eLetters

77 e-Letters

  • A need for better understanding old-age mortality dynamics

    A need for better understanding old-age mortality dynamics
    Sergi Trias-Llimós* & Iñaki Permanyer
    Centre d’Estudis Demogràfics, Carrer de Ca n’Altayó, Edifici E2, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
    * Corresponding author. Email: strias@ced.uab.cat

    Correspondence letter in response to:
    Bergeron-Boucher M-P, Aburto JM, Raalte A van. Diversification in causes of death in low-mortality countries: emerging patterns and implications. BMJ Glob Health. 2020;5(7):e002414.

    Word count: 492

    The recent paper by Bergeron-Boucher et al. published in this journal reports an increasing diversity of cause-of-death mortality in low-mortality populations during the last 20 years [1]. Bergeron-Boucher et al. found that the preponderance of mortality from cardiovascular diseases in the countries under analysis has gradually declined in favour of a wide range of causes of death, including mental and behavioural disorders, nervous system or ill-defined causes. The increasing variability of causes of death is an important matter of potential concern because (a) fragmentation in cause of death might hinder further improvements in life expectancy, (b) preventive health policies have to cope with a more variegated set of causes, which imply more costly and less efficient health policies.
    Despite their enormous interest, these findings should be interpreted with caution. As the authors...

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  • MITIGATION MEASURES TO PREVENT THE NEXT PANDEMIC

    We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1

    COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2

    Airborne or droplet borne. The infectious...

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  • Equity and Access to Global Health Education: Focusing on the Fundamental Problem

    Svadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.

    The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.

    Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-af...

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  • COVID-19, NCDs and emergency care: a plea from Africa's front-lines

    The COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.

    Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.

    A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Ea...

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  • Co-linearity between pre-symptomatic and post-symptomatic mask wearing

    The effectiveness of masks in the household is a critically important topic for control of SARS-CoV-2 transmission. I am concerned the multivariate regression performed in this analysis incorrectly attributed all of the effect of post-symptomatic mask-wearing to the pre-symptomatic mask-wearing variable. It is highly likely that these 2 variables are highly co-linear, and looking at Table 2, it appears likely that those families that wore masks pre-symptoms (n=27 without transmission, n=4 with transmission) were largely the same families where all members of the household wore masks post-symptoms (n=31 without transmission, n=5 with transmission). It's likely there are not enough numbers to further disentangle whether pre-symptom or post-symptom mask-wearing truly was the benefit - most likely it's some of both.

    The message that post-symptomatic mask-wearing has no effect appears to lack sufficient support, so I would caution anyone jumping to use that conclusion here.

  • Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed

    Rapid response

    Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed

    Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794

    Dear Editor,

    In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.

    More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 as...

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  • COVID 19 in India – An Opportunity in Disguise

    We read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.

    Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.

    The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]

    The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favou...

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  • YouTube as a source on information on COVID-19: a pandemic of misinformation? Response

    Dear Editor,

    After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.

    As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
    However, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coron...

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  • COVID-19 restrictions and fathers of infants in neonatal care

    We fully agree with the authors in terms of need for a paradigm shift. We have called it a 'pandemic' but response has been largely country centric and not at all global.

    We would also like to highlight a typical reactionary response globally leading to exclusion of fathers from maternity and neonatal units.

    The Covid-19 pandemic is dividing families all over the world, especially at a time when togetherness is particularly important, such as at the time of birth, death and illness. Many families are experiencing situations that are prone to leave life-long scars.
    While the protection of the health of staff and mothers is of paramount importance, social distancing, curbs to travel and additional restrictions to presence of parents instituted by maternity and neonatal units across the world have created obvious difficulties for families. Having a sick baby in a neonatal unit during this pandemic is a particularly intense hardship for families. We are well aware of negative impacts of separation on children and families and the pandemic related restrictions have made this worse for the whole family, perhaps more so for parents of preterm and sick newborns.
    We have previously highlighted, along with many others, the importance of optimising fathers’ experiences in the neonatal unit (Ref 1-8) and suggested a focus on a co-parenting paradigm with a clear set of recommendations for neonatal and maternity services (Ref 1).
    Even though we...

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  • Integrating tech solutions into traditional gender-based violence programs

    Dear Editor,

    We were pleased to read the review by Eisenhut K, Sauerborn E, García-Moreno C, et al. and appreciated their insights on the landscape of mobile apps addressing violence against women.

    We read with great interest the authors’ observation that “collaborations between mHealth and ‘traditional’ approaches should be actively sought, subordinating the technology to the overall aims of preventing violence against women and mitigating its impacts.” In that spirit, we would like to highlight Physicians for Human Rights’ (PHR) experience implementing a “tech” solution within a larger “low-tech” programmatic ecosystem to address violence against women (VAW).

    The Program on Sexual Violence in Conflict Zones at Physicians for Human Rights works with medical, legal, and law enforcement partners in Central and East Africa to address impunity for sexual violence in conflict. Since 2011, we and our partners have trained more than 2,000 professionals in the collection, documentation, and use of court-admissible forensic evidence of sexual violence. As part of this initiative, PHR developed MediCapt, an award-winning mobile application, which standardizes and digitizes the collection of forensic documentation of medical evidence of sexual violence and combines it with a mobile camera to capture and securely store forensic photographic evidence of injuries. MediCapt was “co-designed” with clinician-partners in Kenya and the Democratic Republic of the Congo a...

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