We use cookies to improve our service and to tailor our content and advertising to you.More infoYou can manage your cookie settings via your browser at any time. To learn more about how we use cookies, please see our cookies policy.
Dear authors,
thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
thanks again and best regards,
Jan Peter
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Of note, the CCHF prevalence map used from WHO dated 2017 (4) identifies Pakistan as risk region with 5 – 49 cases of CCHF reported each year. Our laboratory performs clinical testing or CCHFV and reported 131 cases of CCHF in 2018. Testing is performed using a commercial assay from Altona Diagnostics, GmBH, and results are reported within 24 h of the specimen being received. This data indicates Pakistan is amongst the highest category of risk for CCHFV infections worldwide. Given that dengue fever is also prevalent in the same region and is part of differential diagnosis for CCHF in Pakistan, there is value in rapid diagnosis using a robust rapid RT-PCR assay in high risk cases even though it may be at an increased cost. Therefore, in CCHFV endemic regions having a rapid robust assay for diagnosis of acute infections is extremely important.
References
1. Mazzola LT, Kelly-Cirino C. Diagnostic tests for Crimean-Congo haemorrhagic fever: a widespread tickborne disease. BMJ Glob Health. 2019;4(Suppl 2):e001114.
2. Rai MA, Khanani MR, Warraich HJ, Hayat A, Ali SH. Crimean-Congo hemorrhagic fever in Pakistan. J Med Virol. 2008;80(6):1004-6.
3. Leblebicioglu H, Sunbul M, Memish ZA, Al-Tawfiq JA, Bodur H, Ozkul A, et al. Consensus report: Preventive measures for Crimean-Congo Hemorrhagic Fever during Eid-al-Adha festival. Int J Infect Dis. 2015;38:9-15.
4. WHO. Introduction to Crimean-Congo Haemorrhagic Fever. World Health Organization. Geneva, Switzerland2018. p. https://www.who.int/emergencies/diseases/crimean-congo-haemorrhagic-feve....
What the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.
A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that of urban areas and reported that rates of TB identified is 2.9 times higher in males compared with females. (1) The Multiple Indicator Cluster Survey from 2017 showed that 71.3% of people in urban areas have access to clean water versus 44.5% in rural areas. (2)
The differences between rural and urban areas matter, by any measure of health and development, which greatly influences DALYs. Of the raw data points, extracted from the 68 sources the paper reports that the Institute for Health Metrics and Evaluation used to create the DALYs portrayed in Table 2, only about 15% was from after 2009, which is when the majority of the publications used in this paper were from. Recent comprehensive surveys by the UN had not been updated by the data set, such as the Multiple Indicator Cluster Survey 2017 data, the TB Prevalence Survey 2015-2016, and the Socio-economic, Demographic, and Health survey 2014. (3) However, the publication included papers from 1998 to 2017 in their review. Interestingly, only 24 of the 26,179 data points used to develop the DALYs were from 2016, the year that Table 2 cites. (4)
The aid community has struggled with this paper’s conclusions about gaps in the evidence, as it is a daily battle. The amount of what is unknown versus known about public health nears a ratio of 99 to 1, with the UN, as in-country residential workers, having access to the majority of what is known about the population. When it comes to the amount of data that the UN has versus the NGOs working within the country or scientists visiting the DPRK, the UN has access to a much broader base of evidence than what is published, given its greater ability to negotiate for access. Accomplished researchers within the NGOs who work as aid workers have to make the choice to not publish any data about their work in the DPRK because of the political context. (5) Thus, the paper's argument that research and public health policies are not based on adequate evidence is a conclusion that seems out of touch with the realities on the ground. In more recent years, the DPRK government has shown greater openness to the idea of publishing their data, which is the basis for many UN publications and articles available today.
An interdisciplinary perspective to deconstruct the granularity of existing data will go a long way towards better community-centered public health initiatives, as it will unlock steps to navigating the political gridlock to achieve better public health outcomes. Despite the constraints of perspective this paper holds, it does generate more enthusiasm for others to get into the field. Ultimately, it is only by partnerships among the NGO community, international agencies, and scientists that we can catalyze progress towards addressing health in the DPRK.
The report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.
The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income co...
The report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.
The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income countries could indeed benefit from learning processes that engage service providers with the needs of service users. A relatively small number of studies have investigated the effectiveness of diabetes interventions involving CHWs in low- and middle-income countries (LMICs). These indicated positive outcomes in self-management, glucose control, and body mass index; however, these studies often lacked detailed characterisation of the role played by CHWs (4). The burgeoning epidemic of diabetes in LMICs demands context-specific research to assess the position of CHWs, and to shape opportunities for developing their role in diabetes management.
Adaptation of health interventions at the local level is key to making them relevant and acceptable to the communities they serve. In this area, diabetes management programmes can learn reciprocally from HIV intervention programmes, which have developed beyond reducing transmission, to chronic infection management, community engagement, and raising global awareness. The double burden of diabetes and infectious diseases such as HIV and tuberculosis, known to have interactions at the physiological as well as societal level, demands stronger health systems that can provide joined-up care. Previous studies have shown the central role of community-based individuals for outreach and mobilization in HIV interventions. They furthermore provide guidance on how to adapt interventions to their implementation sites, including the involvement of local staff in the adaptation process (5). Patients must also be stakeholders in the learning and adaptation process. We can anticipate that reciprocal learning approaches to health service development, both internationally and between disease-specific health programmes, will enhance services and strengthen resource-limited health systems.
References
1. van Olmen J, Delobelle P, Guwatudde D, Absetz P, Sanders D, Mölsted Alvesson H, et al. Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes. BMJ Glob Heal. 2018 Nov 26;3(6):e001068.
2. Egbujie BA, Delobelle PA, Levitt N, Puoane T, Sanders D, van Wyk B. Role of community health workers in type 2 diabetes mellitus self-management: A scoping review. PLoS One 2018;13(6):e0198424.
3. Silverman J, Krieger J, Sayre G, Nelson K. The Value of Community Health Workers in Diabetes Management in Low-Income Populations: A Qualitative Study. J Community Health. 2018 Oct 1;43(5):842–7.
4. Alaofè H, Asaolu I, Ehiri J, Moretz H, Asuzu C, Balogun M, et al. Community Health Workers in Diabetes Prevention and Management in Developing Countries. Ann Glob Heal. 2017 May 1;83(3–4):661–75.
5. Kevany S, Khumalo-Sakutukwa G, Murima O, Chingono A, Modiba P, Gray G, et al. Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043). BMC Public Health. 2012 Jun 20;12:459.
Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...
Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.91 (1.30-2.79)), but not in boys (RR 0.84 (0.61-1.17))5.
WHO established a collaboration where four groups (the Institute for Disease Modelling, GSK Vaccines, Imperial College London and the Swiss Tropical and Public Health Institute) modelled the expected public health impact of introducing the RTS,S/AS01 vaccine. Based on the measured vaccine efficacy against clinical malaria, the models estimated that per 100,000 fully vaccinated children in a four-dose schedule, 484 deaths would be averted6. However, if the RTS,S/AS01 mortality results5 were representative, fully vaccinating 100,000 children in a four dose schedule would cause 464 additional deaths: Stratified by sex, 100,000 fully vaccinated boys would result in 252 fewer deaths, whereas 100,000 fully vaccinated girls would result in 1182 additional deaths.
The modelled results are in line with the general perception that vaccines only have one effect: prevention of the target disease. However, increasing evidence suggest that non-live vaccines may have negative non-specific effects despite protection against the target disease. The RTS,S/AS01 results fits the pattern previously observed perfectly: the negative non-specific effects of non-live vaccines are particularly pronounced in females.
Nonetheless, the RTS,S/AS01 vaccine is now being introduced as a four-dose schedule in Ghana, Kenya and Malawi as part of the WHO malaria vaccine pilot programme targeting 720,000 children. Policymakers may feel confident about this decision given the effect on clinical malaria and the modelled mortality data. However, based on the empirical mortality data, and the fact that they fit into an already established pattern of mortality effects on non-live vaccines, we fear that this introduction of RTS,S/AS01 may lead to unnecessary female deaths. Discrepancies between modelled and real-life data must be taken seriously. No model is better than the data and assumptions used. Therefore, empirical data should rank higher.
References
1. Colbourn T, Prost A, Seward N. Making the world a simpler place: the modeller’s temptation to seek alternative trial results. BMJ Global Health 2018;3(5) doi: 10.1136/bmjgh-2018-001194
2. RTS.S Clinical Trials Partnership. Efficacy and safety of RTS,S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. Lancet 2015;386(9988):31-45. doi: 10.1016/S0140-6736(15)60721-8
3. Aaby P, Rodrigues A, Kofoed P-E, et al. RTS,S/AS01 malaria vaccine and child mortality. The Lancet 2015;386(10005):1735-36. doi: 10.1016/S0140-6736(15)00693-5
4. Benn CS, Netea MG, Selin LK, et al. A small jab - a big effect: nonspecific immunomodulation by vaccines. Trends in immunology 2013;34(9):431-9. doi: 10.1016/j.it.2013.04.004
5. Klein SL, Shann F, Moss WJ, et al. RTS,S Malaria Vaccine and Increased Mortality in Girls. mBio 2016;7(2) doi: 10.1128/mBio.00514-16
6. Penny MA, Verity R, Bever CA, et al. Public health impact and cost-effectiveness of the RTS,S/AS01 malaria vaccine: a systematic comparison of predictions from four mathematical models. The Lancet 2016;387(10016):367-75. doi: 10.1016/s0140-6736(15)00725-4
Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.
India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)
This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to...
Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.
India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)
This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to unlocking the potential of the plain packaging policy. The tobacco industry, which made almost a trillion dollars in 2016, in India alone (Statista, 2018), is a big forex earner for most low and middle income countries, and there is a need for future policies to focus on giving societies who provide labor for the system an alternative way of means.
References
McNeill A, Gravely S, Hitchman SC, Bauld L, Hammond D, Hartmann-Boyce J (2017). Tobacco packaging design for reducing tobacco use. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.: CD011244.DOI: 10.1002/14651858.CD011244.pub2.
Steven J. G. (2016): The Australian experience following plain packaging: the impact on tobacco branding, Society for the study of addiction,
Eckhardt, J., Holden, C., & Callard, C. D. (2016) Tobacco Control and the World Trade Organization: Mapping Member States’ Positions after the Framework Convention on Tobacco Control. Tobacco Control. pp. 692-698. ISSN 1468-3318
Statista: tobacco industry statistics & facts. https://www.statista.com/topics/1593/tobacco/ 27 October 2018
Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...
Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access to services, lack of necessary knowledge about contraceptive methods, social opposition to their use, and health concerns about possible side effects.
The finding that ‘providing a behavioral nudge in combination with a voucher for free postpartum contraceptive increases take- up of modern methods’ is, in my view, an important finding, particularly for program planners particularly in Sub-Saharan Africa and other developing countries where there is heavy burden of HIV.
It is key, therefore, to consider this study’s finding of providing both behavioral nudges and some promise of free modern contraceptive methods, especially for women living with HIV as a strategy to improve both PMTCT and the health, human rights and well-being of women.
References:
• John B. Casterline; Steven W. Sinding; Unmet Need for Family Planning in Developing Countries and Implications for Population Policy; wiley online library; (2004);
• Sexual and Reproductive Health, World Contraception Day 2018 report,WHO (http://www.who.int/reproductivehealth/topics/family_planning/world-contr... (retrieved, 3rd November 2018)
Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.
In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.
Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.
The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this d...
Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.
In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.
Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.
The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this dominance - has contributed to the reality that worldwide at least 50% of those in need of insulin are not able to access this life saving treatment. As Gotham and colleagues’ work clearly outlines, the cost differentials in manufacturing a phial of human insulin ($2.28 – $3.42) versus analogue insulin ($3.69 - $6.16) are not reflected in current market prices. Indeed, insulin prices around the world lie far above these ranges, with often excessively high price differentials between human and analogue. The abusive pricing strategies of pharmaceutical corporations must be challenged in light of the limited access globally, and in low income and humanitarian settings in particular.
The majority of insulin that MSF procures is human insulin in phials, from Lily and Novo Nordisk, two of the three insulin market dominators. Activism by people living with HIV, MSF and other advocates for affordable generic antiretrovirals (ARVs) and a coordinated donor response resulted in over 20 million people currently receiving treatment for HIV. The current lack of competitive biosimilar insulins – similar to the lack of generic ARVs 20 years ago – is a huge hurdle to overcome in ensuring access for people living with diabetes today. Regulatory pathways for biosimilars and lack of transparency across price negotiations are just two of the factors challenging competition in the insulin market.
People living with diabetes need insulin today, and the lack of access in 2018 is an outrage. MSF supports a coordinated global response to ensure quality, affordable human and analogue insulin formulations are available in adapted delivery devices for people in need of this life-saving treatment.
Dear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...
Dear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans Frontières showed measles and diarrhea (variables of the CCI) still contributed to the major causes of under five deaths in these areas [3]. There is a gap if coverage here is low despite there being a large workforce. Under usual circumstances when there is not conflict, a large workforce is associated with an increase in CCI. However, this situation does not exist when there is conflict and political upheavals notwithstanding the larger workforce as this does not mitigate against the ravages of internal conflict. Devolution is a type of decentralisation where central government transfers authority to the local government. Devolution occurred in Kenya where political and economic powers were transferred to 47 counties. As a result of this administrative change, decisions were made at the county level by local people rather than at a national level to fulfil their needs according to local factors. However, devolution to counties did not ensure that all citizens received services as some ethnic minorities were without proper services and unable to access benefits due to lack of support at the county level [1]. Table 1 shows that advantaged and disadvantaged groups under devolution have unequal access and distribution of resources. This raises the question: how does the role of decentralised governance justify equity? We believe that human resource capacity plays an important role in the performance of a devolved government. Around 200,000 displaced Somalis seek home in refugee camps in northern Kenya. Due to the large population of Somali people in the camps, outbreaks of diseases and delays in registration affecting provision of food are common. Clearly, the humanitarian as well as governmental actions to control the under-five deaths in refugee population have failed [3]. A review of early implementation of devolution in Kilifi county of Kenya carried out by Tsofa et. al (2017), showed that insufficient human resource capacity caused confusion over management roles, and political interference with management led to job dissatisfaction which resulted in a low retention of the workforce [4]. With these effects and workforce attrition, the county capacity will be inadequate to manage large refugee populations. We agree that decentralisation of governance has shown improved healthcare impacts in developing countries such as South Africa and Rwanda. However, contextual factors like political upheavals affect the maximum benefits that can be achieved through decentralisation. When planning healthcare services, policies and financing consideration should be given to the impact of conflict, refugees, ethnic minorities and displaced populations. Discussion and research focusing on governance in disadvantaged areas will help Kenya to further reduce under-five mortality by identifying if the current governance and its capacity works best within the given circumstances. References: 1. D'Arcy, M., & Cornell, A. (2016). Devolution and corruption in Kenya: Everyone's turn to eat? African Affairs, 115(459), 246-273. 2. Keats, E. C., Macharia, W., Singh, N. S., Akseer, N., Ravishankar, N., Ngugi, A. K., Rizvi, A., Khaemba, E. N., Tole, J., & Bhutta, Z. A. (2018). Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015. BMJ global health, 3(3), e000655. 3. Polonsky, J. A., Ronsse, A., Ciglenecki, I., Rull, M., & Porten, K. (2013). High levels of mortality, malnutrition, and measles, among recently-displaced Somali refugees in Dagahaley camp, Dadaab refugee camp complex, Kenya, 2011. Conflict and health, 7(1), 1. 4. Tsofa, B., Goodman, C., Gilson, L., & Molyneux, S. (2017). Devolution and its effects on health workforce and commodities management–Early implementation experiences in Kilifi County, Kenya. International journal for equity in health, 16(1), 169.
Table 1
Winners and losers under devolution
Group members with a home county who live in their home county
Group members who live outside home county/ groups who lack a home county
Dear authors,
thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
thanks again and best regards,
Jan Peter
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Of note, the CCHF prevale...
Show MoreWhat the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.
A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...
Show MoreThe report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.
The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income co...
Show MoreRecently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
Show MoreWe would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...
Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.
India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)
This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to...
Show MoreMany countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
Show MoreThere is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...
Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.
In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.
Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.
The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this d...
Show MoreDear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...
Show MorePages