Ranzani et al.  elegantly describe the research priority framework to address the deteriorating TB situation for the mainly LMIC countries of Latin America, which has relevance to other regions. Although the countries of WHO Europe have reduced the overall TB burden (by an average 5.1% annually from 2014-18), multidrug resistant TB rates (MDRTB) are persistently high with the proportion of Rifampicin-resistant and MDRTB among new (18%) and previously TB treated (54%) cases significantly exceeding the global average (3.4% and 18% respectively) . The HIV situation in this region is also dire; 1.4 million people were living with HIV in Eastern Europe and Central Asia in 2017, with the two highest proportions in Russia and Ukraine , creating a significant TB-HIV co-infection problem where 13.1% of TB patients tested were HIV infected .
The COVID-19 pandemic has impacted all countries, but acutely on TB diagnostics and treatment especially in high TB burden LMICs. Recently the StopTB partnership examined the diagnosis and treatment statistics for nine countries, including Ukraine, representing 60% of the global TB burden; TB diagnosis and treatment enrolment in 2020 declined by 1 million or an average 23% in individual countries compared to 2019 .
The WHO leads global efforts to prioritise research (and research is a key intervention as one of the pillars of the WHO End TB Strategy) with regional variations [5,6,7]. For Eastern Europe, the global i...
The WHO leads global efforts to prioritise research (and research is a key intervention as one of the pillars of the WHO End TB Strategy) with regional variations [5,6,7]. For Eastern Europe, the global importance of TB and HIV is clear but carefully planned priorities, pre the COVID epidemic, might not be as relevant to clinical investigators on the ground during the pandemic.
Drawing on current and planned research priority topics within the WHO European region , to frame our questionnaire, we surveyed respiratory and infectious disease specialists in the TB and HIV field in four cities in Ukraine, Russia and Moldova, to understand whether the view on these priorities was changing due to the ongoing COVID19 epidemic. Even if the main priorities for the programmes were to remain, would the delivery objectives remain similar? A questionnaire piloted in English, Ukrainian, Russian and Moldovan was cascaded via a senior infectious disease specialist and 42 respondents completed the survey: 17 Moldova (Chisinau), 13 Ukraine (Kharkiv, Vinnytsya) and 12 Russia (Arkhangelsk).
Priorities identified within each country;: 90 to 100% of all respondents prioritised: a whole genomic sequencing or targeted DNA generation sequencing approach for TB drug susceptibility testing from TB cultures or direct from patient sputa; improving HIV community testing and/or replacement of HIV diagnosis confirmation by Western blotting to address late presentation by HIV positive patients; implementation of integrated diagnostic testing strategies for TB, HIV and viral hepatitis (including a mobile laboratory solution).
Additionally, in Moldova between 90 and 100% of respondents prioritised research on a prospective non-sputum biomarker to establish TB diagnosis of TB and to establish cure of MDRTB patients.
In Ukraine, all respondents prioritised research on the effects of internal migration due to conflict – including the healthcare needs of displaced populations. In Russia, all respondents would also pursue research on a clinical trial of short course 12 months therapy of an all oral MDRTB drug regimen.
But reflecting the current pandemic, all Russian specialists, 89% Moldovan and 77% Ukrainian also prioritised understanding effects of COVID on TB and HIV healthcare issues.
In conclusion, we report a high level of interest in understanding COVID-19 impacts on TB and HIV, but overall, a clear determination to continue the core research priorities for TB and HIV which align with WHO European regional priorities [2,4,5,6,7].
 Ranzani, OT, Pescarini, JM, Martinez, L and Garcia-Basteiro, AL. Increasing TB burden in Latin America: an alarming trend for global control efforts. BMA Global Health 2021;6;e005639 doi10.1136/bmjgh-2021-005639.
 ECDC and WHO Regional Office for Europe. TB surveillance and monitoring in Europe: 2020-2018 data. ECDC Stockholm; 2020).
 Ending AIDS:UNAIDS, 2018
 StopTB partnership TB and COVID: One year on Media Brief FINAL 19 March 2021. http://www.stoptb.org/webadmin/cms/docs/20210316_TB%20and%20COVID_One%20...).
 Fifth European Laboratory Initiative (ELI) on TB, HIV and Viral Hepatitis Core Group Meeting Copenhagen, Denmark 14-15 November 2019 https://www.euro.who.int/__data/assets/pdf_file/0015/428001/5th-ELI-meet...
 WHO Regional Workshop on Advancing Implementation Science on HIV and Viral Hepatitis in Eastern Europe and Central Asia. 10–11 February 2020 Berlin, Germany. WHO Europe 2020.
 World Health Organization. (2019). WHO recommends countries move away from the use of western blotting and line immunoassays in HIV testing strategies and algorithms: policy brief. World Health Organization. https://apps.who.int/iris/handle/10665/329915.
None of the authors of this decolonising roadmap listed an association with an academic institution in a low-and middle-income country (LMIC). They represented two London schools, two NGO organizations based in Geneva, and one from a former colony—Australia. No doubt these authors share a wealth of experience in low- and middle-income countries but the platforms they chose to speak from exemplify some of the best of high-income country Western (Northern?) educational and humanitarian outreach.
The critical inequities they cite include:
• Limiting participation of LMIC experts and community representatives
• Arbitrarily choosing interventions or research topics with little coordination or engagement
• Typically placing European or North American ‘experts’ in leadership positions with minimal experience working in the project setting,
• Basing staff, offices and other resources in high-income countries
• Funding application evaluation panels without or with limited representation from affected communities or stakeholders in which work will be done; grants awarded without due consideration for partnership ethics.
A 15 April 2021 Nature Medicine letter reported, “Not one African institution was named in the press release” when a USD30 million grant for assisting African nations in “improved use of data for decision-making in malaria control and elimination” was announced. 1
Perhaps this BMJ GH editorial is a roadmap for s...
Perhaps this BMJ GH editorial is a roadmap for starting a revised and improved dialogue. When viewed through the lens of the LMIC academic community who often are involved directly or indirectly in projects and especially research, there are additional areas of decolonising that require addressing:
• Trusting and supporting local LMIC stakeholders to initiate projects of value to their communities and to head or co-head those projects including shared authority over funds
• Agreeing to share benefits of projects including (but not limited to)
o equipment, travel support for presentations
o authorship equity, i.e., criteria that is not Western dominated 2, 3
• Ensuring bidirectional visits between HIC and LMIC researchers rather than LMIC stakeholders serving only as hosts
• Encouraging international conferences to be “hybrid” with options for virtual presentations and posters to avoid the financial burdens of air travel, visas, and accommodation while allowing for professional advancement and CV entries (the
Covid-19 pandemic demonstrated the feasibility of the virtual and hybrid meetings)
• Promoting recognition for the vital research and programs initiated and performed by LMIC-based organizations such as African Academy of Science, African Union, and institutions including universities in Nigeria, Ghana, Botswana, South Africa, Uganda, Kenya, Ethiopia, Rwanda, etc.
• Discouraging the push to submit articles to “high-impact” (spell that Western, often proprietary that may charge exorbitant fees for open access) journals rather than encouraging publication in the national or continent-wide journals within the LMICs
• Seeking solutions to attenuate the dominance of English proficiency for communication as well as publications
The road to decolonising global health is long with numerous curves and potholes but the authors of the editorial are clearly thoughtful and intentional in addressing the issues. We appreciate the opportunity to expand the dialogue.
1 Erondu, N.A., Aniebo, I., Kyobutungi, C. , Midega J, Okoro E, Okumu F. Open letter to international funders of science and development in Africa. Nat Med. 2021. https://doi.org/10.1038/s41591-021-01307-8
2 International Committee of Medical Journal Editors. Defining the Role of Authors and Contributors. Available at: http://www.icmje.org/recommendations/browse/roles-and-responsibilities/d.... Accessed 15 April 2021.
3 Tarpley M. Letter to the editor: Honorary authorships in surgical literature. World J Surg. 2020; 44(2):644-645. DOI 10.1007/s00268-019-05261-y.
Ghaffar, Rashid, Wanyenze, and Hyder invite to the dialogue and debate on the revision for public health education (PHE) as a topic of global importance. They do it from a diverse perspective including the developed and developing economies, and the challenges of practice.
I want to contribute based on the lessons learned from my experience during a previous pandemic, and my concern on the lack of full realization of the potential of public health methods and knowledge to manage this current crisis.
Since the Influenza A(H1N1) 2009 pandemic, we realized that its management called for work with the economic, educational, agriculture and nutrition, labor, housing, transportation, tourism, and it can be achieved only with established platforms for this collaboration (1). The epidemic demanded for a differentiated care of the poor and those with cultural barriers, the pregnant, of those living with obesity or chronic co-morbidities. That it required massive behavioral change – only possible though effective health promotion functions -, and the assurance of safe settings, medical care (2), and products. That the local action had global implications. It was clear since then the central role of well-organized local public health service delivery, the place for effectively containing the spread. And we saw the importance to constrain the politicizing of the epidemic, by having rigorous, rapid, and fearless exercise of the public health authority....
Since the Influenza A(H1N1) 2009 pandemic, we realized that its management called for work with the economic, educational, agriculture and nutrition, labor, housing, transportation, tourism, and it can be achieved only with established platforms for this collaboration (1). The epidemic demanded for a differentiated care of the poor and those with cultural barriers, the pregnant, of those living with obesity or chronic co-morbidities. That it required massive behavioral change – only possible though effective health promotion functions -, and the assurance of safe settings, medical care (2), and products. That the local action had global implications. It was clear since then the central role of well-organized local public health service delivery, the place for effectively containing the spread. And we saw the importance to constrain the politicizing of the epidemic, by having rigorous, rapid, and fearless exercise of the public health authority.
Still, these elements did not remain embedded in the health systems (3): for the COVID-19 pandemic, we had to go through the process again. That was not reflected in the International Health Regulations (4) and their very limited biomedical scope, the exercise of health authority (5), nor from the accreditation of essential public health services. The PHE graduate programs did not incorporate it either. And we can count the cost of that in the millions of lives lost from COVID-19, avoidable non-COVID mortality, long-term COVID-19 disease burden, and trillions of dollars in human capital lost, besides the Gross World Product lost.
We must frame investment in PHE within a virtuous cycle in the institutional capacity building, integrated with the research enterprise in schools of public health, that assemble practitioners to systematize the lessons learnt from public health practice and make curriculum pertinent. And with the trained workforce, to make structural durable changes in the health system.
With these elements I would like not only to support the “four areas for consideration by schools of public health for the development”, but to propose other four. The first one is Health Regulation for Health Protection (6) at the local, subnational, national, and global levels; the approval and registration of vaccines and medical treatments is the most visible, but also relates to safe disinfectants, meeting paces, workplaces, etc. a function that has failed globally. The second area is Public Health in Social Structures, its integration outside the health system, tackling the social and commercial determinants of health, getting public and private actors the capacity to be agents for health, advancing towards the redefinition of the scope of action of health authorities, and defining the roles of public health practice in other sectors. The third area is Crisis Management. Public health professionals should be readied to address difficult times urgent delivery of services, decision making under pressure, as medical professionals are to care for patients at emergency rooms. They should be able to talk to its audience and to listen to them, be capable communicators, and able to gather the societal resources to deal with the common problem, to plan and advocate for it. And the fourth is Public Health Law, as the way to structure the organized social response, protect human rights, and support a rigorous exercise of the health authority.
The strategy should be a transformation on the perspective of the role of public health in society, and how we see the future role of our graduates in leading a response realizing the potential of public health. The opportunity is there for LMICs countries, but the whole world claims for it.
1. PAHO/Ministry of Health of Mexico. Influenza A(H1N1): Health Promotion Actions, sharing our experience. Publication. México, 2009 https://www.paho.org/mex/index.php?option=com_docman&view=download&alias...
2. Rubinson, L., Mutter, R., Viboud, C., Hupert, N., Uyeki, T., Creanga, A., Finelli, L., Iwashyna, T. J., Carr, B., Merchant, R., Katikineni, D., Vaughn, F., Clancy, C., & Lurie, N. (2013). Impact of the fall 2009 influenza A(H1N1)pdm09 pandemic on US hospitals. Medical care, 51(3), 259–265. https://doi.org/10.1097/MLR.0b013e31827da8ea
3. Cascini F, Hoxhaj I, Zaçe D, Ferranti M, Di Pietro ML, Boccia S, Ricciardi W. How health systems approached respiratory viral pandemics over time: a systematic review. BMJ Glob Health. 2020 Dec;5(12):e003677. doi: 10.1136/bmjgh-2020-003677.
4. Cameron EE, Nuzzo JB, Bell JA. Global Health Security Index. Building Collective Action and Accountability October 2019. Johns Hopkins Health Security Center/Nuclear Threat Initiative. https://www.ghsindex.org/wp-content/uploads/2020/04/2019-Global-Health-S...
5. KPMG. Government and institution measures in response to COVID-19Update 49. Downloaded April 1, 2021. https://home.kpmg/xx/en/home/insights/2020/04/government-response-global...
6. National Academies of Sciences, Engineering, and Medicine 2020. Stronger Food and Drug Regulatory Systems Abroad. Washington, DC: The National Academies Press. https://doi.org/10.17226/25651
To the editor and authors,
We have several concerns about the zinc results in this systematic review
1. Weismann et al. 1990 RCT evaluates zinc for treating, not preventing infections, yet is included in the prevention meta-analyses (Figure-6).
2. Farr et al. 1987 reports post-exposure prophylactic and treatment results for two RCTs. Which RCT was used? Why was the other ignored? Supp-Table-5 reports an incorrect sample size and MD rather than RR. The validity of combining pre- and postexposure prophylactic trials is questionable and at the very least, should be discussed.
3. Turner et al. 2000 reports two RCTs, both had 4 arms. Why was one RCT and two of the three zinc arms ignored? If these arms were included, an explanation for how the means (SDs) were combined is missing.
4. Table 3 lacks transparency as the studies used in each subgroup are not cited and often it is unclear what data was used. For example, none of the five RCTs included in the zinc prevention meta-analysis reported infection rates for males and females, yet this is reported.
5. The authors claim there was no evidence of a dose response for zinc used for treatment. Only two RCTs evaluated a dose ≤13.3mg/day. Both used intranasal sprays/gels. All other treatment studies evaluated lozenges. Comparing doses for different administration routes is clinically meaningless. All this analysis tells us is there is no difference between intranasal and sublingual adminis...
5. The authors claim there was no evidence of a dose response for zinc used for treatment. Only two RCTs evaluated a dose ≤13.3mg/day. Both used intranasal sprays/gels. All other treatment studies evaluated lozenges. Comparing doses for different administration routes is clinically meaningless. All this analysis tells us is there is no difference between intranasal and sublingual administration routes.
6. The control lozenge used by Turner et al. 2000 should probably be classified as an active control as it contained quinine hydrochloride. At the very least it should be discussed, and a sensitivity analysis conducted.
7. The authors fail to acknowledge that language bias is a limitation of their review. Only English language databases were searched, and articles excluded “for which there was no standard translation” are not reported. We are aware of three RCTs indexed only in Chinese language databases and published in Chinese. Two are large RCTs that evaluated a zinc gluconate nasal spray for prevention of upper respiratory infections [1, 2] and the other evaluated zinc gluconate nasal spray for treatment .
8. Other concerns with the comprehensiveness of the literature search include only searching two databases. This is the bare minimum for a systematic review and is not recommended when the intervention is used as a complementary medicine/natural product as some relevant journals are not indexed in PubMed or Embase.
9. Despite searching “published systematic reviews by hand” one zinc RCT identified by two other systematic reviews was missed [4-6].
10. A key RCT that is very relevant to the current pandemic was also missed. In 2007, Prasad et al.  reported an RCT involving 50 participants age 55-87 years who were given 45mg/day of oral zinc or placebo for 12 months. The effects of zinc for prevention of upper respiratory infections, tonsillitis, common cold, and flu were each reported separately.
11. The lack of a protocol and no discussion of the review’s limitations add to our concerns about the reliability of the review findings.
1. Wei J, Chen HW, You LH: [Zinc gluconate nasal spray for the prevention of upper respiratory tract infection: A randomised, double-blinded, placebo-controlled trial]. Medical Journal of Chinese People's Liberation Army 2009, 34(7):838-840.
2. Zhang LJ, Liu GX, Zhang YX, Xing XY, Cai HX, Zeng G: [Zinc gluconate nasal spray for the prevention of acute upper respiratory tract infection]. Journal of Preventive Medicine Information 2009, 25(7):508-510.
3. Yao WZ, Yang W, Shen N, Liu YN, Wang PL, Lin JT: [Zinc gluconate nasal spray versus common cold nasal spray in treating common cold: A randomised, multi-center, controlled trial]. Chinese Journal of Clinical Pharmacology 2005, 21(2):87-90.
4. Belongia EA, Berg R, Liu K: A randomized trial of zinc nasal spray for the treatment of upper respiratory illness in adults. The American journal of medicine 2001, 111(2):103-108.
5. D'Cruze H, Arroll B, Kenealy T: Is intranasal zinc effective and safe for the common cold? A systematic review and meta-analysis. Journal of primary health care 2009, 1(2):134-139.
6. Hulisz D: Efficacy of zinc against common cold viruses: an overview. Journal of the American Pharmacists Association 2004, 44(5):594-603.
7. Prasad AS, Beck FW, Bao B, Fitzgerald JT, Snell DC, Steinberg JD, Cardozo LJ: Zinc supplementation decreases incidence of infections in the elderly: effect of zinc on generation of cytokines and oxidative stress. Am J Clin Nutr 2007, 85(3):837-844.
I thank Ms Besson and colleagues for their useful research into excess mortality in Yemen. They have highlighted effective use of excess mortality as a measure of the COVID-19 pandemic’s impact. Their new technique for determining excess mortality potentially overcomes a major limitation in its normal calculation, that is, the predominance of low quality civil registration systems in many LMICs (1). I would like to offer some comments on this research.
A key element in any determination of excess mortality is the comparative baseline period adopted (2,3). The authors have selected a baseline period beginning in July 2016, but given that the Yemeni conflict began far prior to this, I wonder why this arbitrary start-point was selected (4, 5). Whilst the authors have also referred to armed conflict intensity data, I do not see its application in the final results. Such intensity data could have been useful in selection of the comparative baseline period, in order to provide a more accurate analysis of excess mortality related to COVID-19. As conflict related mortality in Yemen, as well as mortality related to food insecurity, has varied significantly over the last number of years, it is particularly challenging to compare like with like (4, 5). These changing trends in mortality must be accounted for in order to produce a truly accurate calculation of excess mortality. Further to this, whilst 1st April was understandably selected as the date at whic...
I thank Ms Besson and colleagues for their useful research into excess mortality in Yemen. They have highlighted effective use of excess mortality as a measure of the COVID-19 pandemic’s impact. Their new technique for determining excess mortality potentially overcomes a major limitation in its normal calculation, that is, the predominance of low quality civil registration systems in many LMICs (1). I would like to offer some comments on this research.
A key element in any determination of excess mortality is the comparative baseline period adopted (2,3). The authors have selected a baseline period beginning in July 2016, but given that the Yemeni conflict began far prior to this, I wonder why this arbitrary start-point was selected (4, 5). Whilst the authors have also referred to armed conflict intensity data, I do not see its application in the final results. Such intensity data could have been useful in selection of the comparative baseline period, in order to provide a more accurate analysis of excess mortality related to COVID-19. As conflict related mortality in Yemen, as well as mortality related to food insecurity, has varied significantly over the last number of years, it is particularly challenging to compare like with like (4, 5). These changing trends in mortality must be accounted for in order to produce a truly accurate calculation of excess mortality. Further to this, whilst 1st April was understandably selected as the date at which COVID-19 may have begun to have a significant impact, by excluding deaths prior to this period, the results may have been skewed.
Finally, I would like to comment on the differing age distribution in Aden alluded to by the authors. Age stratification of the population, including that as a result of crisis-related migration, may be a useful tool to calculate age-stratified excess mortality (3). This could, in turn, reflect the comparative impact of COVID-19 on the younger echelons of Yemeni society, providing an insight into how living in a conflict area may impact vulnerability to COVID-19. Age stratification could not be completed using this geospatial technique, reflecting one limitation of this method, limiting its application to real world preventive measures.
Ultimately, this technique demonstrates potential to gain true insight into the cumulative effects a pandemic may have in a conflict area. Further application may enable more targeted mitigation measures and more effective aid to be provided.
1. World Bank Group. (2018). Global Civil Registration and Vital Statistics. Retrieved from https://www.worldbank.org/en/topic/health/brief/global-civil-registratio...
2. Checchi, F., & Roberts, L. (2005). Interpreting and using mortality data in humanitarian emergencies. Humanitarian Practice Network, 52
3. Aron, J., Muelbauer, J., Giattino, C., & Ritchie, H. (2020). A pandemic primer on excess mortality statistics and their comparability across countries. Our World in Data, Retrieved from https://ourworldindata.org/covid-excess-mortality.
4. Sharp, J. M. (2021). Yemen: Civil War and Regional Intervention. Congressional Research Service.
5. Parveen, A. (2019). The Yemen Conflict: Domestic and Regional Dynamics. Pentagon Press.
In their laudable analysis of the Prospective Urban and Rural Epidemiology study, Naito and colleagues(1) used multivariable Cox regression to examine social isolation in relation to all-cause mortality, cardiovascular disease (CVD) mortality, and cause-specific incidence and mortality. Drawing upon the latest evidence in the field, the purpose of this letter is to highlight three strengths of this study and propose an alternative explanation for the observed association between social isolation and CVD incidence.
Naito and colleagues’ study contributes novel insights into potential risk factors for social isolation across high, middle and low income settings. Further, their findings in relation to all-cause and CVD mortality strengthen the literature suggesting that greater isolation is associated with increased mortality.(2) While it is unclear that the assumptions required to calculate population attributable fraction(3) are reasonably met when examining social isolation and mortality, the authors' analysis also contribute to growing evidence(4) that raises questions about the validity of the popular claim that social isolation is as bad for health as smoking.(5–8)
Compared to less isolated participants, Naito and colleagues observed 15% increased CVD incidence among the most isolated participants (HR=1.15, 95% CI: 1.05 – 1.25).(1) The CVD incidence outcome they measured “…included fatal or non-fatal myocardial infarction, stroke, heart failure and ot...
Compared to less isolated participants, Naito and colleagues observed 15% increased CVD incidence among the most isolated participants (HR=1.15, 95% CI: 1.05 – 1.25).(1) The CVD incidence outcome they measured “…included fatal or non-fatal myocardial infarction, stroke, heart failure and other fatal CVD events.”(1) The authors suggest that inconsistencies between this finding and previous research may be explained by variation in their social isolation indices and the studied population’s characteristics. Indeed, this remains possible given that the authors use a mix of more and less subjective measures of social relationships and social support to construct their social isolation index. However, the observed association may also be a product of how CVD incidence was measured.
Recent evidence examining social isolation and incident CVD outcomes suggests that social isolation may play a greater role impacting one’s likelihood of surviving their first CVD event rather than one’s risk of developing CVD in the first place.(9) Earlier this month, a prospective analysis of about 940,000 UK adults found that after adjustment potential confounders, social isolation was not associated with non-fatal coronary heart disease (CHD) incidence (HR= 1.01, 95% CI: 0.98-1.04), weakly associated with non-fatal stroke incidence (HR=1.13, 95% CI: 1.08-1.18), and strongly associated with fatal incident CHD (HR= 1.86, 95% CI: 1.63-2.21) and fatal incident stroke events (HR= 1.91, 95% CI: 1.48-2.46).(9) These findings were supported by other recent and large prospective studies from the USA and UK.(10–13) Therefore, the association observed by Naito and colleagues may also be driven by increased risk of fatal incident CVD events among the most isolated participants as opposed to non-fatal events.
Careful outcome measurement is one tool for helping tease-out potential explanatory pathways linking social isolation and health. The latest evidence suggests that timely access to help with seeking healthcare in response to a life threatening event may be a key pathway linking social isolation and CVD mortality outcomes.(9) Perhaps due in part to the timing of publication, Naito and colleagues present several potential explanations for their findings with exception of this “delays in seeking care” hypothesis. Future research examining CVD and non-CVD incidence outcomes should continue explicitly defining the theoretical and conceptual models underpinning the hypothesized relationships between social isolation and specific disease outcomes under investigation.
1. Naito R, Leong DP, Bangdiwala SI, et al. Impact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents. BMJ Glob Heal. 2021;6(3):e004124. doi:10.1136/bmjgh-2020-004124
2. Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and Social Isolation as Risk Factors for Mortality: a Meta-Analytic Review. Perspect Psychol Sci. 2015;10(2):227-237. doi:10.1177/1745691614568352
3. Mansournia MA, Altman DG. Population attributable fraction. BMJ. 2018;360:k757. doi:10.1136/bmj.k757
4. Smith RW, Barnes I, Reeves G, Green J, Beral V, Floud S. P84 Is social isolation as bad for health as smoking 15 cigarettes per day? Findings from two large prospective UK cohorts. J Epidemiol Community Health. 2019;73(Suppl 1):A108 LP-A109. doi:10.1136/jech-2019-SSMabstracts.234
5. Kristof N. Let’s Wage a War on Loneliness. The New York Times. https://www.nytimes.com/2019/11/09/opinion/sunday/britain-loneliness-epi.... Published November 9, 2019. Accessed February 22, 2020.
6. Graham J. Loneliness as a health threat: New campaign raises awareness. STAT News. https://www.statnews.com/2016/11/16/loneliness-health/. Published 2016. Accessed June 28, 2019.
7. Yang YC, Boen C, Gerken K, Li T, Schorpp K, Harris KM. Social relationships and physiological determinants of longevity across the human life span. Proc Natl Acad Sci. 2016;113(3):578-583. doi:10.1073/PNAS.1511085112
8. Courtin E, Knapp M. Social isolation, loneliness and health in old age: a scoping review. Health Soc Care Community. 2017;25(3):799-812. doi:10.1111/hsc.12311
9. Smith RW, Barnes I, Green J, Reeves GK, Beral V, Floud S. Social isolation and risk of heart disease and stroke: analysis of two large UK prospective studies. Lancet Public Heal. 2021. doi:10.1016/S2468-2667(20)30291-7
10. Chang S-C, Glymour M, Cornelis M, et al. Social Integration and Reduced Risk of Coronary Heart Disease in Women: The Role of Lifestyle Behaviors. Circ Res. 2017;120(12):1927-1937. http://circres.ahajournals.org/content/early/2017/03/30/CIRCRESAHA.116.3....
11. Valtorta NK, Kanaan M, Gilbody S, Hanratty B. Loneliness, social isolation and risk of cardiovascular disease in the English Longitudinal Study of Ageing. Eur J Prev Cardiol. 2018;25(13):1387-1396. doi:10.1177/2047487318792696
12. Elovainio M, Hakulinen C, Pulkki-Råback L, et al. Contribution of risk factors to excess mortality in isolated and lonely individuals: an analysis of data from the UK Biobank cohort study. Lancet Public Heal. 2017;2(6):e260-e266. doi:10.1016/S2468-2667(17)30075-0
13. Hakulinen C, Pulkki-Råback L, Virtanen M, Jokela M, Kivimäki M, Elovainio M. Social isolation and loneliness as risk factors for myocardial infarction, stroke and mortality: UK Biobank cohort study of 479 054 men and women. Heart. March 2018. http://heart.bmj.com/content/early/2018/03/16/heartjnl-2017-312663.abstract.
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.
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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....