Coming from an international relations background, I'm pleased to see more discussion of topics like this in global health, which were absent from my Global Health studies. Public health too often doesn't directly deal with power, though power is so central to health outcomes- positive and negative. I think our engagement with power imbalances is a big part of understanding power in public health, which includes seeking economic justice for marginalised groups.
Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.
As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.
Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of th...
Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.
As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.
Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of the global epidemiology of Lyme disease. Caution should be exercised here since Lyme disease as a clinical entity is only reliably described from temperate areas of the northern hemisphere, mirroring the distribution of its tick vectors (2). At least 20 species of bacteria belong to the Bbsl complex (2, 3) and could be transmitted to humans through a tick bite, but only a handful are pathogenic and cause Lyme disease (3). The serology assays used internationally to estimate borrelia exposure may recognise antibodies generated against non-pathogenic Bbsl species. Consequently, the Bbsl global seroprevalence estimate overestimates those who have experienced clinical Lyme disease (or asymptomatic infection) and may explain why Dong et al give Bbsl seroprevalence estimates for countries where no Lyme disease cases have been confirmed.
Dong et al derived a seroprevalence estimate for the UK in the 11-20% range based on two Scottish studies, with calculated seroprevalence estimates of 4.17% and 36.48% (4, 5). One (4) used Scottish blood donors. The other (5) utilised sera from individuals with suspected Lyme disease; it was not a study on either seroprevalence or incidence, was not representative of the general population and its inclusion introduces bias into the results. The true seroprevalence figure for Scotland is likely closer to the 4.2% estimate but importantly, there is regional variation (0 - 8.6%) within Scotland (4). Dong et al have used the biased Scottish estimate to extrapolate from one UK nation to others (England, Wales and Northern Ireland). This is misleading since published data on lab-confirmed Lyme disease cases show a higher incidence for Scotland than the other UK nations (6), although published seroprevalence data for the general populations in the other UK nations is lacking (6).
The study by Dong et al has been widely reported by media outlets leading to headlines claiming 1 in 7 people globally have been exposed to B. burgdorferi at some time (7). As described above, the interpretation of the ‘global’ seroprevalence estimate is flawed as are media releases based on it and may mislead and alarm the public unnecessarily. What is most important is that the public understand where high risk areas are locally and when travelling overseas, so that they can take appropriate measures to limit their exposure to ticks and to prevent Lyme and other tick-borne diseases.
References
1. Dong Y, Zhou G, Cao W, Xu X, Zhang Y, Ji Z, et al. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health. 2022;7(6).
2. Mead PS. Epidemiology of Lyme disease. Infect Dis Clin North Am. 2015;29(2):187-210.
3. Bobe JR, Jutras BL, Horn EJ, Embers ME, Bailey A, Moritz RL, et al. Recent Progress in Lyme Disease and Remaining Challenges. Front Med (Lausanne). 2021;8:666554.
4. Munro H, Mavin S, Duffy K, Evans R, Jarvis LM. Seroprevalence of lyme borreliosis in Scottish blood donors. Transfus Med. 2015;25(4):284-6.
5. Mavin S, Evans R, Milner RM, Chatterton JM, Ho-Yen DO. Local Borrelia burgdorferi sensu stricto and Borrelia afzelii strains in a single mixed antigen improves western blot sensitivity. J Clin Pathol. 2009;62(6):552-4.
6. Lorenc T, Jones-Diette J, Blanchard L, et al. Incidence and surveillance of Lyme disease: systematic review and policy mapping. London: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London; 2017.
7. Wetzel C. More than 1 in 7 people worldwide have had Lyme disease. New Scientist. 2022.
The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
As far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "e...
The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
As far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "emerging infectious diseases", 70% of which would originate, in turn, from one or more animal reservoirs, as definitely proven with the two betacoronaviruses SARS-CoV and MERS-CoV, while being largely plausible and highly suspect also in the case of the pandemic SARS-CoV-2 betacoronavirus (2).
The seven years between 2015 and 2021 have been the hottest ones ever recorded on Earth within the last 140 years, with this significantly impacting also the vectorial efficiency of arthropods toward their respective pathogens. Indeed, under the present meteo-climatological conditions insects and ticks are now being increasingly reported to overcome the autumn and winter seasons ("overwintering") far more easily than in past decades. These progressively higher and higher average temperatures are responsible, in fact, for a (more or less) consistent reduction of the life cycle and replication ("extrinsic incubation period") of the infectious pathogens carried inside insects' and ticks' bodies. Based upon the above, a progressive "transfer to northern latitudes" of arthropod-borne infections, of either viral or non-viral aetiology, has been documented in more or less recent years, as clearly shown by the emergence of bluetongue virus - carried by Culicoides spp. - among ruminants from northern European Countries (3), as well as by the detection of Leishmania spp. - carried by Phlebotomus spp. - in dogs from UK (4).
In consideration of the above and, most importantly, in view of the documented zoonotic potential of many viral and non-viral, arthropod-borne pathogens (including WNV), a "One Health"-based and multidisciplinary approach would be absolutely needed for an "ad hoc" management of the complex ecology and epidemiology of the infections caused by such agents, with this reminding us (once again!) that human, animal and environmental health are mutually and inextricably linked to each other.
References
1) Cantile C, Di Guardo G, Eleni C, Arispici M. (2000). Clinical and neuropathological features of West Nile virus equine encephalomyelitis in Italy. Equine Veterinary Journal 32:31-35. doi: 10.2746/042516400777612080.
3) Carpenter S., Wilson A., Mellor P.S. (2009). Culicoides and the emergence of bluetongue virus in northern Europe. Trends in Microbiology 17:172-178. doi: 10.1016/j.tim.2009.01.001.
4) McKenna M., Attipa C., Tasker S., Augusto M. (2019). Leishmaniosis in a dog with no travel history outside of the UK. Veterinary Record 184:441. doi: 10.1136/vr.105157.
It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?
As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had r...
It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?
As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had received ethical approval, which were typically met with shared concern. Whilst the editorial board had numerous scientific experts examining the study designs and methodologies, they did not have a dedicated ‘ethics expert’ responsible for appraising the ethical appropriateness of the submitted studies. The experience left me with doubt that the editorial team had the interest or capacity to proficiently identify ethical issues in the papers submitted for publication.
Doherty et al.’s commentary together with similar published concerns and my own experiences have left me wondering: is it time to explore the pros and cons of appointing ‘ethics experts’ to the editorial boards of peer-reviewed journals?
Yours sincerely,
Dr Robert Torrance
References:
1. Attarwala, H. TGN1412: From Discovery to Disaster. JYP 2010;2:332.
2. Doshi, P. WHO’s malaria vaccine study represents a “serious breach of international ethical standards.” BMJ 2020.368.
How to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice
A. Metin Gülmezoglu1, Sara Rushwan1
1 Concept Foundation, Geneva, Switzerland
We welcome the paper by Tran et al [1]. There are increasing number of options for postpartum haemorrhage (PPH) prevention and management as recommended by WHO and the context is important. We agree that at the national level the first step is to update the national policies including the guidelines and essential medicine lists (EMLs). Since 2019, Concept Foundation and its partners have been working in 14 East and West African sub-Saharan countries to facilitate those updates [2]. We are pleased to report that in 10 out of the 14 countries – Burkina Faso, DRC, Ethiopia, Ghana, Ivory Coast, Liberia, Rwanda, Sierra Leone, South Sudan, and Uganda – the national guideline and/or EML were updated during this period.
The strength of the project lies in the engagement with policy makers, Ministry of Health officials, clinicians, professional associations, and civil society organizations concurrently. However, competing national policy priorities such as COVID-19, timing of the previous updates, political instability and national capacity and leadership (or lack of) can make the updating process long and challenging even when there is an agreement to update. Secondly, even when the updates happen, proactive dissemination and training within the country can also take time. Thirdly, in the...
How to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice
A. Metin Gülmezoglu1, Sara Rushwan1
1 Concept Foundation, Geneva, Switzerland
We welcome the paper by Tran et al [1]. There are increasing number of options for postpartum haemorrhage (PPH) prevention and management as recommended by WHO and the context is important. We agree that at the national level the first step is to update the national policies including the guidelines and essential medicine lists (EMLs). Since 2019, Concept Foundation and its partners have been working in 14 East and West African sub-Saharan countries to facilitate those updates [2]. We are pleased to report that in 10 out of the 14 countries – Burkina Faso, DRC, Ethiopia, Ghana, Ivory Coast, Liberia, Rwanda, Sierra Leone, South Sudan, and Uganda – the national guideline and/or EML were updated during this period.
The strength of the project lies in the engagement with policy makers, Ministry of Health officials, clinicians, professional associations, and civil society organizations concurrently. However, competing national policy priorities such as COVID-19, timing of the previous updates, political instability and national capacity and leadership (or lack of) can make the updating process long and challenging even when there is an agreement to update. Secondly, even when the updates happen, proactive dissemination and training within the country can also take time. Thirdly, in the case of heat-stable carbetocin (HSC), even when policy updates are accomplished, the regulatory approval that is essential for the drug to enter the country can take time.
In 2021, we expanded our collaboration to include the International Federation of Gynecology and Obstetrics (FIGO) and International Confederation of Midwives (ICM) and their national counterparts to support the transition from policy updates to the development of clinical management protocols and job aids. FIGO and ICM developed a generic protocol on PPH prevention and treatment [3] and engagements with key national stakeholders were held to discuss its usability and adaptability to the country context, and how it could support existing country practices. So far, Ethiopia, Ghana, Rwanda, and Uganda have developed a national PPH clinical protocol that has been approved by the Ministry of Health, and these countries will develop supporting job aids. This work is planned to be completed in 4 other countries – Burkina Faso, Liberia, Sierra Leone, and South Sudan.
The main determinant of choosing which drug(s) to use should be the presence of a skilled birth attendant and reliable cold chain and storage. The more established injectable uterotonics must be kept in cold chain and storage, and quality-assured products must be prioritized for procurement. Implementation considerations must include ensuring that staff know and adhere to the fact that HSC is contraindicated for labour induction and augmentation. HSC is often used for PPH treatment, but this is off-label and the benefits and potential harms are uncertain. Both HSC and tranexamic acid (TXA) should be considered for implementation in peripheral and referral levels of the health care system since at peripheral level the cold chain issues are likely to be more prevalent and the lifesaving role of a quality-assured uterotonic and timely administered TXA in cases of haemorrhage is likely to be crucial. The fact that there seems to be support for intramuscular administration for TXA will make implementation at the periphery easier [4]. In referral settings with surgical capacity, it is essential that TXA is kept in a place where accidental mix-up with local anesthetics that are used in intrathecal anesthesia is avoided, since there have been case reports of deaths due to accidental TXA administration into the intrathecal space [5,6].
We also agree that HSC and TXA should be carefully integrated into the health system in an enabling environment and considering the context perspectives mentioned above. Concept Foundation will conduct implementation pilots in Burkina Faso, Ethiopia, Ghana, Sierra Leone, and Uganda to assess appropriate use following training of healthcare providers, and integration of the two medicines into routine PPH care management. The results of this research will be useful in better understanding the enablers and barriers for successful introduction of essential PPH medicines into clinical practice.
Our experience demonstrates that there are several barriers to access essential, heat-stable PPH medicines that require operationalization of end-to-end thinking at the national level. By end-to-end thinking, we mean addressing the challenges from the highest national policy level right down to the practicing care provider in the most peripheral level of health care where childbirth takes place. To date, most existing programs have focused either on policy level change or health care provider behavior change. Our project adopts a holistic approach, that seeks to align normative change, clinical protocol development, pilot implementation, procurement, and product introduction.
Progress in our project presents a great opportunity to allow the objectives and approach to be achieved in most high-burden countries with modest resources. However, there is undoubtedly a greater need for investment in advocacy, training, and dissemination tools to support the implementation of national guidelines in a locally appropriate way, while ensuring the WHO recommendations are reflected accurately.
References:
[1] Tran NT, Schulte-Hillen C, et al. How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health. 2022; 7:e008913.
[2] Concept Foundation, Country Support page. Geneva; 2021. https://www.conceptfoundation.org/what-we-do/country-support/. Accessed April 28, 2022.
[3] International Federation of Gynecology and Obstetrics (FIGO), Current FIGO projects, IAP page, Project Resources. London; 2022. https://www.figo.org/improving-access-essential-medicines-reduce-postpar.... Accessed April 29, 2022.
[4] Arribas M, Roberts I, et al. WOMAN-PharmacoTXA trial: Study
protocol for a randomised controlled trial to assess the pharmacokinetics and
pharmacodynamics of intramuscular, intravenous and oral administration of
tranexamic acid in women giving birth by caesarean section. Wellcome Open Res. 2021; 6:157.
[5] Patel S, Robertson B, et al. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019; 74: 904-914.
[6] Palanisamy A, Kinsella SM. Spinal tranexamic acid – a new killer in town. Anaesthesia. 2019; 74: 831-833.
The activities in this narrative were supported by funding from MSD, through its MSD for Mothers initiative and are the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Rahway, NJ, USA
Dear Editor
Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)
The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.
However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.
When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.
Dear Editor
Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)
The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.
However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.
When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.
Thus, a new implementation strategy could be significantly more costly than the previous one.
Yours Sincerely
Thomas Walsh
References
1. Ross I, Esteves Mills J, Slaymaker T, et al. Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries. BMJ Global Health 2021;6:e007361.
The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.
In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationa...
The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.
In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationally accepted methodologies and standards to conduct independent investigations that lasted several months and concluded the conflict could not be labeled as ethnic cleansing or genocide; and that acts of sexual violence were committed by individual soldiers and militia from all warring factions including those operating under the TPLF umbrella (3).
In describing humanitarian efforts in the region, the analysis fails to mention that food aid was systematically diverted to combatants rather than civilians and has been used by TPLF leadership in what could be fairly labeled “food as weapons for military recruitment”. Further, the analysis focuses on the assistance of multilateral organizations but fails to describe the extensive assistance provided by the Federal Ministry of Health of Ethiopia in the form of healthcare equipment (worth billions of Ethiopian Birr), medicines, salaries and other benefit packages for over 20,000 healthcare workers in the region, and to analyze the impact of the deployment of over 400 Ethiopian healthcare professionals to the Tigray region to support the Health Care Restoration Plan between November 2020 and June 2021.
This protracted war has indeed ravaged health infrastructure – not only in Tigray, but also in vast regions of Amhara and Afar. It has cost too many lives, devastated the economy, broken families, torn friendships apart, and set back global health and economic initiatives aiming to improve the health and well-being of all Ethiopians. The main victims of this war are ordinary Ethiopians: farmers, drivers, clerks, storekeepers, healthcare workers, mothers and children. We owe it to them to respect the basic tenets of academic integrity, and base our analyses on an even-handed look at the evidence and clearly reasoned arguments, rather than faulty premises and distorted narratives.
Hi,
Its more of a doubt. I would like to know what risk of bias tool was used by the team? What were the findings on risk of bias, since I couldn't find anywhere in the article reporting the same.
Dear authors,
Since I have worked in remotest of PHCs in Himachal Pradesh, India and now am supervising them, the most unfavorable atmosphere for embedded research at grass roots is non availability of ethical committees and due to that either doctor fail to do research in field conditions or their research is hijacked by the medical colleges as PIs . Most of the medical colleges don't allow outside field doctors to get ethical clearance and have condition that medical college faculty would be PI for any research proposal/project, only then anyone can get research proposal listed in IEC.
I am trying to have an ethical committee notified at the level of Directorate of health so that PHC doctors can also get ethical clearance for their research this paper is talking about.
Thanks for raising this issue at global level.
Regards,
Dr. Omesh Kumar Bharti, Field Epidemiologist bhartiomesh@yahoo.com
We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
India has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now...
We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
India has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now begun to see the ill effects of pandemic on nutrition as collateral damage.We report two important observations on occurrence of Neural tube defects and severe acute malnutrition in children during the years from 1st January to 31st December of 2020 and 2021. The study has been done in Maharashtra, India, where a team of doctors under the national health program of RBSK(Rashtriya Bal Swasthya Karyakram), examined children below 18 years for '4Ds' i.e. Defects at birth, Diseases in children, Deficiency conditions and Developmental delays including disabilities. The same districts and anganwadis were screened in 2020 and 2021. The year 2020 was a reflection of health and nutrition status of adolescent girls, who were married in the pre-Covid years and delivered babies in the year 2020 and children in precovid time. The year 2021 reflected the health and nutrition status of women in the Covid year of 2020 who had to bear the brunt of the pandemic. It also reflected the status of nutrition in children in 2020 i.e. precovid times and 2021 reflecting nutritional insult in 2020.
A total number of 2121564 children were examined in 2020. Out of them 112(0.005%) were detected to have neural tube defects ( NTDs-meningocoele, meningomyelocoele, spina bifida), though anencephaly with resultant still births do not get reported in this data. In 2021, a total of 516655 babies were examined and 101(0.02%) had neural tube defects which are four times that of 2020 as per records from RBSK .The difference is statistically highly significant.(p<0.001). The number of babies born with NTDs were probably affected by Covid induced collateral nutrition insult i.e. folic acid deficiency in women during periconceptional period. Severe acute malnutrition was detected by measuring weight for height below -3SD on WHO growth charts. 7482 children had SAM (0.353%) in 2020 and 7148 (1.38%) children had SAM in 2021.The difference is statistically highly significant (p<0.001).
Occurrence of SAM is a measure of nutritional status of children of the community. It also is indicative of acuteness of nutritional insult. Unimaginably, it stands to reason that inadequate nutrition in 2020 manifested in more children developing SAM and the number is four times more than previous year.
High incidence of NTDs is even more alarming. Covid 19 resulted in women consuming less folate rich green vegetables, and they could probably not receive iron folic acid tablets during lockdowns. This resulted in birth of more children with neural tube defects.
NTDs are a surrogate marker of micronutrient deficiency in mothers during periconceptional period ; highlighting the importance of adolescent pre pregnancy and antenatal health. This is probably the first report of micronutrient impact of Covid 19 in periconceptional women.
Both these results depict nutritional impact of Covid 19 on women and children from Maharashtra, India.
We declare no conflict of interest.
1. Sr. Adv, and former Vice Chancellor, MUHS, Mumbai, India
2. Nutrition Specialist, UNICEF, Mumbai, India,
3. Assoc. Prof, Ped and Med Edu, DYP. Med college, Pune,India
4. Sr. Consultant, Pub.health, RJNM,Mumbai, India
5. Addl Chief Sec. Govt of Mah,Mumbai, India.
References
1.Zeus Aranda, Thierry Binda, Katherine Tashman,Ananya Tadikon Daniel Maweu,Emma Jean Boley6,Isaac Mphande, Isata Dumbuya, Mariana Montaño, Mary Clisbee, Mc Geofrey Mvula,
Melino Ndayizigiye Meredith Casella Jean-Baptiste, Prince F Varney,Sarah Anyango Karen Ann GrépiJean Bethany Hedt-Gauthier, Isabel R Fulcher on behalf of the Cross-site COVID-19 Syndromic Surveillance Working Group. Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries BMJ Global Health 2021 Vol7 issue1http://dx.doi.org/10.1136/bmjgh-2021-007247)
Coming from an international relations background, I'm pleased to see more discussion of topics like this in global health, which were absent from my Global Health studies. Public health too often doesn't directly deal with power, though power is so central to health outcomes- positive and negative. I think our engagement with power imbalances is a big part of understanding power in public health, which includes seeking economic justice for marginalised groups.
Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.
As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.
Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of th...
Show MoreDear Editor,
The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
Show MoreAs far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "e...
Dear Editor,
It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?
As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had r...
Show MoreHow to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice
A. Metin Gülmezoglu1, Sara Rushwan1
Show More1 Concept Foundation, Geneva, Switzerland
We welcome the paper by Tran et al [1]. There are increasing number of options for postpartum haemorrhage (PPH) prevention and management as recommended by WHO and the context is important. We agree that at the national level the first step is to update the national policies including the guidelines and essential medicine lists (EMLs). Since 2019, Concept Foundation and its partners have been working in 14 East and West African sub-Saharan countries to facilitate those updates [2]. We are pleased to report that in 10 out of the 14 countries – Burkina Faso, DRC, Ethiopia, Ghana, Ivory Coast, Liberia, Rwanda, Sierra Leone, South Sudan, and Uganda – the national guideline and/or EML were updated during this period.
The strength of the project lies in the engagement with policy makers, Ministry of Health officials, clinicians, professional associations, and civil society organizations concurrently. However, competing national policy priorities such as COVID-19, timing of the previous updates, political instability and national capacity and leadership (or lack of) can make the updating process long and challenging even when there is an agreement to update. Secondly, even when the updates happen, proactive dissemination and training within the country can also take time. Thirdly, in the...
Dear Editor
Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)
The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.
However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.
When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.
Thus, a new implementation strategy...
Show MoreDear Editor
The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.
In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationa...
Show MoreHi,
Its more of a doubt. I would like to know what risk of bias tool was used by the team? What were the findings on risk of bias, since I couldn't find anywhere in the article reporting the same.
Dear authors,
Since I have worked in remotest of PHCs in Himachal Pradesh, India and now am supervising them, the most unfavorable atmosphere for embedded research at grass roots is non availability of ethical committees and due to that either doctor fail to do research in field conditions or their research is hijacked by the medical colleges as PIs . Most of the medical colleges don't allow outside field doctors to get ethical clearance and have condition that medical college faculty would be PI for any research proposal/project, only then anyone can get research proposal listed in IEC.
I am trying to have an ethical committee notified at the level of Directorate of health so that PHC doctors can also get ethical clearance for their research this paper is talking about.
Thanks for raising this issue at global level.
Regards,
Dr. Omesh Kumar Bharti, Field Epidemiologist
bhartiomesh@yahoo.com
Covid 19- women’s health, occurrence of neural tube defects and severe acute malnutrition in children
Phadke M1,Nair R2,Menon P3,Jotkar R4, Saunik S5
Dear sir,
We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
Show MoreIndia has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now...
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