104 e-Letters

published between 2019 and 2022

  • Lockdowns and Climate Change: A Spur to Action

    In the BMJ Global Health article, “Is the cure really worse than the disease? The health impacts of lockdowns during COVID-19“, Meyerowitz-Katz et al. (1) seek to assess the impact of lockdowns on population health. However, any comprehensive evaluation of the impacts of lockdown may benefit from including the broader effects that such restrictions may have on health due to environmental changes - particularly in regard to air pollution and greenhouse gas (GHG) emissions and the flow-on effects these have on human health due to climate change.

    As described by the authors, lockdowns are associated with broad detriments to human health and are generally undesirable. However, there is now considerable evidence that lockdowns result in noticeable decreases in air pollution. The 6th IPCC Assessment Report deems with high confidence that air quality improved as a result of COVID-19 lockdowns (2). When global lockdowns reached their most widespread point in April 2020, global CO2 emissions decreased by 17% (3), while global NOx emissions decreased by 30% (4), representing reductions in both long-lived and short-lived climate forcers.

    Unfortunately, though these variations are measurable, the effect of such fluctuations on climate change are likely to be negligible (4) and transitory in nature (5, 6). Despite the popular perception that “nature is healing” as a result of lockdowns, the effects are unlikely to mitigate climate change on their own.

    Yet even so...

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  • Commentary on “The Merit Privilege” by Dr. Prashanth N Srinivas

    Since long, the debate on meritocracy has been in the academic circle which originated from academicians, researchers, professionals and students belonging to ‘lower and/or backward’ castes. However, not much attention was paid to such discussions by the privileged and elite majorly because of their vested interests associated with it or due to the fact that we considered this caste as an uneducated, uncivilized and voiceless community unless they are educated and speak for themselves their voice become a part of the politicization of caste system.

    This uncomfortable point is time and again raised by many on several instances like suicide of Rohith Vemula (Leonard, 2019: 52), hurling abuses by Prof Seema Singh to the marginalized caste students in IIT Kg (Datta, 2021), etc. however, meritocracy becomes a topic of intense discussion when a globally recognized political philosopher Michael Sandel put them into words and problematizing the way the elites think.

    Once again, the lateral entry in UPSC was criticised at various fronts ranging from students’ protests to policy researchers. The connection of meritocracy with public policy and public health is due to technocracies and the policy decisions which were not so fruitful in the recent past. However, this was the same danger which dissenters were warning the world. That reminds us of Avengers Endgame when Tony Stark said to Steve Rogers that we are Avengers and not “pre-vengers”.

    Similarly, scien...

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  • Age difference and changing marriage age can add to male surplus

    An additional factor of importance in the perception of a gender imbalance is the consequence of an age difference between partners (e.g. groom and bride) and the growth rate of the respective society. If, for example, there was a constant age difference of 5 years between (older) men and (younger) woman, and around 2% of annual population growth, leading to an increase of 10% in the number of births over each 5 years, that in its effect would just counterbalance a 10:9 sex imbalance (around 47.5% women to 52.5% men). In a shrinking society with a similar preference for younger women, the two effects would add and the imbalance in birth rates would feel even worse for men.

    The imbalance would ultimately affect the “market power” of the respective genders in partnerships and/or the “marriage market”. If women actually prefer a partner of similar age, and woman of one cohort can start to pursue that preference due to the “oversupply” of men, this would further enhance the marriage squeeze for men, as even more of the older bachelors would be left out while the women turn to the younger competitors of the older men. Certainly, in the advent of such transition, some men will overlook that effect and thus be left out unmarried once the patterns have changed.

    A gradual increase of the age of marriage may also trigger or enhance that effect: Young women (or their parents, to the extent they are participating in the choice of their daughters partner or life partner)...

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  • What is being disinfected?

    The authors report a reduction in transmission in households regularly disinfecting with chlorine or ethanol based agents, but what is being disinfected is quite vague. Does this include household that, for example, only use bleach in the bathroom? Was this limited to household disinfecting ALL non-porous contacted surfaces? Did this include the use of bleach on laundry? If the authors could clarify what cleaning practices this actually encompasses, that would be appreciated.

  • “Antibiotic” does the term lead to confusion?

    McKinn et all state in their work published in the BMJ state that drivers of antibiotic misuse in Vietnam are socio-economic than biomedical in nature (1). However, does linguistics play a role as well?

    What is an antibiotic? The generally accepted definition is that an antibiotic is a drug that is used for the treatment of bacterial infections (less commonly to prevent), these agents can either kill or inhibit the growth of bacteria.

    However, the term antibiotic, as opposed to an antibacterial, may denote a drug with a wider activity, an agent that is active against any “biotic”. Reading on the origin of this term, it appears that this was the original meaning of this term (2).

    In a couple of recent surveys that we conducted, we identified that many people have this misconception. This was more obvious in open ended questions. In an online survey conducted in Sri Lanka, 190 (93.1%) participants out of 204 stated they knew what an antibiotic is and defined it in their own terms. However, 51 (26.8%) of this190 defined antibiotics as agents that can kill any micro-organism (3).

    In the same group of people, 12 mentioned substances other than antibiotics as examples of antibiotics, including antiseptics with antibacterial properties such as povidone iodine and triclosan, a vaccine (anti-rabies vaccine), paracetamol, chlorpheniramine and cetirizine, domperidone, aspirin, insulin, saline, and plants (cannabis and “weniwelgeta”).

    In both the...

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  • The COVID-19 pandemic as a watershed moment: the importance of improved monitoring of population health needs

    Tamrakar and colleagues have undertaken a welcome, and coherent, evaluation of the completeness and representativeness of prevalence inputs for low back pain used in the Global Burden of Disease (GBD) 2017 study [1]. These types of assessments are particularly important so that users are aware of the uncertainties at each stage of the process for estimating disability-adjusted life years – and even more so for low back pain, which is consistently found to be one of the leading causes of health losses worldwide. They can assist users in appraising modelled estimates in a way that can more readily be triangulated with country-level evidence.

    Issues of uncertainty and generalizability of modelled estimates mainly arise due to a paucity of data. From the perspective of burden of disease assessment this is common across many health conditions which are data sparse, and thus have to rely on modelled estimates on the occurrence and distribution of severity of cases [2]. In the case of low back pain this mainly arises because a large proportion of people do not routinely access care services to manage their symptoms, which is also common for other musculoskeletal disorders and headaches. In both the GBD and national burden of disease assessments, the reliance of secondary use of administrative data (e.g. hospital, prescriptions or GP consultation records) is not an ideal proxy.

    The public health monitoring of individual health conditions has reached a watershed mome...

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  • Research Priorities to address TB and HIV in Eastern Europe against a background of COVID-19.

    Ranzani et al. [1] elegantly describe the research priority framework to address the deteriorating TB situation for the mainly LMIC countries of Latin America, which has relevance to other regions. Although the countries of WHO Europe have reduced the overall TB burden (by an average 5.1% annually from 2014-18), multidrug resistant TB rates (MDRTB) are persistently high with the proportion of Rifampicin-resistant and MDRTB among new (18%) and previously TB treated (54%) cases significantly exceeding the global average (3.4% and 18% respectively) [2]. The HIV situation in this region is also dire; 1.4 million people were living with HIV in Eastern Europe and Central Asia in 2017, with the two highest proportions in Russia and Ukraine [3], creating a significant TB-HIV co-infection problem where 13.1% of TB patients tested were HIV infected [2].

    The COVID-19 pandemic has impacted all countries, but acutely on TB diagnostics and treatment especially in high TB burden LMICs. Recently the StopTB partnership examined the diagnosis and treatment statistics for nine countries, including Ukraine, representing 60% of the global TB burden; TB diagnosis and treatment enrolment in 2020 declined by 1 million or an average 23% in individual countries compared to 2019 [4].

    The WHO leads global efforts to prioritise research (and research is a key intervention as one of the pillars of the WHO End TB Strategy) with regional variations [5,6,7]. For Eastern Europe, the global i...

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  • Questionable reliability of the zinc results

    To the editor and authors,

    We have several concerns about the zinc results in this systematic review

    1. Weismann et al. 1990 RCT evaluates zinc for treating, not preventing infections, yet is included in the prevention meta-analyses (Figure-6).

    2. Farr et al. 1987 reports post-exposure prophylactic and treatment results for two RCTs. Which RCT was used? Why was the other ignored? Supp-Table-5 reports an incorrect sample size and MD rather than RR. The validity of combining pre- and postexposure prophylactic trials is questionable and at the very least, should be discussed.

    3. Turner et al. 2000 reports two RCTs, both had 4 arms. Why was one RCT and two of the three zinc arms ignored? If these arms were included, an explanation for how the means (SDs) were combined is missing.

    4. Table 3 lacks transparency as the studies used in each subgroup are not cited and often it is unclear what data was used. For example, none of the five RCTs included in the zinc prevention meta-analysis reported infection rates for males and females, yet this is reported.

    5. The authors claim there was no evidence of a dose response for zinc used for treatment. Only two RCTs evaluated a dose ≤13.3mg/day. Both used intranasal sprays/gels. All other treatment studies evaluated lozenges. Comparing doses for different administration routes is clinically meaningless. All this analysis tells us is there is no difference between intranasal and sublingual adminis...

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  • Social isolation may have different associations with fatal versus non-fatal incident CVD

    In their laudable analysis of the Prospective Urban and Rural Epidemiology study, Naito and colleagues(1) used multivariable Cox regression to examine social isolation in relation to all-cause mortality, cardiovascular disease (CVD) mortality, and cause-specific incidence and mortality. Drawing upon the latest evidence in the field, the purpose of this letter is to highlight three strengths of this study and propose an alternative explanation for the observed association between social isolation and CVD incidence.

    Naito and colleagues’ study contributes novel insights into potential risk factors for social isolation across high, middle and low income settings. Further, their findings in relation to all-cause and CVD mortality strengthen the literature suggesting that greater isolation is associated with increased mortality.(2) While it is unclear that the assumptions required to calculate population attributable fraction(3) are reasonably met when examining social isolation and mortality, the authors' analysis also contribute to growing evidence(4) that raises questions about the validity of the popular claim that social isolation is as bad for health as smoking.(5–8)

    Compared to less isolated participants, Naito and colleagues observed 15% increased CVD incidence among the most isolated participants (HR=1.15, 95% CI: 1.05 – 1.25).(1) The CVD incidence outcome they measured “…included fatal or non-fatal myocardial infarction, stroke, heart failure and ot...

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  • Excess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Aden governorate, Yemen - A Response

    Dear Editor,
    I thank Ms Besson and colleagues for their useful research into excess mortality in Yemen. They have highlighted effective use of excess mortality as a measure of the COVID-19 pandemic’s impact. Their new technique for determining excess mortality potentially overcomes a major limitation in its normal calculation, that is, the predominance of low quality civil registration systems in many LMICs (1). I would like to offer some comments on this research.
    A key element in any determination of excess mortality is the comparative baseline period adopted (2,3). The authors have selected a baseline period beginning in July 2016, but given that the Yemeni conflict began far prior to this, I wonder why this arbitrary start-point was selected (4, 5). Whilst the authors have also referred to armed conflict intensity data, I do not see its application in the final results. Such intensity data could have been useful in selection of the comparative baseline period, in order to provide a more accurate analysis of excess mortality related to COVID-19. As conflict related mortality in Yemen, as well as mortality related to food insecurity, has varied significantly over the last number of years, it is particularly challenging to compare like with like (4, 5). These changing trends in mortality must be accounted for in order to produce a truly accurate calculation of excess mortality. Further to this, whilst 1st April was understandably selected as the date at whic...

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