We would like to congratulate Suman PN Rao et al on this very important and useful work.
On behalf of the Global Newborn Society would strongly advocate unrestricted access of parents to their infants and to skin to skin care.
Current SARS-CoV-2 pandemic-related restrictions on skin-to-skin contact (SSC) and parental involvement in neonatal care, in place in many parts of the world, are not based on clinical evidence. Hospitals and neonatal units have, to varying degrees, restricted parental access and SSC without due consideration of the harms this might cause on multiple fronts (1). Based on current evidence a ‘blanket ban’ on SSC by various maternity and neonatal services across the globe is unfortunate, not evidence based and needs to be reviewed on an urgent basis.
The World Health Organization (WHO) recommends skin-to-skin contact (SSC) following delivery in babies weighing 2000 grams or less at birth, as soon as they are clinically stable to prevent hypothermia (2). In low resource settings lack of initiation of early SSC is an independent predictor of hypothermia, contributing to neonatal mortality and morbidity (3). The United Nations Children’s Fund Baby Friendly Hospital Initiative recommends immediate SSC after birth based on physiological, social, and psychological benefits for both mother and baby (4).
The risk of SARS-CoV-2 infection in neonates both vertical and horizontal is relatively low with no significant mortality (5), how...
The risk of SARS-CoV-2 infection in neonates both vertical and horizontal is relatively low with no significant mortality (5), however lack of SSC and parental involvement will lead to increased mortality and additional adverse long term outcomes (6). Systematic reviews and guidelines have already provided guidance on the treatment and management of COVID-19 positive mothers and their infants (7, 8).
All these restrictions, largely knee jerk reactions to the pandemic, will only serve to negate a lot of the hard work invested in best practice guidance and standards outlined for both low and high income countries (9, 10,11).
Recently, in response to suboptimal practice during the pandemic, both professional and parent organizations have joined the call to re-establish parents as essential partners in care, and not to be considered as visitors, which they most definitely aren’t. (12, 13).
We recommend that neonatal organizations, hospitals and health services all across the world urgently advocate on this important issue and ensure that we encourage unrestricted SSC and zero separation of infants and parents, to prevent significant long term collateral damage.
1. Rao SPN, et al. Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers' voices and experiences. BMJ Glob Health. 2021 Mar;6(3):e004347. doi: 10.1136/bmjgh-2020-004347.2.
2. World Health Organization. (2015). WHO recommendations on interventions to improve preterm birth outcomes.
3. Moore ER, Bergman N, Anderson GC,et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016 Nov 25;11:CD0035193.
4. Brimdyr K, Cadwell K, Steevens J, Takahashi Y. An implementation algorithm to improve skin-to-skin practice in the first hour after birth. Matern Child Nutr. 2018;14(2):e12571.
5. Mullins E, Hudak ML, Banerjee J, et al. Pregnancy and neonatal outcomes of COVID-19: co-reporting of common outcomes from PAN-COVID and AAP SONPM registries. Ultrasound Obstet Gynecol. 2021 Feb 23. doi: 10.1002/uog.23619.
6. Bergman NJ. Birth practices: Maternal-neonate separation as a source of toxic stress. Birth Defects Res 2019; 111:1087–109.
7. RCPCH/BAPM Paediatric COVID-19 guidance. Available online: https://www.rcpch.ac.uk/resources/covid-19-guidance-paediatric-services
8. American Academy of Paediatrics: COVID-19 guidance. Available online: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infect...
9. EFCNI. European Standards of Care for Newborn Health. 2018.
10. WHO (World Health Organization). Survive & thrive: Transforming care for every small and sick newborn. 2019.
11. Global Alliance for Newborn Care - GLANCE [Internet]. [cited 2020 Jul 8]. Available online: https://www.glance-network.org/
12. British Association of Perinatal Medicine: Family Integrated Care for COVID-19. Available online: https://hubble-live-assets.s3.amazonaws.com/bapm/redactor2_assets/files/...
13. Bliss. Bliss Statement: COVID-19 and parental involvement on neonatal units. Available online: https://www.bliss.org.uk/health-professionals/information-and-resources/...
I read with great interest the article that helped Mauritius overcome their first wave of COVID-19 infection. Unfortunately, just like several successful countries, Mauritius is now facing a second wave of infection and a second lock-down has been declared by the Prime Minister, starting on the 11th March 2021. As the number of COVID-19 cases continues to rise daily, the Mauritian Government is relying heavily on the cooperation of its citizens, as well as their massive vaccination campaign to reach herd immunity. The vaccine was first made available to the elderly and those at higher risks( including front-liners). Since the lock-down, the Mauritian Government has further prioritized everyone who is a front-liner or has a valid "work access permit". As of the 18th March 2021, around 74,000 Mauritians have already been vaccinated and a daily target of 8,000 new vaccinations is being provided through the 14 vaccination centers set up across the island. The Minister of Health and Quality of Life also confirmed the arrival of another 200,000 doses of COVAXIN from India on the 19th of March 2021.
Mauritius has, once again, reacted fast and strongly to the outbreak. The lockdown was issued without hesitation and the population has been more compliant with the orders compared to last year. Hopefully, once the country achieves its target of vaccinating 60% of the population, herd immunity will be reached and gradually the pandemic will be under control.
A recent commentary advocates for the inclusion of rabies vaccine in EPI,1 referring to lack of timely available post-exposure prophylaxis (PEP) in most low-income settings. Priming with pre-exposure profylaxis (PreP) in the form of rabies vaccine extends the response window and might even provide protection without subsequent PEP.
The authors are commended for shedding light on a neglected tropical disease, and we sympathize with the notion that universal health policy should implicate equal access to vaccines, and not be restricted to wealthy travelers in rabies endemic zones.
However, the benefit of implementing routine rabies vaccinations is not self-evident. A plethora of epidemiological and clinical studies find that some vaccines have non-specific effects (NSE), i.e. modifying resistance to diseases unrelated to the target pathogen. The live BCG and measles vaccine (MV) have been shown to reduce mortality to non-tuberculosis and non-measles infections, respectively. In contrast, the non-live vaccine DTP has been associated with deleterious NSE, increasing overall mortality in girls.2
The rabies vaccine, currently a non-live vaccine, has also received attention for its putative NSE. A malaria vaccine trial using rabies vaccine as control in one study arm found that girls receiving the malaria vaccine had a 2-times higher overall mortality than controls, indicating a detrimental effect of the malaria vaccine,3 or a beneficial NSE of the rabies (...
The rabies vaccine, currently a non-live vaccine, has also received attention for its putative NSE. A malaria vaccine trial using rabies vaccine as control in one study arm found that girls receiving the malaria vaccine had a 2-times higher overall mortality than controls, indicating a detrimental effect of the malaria vaccine,3 or a beneficial NSE of the rabies (control) vaccine.4
In contrast, a randomized trial in puppies found that rabies vaccination at 6 weeks was associated with three-fold higher mortality risk at 13 weeks in females born to rabies vaccinated dogs (hazard ratio: 3.09 (95%CI: 1.24-7.69)),5 the HR in females being 2.69 (1.27–5.69) at 20 weeks after the receipt of rabies vaccine at 13 weeks in both groups.6 Recently, we conducted an RCT in which rabies vaccine was associated with increased risk of mortality and antibiotic treatment in male piglets (proportion ratio: 1.56 (1.13-2.15)), but not in female piglets born to rabies-naïve sows, with an opposite effect in piglets of rabies-vaccinated sows.7
The specific protective effects of rabies prophylaxis notwithstanding, the lack of unambiguous data refuting a negative impact on rabies-unrelated health calls for a controlled real-world safety RCT, recording also rabies-unrelated health, including effects on all-cause morbidity and mortality.
The analyses should be stratified by sex as NSE may be sex-differential and preferably by maternal immunity status as maternal immunity may modify the NSE. Furthermore, the potential interaction with other vaccines should be investigated.2 Soentjes et al. suggest 3 rabies vaccinations at 9–12 months, 6 and 12 years.1 The first dose would then often coincide with routine measles vaccine in the EPI schedule. Whereas several studies have documented beneficial NSE of MV,2 our research have highlighted that the timing of vaccines may have significant implications for the NSE. In brief, the last vaccine determines the direction of the NSE.2 Rabies vaccine given after MV may reduce the beneficial NSE of MV.
In conclusion, the overall health benefits of routine rabies vaccine should be investigated and weighed against the potential costs. Hard evidence must determine the net ratio of these weights and guide to an optimal vaccine schedule.
1 Soentjens P, Berens-Riha N, Van Herrewege Y, Van Damme P, Bottieau E, Ravinetto R. Vaccinating children in high-endemic rabies regions: what are we waiting for? BMJ Glob Health 2021; 6: e004074.
2 Benn CS, Fisker AB, Rieckmann A, Sørup S, Aaby P. Vaccinology: time to change the paradigm? Lancet InfectDis 2020; 20: e274–83.
3 Klein SL, Shann F, Moss WJ, Benn CS, Aaby P. RTS,S Malaria Vaccine and Increased Mortality in Girls. MBio 2016; 7: e00514–6.
4 Gessner BD, Knobel DL, Conan A, Finn A. Could the RTS,S/AS01 meningitis safety signal really be a protective effect of rabies vaccine? Vaccine 2017; 35: 716–21.
5 Arega S, Conan A, Sabeta CT, et al. Rabies Vaccination of 6-Week-Old Puppies Born to Immunized Mothers: A Randomized Controlled Trial in a High-Mortality Population of Owned, Free-Roaming Dogs. TropMedInfectDis 2020; 5.
6 Knobel DL, Arega SM, Conan A. Sex-differential non-specific effects of rabies vaccine in dogs: An extended analysis of a randomized controlled trial in a high-mortality population. Vaccine 2021; : S0264410X21000451.
7 Jensen KJ, Tolstrup LK, Knobel DL, et al. Non-specific effects of maternal and offspring rabies vaccination on mortality and antibiotic use in a Danish pig herd: a randomized trial. [In revision].
Lotta Velin1,2, Ulrick Sidney Kanmounye1,3, Michelle Nyah Joseph1,4
1. Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
2. WHO Collaborating Center for Surgery and Public Health, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
3. Department of Neurosurgery, University of Kinshasa Faculty of Medicine, Kinshasa, Congo (the Democratic Republic of the)
4. Warwick Clinical Trials Unit, Warwick Medical School, Coventry, West Midlands, UK
Correspondence to: Dr Michelle Nyah Joseph; Michelle_Joseph@hms.harvard.edu
We want to congratulate Phan et al. on their thoughtful analysis of our article “Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences” (1). Phan et al. are addressing inequities in global health conferences. This is evidenced by their inspiring work with transitioning the Global Women’s Research Conference (GLOW) from a physical to an online event. It is clear from Phan et al. recount that the transition helped increase access and equity to a major global health conference. We agree with the authors that such a strategy can help address many of the barriers we identified in our systematic review.
Prior to 2019, some global health events offered an online component; however, none of the major global health conferences hel...
Prior to 2019, some global health events offered an online component; however, none of the major global health conferences held fully virtual events. The Covid-19 pandemic has accelerated this shift online, and at the same time, created a window of opportunity for us to address systemic inequities in the global health field. Now is the time to reflect on failures, and to develop and implement solutions that end these disparities. In our systematic review (2), we define conference equity as: the attainment of an equitable level of attendee active engagement, influence and access to a conference regardless of country of origin, location, available funds or affiliation, through the mitigation of known barriers and enhancement of efficacious facilitators. We highlighted visa issues and conference locations, primarily in high-income countries, as two barriers to conference equity. Although, Phan et al. have shown that these barriers can be overcome with online conferences, the issue of conference equity by definition, is far greater than these two barriers. Fully virtual events alone create a new set of challenges, and will not suffice to achieve conference equity.
Over a year into the pandemic, we have data to suggest online conferences are not the great equalizer of global health conferences. Limited access due to time zone differences and cost are the obvious inherent obstacles that perpetuate the inequities we witness. The financial burden of global health conference attendance has been shifted from travel, conference registration, and accommodation to the cost of internet broadband. According to the United Nations Broadband Commission, over a billion people live in countries that fail to meet the “1 for 2” recommendation, that is, 1 gigabyte should cost no more than 2% of the average monthly income to allow efficient internet use (3). Zoom (San José, California, USA), the most widely used video conferencing platform, uses 810MB-2.4GB per hour for group meetings (4). Hence a two-day 8-hour conference could cost in excess of 26.0-76.8% of the average monthly income (total broadband consumption 13.0GB-38.4GB).
Beyond financial barriers and attendee demographics, prioritization must be given to developing metrics in active conference engagement. The global health community need to ensure equity when setting conference agendas and avoid global north dominance. A conscious decision to diversify panels and provide support for low- and middle-income country researchers in presenting is an initial step.
Global health conferences are currently undergoing a major transformation, such change lends itself to research opportunities that we hope will be further explored. We thank Phan et al. for their prior communication with our team, and seizing the opportunity to propose tangible solutions. We hope online conference organizers assess their current equity status; acting upon the findings may lead to the attainment of conference equity.
1. Phan T, Lightly K, Weeks A. Conference equity in global health: are online conferences a solution? BMJ Glob Health [Internet]. 2021 Feb 25; Available from: https://gh.bmj.com/content/6/1/e003455.responses#conference-equity-in-gl...
2. Velin L, Lartigue J-W, Johnson SA, Zorigtbaatar A, Kanmounye US, Truche P, et al. Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences. BMJ Glob Health. 2021 Jan 1;6(1):e003455.
3. Alliance for Affordable Internet. 2020 Affordability Report [Internet]. 2020. Available from: https://a4ai.org/affordability-report/report/2020/
4. Hannula L. How Much Data Does Zoom Use? [Internet]. WhistleOut. 2020 [cited 2021 Mar 15]. Available from: https://www.whistleout.com/Internet/Guides/zoom-video-call-data-use#:~:t....
In this systematic review and meta-analysis of evidence-based interventions to reduce mortality among preterm and low birthweight (LBW) neonates in low-income and middle-income countries, the implementation of four effective interventions in current WHO guidelines is encouraged: cord and skin cleansing with chlorhexidine, community kangaroo mother care, home-based new-born care and early Bacille Calmette-Guérin (BCG) vaccination.
Regarding BCG vaccination, the authors identified two randomised controlled trials (RCTs) of BCG-Denmark vs. no-BCG to LBW neonates and estimated that providing early BCG reduces neonatal mortality by 36% (14% to 52%). In addition to the two trials, a small RCT of BCG-Denmark to LBW neonates reported an effect estimate of 0.28 (0.06 to 1.37). In a combined analysis of the three datasets, providing early BCG-Denmark to LBW neonates at hospital discharge was associated with a 38% (17% to 54%) reduction in neonatal mortality. Also, a recent Ugandan RCT of BCG-Denmark vs. no-BCG found BCG-Denmark associated with fewer early-life infections, particularly for LBW, further strengthening the argument for using BCG-Denmark as an evidence-based intervention for LBW neonates.
Many manufacturers produce BCG world-wide, and the genetically different BCG strains might not have the same effects on all-cause mortality. For example, two RCTs conducted in India evaluated the effects of providing BCG-Russia vs. no-BCG to a cohort of neonates...
Many manufacturers produce BCG world-wide, and the genetically different BCG strains might not have the same effects on all-cause mortality. For example, two RCTs conducted in India evaluated the effects of providing BCG-Russia vs. no-BCG to a cohort of neonates weighing <2000 g that were admitted for intensive care. In the two frail cohorts with a high overall mortality of 17% but few infectious disease deaths, BCG-Russia had no effect on in-hospital all-cause mortality, the combined hazard ratio being 0.98 (0.85 to 1.11).
It is not known whether the lack of an effect in the India RCTs was due to the use of BCG-Russia rather than BCG-Denmark or the frailty of the cohorts (lower-weight neonates admitted for intensive care treatment with a high mortality risk mainly from perinatal complications rather than infection). Either way, it deserves to be emphasized that the current evidence supports that providing early BCG-Denmark at discharge is associated with reduced neonatal mortality risk from infectious diseases.
Providing immunogenic BCG strains early is also associated with improved long-term survival; in a cohort of neonates vaccinated within 1 week of life, we showed that having a BCG skin reaction by 2 months of age is associated with a 51% (5% to 74%) reduced mortality between 2-12 months of age. Also, there was a linear trend of decreasing mortality with increasing reaction size.
Unfortunately, BCG is often delayed; in rural Africa more than half of children are not vaccinated within the first month of life due to regulations to restrict vial-dose wastage, antiquated guidelines of not vaccinating LBW neonates and logistical hurdles. New WHO guidelines emphasising immunogenic BCG strains as a life-saving intervention provided at birth and the assessment of BCG vaccination coverage by 1 months of age as a vaccine program indicator would help increase its early deployment and impact.
We congratulate the authors on their systematic review of conference equity in global health (1) and agree that this is a key step towards decolonising global health research. Their review identifies barriers and facilitators impacting attendance from low-and-middle-income countries (LMICs). The authors have identified many solutions to improve the equity of conferences but did not mention online conferences. These have rapidly become the norm during the COVID-19 pandemic and could offer a feasible solution. (2)
The global pandemic forced the Global Women’s Research Society (GLOW) society conference to go online for the first time and it had dramatic impacts on the reach of the conference. We have run the annual UK-based GLOW conferences in global reproductive, maternal and new-born health since 2012, with a typical attendance of 70-140. In 2020, however, the pandemic forced us to pivot to an online conference. We fundraised £25,700 to provide the online platform and recordings, allowing free attendance for anyone from around the world. As a result, over 1300 people from 70 countries registered, with up to 1076 live views at one time. This works out at just £20 per registrant. During 2 days of the conference, there were a total of 3347 views, with 546 of those from LMICs. Additionally, there have been nearly 500 views of the videos on the YouTube channel since the September conference. We estimate costs of over £1,000,000 if all registrants and presenters had attend...
The global pandemic forced the Global Women’s Research Society (GLOW) society conference to go online for the first time and it had dramatic impacts on the reach of the conference. We have run the annual UK-based GLOW conferences in global reproductive, maternal and new-born health since 2012, with a typical attendance of 70-140. In 2020, however, the pandemic forced us to pivot to an online conference. We fundraised £25,700 to provide the online platform and recordings, allowing free attendance for anyone from around the world. As a result, over 1300 people from 70 countries registered, with up to 1076 live views at one time. This works out at just £20 per registrant. During 2 days of the conference, there were a total of 3347 views, with 546 of those from LMICs. Additionally, there have been nearly 500 views of the videos on the YouTube channel since the September conference. We estimate costs of over £1,000,000 if all registrants and presenters had attended in person. This works out at nearly £800 per person, or more if attendance is lower. Further details will be reported in a separate publication.
Feedback from 226 attendees clearly demonstrated that the online format overcame several barriers presented in this review. 83% rated the conference as very good or outstanding. Attendees’ feedback highlighted the benefits of no visa, travel and subsistence costs. It is likely that political barriers and unconscious bias inhibiting attendance and engagement may have also been reduced.
Nevertheless, there are several ongoing concerns with the virtual format. These include poor internet access and unstable connections, technological challenges, co-ordination across time zones and underdeveloped conference platforms and tools. Additionally, virtual conferences cannot offer the same networking opportunities, informal feedback and opportunities for focused attention for the entire event. (3)
We believe that online conferences or hybrid events offer one solution to reducing conference inequity. This requires purposeful action from conference organisers and funders to increase accessibility to those in LMICs. Further comprehensive evaluation of the impact of the virtual format, aimed at exploring whether this format reduces conference inequity, is required.
1. Velin L, Lartigue J-W, Johnson SA, et al. Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences. BMJ Global Health 2021;6(1):e003455. doi: 10.1136/bmjgh-2020-003455
2. Sarabipour S. Virtual conferences raise standards for accessibility and interactions. Elife 2020;9 doi: 10.7554/eLife.62668 [published Online First: 2020/11/05]
3. Falk MT, Hagsten E. When international academic conferences go virtual. Scientometrics 2020:1-18. doi: 10.1007/s11192-020-03754-5 [published Online First: 2020/11/25]
We read the commentary by Rahi, M. et al., with great interest, about the need of digitisation of malaria surveillance data and its integration on a single digital platform for malaria elimination in India1. There is no doubt that digitisation of malaria surveillance tools and data will help patients, clinician, researchers, policy makers alike and ultimately may contribute in malaria elimination, if implemented timely and efficiently. However, the proposition of digital dashboard for collection, integration and sharing of data on malaria, though important, but seems a little far-fetched conjecture at this moment as majority of malaria cases are reported from rural/tribal areas with sparsely distributed health care and telecommunication infrastructure. The top ten tribal dominated states with a population of 36 % contribute about 73 % of total malaria cases2. The strength of healthcare workforce is poor in rural/tribal areas of India in comparison to the WHO minimum threshold of 22.8 per 10 000 population3. Further, there is strong need to strengthen the power (electricity), telecommunication and transport infrastructure in rural/tribal areas. Such healthcare environment in tribal areas increases the reluctance among tribal people for the public health care system and leads them towards quacks, traditional healers and nearby private practitioners. Further, this digital drive of healthcare system would require additional human resource, periodical training and digital infr...
We read the commentary by Rahi, M. et al., with great interest, about the need of digitisation of malaria surveillance data and its integration on a single digital platform for malaria elimination in India1. There is no doubt that digitisation of malaria surveillance tools and data will help patients, clinician, researchers, policy makers alike and ultimately may contribute in malaria elimination, if implemented timely and efficiently. However, the proposition of digital dashboard for collection, integration and sharing of data on malaria, though important, but seems a little far-fetched conjecture at this moment as majority of malaria cases are reported from rural/tribal areas with sparsely distributed health care and telecommunication infrastructure. The top ten tribal dominated states with a population of 36 % contribute about 73 % of total malaria cases2. The strength of healthcare workforce is poor in rural/tribal areas of India in comparison to the WHO minimum threshold of 22.8 per 10 000 population3. Further, there is strong need to strengthen the power (electricity), telecommunication and transport infrastructure in rural/tribal areas. Such healthcare environment in tribal areas increases the reluctance among tribal people for the public health care system and leads them towards quacks, traditional healers and nearby private practitioners. Further, this digital drive of healthcare system would require additional human resource, periodical training and digital infrastructure. The Govt. of India has recently proposed the idea of national digital health mission and is planning to digitise the public health system4. Digital Malaria dash board35 may be a part of it. However, regular collection of minimal data set at local level may suffer from the same ailments as paper trail method until unless trained human resource with proper tools are not deputed. The incentive-based involvement of ASHA and local millennials laced with smartphone (as malaria ambassador) based surveillance tools may prove useful in getting high resolution geotagged data. Further, ASHA may serve as a link among quacks, traditional healer and private practitioner for data collection on notification. However, poor telecom infrastructure and tele-density in tribal areas is a matter of concern. Though the tele-density and number of smartphone owner is growing in tribal areas yet there are villages in malaria endemic regions which are difficult to access and where there is no telecommunication network. Therefore, getting high resolution data at the household/village level may be very difficult in tribal areas without the development of telecom infrastructure. Further, the expansion of telecom infrastructure will help in getting the data in real-time and at regular intervals. In toto, the development of digital dashboard for malaria and digitization of healthcare services will definitely improve service delivery; however, its sustainability is linked with development of basic infrastructure in malaria endemic tribal areas.
1. Rahi M, Sharma A. For malaria elimination India needs a platform for data integration. BMJ Glob Health 2020;5(12) doi: bmjgh-2020-004198 [pii] 10.1136/bmjgh-2020-004198 [published Online First: 2021/01/01]
2. https://nvbdcp.gov.in/WriteReadData/l892s/63783729891610104793.pdf (accessed on 08/02/210
3. Karan A, Negandhi H, Nair R, et al. Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data. BMJ Open 2019;9(4):e025979. doi: bmjopen-2018-025979 [pii] 10.1136/bmjopen-2018-025979 [published Online First: 2019/05/28]
4. https://www.nhp.gov.in/national-digital-health-mission-(ndhm)_pg(accessed on 08/02/210
5. Nema S, Verma AK, Tiwari A, et al. Digital Health Care Services to Control and Eliminate Malaria in India. Trends Parasitol 2021;37(2):96-99. doi: S1471-4922(20)30315-9 [pii] 10.1016/j.pt.2020.11.002 [published Online First: 2020/12/03]
Many thanks to Dominic Pimenta for the interesting comment. I respect Pimenta’s well-intentioned activism during the COVID-19 crisis, but here he polarizes the discussion between two schools of thought by using a strawman argument, i.e. that one of the two schools wants to promote high community transmission. Such strawman arguments are prevalent in social media and the blogosphere, but they do not serve scientific discourse for resolution of major questions. I have signed neither the Great Barrington Declaration nor the John Snow Memorandum, so I cannot become an insider apologist for either (1). However, my reading of both documents suggests that neither of them advocates to promote high community transmission. If they do, this is certainly not what I would personally advocate.
Pimenta draws a correlation from 10 observations on the data that I present on nursing home shielding factors (my Table 3) reaching the conclusion that precision shielding is impossible under high community transmission. This is a precarious exercise with rushed conclusions. These are ecological, whole-country data including only 4 observations with high community transmission. Drawing firm causal inferences from an ecological regression with effective sample size of n=4 is impossible. Sadly, over-confident, stretched causal inferences are common during the COVID-19 crisis. A similar look at the age-stratified data on Table 2 shows that shielding of the elderly was achieved in countries w...
Pimenta draws a correlation from 10 observations on the data that I present on nursing home shielding factors (my Table 3) reaching the conclusion that precision shielding is impossible under high community transmission. This is a precarious exercise with rushed conclusions. These are ecological, whole-country data including only 4 observations with high community transmission. Drawing firm causal inferences from an ecological regression with effective sample size of n=4 is impossible. Sadly, over-confident, stretched causal inferences are common during the COVID-19 crisis. A similar look at the age-stratified data on Table 2 shows that shielding of the elderly was achieved in countries with high community transmission (e.g. UK and USA), while it was probably not achieved in Hungary, despite low community transmission. China exemplifies significant inverse protection, even though it managed to practically bring community transmission to almost zero.
For the 4 countries with high S values in nursing homes and high community transmission (Spain, UK, Belgium, and Sweden), there are many other explanations for high S values, as I explain in my article. With limited testing of staff, suboptimal infection control, poor living conditions, and with staff making shifts across multiple nursing homes, disaster is expected. Not only nursing home residents, but also their staff should be handled as high-risk individuals. Unfortunately, the opposite happened, perhaps because of flawed over-confidence that general population measures would suffice. Rational efforts to reduce community transmission are most welcome, provided that they do not do more harm on several other aspects of health and societal well-being (2). However, it is naïve to expect that simply taking community measures will salvage nursing homes without additional, draconian, focused measures. To use an analogy, when a known serial murderer has declared his clear intention to kill someone, the specific candidate victim should be immediately, actively, specifically protected. Dispatching more policemen at random locations around the country or preaching to a community congregation to love each other will not save his life.
John P.A. Ioannidis, MD, DSc
Stanford University, Stanford, CA, USA. E-mail: email@example.com
1. Ioannidis JP. Scientific petitions and open letters in the era of covid-19. BMJ. 2020 Oct 26;371:m4048.
2. Ioannidis JPA. Global perspective of COVID-19 epidemiology for a full-cycle pandemic. Eur J Clin Invest. 2020 Oct 7:e13423.
I don't think this research is particularly useful for policy analysis.
Any analysis of leader's age, marital status or whether they had children?
These are also likely to effect rhetoric.
The short time period of the analysis also casts doubts on the validity of the study and usefulness of any conclusions.
Dear Dr Abimbola,
We read with interest the article ‘How global is global health Research? A large-scale analysis of tends in authorship’ by Dimitris and colleagues published in BMJ Global Health January 2021.1 The authors’ research highlights the slow progress in proportion of studies with any, first, and, last authors affiliated with a low- or middle-income country (LMICs), particularly in first and last authorship. The authors welcome and have called for a thorough discussion about the implications of these findings, particularly in identifying the barriers and facilitators to diversity in authorship.
Reflecting on our experience of international research in infectious diseases and antimicrobial resistance we present here some of the barriers we have faced together with the solutions which we have identified. Recognising however, that addressing this inequity requires broader inclusion and participation from academic institutions, scientific journals and funders, we propose remedial steps at every level which will require a different approach to scientific research funding and communication.
There is a culture and hierarchy within academia which manifests itself in the authorship order. It is accepted that the first leads the writing and last author leads the research with all authors contributing to the final manuscript. There are of course the guidelines from the International Committee of medical Journal Editors which clearly stipulate the rol...
There is a culture and hierarchy within academia which manifests itself in the authorship order. It is accepted that the first leads the writing and last author leads the research with all authors contributing to the final manuscript. There are of course the guidelines from the International Committee of medical Journal Editors which clearly stipulate the roles of authors and contributors.2 Writing manuscripts requires not only the skills to undertake research but to communicate it. Barriers to inclusion of LMICs first and last authors often is due to the inexperience of junior researchers writing research to a standard that is accepted by mainstream scientific journals, the majority of which are in English. Hence, writing scientific literature requires not only expertise in research but also in English. In collaborative, international research projects it is imperative to enable space for growth, learning and capacity building within country, and move away from the culture of well-funded high income research institutes dispatching researchers to LMICs to conduct research, leaving little opportunity for knowledge exchange and development. To do this effectively capacity building must be core to research collaborations, including investment in workforce and training.3 We have found success in developing mentorship programmes in our research collaborations which ensure that researchers are employed locally and trained by the extended research team. The mentorship has included supporting junior researchers to participate in writing research papers and have the opportunity to be first authors on work that they have driven locally. This has meant a conscious effort to consistently scrutinise and evaluate the equity and balance in representation in every piece of work that is submitted. As a rule of thumb a baseline expectation should be to ensure that one of either first or last authorship is assigned to LMICs partners for work being carried out in or in collaboration with LMICs. This means that from the outset there are clear expectations on work from each partner and decisions about authorship are not left to the last minute. This approach also clarifies the level of involvement and work that each person in the research team has to contribute to be acknowledged as an author. To do this effectively and sustainably there has to be capacity building in place to ensure that knowledge and skills are developed alongside data gathering and analysis (Figure 1).
Figure 1 The steps required to address barrier to and facilitate equity in authorship of global health research
Another barrier which is increasingly more difficult to address is the costs of publication and unfamiliarity with the submission process, which means that much of the world is not equitably represented in academic publishing. Additionally, the current predominantly anonymised peer review process limits the learning potential from the academic peer review dialogue that often helps transform manuscripts into published articles. Publication costs are an enormous barrier, particularly in LMICs where institutions often do not benefit from the block funding available to many high-income academic institutions to cover costs of publication for their researchers. What this means that occasionally the LMICs researchers have to rely on out-of-pocket expenses which range between £1200 to over £2000 for open access publishing. As we write this letter, we are in the process of trying to reverse one such cost inflicted on colleagues who were invited to submit research undertaken in Uganda. The solution to this lies in part with scientific journals, academic institutions, and funders. Scientific journals need to have clear policies for submitted research from LMICs where there is no institutional support for open access funding, with reduced LMICs fees and options for waiving publication fees from researchers who do not have grant funding or institutional support. Reviewers and editors need to call out academic manuscripts which do not have equitable representation of authors from countries where the research is conducted, and question submitting authors on this. Academic institutions in high income countries need to relax their rules around funding research articles for publications where the first, last, and/or corresponding author is not from their institution. Funders should stipulate a condition of their grant to be that for research that involves LMICs partners the authorship should be equitable and balanced in first, last, and corresponding authorship. Furthermore, they need to recognise that capacity building and research communication costs need to be adequately detailed and costed in international grant applications and be part of the monitoring and evaluation process.
Only when the need for equitable funding is recognised at all these levels, can we address the current disparities in representation in research from LMICs partners.
1. Dimitris MC, Gittings M, King N. How global is global health Research? A large-scale analysis of tends in authorship. BMJ Global Health 2021;6:e003758.
2. International Committee of Medical Journal Editors. Defining the role of Authors and Contributors. Website: http://www.icmje.org/recommendations/browse/roles-and-responsibilities/d... Date accessed: 05 February 2021
3. P Veepanattu, S Singh, M Mendelson, V Nampoothiri, F Edathadatil, S Surendran, C Bonaconsa, O Mbamalu, S Ahuja, G Birgand, C Tarrant, N Sevdalis, R Ahmad, A Holmes, E Charani. Building resilient and responsive research collaborations to tackle antimicrobial resistance – lessons learnt from India, South Africa and UK. Int J of Infect Dis 2020;100:278-282.