104 e-Letters

published between 2019 and 2022

  • 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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  • Using early BCG vaccination to reduce mortality among low-birthweight neonates

    In this systematic review and meta-analysis of evidence-based interventions to reduce mortality among preterm and low birthweight (LBW) neonates in low-income and middle-income countries, the implementation of four effective interventions in current WHO guidelines is encouraged: cord and skin cleansing with chlorhexidine, community kangaroo mother care, home-based new-born care and early Bacille Calmette-Guérin (BCG) vaccination.

    Regarding BCG vaccination, the authors identified two randomised controlled trials (RCTs) of BCG-Denmark vs. no-BCG to LBW neonates and estimated that providing early BCG reduces neonatal mortality by 36% (14% to 52%). In addition to the two trials, a small RCT of BCG-Denmark to LBW neonates reported an effect estimate of 0.28 (0.06 to 1.37).[1] In a combined analysis of the three datasets, providing early BCG-Denmark to LBW neonates at hospital discharge was associated with a 38% (17% to 54%) reduction in neonatal mortality.[2] Also, a recent Ugandan RCT of BCG-Denmark vs. no-BCG[3] found BCG-Denmark associated with fewer early-life infections, particularly for LBW, further strengthening the argument for using BCG-Denmark as an evidence-based intervention for LBW neonates.

    Many manufacturers produce BCG world-wide, and the genetically different BCG strains might not have the same effects on all-cause mortality. For example, two RCTs conducted in India evaluated the effects of providing BCG-Russia vs. no-BCG to a cohort of neonates...

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  • Conference equity in global health: are online conferences a solution?

    We congratulate the authors on their systematic review of conference equity in global health (1) and agree that this is a key step towards decolonising global health research. Their review identifies barriers and facilitators impacting attendance from low-and-middle-income countries (LMICs). The authors have identified many solutions to improve the equity of conferences but did not mention online conferences. These have rapidly become the norm during the COVID-19 pandemic and could offer a feasible solution. (2)

    The global pandemic forced the Global Women’s Research Society (GLOW) society conference to go online for the first time and it had dramatic impacts on the reach of the conference. We have run the annual UK-based GLOW conferences in global reproductive, maternal and new-born health since 2012, with a typical attendance of 70-140. In 2020, however, the pandemic forced us to pivot to an online conference. We fundraised £25,700 to provide the online platform and recordings, allowing free attendance for anyone from around the world. As a result, over 1300 people from 70 countries registered, with up to 1076 live views at one time. This works out at just £20 per registrant. During 2 days of the conference, there were a total of 3347 views, with 546 of those from LMICs. Additionally, there have been nearly 500 views of the videos on the YouTube channel since the September conference. We estimate costs of over £1,000,000 if all registrants and presenters had attend...

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  • The success of malaria digital dashboard is linked with development of basic health care infrastructure in rural/tribal areas

    We read the commentary by Rahi, M. et al., with great interest, about the need of digitisation of malaria surveillance data and its integration on a single digital platform for malaria elimination in India1. There is no doubt that digitisation of malaria surveillance tools and data will help patients, clinician, researchers, policy makers alike and ultimately may contribute in malaria elimination, if implemented timely and efficiently. However, the proposition of digital dashboard for collection, integration and sharing of data on malaria, though important, but seems a little far-fetched conjecture at this moment as majority of malaria cases are reported from rural/tribal areas with sparsely distributed health care and telecommunication infrastructure. The top ten tribal dominated states with a population of 36 % contribute about 73 % of total malaria cases2. The strength of healthcare workforce is poor in rural/tribal areas of India in comparison to the WHO minimum threshold of 22.8 per 10 000 population3. Further, there is strong need to strengthen the power (electricity), telecommunication and transport infrastructure in rural/tribal areas. Such healthcare environment in tribal areas increases the reluctance among tribal people for the public health care system and leads them towards quacks, traditional healers and nearby private practitioners. Further, this digital drive of healthcare system would require additional human resource, periodical training and digital infr...

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  • In reply to Pimenta

    Many thanks to Dominic Pimenta for the interesting comment. I respect Pimenta’s well-intentioned activism during the COVID-19 crisis, but here he polarizes the discussion between two schools of thought by using a strawman argument, i.e. that one of the two schools wants to promote high community transmission. Such strawman arguments are prevalent in social media and the blogosphere, but they do not serve scientific discourse for resolution of major questions. I have signed neither the Great Barrington Declaration nor the John Snow Memorandum, so I cannot become an insider apologist for either (1). However, my reading of both documents suggests that neither of them advocates to promote high community transmission. If they do, this is certainly not what I would personally advocate.

    Pimenta draws a correlation from 10 observations on the data that I present on nursing home shielding factors (my Table 3) reaching the conclusion that precision shielding is impossible under high community transmission. This is a precarious exercise with rushed conclusions. These are ecological, whole-country data including only 4 observations with high community transmission. Drawing firm causal inferences from an ecological regression with effective sample size of n=4 is impossible. Sadly, over-confident, stretched causal inferences are common during the COVID-19 crisis. A similar look at the age-stratified data on Table 2 shows that shielding of the elderly was achieved in countries w...

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