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.
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...
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 than robust comparison of outcomes between the two RUTF groups and the augmented energy-dense home-prepared foods group as energy intake in the comparison group is not known.
3.It will be useful if the authors provide opinion about efficacy of centrally produced RUTF in comparison to locally produced RUTF in treating SAM as adequate data in this regard are available to them in the study to do so. This information will be relevant from programmatic point of view as programmes for treatment of SAM in some states of India are using centrally produced RUTF.1
4.The study has reported that centrally produced RUTF was not efficacious in comparison to nutrient-rich homemade foods to treat SAM. It will be useful if authors can provide some underlying factors for this finding, just like they have explained many other findings in the discussion.
Reference:
1. National Health Mission – Government of Rajasthan. Poshan. Available at: http://nrhmrajasthan.nic.in/POSHAN.asp
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...
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 surveillance system for detecting cases and ensuring completion of treatment would have to play the major roles in coming days.6
References
1.Pai M, Bhaumik S, Bhuyan SS. India's plan to eliminate tuberculosis by 2025: converting rhetoric into reality. BMJ Global Health 2017;2:e000326. doi:10.1136/bmjgh-2017- 000326
2.Aditi Tandon. Soon, TB services on doorstep: Polio-like campaign to address TB burden from Jan 16. The Tribune, Jan 4, 2017. (Available from
http://www.tribuneindia.com/news/nation/soon-tb-services-on-doorstep/345735.html, last accessed on 22nd March, 2017)
3.Revised National Tuberculosis Control Programme. TB India 2016 annual status report. 2016. (Available from http://www.tbcindia.nic.in/index1.php?lang=1&level=2&sublinkid=4569&lid=3174, last accessed on 22nd March, 2017)
4.Anandhi CL, Nagaraj VK, Kumar R. Knowledge and practice pattern of non-allopathic indigenous medical practitioners regarding tuberculosis in a rural area of India. Indian J Tuberc 2002;6:553–55.
5.Satyanarayana S, Kwan A, Daniels B, et al. Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study. Lancet Infect Dis 2016;16:1261–68.
6.Law S, Piatek AS, Vincent C, Oxlade O, Menzies D. Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. Lancet Public Health 2017:2:e47-55.
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...
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 UK and Ireland they select only Protestants of Anglican religion – specifically, for the UK regions, the category Anglicans was used and then for Ireland Anglicans (Church of Ireland) is used. The rationale for confining the analysis to Anglican Protestants alone is not explained and the exclusion of data on the other Protestant religions such as Presbyterians, Methodists etc. strikes us as an important omission. For example, in Ireland the percentage of Anglicans is 2.9% (Ref 1). If other Protestant religions were included, this proportion would increase by a quarter to 3.6%. Similarly for the UK, the exclusion of non-Anglican Protestants in the four UK regions is also likely to have impacted on the results. Not being consistent and complete in the manner in which the Protestant groups were determined and enumerated undermines the scientific credibility of this work.
The presentation of results is of concern. The authors fail to clarify that each dot in Figure 2 represents findings from population groups that vary in size from the largest at a population of 53 million population for England to just under 32,000 for the smallest county In Ireland. Presenting results from such disparate population sizes can mislead reader’s interpretation of the scatter plot. Also, it is odd that the US data is presented separately from the other four countries included in the within-country analysis. Of note is the fact that the US was the outlier in that it differed from the others in having breast feeding rates that actually positively correlated with state-level proportions of Catholics. However, the authors subjected these data to a different analysis and presented the results separately. Of concern to us is that, unlike what had been done for the other four countries as displayed in Figure 2 and Table 3, the results by US state is not presented. Rather, the US data analysis included additional stratification by ethnicity (Non-Hispanic white, Hispanic white and Black) and presented separately in Table 4. As a result of this further analysis, the finding of the positive correlation with proportion of Catholics in US states is somewhat diluted.
There are a number of political factors and economic factors that impact on breastfeeding initiation rates and yet the authors have not included or considered these in this paper. It would have been particularly helpful if they had considered important potential confounders that may be associated with historical religious affiliations and infant feeding practices such as the economic importance of the dairy industry, including formula milk production, as well as demographic factors such as urban/rural population ratios.
Low levels of breastfeeding is a serious public health problem in many countries. In Ireland, we have one of the lowest breastfeeding rates in the world and, significantly, Ireland currently holds 10% of the global market share of infant formula production (Ref 2). Those of us working at improving breastfeeding rates seek to use the best evidence to inform the range of necessary interventions. We feel that it is therefore very important to highlight our concerns about the limited scope, flawed methods and difficulties in the presentation of the results of this study. In the interests of policy, practice and research, we argue that this paper fails to present convincing evidence to support the stated conclusion.
1.The Central Statistics Office Ireland, Census 2011, accessed 22nd Mar 2017 at: http://www.cso.ie/en/census/
2.Performance and Prospects 2014-2015 Bord Bia, Irish Food Board, accessed 22nd Mar 2017 at: http://www.bordbia.ie/industry/manufacturers/insight/publications/MarketReviews/Documents/Export-Performance-and-Prospects-2015.pdf
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...
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 published studies have suggested inadequate quality of drugs, bureaucratic process of drugs approval as barrier to the implementation of free drugs service which should not be ignored(Singh et al. 2017). Furthermore a cross sectional study done in Kathmandu, Nepal to assess the quality of drugs present in Nepalese market concluded that substandard medicine are available in Nepalese market and weak regulation and no uniformity in similar pharmaceuticals products(Gyanwali et al. 2015).
Although there are production of some essential medicines in Nepal more than half of the drugs required are imported from other countries and majority of them are distributed through different government and non-government organizations and international humanitarian aids. According to National List of Essential Medicines 2011, Of the 537 products in various strengths and dosages, Nepali companies were producing less than one third, 176 products(Brhlikova et al. 2015). Nepali health programs funded by international aid largely bypass government regulators and local producers as international agencies procure through large companies with an international GMP certificate. The Nepali local pharmaceutical industry has been growing significantly over the last decade. Many local producers are not affected by international quality standards as they do not export medicines and the Department of drug administration (DDA) does not enforce the WHO GMP standards strictly.
Further research exploring the quality of medicines in the Nepalese context seems as the need of the hour.
Brhlikova, P. et al., 2015. Aid conditionalities, international Good Manufacturing Practice standards and local production rights: a case study of local production in Nepal. Globalization and health, 11(1), p.25. Available at: http://www.scopus.com/inward/record.url?eid=2-s2.0-84935862368&partnerID=tZOtx3y1.
Central Bureau of Statistics, 2015. Nepal in Figures,
Gyanwali, P. et al., 2015. Surveillance of Quality of Medicines Available in the Nepalese Market: A Study from Kathmandu Valley. Journal of Nepal Health Research Council, 13(31), pp.233–240.
Nebot Giralt, A. et al., 2017. Quality assurance of medicines supplied to low-income and middle-income countries: poor products in shiny boxes? BMJ Global Health, 2(2), pp.1–7. Available at: http://gh.bmj.com/content/2/2/e000172.
Pandey, J., 2012. Elephantiasis : Banke folk worried about campaign. The Kathmandu Post. Available at: http://kathmandupost.ekantipur.com/printedition/news/2012-01-07/elephantiasis-banke-folk-worried-about-campaign.html.
Singh, D. et al., 2017. Designing the Free Drugs List in Nepal. MDM Policy & Practice, 2(1), p.238146831769176. Available at: http://journals.sagepub.com/doi/10.1177/2381468317691766.
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...
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 children in the RUTF-L group were no longer SAM.
We also note the concern that the ease and extent of recovery in our study is less than reported in African trials. However, as indicated in the paper, the population in our trial was significantly different from that in African trials: only 0.2% of our children had oedema, while it ranged from 38-80% in African trials. The mean WHZ score in our trial population was -3.5 while the mean ranged from -2.0 to -2.8 in Africa. Such differences make comparisons on ease and speed of recovery quite hazardous. One informed expectation is that recovery in the Indian population would take longer as they were further from the target of WHZ ≥ -2 SD.
We acknowledge Dr. Dadhich’s interest in the comparison of the performance of RUTF-C and RUTF-L. However, the trial was not designed to compare them. Given the lack of power for this comparison, we refrained from examining possible differences in their efficacy. We know that the composition of the two products was essentially the same and believe that any potential differences would likely be due to users’ preferences.
We agree that additional ways need to be found to rehabilitate these children. We see that in responding to SAM needs actions at the hospital level for children with complicated SAM, and at the community level, for treatment of uncomplicated cases, rehabilitation and prevention. Success requires that we provide treatment and also support families through comprehensive child care and promoting the best use of local resources. The rehabilitation of malnourished children, the sustainability of improvements and prevention of SAM need greater attention and possibly new approaches. We may need to extend the period of treatment while scaling down the management with therapeutic foods, or we may be more successful by increasing efforts to improve complementary feeding while continuing to use therapeutic foods as a supplement, or we may focus our efforts on improving complementary feeding without recourse to supplements. These approaches – or other that may be identified – should be tested to guide future efforts.
In the end, rehabilitation by whatever means must be a part of a comprehensive program and reach all target infants and children. This will require engagement at home, community and facility and not only facility-based interaction. It may be that some redesign of our overall strategy is needed. The issue of nutrition and growth in early life is critical and needs an evidence-based, thoughtful and yet practical way forward.
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...
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 between rates of Catholic affiliation and breastfeeding initiation. For the U.S., however, the crude correlations were in the opposite direction, because they were confounded by race/ethnicity and education. Displaying the crude data for U.S. states would therefore mislead the reader from the “true” (unconfounded) result: again, a negative correlation between the rates of Catholics affiliation and breastfeeding initiation among non-Hispanic Whites. We do not deny that other factors affect breastfeeding initiation rates in Western countries and could confound the association we observed with religious affiliation. They might also modify the effect of religious affiliation on breastfeeding. Race/ethnicity is one such factor, which is why we stratified our analysis of U.S. states by race/ethnicity. 1. Bernard JY, Cohen E, Kramer MS. Breastfeeding initiation rate across Western countries: does religion matter? An ecological study. BMJ Glob Health 2016;1(4):e000151. doi:10.1136/bmjgh-2016-000151.
I read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.
One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total...
I read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.
One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total fund utilized for renovation and equipment procurement were USD 170,000 and we can work on all the organisms which can be handled in a BSL-3 laboratory including viral and Orientia tsutsugamushi culture. We are also capable of performing PCR and RT PCR. We now propose that such One Health laboratories may be established at district headquarters.
Integrated diagnostic platform: Our laboratory is unique in the manner that we use integrated diagnostic platform for various organisms following the concept of public health laboratory given by Parson et al.3
Frontline Healthcare workers: In India, we have accredited social health activists (ASHA) working with community and the central government has recently started a course on frontline healthcare workers (akin to community health worker, CHW) as part of skill development. We propose to train these workers on animal health as well so as to make them One Health workers. They will also have access to smart phones with an innovative application for use of the CHW, medical officer and the local and central laboratories for maintaining health records of the patient using a biometric system, generation of requisition for various tests, tracking of samples shipped in a specially designed container to the reference laboratory, retrieval of results and prescription of treatment.
Newer Diagnostics for diseases of zoonotic importance: In tune of newer diagnostics for TB, we are also working on development of diagnostics tools for diseases common in our area, viz. malaria, brucellosis, scrub typhus and leptospirosis.
References:
Thierry Nyatanyi, Michael Wilkes, Haley McDermott, Serge Nzietchueng, Isidore Gafarasi, Antoine Mudakikwa, Jean Felix Kinani, Joseph Rukelibuga, Jared Omolo, Denise Mupfasoni, Adeline Kabeja, Jose Nyamusore, Julius Nziza, Jean Leonard Hakizimana, Julius Kamugisha, Richard Nkunda, Robert Kibuuka, Etienne Rugigana, Paul Farmer, Philip Cotton, AgnesBinagwaho. Implementing One Health as an integrated approach to health in Rwanda. BMJ Global Health Feb 2017, 2 (1) e000121; DOI: 10.1136/bmjgh-2016-000121
Narang R, Narang P, Deotale V. Containment Laboratory Running on Hybrid Power Sources: A Solution for Countries With Limited Access to Electricity? Int J Tuberc Lung Dis 2017; 21 (4), 480.
Parsons LM, Somoskövi Á, Gutierrez C, Lee E, Paramasivan CN, Abimiku AL, Spector S, Roscigno G, Nkengasong J. Laboratory diagnosis of tuberculosis in resource-poor countries: challenges and opportunities. Clinical microbiology reviews. 2011 Apr 1;24(2):314-50
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited reasons (5). Since centuries, the burden of pregnancy-related sufferings is very high in African and Asian countries. With all said above, I strongly commend the authors (1) for the challenges they have taken towards estimation of the pregnancy-related health crisis in India, Pakistan, Kenya, and Malavi. Regularization, standardization, and effectiveness are warned in pregnancy cares. In summary, India needs to act fast and effective to achieve the set sustainable developmental goals for safeguarding women's health.
Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...
Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or other interventions.
The cost of A-HPF (Augmented, Energy-Dense, Home-Prepared Food) was overestimated: (i) food was supplied at 1.5 times assumed requirements along with fuel, which merited costing or additional benefits adjustment; (ii) in Government programme, food procurement costs will be substantially lower because of expected integration with Public Distribution System and National Food Security Act; (iii) for bulk procurement, multivitamin mineral mix costs would be lower than pharmaceutical syrup used; (iv) as with exclusion of hospitalisation expenses, iron supplementation costs for anemic children should not be included because it is part of the National Iron Plus Initiative; (v) long-term benefits for the index child and family members, of extra counselling time for preparing various recipes needed to be factored in. Similarly, in the RUTF-L (Locally produced ready-to-use food) arm, employment and local economy benefits could have been accounted for.
It is unrealistic to expect a meagrely incentivised (INR 150) ASHA with several competing responsibilities to provide the same intensity and efficiency of ‘peer support’ as in the trial (incentive INR 700). The government guidelines cited to justify the ASHA incentive actually pertain to USHAs in urban contexts, which are awaiting implementation. Considering the potential for spontaneous recovery and lack of robust cost-effectiveness data from a “real world” Indian setting, a recommendation for scaling up CMAM through ASHAs is very premature.
Finite resources for public health spending invariably compel governments in LMICs to choose among interventions labelled as “very cost-effective”. An illustrative dilemma in Government setting comprises choices between cost of recovery for one SAM child, maternity cash entitlement (INR 6000) for four women, enrolling 20-24 additional families for Ayushman Bharat (annual health insurance cover of INR 5 lakh)3, or eggs twice a week for 46-58 children. All stakeholders, particularly the intended beneficiaries, should be an integral part of such selection process.4
References
1. Bhandari N, Mohan SB, Bose A, Iyengar SD, Taneja S, Mazumder S, Pricilla RA, Iyengar K, Sachdev HS, Mohan VR, Suhalka V, Yoshida S, Martines J, Bahl R, for the Study Group. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Global Health 2016;1:e000144. doi:10.1136/bmjgh-2016-000144.
2. Sachdev HS, Sinha S, Sareen N, Pandey RM, Kapil U. Survival and recovery in severely wasted under-five children without community management of acute malnutrition programme. Indian Pediatr 2017;54:817-24.
3. FE Bureau. Modicare: Cabinet nod for Ayushman Bharat. Financial Express, New Delhi, March 22, 2018. https://www.financialexpress.com/industry/modicare-cabinet-nod-for-ayush... accessed April 18, 2018.
4. Marseille E, Larson B, Kazi DS, Kahn JG, Rosen S. Thresholds for the cost–effectiveness of interventions: alternative approaches. WHO Bulletin 2015;93:118-24.
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.
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).
Show MoreStill, 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...
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...
Show MoreWe 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...
Show MoreI read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.
One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total...
Show MoreTo an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
Show MoreGarg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...
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