140 e-Letters

  • 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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  • 'Decolonising’ the decolonising rhetoric

    None of the authors of this decolonising roadmap listed an association with an academic institution in a low-and middle-income country (LMIC). They represented two London schools, two NGO organizations based in Geneva, and one from a former colony—Australia. No doubt these authors share a wealth of experience in low- and middle-income countries but the platforms they chose to speak from exemplify some of the best of high-income country Western (Northern?) educational and humanitarian outreach.

    The critical inequities they cite include:
    • Limiting participation of LMIC experts and community representatives
    • Arbitrarily choosing interventions or research topics with little coordination or engagement
    • Typically placing European or North American ‘experts’ in leadership positions with minimal experience working in the project setting,
    • Basing staff, offices and other resources in high-income countries
    • Funding application evaluation panels without or with limited representation from affected communities or stakeholders in which work will be done; grants awarded without due consideration for partnership ethics.

    A 15 April 2021 Nature Medicine letter reported, “Not one African institution was named in the press release” when a USD30 million grant for assisting African nations in “improved use of data for decision-making in malaria control and elimination” was announced. 1

    Perhaps this BMJ GH editorial is a roadmap for s...

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  • Public health education integral to structural health system change

    Dear Editor:

    Ghaffar, Rashid, Wanyenze, and Hyder invite to the dialogue and debate on the revision for public health education (PHE) as a topic of global importance. They do it from a diverse perspective including the developed and developing economies, and the challenges of practice.
    I want to contribute based on the lessons learned from my experience during a previous pandemic, and my concern on the lack of full realization of the potential of public health methods and knowledge to manage this current crisis.

    Since the Influenza A(H1N1) 2009 pandemic, we realized that its management called for work with the economic, educational, agriculture and nutrition, labor, housing, transportation, tourism, and it can be achieved only with established platforms for this collaboration (1). The epidemic demanded for a differentiated care of the poor and those with cultural barriers, the pregnant, of those living with obesity or chronic co-morbidities. That it required massive behavioral change – only possible though effective health promotion functions -, and the assurance of safe settings, medical care (2), and products. That the local action had global implications. It was clear since then the central role of well-organized local public health service delivery, the place for effectively containing the spread. And we saw the importance to constrain the politicizing of the epidemic, by having rigorous, rapid, and fearless exercise of the public health authority....

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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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  • 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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  • 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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  • We strongly strongly advocate unrestricted access of parents to their infants and to skin to skin care

    We would like to congratulate Suman PN Rao et al on this very important and useful work.
    On behalf of the Global Newborn Society would strongly advocate unrestricted access of parents to their infants and to skin to skin care.

    Current SARS-CoV-2 pandemic-related restrictions on skin-to-skin contact (SSC) and parental involvement in neonatal care, in place in many parts of the world, are not based on clinical evidence. Hospitals and neonatal units have, to varying degrees, restricted parental access and SSC without due consideration of the harms this might cause on multiple fronts (1). Based on current evidence a ‘blanket ban’ on SSC by various maternity and neonatal services across the globe is unfortunate, not evidence based and needs to be reviewed on an urgent basis.

    The World Health Organization (WHO) recommends skin-to-skin contact (SSC) following delivery in babies weighing 2000 grams or less at birth, as soon as they are clinically stable to prevent hypothermia (2). In low resource settings lack of initiation of early SSC is an independent predictor of hypothermia, contributing to neonatal mortality and morbidity (3). The United Nations Children’s Fund Baby Friendly Hospital Initiative recommends immediate SSC after birth based on physiological, social, and psychological benefits for both mother and baby (4).

    The risk of SARS-CoV-2 infection in neonates both vertical and horizontal is relatively low with no significant mortality (5), how...

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  • A second wave but a stronger Mauritius

    I read with great interest the article that helped Mauritius overcome their first wave of COVID-19 infection. Unfortunately, just like several successful countries, Mauritius is now facing a second wave of infection and a second lock-down has been declared by the Prime Minister, starting on the 11th March 2021. As the number of COVID-19 cases continues to rise daily, the Mauritian Government is relying heavily on the cooperation of its citizens, as well as their massive vaccination campaign to reach herd immunity. The vaccine was first made available to the elderly and those at higher risks( including front-liners). Since the lock-down, the Mauritian Government has further prioritized everyone who is a front-liner or has a valid "work access permit". As of the 18th March 2021, around 74,000 Mauritians have already been vaccinated and a daily target of 8,000 new vaccinations is being provided through the 14 vaccination centers set up across the island. The Minister of Health and Quality of Life also confirmed the arrival of another 200,000 doses of COVAXIN from India on the 19th of March 2021.
    Mauritius has, once again, reacted fast and strongly to the outbreak. The lockdown was issued without hesitation and the population has been more compliant with the orders compared to last year. Hopefully, once the country achieves its target of vaccinating 60% of the population, herd immunity will be reached and gradually the pandemic will be under control.


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  • Vaccinating children in high-endemic rabies regions: why we should test assumptions first

    A recent commentary advocates for the inclusion of rabies vaccine in EPI,1 referring to lack of timely available post-exposure prophylaxis (PEP) in most low-income settings. Priming with pre-exposure profylaxis (PreP) in the form of rabies vaccine extends the response window and might even provide protection without subsequent PEP.

    The authors are commended for shedding light on a neglected tropical disease, and we sympathize with the notion that universal health policy should implicate equal access to vaccines, and not be restricted to wealthy travelers in rabies endemic zones.

    However, the benefit of implementing routine rabies vaccinations is not self-evident. A plethora of epidemiological and clinical studies find that some vaccines have non-specific effects (NSE), i.e. modifying resistance to diseases unrelated to the target pathogen. The live BCG and measles vaccine (MV) have been shown to reduce mortality to non-tuberculosis and non-measles infections, respectively. In contrast, the non-live vaccine DTP has been associated with deleterious NSE, increasing overall mortality in girls.2

    The rabies vaccine, currently a non-live vaccine, has also received attention for its putative NSE. A malaria vaccine trial using rabies vaccine as control in one study arm found that girls receiving the malaria vaccine had a 2-times higher overall mortality than controls, indicating a detrimental effect of the malaria vaccine,3 or a beneficial NSE of the rabies (...

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  • Letter to the editor: “Conference equity in global health: are online conferences a solution?"

    Lotta Velin1,2, Ulrick Sidney Kanmounye1,3, Michelle Nyah Joseph1,4

    1. Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
    2. WHO Collaborating Center for Surgery and Public Health, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
    3. Department of Neurosurgery, University of Kinshasa Faculty of Medicine, Kinshasa, Congo (the Democratic Republic of the)
    4. Warwick Clinical Trials Unit, Warwick Medical School, Coventry, West Midlands, UK

    Correspondence to: Dr Michelle Nyah Joseph; Michelle_Joseph@hms.harvard.edu

    We want to congratulate Phan et al. on their thoughtful analysis of our article “Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences” (1). Phan et al. are addressing inequities in global health conferences. This is evidenced by their inspiring work with transitioning the Global Women’s Research Conference (GLOW) from a physical to an online event. It is clear from Phan et al. recount that the transition helped increase access and equity to a major global health conference. We agree with the authors that such a strategy can help address many of the barriers we identified in our systematic review.

    Prior to 2019, some global health events offered an online component; however, none of the major global health conferences hel...

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