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.
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...
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