137 e-Letters

  • RE: Author's response

    We thank Cooney and Partridge for their interest in our article.1 We believe, however, that they have misunderstood much of what we wrote. We accessed websites with publicly available national and subnational data on population-level rates of religious affiliation and breastfeeding initiation. As we explained, two other selection criteria reduced the number of countries we examined: (1) sufficient within-population variability in both religious affiliation and breastfeeding initiation and (2) data on both variables, so that they could be associated at the same ecological (geographical) level. As we acknowledged, we did not find Lander-level data for Germany, the country that best met our selection criteria. Our inclusion of data from French-speaking regions is clearly a strength of our study--not a limitation. We used Protestant affiliation as defined in the databases we found, and we focused on the major Protestant groups in the general population. Since the data we used are publicly available, we invite Cooney and Partridge to analyse the associations between minor Protestant groups and breastfeeding rates in Ireland. Regarding the definition of Protestants, any degree of misclassification should have reduced, rather than increased, the associations we observed. Our scatterplots show the crude (unadjusted) data together with the crude correlations. For France, Ireland, the UK and Canada, crude and adjusted results were all in the same direction: a negative correlation be...

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  • RE: Response of the authors to the E-letters

    Drs. Dadhich and Prasad raise important issues in their comments and questions about our study on home-based management of children with uncomplicated severe acute malnutrition (SAM).  We are grateful for the opportunity to respond to them.

    In our view, there are two distinct goals in the management of children with SAM. The first, and more urgent, is to treat and move them away from severe malnutrition, a state of high risk of death. The second is to rehabilitate them to the point they are no longer malnourished. The treatments examined in the study achieved the first goal well. By the end of the treatment phase, 84.5% of the children in the RUTF-L group were no longer SAM. However, they did less well in achieving the second goal.  By the end of the treatment phase, 57% of those receiving RUTF-L had recovered to the point of no longer being malnourished. Should we have applied the same approach as most studies to calculate their WHZ - using height at enrolment and current weight, rather than concurrently measured height and weight - 81% of the children in the RUTF-L group would no longer be classified as malnourished by the end of the treatment phase.

    We note Dr. Prasad’s misunderstanding that over 40% of the children in our study remained SAM by the end of the treatment with RUTF-L. Should her interpretation have been correct, it would justify her expressed concern. However, as stated above, by the end of the treatment phase 84.5% of the c...

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  • Medicines in Nepal: What do we know about it’s quality?

    Medicines supplied in low and middle income countries are a matter of concern especially in regard to their quality. This article has raised a very genuine issue regarding the quality of medicine supplied to low and middle income countries(Nebot Giralt et al. 2017). This comment has been written in context to Nepal, a low income country as per the World Bank classification with population of around 28 million, out of which around 25 % of the people are living below the poverty line and 80% of the people living in rural areas(Central Bureau of Statistics 2015). The current ongoing Mass Drug Administration (MDA) for Elephantiasis in Nepal as a target to eliminate filariasis by 2020 has not been able to achieve its target due to poor compliance to the medicine. One of the reason could be due to people questioning about the quality of medicine distributed by government which could be the result of news spread five years back which stated five deaths, which later on was declared MDA not being the cause of death and more than 800 people falling ill after taking the medications. But still the fact cannot be ignored without proper investigation(Pandey 2012). 
    Still, many regions of the country lack access to basic health facility and essential medicine. The government of Nepal as per the national health policy has listed around 70 different drugs like anti-viral, anti-protozoal, some drugs for non-communicable diseases and so on to be distributed free of cost. The few p...

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  • RE: Concerns about a recent study on the influence of religion on breastfeeding rates
    We are concerned that the recent paper by Bernard et al published in BMJ Global Health 2016 fails to provide a scientific basis to support the stated conclusion that within Western countries the proportion of Catholics in the population influences the breastfeeding initiation rates. 
    The paper does not include a literature review on the role of religion in relation to infant feeding and there is no convincing scientific rationale presented to support the hypothesis being tested. There then follows a description of the study’s methods and results which reveals a series of methodological and reporting problems which, in our view, renders the work wide open to biases, confounders and incorrect deductions.There is evidence of selection bias in the five countries selected for within-country analyses, all limited to specific Western countries, with no explanation as why these particular countries were selected for inclusion.  It is noteworthy that of these selected five, the dominant languages for each is either English or French which suggests language bias may also be a factor. 
    A further problem with the methods is the unexplained differences in the selection of the Protestant populations for each of the five countries. For the US the researchers included two categories of Protestants in their analysis (Evangelical Protestants and Mainline Protestants), for Canada and France the category of Protestants was used but then for the U...
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  • Recent efforts to boost India’s plan of tuberculosis elimination
    Dear Editor,
    Pai et al put up a timely assessment of India’s ambition of achieving tuberculosis elimination by 2025.1 However, the authors seemed to have overlooked the major developments that have been introduced recently in the country. Inclusion of the updated facts could have enriched the discussion, I believe.
    In January 2017, a door to door campaign for active case finding for tuberculosis has been started by the Central TB Division (CTD).2 The scheme, if proved successful, has the capacity to effectively reduce the mean delay of two months between appearance of symptoms and initiation of treatment. This, along with introduction of bedaquiline at six referral sites and enhancing the use of cartridge based nucleic acid amplification test across the country, is expected to boost the performance of Revised National TB Control Programme in near future. In fact, CTD has already decided to start daily regimen in 104 districts, spread over five states.3 
    Now, apart from the budget, the future would also depend on successful vigilance on the dispensing pattern of anti tubercular drugs from private and informal sectors. A study earlier has demonstrated the use of steroids and fluoroquinolones by the pharmacists for probable cases of tuberculosis.5 With the warning against the silent rise of drug resistant tuberculosis and a projected 275% increase in the risk of multi-drug resistant tuberculosis in India over next 20 years, the...
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  • RE: Is it prudent to recommend RUTF in India based on the results of this trial?
    This RUTF trial from India has compared the efficacy of  RUTF (centrally produced and locally produced) with augmented energy-dense home-prepared foods (comparison group) for home based management of uncomplicated severe acute malnutrition (SAM). 
    I would like to draw attention of the authors on following issues. 
    1. The study reports that 40% children affected with SAM in the study did not recover even with a prolonged (16 weeks), supervised treatment with RUTF and other supportive measures like deworming, antibiotics at the initiation of treatment and increased access to healthcare for morbidity. The recovery rate was 17.3% with the use of locally produced RUTF and 12.1% with centrally produced RUTF at 16 weeks after the end of treatment phase. With such low recovery rates, is it prudent to make a recommendation for the policy that “Children with uncomplicated SAM can be managed at home with RUTF instead of through inpatient hospitalization”?
    2. In this trial, researchers aimed to achieve an intake of 175 kcal/kg body weight/ day for the enrolled children and collected consumption data for both the RUTF groups which were largely comparable. But they fail to do so for the comparison group stating greater difficulty in capturing valid information. Authors need to explain if this has led to a less th...
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  • re

    Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.


  • RE: Reading Between the Lines of the RUTF trial, India

        Reading Between the Lines of the RUTF trial, India
    Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
    It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...

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  • Researching the Syrian tragedy: The need for evidence and moral reflexivity

    ‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
    We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.

    Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russ...

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  • Essential Medicines List: a good start, but just a start

    The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.

    However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...

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