Williams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.
Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).
There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the...
Williams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.
Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).
There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the cost-effectiveness/cost-benefit analysis of tranexamic acid for the treatment of TBI by including variables of disease severity should also be conducted.
References
1. Williams J, Roberts I, Shakur-Still H, et al. Cost-effectiveness analysis of tranexamic acid for the treatment of traumatic brain injury, based on the results of the CRASH-3 randomised trial: a decision modelling approach. BMJ Glob Health. 2020;5(9):e002716.
2. Rowell SE, Meier EN, McKnight B, et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury. JAMA. 2020;324(10):961-974.
3. Cone DC, Spaite DW, Coats TJ. Out-of-Hospital Tranexamic Acid for Traumatic Brain Injury. JAMA. 2020;324(10):946-947.
4. Kawada T. The efficacy of tranexamic acid for brain injury. Am J Emerg Med. 2020 doi:10.1016/j.ajem.2020.07.048
To the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportio...
To the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportionately affects women (who are often managing unpaid work, including caretaking responsibilities, while continuing to engage in paid work), migrant workers, asylum seekers, and other marginalized groups (5). Global health organisations are often run by leaders who came from high-income countries and it is difficult for them to accept civil society representation on their boards (6). Even if they have diverse representation, many of those appointed do not have decision-making privileges (6). These are the “discriminatory social arrangement(s) that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others” to which Buyum et al refer.
However, recent observations suggest that a human rights approach is needed in order to achieve equity for all. In September 2020 in Melbourne, Australia a man experiencing an exacerbation of severe mental illness was intentionally hit by a police car and kicked in the head by a police officer as he struggled on the ground (7). The police officers involved have been suspended on full pay pending criminal investigations but this excessive use of force is symptomatic of state-sanctioned violence within the Australian police force. An Australian nationwide survey of more than 6000 international students and other temporary migrants conducted during the pandemic found systemic racism against international students in Australia (8). The study revealed the depth of Australia’s racist COVID policies (8). Although there is anti-racist rhetoric in Australia, (e.g. the National Anti-Racism Strategy) (9), there are many cases of racial discrimination against Asian students, particularly during the pandemic (9). In early June, the Chinese Ministry of Culture and Tourism warned Chinese citizens about a significant rise in racial discrimination and violence against Chinese and Asian people in Australia as an impact of the COVID-19 pandemic (10). In addition, in many countries around the world the small progress that has been made in ensuring girls receive an education is predicted to be undone by the COVID shelter at home restrictions (11). Increased “household responsibilities, child labour, early marriage and teenage pregnancy may prevent many girls from returning to school” (11). Other structural determinants include prioritisation of funding to other economic activities, instead of education, as countries emerge from the pandemic. Among those girls who do return to school post COVID, gender norms may inhibit their ambition. Education for women is consistent with part of the solution posed by Buyum et al namely a ‘knowledge shift’ which makes education widespread, bi-directional, and inclusive of new learning.
A human rights-based approach is a conceptual framework that can be applied to a broad range of program areas, including health. It is informed by international human rights law (12). The approach asserts that the integration of human rights law and principles should be visible in all activities and should contribute directly to the realization of human rights. Key elements of a human rights-based approach include participation, accountability, non-discrimination, empowerment, linkage to rights and sustainability. Applying this to the case of police brutality against people with mental illness suggests police be called on to view those with mental illness as human beings first with entitlements rather than letting the stigmatization of mental illness drive their actions. Police brutality to a marginalized group with little accountability is discriminatory, disempowering and dislocated from international human rights. It is unsustainable, and is unacceptable. In the case of maternal education a human rights-based approach would recognize the right of girls to an education. It would recognize there are no human rights, as enshrined in the Universal Declaration of Human Rights and other humanitarian instruments, without their universal application, irrespective of gender, ethnicity, occupation, country of birth. More broadly a human rights-based approach to structural determinants would re-orientate key public services and structures across multiple jurisdictions to ensure equity in participation and treatment irrespective of human characteristics.
Dismantling structural oppression is indeed key to improving global health. A human rights-based approach for addressing structural violence is a way of achieving this.
Aarya Desai MPH Student
Sundeep Manoth MPH Student
John Oldroyd MPH Co-ordinator
Australian Catholic University, Fitzroy, Australia.
A need for better understanding old-age mortality dynamics
Sergi Trias-Llimós* & Iñaki Permanyer
Centre d’Estudis Demogràfics, Carrer de Ca n’Altayó, Edifici E2, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
* Corresponding author. Email: strias@ced.uab.cat
Correspondence letter in response to:
Bergeron-Boucher M-P, Aburto JM, Raalte A van. Diversification in causes of death in low-mortality countries: emerging patterns and implications. BMJ Glob Health. 2020;5(7):e002414.
Word count: 492
The recent paper by Bergeron-Boucher et al. published in this journal reports an increasing diversity of cause-of-death mortality in low-mortality populations during the last 20 years [1]. Bergeron-Boucher et al. found that the preponderance of mortality from cardiovascular diseases in the countries under analysis has gradually declined in favour of a wide range of causes of death, including mental and behavioural disorders, nervous system or ill-defined causes. The increasing variability of causes of death is an important matter of potential concern because (a) fragmentation in cause of death might hinder further improvements in life expectancy, (b) preventive health policies have to cope with a more variegated set of causes, which imply more costly and less efficient health policies.
Despite their enormous interest, these findings should be interpreted with caution. As the authors...
A need for better understanding old-age mortality dynamics
Sergi Trias-Llimós* & Iñaki Permanyer
Centre d’Estudis Demogràfics, Carrer de Ca n’Altayó, Edifici E2, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
* Corresponding author. Email: strias@ced.uab.cat
Correspondence letter in response to:
Bergeron-Boucher M-P, Aburto JM, Raalte A van. Diversification in causes of death in low-mortality countries: emerging patterns and implications. BMJ Glob Health. 2020;5(7):e002414.
Word count: 492
The recent paper by Bergeron-Boucher et al. published in this journal reports an increasing diversity of cause-of-death mortality in low-mortality populations during the last 20 years [1]. Bergeron-Boucher et al. found that the preponderance of mortality from cardiovascular diseases in the countries under analysis has gradually declined in favour of a wide range of causes of death, including mental and behavioural disorders, nervous system or ill-defined causes. The increasing variability of causes of death is an important matter of potential concern because (a) fragmentation in cause of death might hinder further improvements in life expectancy, (b) preventive health policies have to cope with a more variegated set of causes, which imply more costly and less efficient health policies.
Despite their enormous interest, these findings should be interpreted with caution. As the authors themselves illustrate, most of the action takes place at advanced ages, that is: increases in the causes-of-death diversity indicators are driven by the changing distribution of causes among the elder, but not by what happens among children, youth or middle-aged adults. Remarkably, most of the deaths registered in the 15 low-mortality countries analysed in the paper increasingly occur among the elder (81% of the deaths occurs in the 65+ age group). As mortality shifts towards older ages, the surviving population becomes increasingly heterogeneous in its mortality risks [2] – a phenomenon that has led to worldwide increases in length-of-life inequality among those who survive above retirement age (e.g. around 65 years) [3]. This implies that an increasing share of population suffers comorbidities and is affected by the coexistence of well-known risk factors (e.g. diabetes) associated with several major diseases. In this context, there is mounting evidence suggesting that, as individuals age, it becomes increasingly difficult and controversial to attribute their deaths to a single underlying cause of death [4].
Taken together, the evidence suggests that it is now more complex than ever to predict the underlying causes of death [5]. Further studies examining old-age mortality could move towards different and complementary directions that attracted rather little attention so far. On the one hand, performing more post-mortem examinations comparing their results with the data reported in death certificates would contribute to validate and potentially correct some of the inaccuracies filling cause-of-death documents. On the other hand, using all cause-of-death information in the death certificates would allow grasping on risk factors and main drivers contributing to cause-specific mortality. This is particularly relevant as the number of causes of death reported in the death certificate increases with age. Unfortunately, little research has explored these interrelations; and comparability research between post-mortem examinations and cause of death data are scarce.
Mortality at old age is increasingly becoming a relevant public health challenge, and therefore requires the resources and implication of professionals from different fields, including medical doctors, demographers and public health experts. Beyond the use of underlying causes of death, further efforts should be invested in exploring the role of comorbidities in the old-age mortality dynamics.
Funding
This research has received funding from the European Research Council (ERC-2019-COG agreement No 864616 lead by Iñaki Permanyer).
References
1 Bergeron-Boucher M-P, Aburto JM, Raalte A van. Diversification in causes of death in low-mortality countries: emerging patterns and implications. BMJ Glob Health 2020;5:e002414. doi:10.1136/bmjgh-2020-002414
2 Engelman M, Canudas‐Romo V, Agree EM. The Implications of Increased Survivorship for Mortality Variation in Aging Populations. Popul Dev Rev 2010;36:511–39. doi:10.1111/j.1728-4457.2010.00344.x
3 Permanyer I, Scholl N. Global trends in lifespan inequality: 1950-2015. PloS One 2019;14:e0215742.
4 Tinetti ME, McAvay GJ, Murphy TE, et al. Contribution of Individual Diseases to Death in Older Adults with Multiple Diseases. J Am Geriatr Soc 2012;60:1448–56. doi:10.1111/j.1532-5415.2012.04077.x
5 Alpérovitch A, Bertrand M, Jougla E, et al. Do we really know the cause of death of the very old? Comparison between official mortality statistics and cohort study classification. Eur J Epidemiol 2009;24:669–75. doi:10.1007/s10654-009-9383-2
We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2
We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2
Airborne or droplet borne. The infectiousness of a disease is determined by the ability of the primary case to cause secondary cases in a susceptible population. It is based on Susceptibility – Infectivity-Recovery/Death (SIR) model and is quantified by the reproductive number (R0). The R0 is dependent on the proportion of susceptible population in a given cohort and its density and reduces with decongestion.3 The initial R0 for SARS CoV 2 at Diamond Princess, a cruise ship was 14.8 and was lowered to 1.78 with disembarkation of passengers and prevented almost 2000 extra individuals from getting infected.4 The transmission onboard ships would be both airborne through ventilatory ducts and by droplet transmission because of the close environment.
High vs Low Viral Load. Contact tracing data have found the contacts to be located mostly near the cases and did not spread to the rest of the population in the 2.2 square km slum area. Moreover, such transmission zones are comprised of only asymptomatic, mild or moderate cases, who have low viral load. High level of infectiousness in clusters of close quarters of susceptible hosts explains droplet and short distance aerosol transmission as has been endorsed by World Health Organisation (WHO) in their recent statement.5 Breaking the chain of transmission in a densely populated slum would have been possible because of droplet transmission from mildly symptomatic and asymptomatic cases and absence of airborne transmission from them. In the hospital setting however, high viral load in severely symptomatic patients and aerosol generating procedures may be accompanied by airborne transmission. This has been emphasised by several studies and endorsed by WHO.6
Way Ahead. Non-pharmacological Interventions of maintaining social distance, wearing of masks will have to be habit forming in the community. The hospitals have to bring in architectural modifications in their wards to include negative air pressure isolation facility alongwith HEPA filters and use of UV lights. Proper protective gears for health care workers need to be emphasised at all levels. Food habits for the general population will include known immune boosting products, also antioxidants and avoid junk; this will not only reduce the co morbidities like obesity and diabetes but will prevent mild infectious diseases. Future mitigating measures will have to emphasise on alteration of residences with proper ventilation, enough exhausts in bathrooms, multiple air exchange air conditioning system, which are essential measures for prevention and control of airborne diseases.
References
1. Khosla R, Allotey P, Gruskin S. Global health and human rights for a postpandemic world. BMJ Global Health 2020;5:e003548. doi:10.1136/ bmjgh-2020-003548
2. Prem K, Liu Y, Russell TW, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study [published correction appears in Lancet Public Health. 2020 May;5(5):e260]. Lancet Public Health. 2020;5(5):e261-e270.
3. JK Aronson, Jon Brassey, KR Nahtani. When will it be over? An introduction to viral reproduction numbers (R0 and Re). Available at https://www.cebm.net/covid-19/when-will-it-be-over-an-introduction-to-vi.... Accessed on 14 Aug 2020.
4. Zhang S, Diao M, Yu W, Pei L, Lin Z, Chen D. Estimation of the reproductive number of novel coronavirus (COVID-19) and the probable outbreak size on the Diamond Princess cruise ship: A data-driven analysis. Int J Infect Dis. 2020;93:201‐204.
5. Coronavirus: What is the Dharavi model being praised by WHO chief Tedros Adhanom. Available at https://www.indiatoday.in/india/story/what-is-the-dharavi-model-being-pr.... Accessed on 11 Aug 2020
Svadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.
The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.
Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-af...
Svadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.
The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.
Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-affiliated third party months in advance, embassies can hold passports for long periods, with applicants needing to satisfy vague criteria that can allow visa officials to arbitrarily deny applications. Furthermore, LMIC students often have to apply multiple times (paying new fees each time) to obtain a visa – which can be denied – thereby leaving students dejected having to delay or abandon their education abroad.
LMIC students have particular issues satisfying visa criteria around financial sufficiency, intent of return to home country (including family ties), and lack of job prospects in home country. [4] These criteria are often subjectively adjudicated by immigration officers with arbitrary results – e.g., anecdotal reports of LMIC students with full scholarships being rejected on the basis of financial insufficiency. Thus, merely offering LMIC students visa support/advice is not sufficient. Change is required in immigration policy and practice in HICs, particularly in Canada, UK, and the USA [5], to ensure LMIC students wanting to study global health can gain entry.
There are also important regional differences in how this is experienced across LMICs, with African students being more likely to be refused visas. [5, 6] Students from Asian LMICs (e.g., China, Japan, India) tend to have the easiest time at getting student visa to study in HICs – which results in HIC universities tending to concentrate their recruitment efforts in these countries, further entrenching educational inequities among LMICs.
Achieving equity in global health education will be ultimately secured as it will be in global health practice – by adequately addressing the underlying structural conditions/drivers. While everyone should support lower tuition fees and increased scholarship support for LMIC students, without a fundamental change to the current discriminatory approach to visa issuance, we will not be able to achieve equity in global health education.
References
1. Svadzian A, Vasquez NA, Abimbola S, et al. Global health degrees: at what cost? BMJ Glob Health 2020;5(8) doi: 10.1136/bmjgh-2020-003310 [published Online First: 2020/08/08]
5. The Lancet Global Health. Passports and privilege: access denied. Lancet Glob Health 2019;7(9):e1147. doi: 10.1016/S2214-109X(19)30337-7 [published Online First: 2019/08/14]
The COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.
Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.
A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Ea...
The COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.
Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.
A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Eastern Africa. As with any pandemic, emergency care acts as the receptacle for patients in extremis, with severe cases of illness, including those with imminent oxygen needs and breathing support with COVID-19 - two needs highlighted by Cabore et al. This has occurred with COVID-19 [4], as in other public health crises before it. The spotlight on emergency care as a priority for government agendas globally in the 2019 WHA 72.16 [5] resolution was a step in the right direction for the progress needed in countries where neglect of emergency care infrastructure has been appalling, and even fatal. Further research on best practices for emergency care in LMICs, including responsiveness in crises, understanding burden of NCDs in the emergency care setting, and the effect of the double burden in populations seeking care there cannot be overstated. To that end, our recent study in the largest public emergency department in East Africa [6] called Kenyatta National Hospital, shows equal or worse outcomes for all NCDs and leading risk factors outlined by the WHO’s 2013 action plan [7]. All the same, the capacity to handle emergency cases in Kenya, like most African nations, remains dismal at best due to lack of prioritization: lack of basic resources like oxygen, lack of adequately trained emergency professionals, and lack of health system infrastructure that facilitates timely access for patients.
For the first time, the global health community may have realized the crux of emergency care: as the front-lines to our healthcare systems. Communicable disease pandemics, and NCD co-afflictions alike. The WHO’s emergency care office is home to many initiatives that advance this agenda. I would hope that the remainder of the global health community follows suit.
1. Coronavirus Disease 2019 (COVID-19): Africa CDC Dashboard. 2020; Available from: https://africacdc.org/covid-19/.
2. World Health Organization. (2020). Laboratory testing strategy recommendations for COVID-19: interim guidance, 21 March 2020. World Health Organization. https://apps.who.int/iris/handle/10665/331509. License: CC BY-NC-SA 3.0 IGO.
3. Yang, J., et al., Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis, 2020. 94: p. 91-95.
4. Giving Oxygen to COVID-19 Patients in Kenya. 2020 August 8th, 2020]; Available from: https://www.emergencymedicinekenya.org/oxygenmanifold/.
5. World Health Assembly, Resolution 72.16. Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured. 2019.
6. Ngaruiya, M., MSc, DTMH, Christine, et al., The last frontier for global Non-Communicable Disease action: the Emergency Department - a cross-sectional study from East Africa. medRxiv, 2020: p. 2020.07.29.20164632.
7. World Health Organization. WHO global action plan: for the prevention and control of noncommunicable diseases 2013-2020. 2013; Available from: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf.
The effectiveness of masks in the household is a critically important topic for control of SARS-CoV-2 transmission. I am concerned the multivariate regression performed in this analysis incorrectly attributed all of the effect of post-symptomatic mask-wearing to the pre-symptomatic mask-wearing variable. It is highly likely that these 2 variables are highly co-linear, and looking at Table 2, it appears likely that those families that wore masks pre-symptoms (n=27 without transmission, n=4 with transmission) were largely the same families where all members of the household wore masks post-symptoms (n=31 without transmission, n=5 with transmission). It's likely there are not enough numbers to further disentangle whether pre-symptom or post-symptom mask-wearing truly was the benefit - most likely it's some of both.
The message that post-symptomatic mask-wearing has no effect appears to lack sufficient support, so I would caution anyone jumping to use that conclusion here.
Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed
Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
Dear Editor,
In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.
More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 as...
Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed
Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
Dear Editor,
In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.
More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 asymptomatic, 53 with mild symptoms, 7 severe cases and 1 critical case ). The median size of the families participating in this retrospective cohort study was 4 (ranging from 2 to 9 usually with children, parents and grandparents).
The conclusion and advices in the article based on data and design of the study presented needs more evidence. A retrospective cohort study based on questionnaires via telephone interviews is highly sensitive to bias and confounding. Several aspects that can influence viral infections and transmission in households have not been discussed, neither the negative aspects of implementing NPI in households and universal facemask wearing are discussed.
In this rapid response we briefly explain our interpretation of the data presented and the impact of universal face masking, social distancing and NPI as a preventive strategy in viral transmissions in households.
1. Unfortunately, the study does not explain why 39 households met exclusion criteria in the 128 households without secondary transmission compared to only 1 household in the 49 households with secondary transmission.
2. The authors do not discuss a higher percentage of people with co-morbidities in the households with secondary transmission (Table 1). Or whether severe and critical cases in the second transmission were people suffering from co-morbidities wearing masks prior to showing symptoms and/or the primary case was wearing a facemask all day or sometimes 2 days before the onset of symptoms. In many scientific publications and media articles a relation of developing severe COVID-19, Acute Respiratory Distress Syndrome (ARDS) for people with overweight, diabetes, cardiovascular disease and elderly, frail people has been described. As well as a disproportionate burden on black, Asian and minority ethnic individuals and communities.
3. In Table 2 a delay in laboratory confirmation in the group of people with secondary transmission as compared to the group of families without secondary transmission is observed. Previously, it has been reported that there have been difficulties with RT PCR tests at some stages of the epidemic in China (2). It is not clear if people have been repeatedly tested for the presence of SARS-COV-2 virus to confirm infection with the virus. The article states that the virus in respiratory or blood specimen was ‘highly homologous’ with known SARS-COV-2 through gene sequencing. It is not clear if this could be SARS-COV-1 or one of the other beta coronavirus frequently causing respiratory infections during winter times.
4. Table 3 shows a major difference in the ventilation duration per day which was less in frequency and total hours per day and residential area per capita in the group of families with secondary transmission. The review of prof Moriyama et al. “Seasonality of respiratory viral infections” indicate that the winter environment promotes the spread of a variety of respiratory virus infections. In the industrialized world most people interact and spend 90 % of their lifetime in enclosed spaces and share a limited amount of breathing air. The implication is that indoor climate and air change rates, modulated by outdoor seasonal conditions are the key drivers of seasonal patterns in epidemiology. In addition, exposure to outdoor conditions (albeit 10 % of lifetime) contributes to alteration of respiratory defence of the existing virome (3). The possibility that dry and unventilated air can increase opportunity to spread influenza virus infection in winter times has been demonstrated in mice studies. The inhalation of dry air causes immediate effects by epithelial cilia loss, impaired epithelial cell repair in lungs and inflammation of the trachea in a study with guinea pigs. Ventilation to refresh the air in crowded homes to remove aerosols with virions and support an effective immune system is important. Furthermore, recent studies reveal that season dependent environmental factors, such as temperature and humidity can affect the host antiviral innate immunity against respiratory infections (3). Therefore, it cannot be excluded that a simple ventilation of the home could have been of influence in the second transmission in the group of families with second transmissions.
5. Table 1 describes that various facemasks (cloth masks, medical masks or N95 masks) were used. How frequently masks were refreshed or washed, taken of, re-used and disposed in an appropriate way is not documented. The quality of facemasks can differ in pore size and materials used. Depending on the materials used toxic material or fibres may impair the innate immune system. A study of Chughtai et al demonstrated the existence of respiratory pathogens on the outer surface of used medical masks which may result in self-contamination. The risk was higher with longer duration of mask use (> 6h) and with higher rates of clinical contact (4). Furthermore, heart rate, microclimate temperature humidity and subjective ratings were significantly influenced by wearing of different kinds of facemasks. The local thermal stimulus also affected heat exchange from the respiratory tract. Microclimate temperature, humidity and skin temperature inside the facemask increased with the start of step exercise, which led to different perceptions of humidity, heat and high breathing resistance among subjects wearing facemasks. High breathing resistance makes it difficult for the subject to breathe and take in sufficient oxygen. Shortage of oxygen stimulates the sympathetic nervous system and increase heart rate and may results in stress and anxiety experience (5). It is probable that people feel unfit, fatigued and overall discomfort due to this reason. For people and children with hearing loss face masks can be devastating (6).
If facemasks determine a humid habitat where the SARS-COV-2 virus can remain active due to the water vapour continuously provided by breathing and captured by the mask fabric , they determine an increase in viral load and therefore they can defeat of the innate immunity and increase in infections. Whereas the main purpose of the innate immune system is to prevent the spread and movement of pathogens through the body. Other important potential side effects of wearing face masks that we should bear in mind have been clearly described by dr AL Lazzarino on 20 April 2020 in a rapid response to the article of Greenlagh et al; Face masks for the public during covid-19 crisis(7)
In the Advice on the use of masks in the context of COVID-19, interim guidance 5 June 2020 the WHO writes that potential harms and risks should be carefully taken into account when adopting the approach of targeted continuous medical mask use including self-contamination, dermatitis, false security, uncomfortable to wear, risk for droplet transmission, difficulty wearing in hot and humid environments and by vulnerable populations with mental health disorders, developmental disabilities, the deaf and hard of hearing community and children (8).
6. The negative influence of stress and anxiety on the immune system increasing the risk of upper respiratory tract infections has been well documented (9). In the period February – March China was in lockdown and families with people infected with COVID-19 virus were in quarantine. Symptoms of Post-Traumatic Stress Disorder (PTSD) and depression were observed in 28,9 % and 31,2 % of respondents in the study, respectively. has been described in Toronto after a period of quarantine during the SARS epidemic in 2002 (10). Longer durations of quarantine was associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive symptoms.
7. Another major impact on the effectiveness of the immune system is nutrition and lifestyle. It is not clear if persons included in the study started to eat differently due to stress, more sitting hours in a crowded home and if families had less possibilities to buy fresh food i.e. unprocessed vegetables, fruit and meat. There could have been a difference between the group of families without transmission and families with a secondary transmission. The role of nutrition and lifestyle (sleep, social interaction and being active outdoors) in view of the preparedness for a second peak of COVID-19 for all people especially for those at higher risk preventing severe viral infections by reversing weight loss, diabetes type 2 and other chronic diseases was published by Fiona Godlee : editor in chief of the BMJ (11).
8. In the perspective on Universal Masking in Hospitals in the Covid-19 era American doctors wrote in the New England Journal of Medicine “We know that wearing a mask outside healthcare facilities, offers little, if any protection from infection. Public health authorities define a significant exposure to Covid-19 as face to face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflective reaction to anxiety over the pandemic. Focusing on universal masking alone may paradoxically lead to more transmission of Covid-19 if it diverts attention from more fundamental infection-control measures”
Results from cluster randomized controlled trials on the use of masks among young adults living in university residences in the United States of America indicate that face masks may reduce the rate of influenza-like illness but showed no impact on risk of laboratory confirmed influenza. At present there is no direct evidence (from studies on COVID-19 and in healthy people in the community) on the effectiveness of universal masking of healthy people in the community to prevent infection with respiratory viruses, including COVID-19 (12)
Advice on universal face mask use and other NPI in households for people at risk or during epidemics for persons of a family of whom one or more are working in healthcare needs more advanced studies. Not only is the evidential basis insufficient, also potential risks argue against the implementation of mask wearing by billions of people and healthcare workers in family circumstances. A review of available scientific publications evaluating on the efficacy in limiting viral transmission and the impact on the physiology, immunity, mental, social, ecological (environmental) and economic level will be highly valuable for defining strategies to prevent future viral infections and transmissions. Especially in the presence of young children, people with mental disorders and disabilities and elderly people in households the negative impact on physiology, immunity as well as psychology with limitations in verbal and nonverbal expression and a risk of developing a Post-Traumatic Stress Syndrome due to quarantine needs more attention. Simple ventilation and sufficient air humidity % instructions in households, offices, transport, public areas and healthcare settings might be more effective in limiting viral transmission and entail less negative effects on physiology, immunological, social and mental level. At the mental-psychological level, face masks interfere with the exchange of facial expressions, which is quintessential for mental health. Research on mirror neurons (13) showed that humans constantly mirror each other’s facial expressions and that this exchange is the neural basis of empathy, in this respect that it allows to gauge the affective and emotional state of the other. In particular within the mother-child relationship, the quality of the affective exchange is directly related to overall mental and physical health, to this extent that when quality is poor, mortality rates in children raise dramatically (14). This has been confirmed in the most straightforward way in the field of psycho-neuro-immunology, remarkably enough specifically in viral lung disease. In 2008, Nielsen and his colleagues (15) found in a naturalistic study that mental stress leads to significantly higher mortality rates in humans suffering from viral lung disease; in 2020, Wieduwild et al.(16) reported that mice are 40% more likely to die from viral infections due to experimentally generated stress.
Moreover, with higher temperatures, sunlight and high humidity in countries in the Northern hemisphere the number of people dying from Covid-19 have been drastically reduced in the past two months. We need to use the summertime effectively to repair and boost the immune system and develop a humoral and cellular immunity to the SARS-COV-2 virus developing herd immunity among the population by being outdoors, social interactions and exposure to sunlight. At the same time improve the ventilation and absolute humidity in healthcare settings and support the immune system by improving the vitamin status of elderly people and people with co-morbidities at risk for viral infections.
References
1. Wang Y, Tian H, Zhang L, Zhang M, Guo D, Wu W et al. Reduction of secondary transmission of SARS-COV-2 in households by face mask use, disinfection and social distancing: a short study in Beijing China. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
2. Li Y, Yar L, Li J, Chen L, Sang Y, Cai Z, Yang C. Stability issues on RT-PCR Testing of SARS-COV-2 for hospitalized patients clinically diagnosed with COVID19. J. Med. Virol. 2020; 92:903-908. Doi: 10.1002/jmv/25768.
3. Moriyama M, Hugentobler WJ, Iwasaki I. Seasonality of respiratory viral infections. Annual reviews of virology. 2020 7: 2.1-2.19 doi: 10.1146/annurev-virology-012420-02445
4. Chughtai AA, Stelzer-braid S, Rawlinson W, Potivivio G, Wang Q, Pan Y et al. Contamination by respiratory viruses on the outer surface of medical masks used by hospital healthcare workers. BMC Infect. Dis. 2019: 19:491. Doi:1186/s12879-019-4109-x
5. Liu Y, Tokura H, Guo YP, Wong ASW, Wong T, Chung J and Newton E. Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. Int Arch Occup Environ Health 2005; 78(5): 501-509. Doi 10.1007/s00420-004-0584-4
6. Chodosh J, Freedman ML, Weinstein BE, Blustein J. Face masks can be devastating for people with hearing loss BMJ 2020: 370 doi: /10.1136/bmj.m2683
7. Greenlagh T, Schmid MB. Czypionka T, Bassler D, Gruer L. Face masks for the public during the covid-19 crisis. BMJ 2020:369:m1435 doi:10.1136bmj.m1435. Rapid response Covid-19: important potential side effects of wearing face masks that we should bear in mind. Lazzarino AL. 20 April 2020.
8. Advice on the use of masks in the context of COVID-19. Interim guidance. 5 June 2020. https//www.who.int/publications-detail/global-surveillance-for-covid-19 caused-by-human-infection-with-covid19-virus-interim-guidance
9. Drummond PD, Hewson-Brower B. Increased psychosocial stress and decreased mucosal immunity in children with recurrent upper respiratory tract infections. J. Psych. Res. 1997.43(3):271-278. Doi:10.1016/S0022-3999(97)00002-0
10. Hawryluck L, Gold WL, Robinson S, Pogorski S, Gales S Styra R. SARS Control and Psychological effects of quarantine. Emerg. Infect. Dis. 2004. 10(7): 1206-1212. Doi: 10.3201/eid1007.030703
11. Godlee F. Covid-19: What we eat matters all the more now. BMJ 2020;370:n2840. Doi.org/10136/bmjm2840
12. Klompas M, Morris CA, Sinclair J, Pearson M, Shenoy ES et al. Universal masking in Hospitals in the Covid-19 era. New England Journal of Medicine. 2020; 382:e63 doi: 10.1056/NEJMp2006372
13. Rizolatti G, Craighero L. The mirror neuron system. Annu Rev Neurosci 2004; 27:169-192. Doi: 10.1146/annurev.neuro.27.070203.144230
14. Spitz, R. A. (1965). The first year of life: a psychoanalytic study of normal and deviant development of object relations. New York: International Universities Press.
15. Nielsen N, Kristensen T, Schnohr P, Gronbaek M. Perceived stress and cause-specific mortality among men and women: results from a prospective cohort study. Am J Epid 2008; 168(5); 481-491. https://doi.org/10.1093/aje/kwn154
16. Wieduwild E., Girard-Madoux JM, Quatrini , Laprie C, Chasson L, Rossignol R, Bernat C, Guia S, Ugolini S. 2-adrenergic signas downregulate the innate immune response and reduce host resistance to viral infection. J Exp Med 2020; 217(4). e20190554. Doi.org/10.1084/jem.20190554
Competing interests: none
Dr Carla Peeters
CEO COBALA Good Care Feels Better®
Immunology, nutrition and health transformation expert
Utrecht, The Netherlands
Professor Dr Mattias Desmet
Faculty of Psychology and Educational Sciences
University Ghent
Ghent, Belgium
We read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.
Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.
The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]
The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favou...
We read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.
Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.
The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]
The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favourable young demographic profile. However, in the highly dense urban metropolitan areas like Mumbai, Chennai and Delhi, maintenance of social distancing in overcrowded clusters is a challenge. The otherwise neglected public health care system is struggling to play the pivotal role in undertaking control measures in these areas. Lack of properly manufactured PPEs, isolation beds for mild and moderate symptomatic patients and adequate negative air pressure isolation wards for serious patients with high viral load are being highlighted at different forums [3, 4, 5]. Yet India is fighting the virus with optimism for the future.
Effective mitigation strategies will be critical to establish positive impact in control of future emerging airborne pandemics either in a mutated form or as a bioweapon. Host preferences of social distancing, restrictions on spitting, practicing hand hygiene, using disposal tissue or napkins while coughing and sneezing in public and practicing the Indian tradition of Namaste will be important in breaking the chain of transmission in other airborne diseases as well, like tuberculosis. Creation of many quarantine facilities in metropolitan cities and construction of negative air pressure isolation wards in the hospitals will be needed for successful control. Research conducted in unknown areas like aerosol transmissibility of the virus and its surface stability in the Indian circumstances will be forthcoming for undertaking disinfection [6].
References
1. Paul E, Brown GW, Ridde V COVID-19: time for paradigm shift in the nexus between local, national and global health BMJ Global Health 2020;5:e002622.
2. Brauer F. A simple model for behaviour change in epidemics. BMC Public Health. 2011;11:S3.
3. Narain JP. Public Health Challenges in India: Seizing the Opportunities. Indian J Community Med. 2016;41(2):85–88
4. R Srinivasan. Health Care in India: Issues and Prospects. Available at . Accessed on 15 Apr 2020.
5. T Jacob John. Tuberculosis Control in India: Why are we Failing? Indian Pediatrics 2014;51:523-527
6. Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020; 382:1564-1567.
After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.
As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
However, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coron...
After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.
As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
However, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coronavirus that is not align with or is against the recommendations of WHO and local health authorities, is now not allowed on YouTube (3) This raises the question of whether the results of this study would still be applicable now, given that it was initially conducted relatively early on in the pandemic when limited information was available from scientific bodies.
There is a lack of evidence supporting whether this new policy actually helps to reduce the number of non-factual videos gaining views on YouTube as a source of information, likely due to the fact the policy was only implemented in May 2020. It is however a positive step in a direction to combating medical misinformation.
As mentioned by the authors, the numerous ways YouTube presents content ensures that important healthcare information has the potential to reach over 2 billion users (4) of all demographic backgrounds. Although this study provides insight into the use of YouTube to disseminate reliable information during the current pandemic, as an advancement it would be useful to determine the impact of these videos on public health efforts. The YouTube videos are seen by viewers that use keywords to search for information on the virus but may not reach the wider audience needed to successfully manage the crisis. To address this concern, further studies are needed to evaluate the impact healthcare information available on YouTube is having and explore how to improve outreach of the videos containing the accurate information. This research has shown that 27.5% of the YouTube videos included spread non-factual information about COVID-19 to 24.1% of viewers (2) thus highlighting the need for social media platforms, such as YouTube, to use algorithms to prevent upload and viewing of misleading information. These changes would further the effort of public health agencies to present more of the population with accurate information to help successfully manage future public health crises.
Finally, YouTube, and social media platforms in general, may be criticised for acting as a vector in allowing misinformation to be released into the public without proper factual checks. However, there are plenty of useful roles for YouTube to play in a situation such as a pandemic. Hand washing has been proven to be one of the most effective methods of fighting the virus. (5) A study into the educational usefulness of YouTube videos about proper hand washing found 55.7% of 70 videos analysed were described as educationally useful. (6) This was a similar sample size to the original article, and demonstrates a positive role YouTube has played in providing education on a simple yet highly effective method of infection control. Social media platforms have a large influence in society and continue to grow, this creates a need for government and professionals to ensure they are effectively utilising platforms used by their populations to provide factual content to a wide audience; this is critical in a situation such as a pandemic to prevent non-factual information becoming more dominant and potentially hindering the public health initiative.
Again, we send our appreciation to the authors for bringing this very topical piece of research to light and hope the insight gained from such work can be acted upon by local, national and international governments and professional bodies in the future.
REFERENCE LIST:
Limaye RJ, Sauer M, Ali J, et al. Building trust while influencing online COVID-19 content in the social media world. The Lancet Digital Health. 2020;2;e277-e278
Li HO, Bailey A, Huynh D, et al. YouTube as a source of information on COVID-19: a pandemic of misinformation?. BMJ Global Health 2020;5:e002604.
Youtube. YouTube Policy Update 2020: Help Centre. Available at: https://support.google.com/youtube/answer/9891785 [Accessed: 10 June 2020]
Google. Press, 2020. Available at: https://www.youtube.com/about/press/ [Accessed: 11 Jun 2020]
Lotfinejad N, Peters A, Pittet D. Hand hygiene and the novel coronavirus pandemic: The role of healthcare workers. Journal of hospital infection. 2020
Lim K, Kilpatrick C, Storr J, et al. Exploring the use of entertainment-education Youtube videos focused on infection prevention and control. AM J Infect Control. 2018;46(11):1218-1223
Williams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.
Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).
There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the...
Show MoreTo the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportio...
Show MoreA need for better understanding old-age mortality dynamics
Sergi Trias-Llimós* & Iñaki Permanyer
Centre d’Estudis Demogràfics, Carrer de Ca n’Altayó, Edifici E2, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
* Corresponding author. Email: strias@ced.uab.cat
Correspondence letter in response to:
Bergeron-Boucher M-P, Aburto JM, Raalte A van. Diversification in causes of death in low-mortality countries: emerging patterns and implications. BMJ Glob Health. 2020;5(7):e002414.
Word count: 492
The recent paper by Bergeron-Boucher et al. published in this journal reports an increasing diversity of cause-of-death mortality in low-mortality populations during the last 20 years [1]. Bergeron-Boucher et al. found that the preponderance of mortality from cardiovascular diseases in the countries under analysis has gradually declined in favour of a wide range of causes of death, including mental and behavioural disorders, nervous system or ill-defined causes. The increasing variability of causes of death is an important matter of potential concern because (a) fragmentation in cause of death might hinder further improvements in life expectancy, (b) preventive health policies have to cope with a more variegated set of causes, which imply more costly and less efficient health policies.
Show MoreDespite their enormous interest, these findings should be interpreted with caution. As the authors...
We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2
Airborne or droplet borne. The infectious...
Show MoreSvadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.
The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.
Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-af...
Show MoreThe COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.
Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.
A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Ea...
Show MoreThe effectiveness of masks in the household is a critically important topic for control of SARS-CoV-2 transmission. I am concerned the multivariate regression performed in this analysis incorrectly attributed all of the effect of post-symptomatic mask-wearing to the pre-symptomatic mask-wearing variable. It is highly likely that these 2 variables are highly co-linear, and looking at Table 2, it appears likely that those families that wore masks pre-symptoms (n=27 without transmission, n=4 with transmission) were largely the same families where all members of the household wore masks post-symptoms (n=31 without transmission, n=5 with transmission). It's likely there are not enough numbers to further disentangle whether pre-symptom or post-symptom mask-wearing truly was the benefit - most likely it's some of both.
The message that post-symptomatic mask-wearing has no effect appears to lack sufficient support, so I would caution anyone jumping to use that conclusion here.
Rapid response
Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed
Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
Dear Editor,
In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.
More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 as...
Show MoreWe read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.
Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.
The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]
The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favou...
Show MoreDear Editor,
After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.
As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
Show MoreHowever, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coron...
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