particularly evident in the UK, where the ‘richness’ and value of NHS data is often highlighted as a beneficial feature. Here, panellists emphasised the need to extract and share insights to realise the UK’s potential as a world-leading location for delivering research.
Lessons learned throughout the COVID-19 pandemic can provide a solid foundation to enhance and improve the use of NHS data. As Lock highlighted in the webinar, NIHR’s network model served as an important asset as the industry adapted to changes in research.
“The power of a network is way more than the sum of its parts,” he explained. “We’ve seen huge changes in the way that research is conducted in a way that would be impossible if you direct-funded into organisations.”
As we move beyond the pandemic, attention is beginning to turn to how this data-driven and collaborative research approach can be applied to other areas of healthcare.
As Wroe explains, “If we can take the learnings from COVID research about how we identify participants and support recruitment this will be an asset across other disease areas and geographies.”
About the panel
Caroline Wroe is a consultant nephrologist at Newcastle upon Tyne Hospitals NHS Foundation Trust & clinical director of the NIHR North East and North Cumbria Local Clinical Research Network. As clinical director of the CRN North East and North Cumbria Caroline leads a team working with colleagues across 30 clinical specialties, primary care, public health and social care to co-ordinate and facilitate research study delivery across the North East of England. She supports the wider NIHR under-served Programme Board across the UK to improve research accessibility for participants at site level and has experience using population data to develop bespoke regional funding calls to meet patient needs.
Stephen Lock is head of business intelligence at NIHR Clinical Research Network. Stephen Lock is an improvement expert with twenty years experience in the healthcare and IT industries. Over the last ten years, working in research networks, he has developed many innovative and award winning ways of delivering clinical research to patients, including a pioneering use of social media marketing to help enroll patients into studies. Currently working as Head of Business Intelligence for NIHR CRN CC, where he has a national role in reporting and analysing research activity, Stephen is also a graduate of the global Innovating Health for Tomorrow Programme run through INSEAD Paris.
Ed Merivale is therapy relationship manager, oncology at Roche. Ed has worked in clinical operations at Roche for 15 years, supporting the delivery and strategy for Roche’s oncology portfolio. Over the last 18 months he has focused on transforming Roche’s culture, processes and collaborations to improve diversity and the experience of patients who take part in our trials
Eloise McLennan is the editor for pharmaphorum’s Deep Dive magazine. She has been a journalist and editor in the healthcare field for more than five years and has worked at several leading publications in the UK. (moderator)
The post Unlocking the potential of healthcare data in research appeared first on .treatment clinical trials therapy pandemic covid-19 uk
Optimism Slowly Returns To The Tourism Sector
Optimism Slowly Returns To The Tourism Sector
Coming off the worst year in tourism history, 2021 wasn’t much of an improvement, as travel…
Coming off the worst year in tourism history, 2021 wasn't much of an improvement, as travel remained subdued in the face of the persistent threat posed by Covid-19.
According to the United Nations World Tourism Organization (UNWTO), export revenues from tourism (including passenger transport receipts) remained more than $1 trillion below pre-pandemic levels in 2021, marking the second trillion-dollar loss for the tourism industry in as many years.
As Statista's Felix Richter details below, while the brief rebound in the summer months of 2020 had fueled hopes of a quick recovery for the tourism sector, those hopes were dashed with each subsequent wave of the pandemic.
And despite a record-breaking global vaccine rollout, travel experts struggled to stay optimistic in 2021, as governments kept many restrictions in place in their effort to curb the spread of new, potentially more dangerous variants of the coronavirus.
Halfway through 2022, optimism has returned to the industry, however, as travel demand is ticking up in many regions.
You will find more infographics at Statista
According to UNWTO's latest Tourism Barometer, industry experts are now considerably more confident than they were at the beginning of the year, with 48 percent of expert panel participants expecting a full recovery of the tourism sector in 2023, up from just 32 percent in January. 44 percent of surveyed industry insiders still think it'll take until 2024 or longer for tourism to return to pre-pandemic levels, another notable improvement from 64 percent in January.
Doctors’ Group Urges Biden Administration To End Quarantine, Vaccine Recommendations For Children
Doctors’ Group Urges Biden Administration To End Quarantine, Vaccine Recommendations For Children
Authored by Zachary Stieber via The Epoch…
Authored by Zachary Stieber via The Epoch Times (emphasis ours),
A group of doctors is urging top government officials to quickly reverse recommendations that have left children in isolation for days and advice that virtually every child get a COVID-19 vaccine.
“We strongly urge you to revise the CDC’s COVID-19 guidelines with regards to testing, isolation, and vaccine recommendations for children to ensure that public health policies are not doing more harm than good,” the group, Urgency of Normal, wrote in a June 21 open letter to Dr. Ashish Jha, the White House’s COVID-19 response coordinator, and Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention (CDC).
The CDC’s guidelines say that people, including children, who are exposed to COVID-19 should quarantine for at least five days, and encourage widespread COVID-19 testing.
The agency also recommends that all children 6 months of age or older get a COVID-19 vaccine, following the recent authorization of the Moderna and Pfizer shots for kids under 5.
The doctors noted that many European countries, U.S. states, and other areas have updated COVID-19 policies to greatly reduce periods of quarantine, COVID-19 testing frequency, and forced vaccination.
They’re asking U.S. officials to adapt to a “test-to-treat” approach, which would focus on recommending vaccination and treatments to those at the highest risk from COVID-19, which are primarily the elderly and others with serious underlying health conditions.
Read more here...
This Week in Apps: Twitter Notes, Instagram age verification, Spotify’s Live Events
Welcome back to This Week in Apps, the weekly TechCrunch series that recaps the latest in mobile OS news, mobile applications and the overall app economy….
Welcome back to This Week in Apps, the weekly TechCrunch series that recaps the latest in mobile OS news, mobile applications and the overall app economy.
The app industry continues to grow, with a record number of downloads and consumer spending across both the iOS and Google Play stores combined in 2021, according to the latest year-end reports. Global spending across iOS, Google Play and third-party Android app stores in China grew 19% in 2021 to reach $170 billion. Downloads of apps also grew by 5%, reaching 230 billion in 2021, and mobile ad spend grew 23% year over year to reach $295 billion.
Today’s consumers now spend more time in apps than ever before — even topping the time they spend watching TV, in some cases. The average American watches 3.1 hours of TV per day, for example, but in 2021, they spent 4.1 hours on their mobile device. And they’re not even the world’s heaviest mobile users. In markets like Brazil, Indonesia and South Korea, users surpassed five hours per day in mobile apps in 2021.
Apps aren’t just a way to pass idle hours, either. They can grow to become huge businesses. In 2021, 233 apps and games generated over $100 million in consumer spend and 13 topped $1 billion in revenue. This was up 20% from 2020, when 193 apps and games topped $100 million in annual consumer spend and just eight apps topped $1 billion.
This Week in Apps offers a way to keep up with this fast-moving industry in one place, with the latest from the world of apps, including news, updates, startup fundings, mergers and acquisitions and suggestions about new apps to try, too.
Do you want This Week in Apps in your inbox every Saturday? Sign up here: techcrunch.com/newsletters
Instagram to verify users’ ages in new test
Instagram announced this week it’s testing a new set of features for verifying users’ ages in the app, including things like video selfies, vouching from adult friends and providing an ID. The tests, which will begin in the U.S., will apply to users who try to change their age to 18 or over after being previously set to under 18. These users may be trying to correct an earlier mistake or they could be teens trying to circumvent the app’s newer age-appropriate restrictions.
If users are prompted to provide an ID card, like a passport or driver’s license, Meta will store it on its servers for 30 days before deletion. If users choose the social vouching option, they’ll need at least three other adult friends to vouch for their age — and Instagram will choose a list of six people randomly who meet the criteria. Those users can’t have a new account or be vouching for others at the same time.
The company also said it’s using AI that can estimate users’ ages in video selfies. The company is working with the London-based digital identify firm Yoti which will examine the file, make an estimate, then delete the file.
Age verification is an increasingly common feature in social apps used by younger users as a result of tighter regulations. Another company catering to Gen Z users, Yubo, recently rolled out its own age estimating tech as well.
Twitter goes long form
The news is one of Twitter’s more significant changes since doubling the character count from 140 to 280 characters, as it will allow users to write on Twitter directly, as if it’s a blogging platform. With Twitter Notes, users are able to create articles using rich formatting and uploaded media, which can then be tweeted and shared with followers upon publishing. The company also said it would merge its newsletter service, Revue, into Twitter Notes.
Users with access can create Twitter Notes from the “Write” link in Twitter’s navigation. For the time being, Twitter is testing Notes with a small group of writers in the United States, Canada, Ghana and the United Kingdom. The Notes can be up to 2,500 words in length.
The feature could encourage users to rely on Twitter Thread (tweetstorms) less in order to share their longer thoughts, ideas or stories with their Twitter followers, Community or Circle. It could also put an end to using a screenshot from the Notes app to tweet something longer than 280 characters. Meanwhile, Twitter Notes can tap into the potential for viral distribution that comes with posting to the platform. Like tweets, the Notes would have their own link and could be tweeted, retweeted, sent in DMs, liked and bookmarked. They can also be reported and must comply with Twitter’s rules.
It’s worth noting (ha!) that Twitter Notes also gives the company a new business and potential revenue stream as it further develops the product. The feature may allow the social platform to compete with established services, like Medium for blogging, or Substack’s newsletters.
- Apple released the second developer beta for iOS 16 and iPadOS 16, along with other betas for Mac, Apple Watch and Apple TV. Among the changes is support for cellular iCloud backups over LTE; a new feature that shows a brand or company’s logo beside their email in the Mail app to cut down on phishing; tech that lets you skip CAPTCHAs; plus new SMS filters and the ability to tap to report a junk SMS sender in the U.S. But another thing to note if you’re testing iOS 16 — the current beta’s editable iMessage feature doesn’t work with older iPhones, meaning your edits are texted to the person after the original message.
- Apple also rolled out Xcode 14 beta 2 which now includes a Stage Manager simulator.
- The iPad will no longer work as a home hub in iOS 16 according to information discovered in the Home app.
- As part of its ongoing efforts to expand into e-commerce, Twitter announced a new partnership with Shopify. The deal will see Twitter launching a sales channel app that will be made available to all of Shopify’s U.S. merchants through its app store. The app allows merchants to onboard themselves to Twitter’s Shopping Manager, the dashboard offered by the social media company where sellers can access product catalog tools and enable other shopping features for their profiles. Merchants will be able to use the new sales channel app to connect their Twitter account to their Shopify admin then get set up with Twitter’s Shopping Manager and other free tools Twitter built for “Professionals.” This includes Twitter’s launch of a new feature called Location Spotlight, which allows local businesses in the U.S., Canada, U.K. and Australia to display information like their street address, contact info and operating hours directly on their profile.
- Walmart gave its app an AR upgrade with the launch of View in Your Space, which allows customers to see home décor and furniture in their own homes. The feature will be rolled out to over 300 items on Walmart’s iOS app by early July.
- Tim Cook may have hinted at Apple’s AR headset plans when he told a Chinese state-run news outlet to “stay tuned” to see what Apple had in store next for AR in an interview. A later investor note by Ming-Chi Kuo also suggested the new hardware could arrive as soon as early 2023.
- IKEA launched a new in-app design experience, called IKEA Kreativ, that lets U.S. shoppers visualize furniture in their own spaces using AR and AI. The feature can also remove the existing furniture from your room so you can better imagine the changes.
- Snap shared some data about AR shopping trends, noting that there was a 32% increased use of shoppable AR during the pandemic and that 69% of consumers believed AR was a part of shopping’s future.
- Coinbase is shutting down its standalone Pro service by year’s end and replacing it with Advanced Trade across its website and app. The latter offers comparable features to the Pro service, which had lowered fees to traders who interacted directly with the Coinbase Exchange order book.
- Facebook Pay formally rebranded to Meta Pay. The change had already been announced but is now rolling out in the U.S. before expanding globally.
- Snapchat announced its first accelerator program for emerging Black creators, which will see 25 selected participants receive $10,000 per month to launch their careers across a total $3 million investment.
- Instagram has been experimenting with a new feature that would allow users to leave notes for their friends at the top of the DM inbox. The feature could help users share urgent or more important messages that could be overlooked in Stories or in messages.
- Meta announced more ways for creators to make money on Facebook and Instagram and the expansion of other monetization tools to more creators. The company will keep paid online events, fan subscriptions, badges and its upcoming independent news products free for creators until 2024, instead of 2023, as it had said before. Meta is also testing a designated place on Instagram where creators can get discovered by brands for partnerships; will launch a way for users to subscribe to Facebook Groups even for those who have paid for access on another platform; and is expanding the Reels Play Bonus program to more creators and making Facebook Stars available to all.
- Twitter announced the return of its developer conference, Chirp. The event was first held in 2010 but was then canceled the next year. At the time, the event had been a reflection of Twitter’s attitude toward its developer community in general — disorganized and constantly in flux as the company’s business initiatives changed. Times have since changed and Twitter has been trying to woo back developers with its new API, even by promoting some apps on Twitter itself.
- Telegram said it now has over 700 monthly active users and announced Telegram Premium, a subscription that gives users access to exclusive features like doubled limits, 4 GB file uploads, faster downloads, exclusive stickers and reactions, improved chat management and more.
- Camera+, an alternative to Apple’s built-in app, added a new “UltraRes upscaling” feature. With machine learning technology, the app can upscale images to up to four times what the native sensor can capture.
- Match-owned Hinge added a new feature that allows users to share their “Dating Intentions” — meaning whether they’re looking for long-term, short-term, open relationships and more. The update changes Hinge’s focus as the company has historically been the app designed to connect people looking for more serious relationships, while Match-owned Tinder was aimed at those seeking casual encounters.
Streaming & Entertainment
- Spotify revamped its concert discovery feature with the launch of a new Live Events Feed. The personalized feature will allow users to find favorite artists’ events in your area and will now include artist imagery and more tour details. Local events will also be highlighted while streaming and soon, in other places in the Spotify app.
- Clubhouse is testing a new feature called Houses, per Bloomberg, which are private rooms aimed at encouraging social interactions where anyone can unmute themselves and speak.
- Reddit Talk, the company’s live audio Clubhouse-like feature, announced its Host program would launch on July 11th. The program will promote hosts’ audio across the site. Reddit Talk also gained new features like a soundboard and topic selector for discovery purposes.
- Apple Music raised the price of its student plan in the United States, Canada and the United Kingdom. In the United States and Canada, the price for the plan has increased from $4.99 to $5.99. In the United Kingdom, the price has increased from £4.99 to £5.99.
- Epic Games has come up with a new system for game ratings. While these changes apply to its own online games store, it’s an example of why alternative app stores could be useful to provide competition with Apple’s own — they can be a ground to test out new ideas. In Epic’s case, random players who have played a game for over two hours will be asked to rate the game on a five-point scale. Over time, these will create the game’s Overall Rating. The system, which relies on random sampling, could cut down on review bombing and reviews left by those who aren’t actual players, the company notes.
- China’s regulation of the mobile gaming market may be leading to declining use of the App Store in the country, according to Morgan Stanley. The firm’s latest analysis estimated that the App Store only saw 1% growth in June so far, compared with 6% growth in May.
Health & Fitness
- Fitbit added a new premium feature, “Sleep Profile,” which will allow users to track their sleep patterns across 10 key metrics, including new data points like bedtime consistency, the time before sound sleep and disrupted sleep. The feature is rolling out to the Fitbit app’s Premium users and supports devices including Sense, Versa 3, Versa 2, Charge 5, Luxe or Inspire 2.
Travel & Transportation
- Apple is planning to expand its CarPlay experience to China, according to a job posting.
- Polestar has now added Apple CarPlay to its all-electric Polestar 2 sedan via an over-the-air software update, after previously only supporting Android Auto.
- Car rental apps saw their MAUs grow 19% year-over-year in the U.S. in May, reported Apptopia, despite rising gas prices.
Government & Policy
- TikTok offered a series of commitments in the EU to improve user reporting and disclosure requirements around ads/sponsored content as well as an agreement to boost transparency around its digital coins and virtual gifts. The agreement follows a series of complaints over child safety and consumer protection complaints filed back in February 2021.
- The U.S. Department of Justice today entered into an agreement with Meta to resolve a lawsuit that alleged Meta engaged in discriminatory advertising in violation of the Fair Housing Act (FHA). As a result, Meta has agreed to develop a new system for housing ads and will pay a roughly $115,000 penalty, the maximum under the FHA.
Reading & News
- India-based VerSe Innovation rolled out its news aggregator Dailyhunt in the UAE, Saudi Arabia, Bahrain, Oman, Qatar and Kuwait, with over 5,000 content partners in the region.
Security & Privacy
- Google Chrome for iOS gained a number of new features in a recent update, including access to Enhanced Safe Browsing to protect users from dangerous websites and malware, as well as the ability to make Google Password Manager your Autofill provider. Other additions include Chrome Actions (typed commands in the URL bar) and access to Google’s Discover feed on the main page.
- Daycare apps including those from Brightwheel, HiMama and others were found to lack 2FA and other privacy protections, in an analysis.
- Google threat researchers detailed a commercial spyware system called Hermit, used in Kazakhstan and Italy, which targeted both Android and iOS. The iOS version had six exploits, including two zero-days. Targeted victims are tricked into installing a malicious app — which masquerades as a legitimate branded telco or messaging app — from outside the app store.
Funding and M&A
Courier raised $35 million in a Series B funding round led by GV. The company provides an API for sending notifications across multiple channels, including email, text, web and mobile.
Ghana-based fintech Fido raised $30 million in equity investment and some undisclosed debt funding in a Series A round led by Israel-based private equity fund Fortissimo Capital. The round brings the total equity investment raised to date to $38 million. The startup says it’s adding savings and payment products to its portfolio later this year and will enter Uganda.
Twitter asked its shareholders to approve the $44 billion Elon Musk acquisition. At the time of its SEC filing, Twitter’s share price was around $38.12 — lower than Musk’s offer price of $54.20 a share. The company’s market cap had also dropped below $30 billion, making a $44 billion deal look very good.
The app is not the best experience for watching videos, as you may have guessed, but it is pretty wild that it actually works. The app by default shows you top trending videos, but you can customize this so the videos that appear are selected from a particular genre, like Music, News, Gaming, Movies and more. While it would be enough to just accomplish bringing YouTube to the Watch, the developer also added other features like the ability to search for videos, save videos to the app’s local Library and subscribe to Channels. When you get back to your other devices, you can also scan a QR code to share the video back to your iPhone or iPad.default pandemic link testing consumer spending south korea india brazil canada italy eu china
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