Review of 'Assessing the infection burden and associated risk factors in children under 5 across Jaipurs urban slums: A feasibility study using a One Health approach'

On behalf of Mustafa Abbas

Thank you very much for your submission to UCL Open Environment. It was a pleasure to read your work and consider your approach and points raised. You present what you describe as a feasibility study for a future longitudinal data gathering project via the CHIP consortium and aim to argue the need and usefulness of such research. I’ve had the opportunity to study your piece and I do have three areas of major issue that encompasses most of the paper, but I have included a fourth segment at the end on what I think you can do to make this a very valuable essay for the international health and environment community. Many thanks.

1: I think major the first thing to say is that you have not justified the need for such a future longitudinal project and reading through I do not see a basis for such research. It is quite clearly known the relationship between WASH and U5 mortality and morbidity, as you correctly cite in your discussion. What do you hope to add? Based on your investigative survey questions, I do not see what new information you could glean that would alter or influence intervention. The purpose you have given in the abstract (“Infectious diseases are one of the leading causes of death among children under five (U5s) across both India & globally. This is worse in slum environments with poor access to water, sanitation & hygiene (WASH), good nutrition & a safe built environment.”) is no research purpose at all, but a very basic description of what is already known.

Similarly, what do you hope to achieve or intervene with whatever information you may pick up? You have no substantive mention of intervention in your script save for a mention at the end around “co-development of integrated interventions to improve the slum-built environment & WASH alongside better animal husbandry and preventive practices to reduce the U5 infection”. I am not sure why this cannot already be done with current data and what more information you need to know to help local NGOs (which on your website is your target medium for intervention) achieve this. What’s missing, essentially, is why you need the new data you are hoping to find, and then what can realistically be done that is different and could not be done, or done as well, with current data. I think your piece reads so strongly like a preliminary and quick-scan study, it does not explain or justify the definitive need for such a study, or what potential benefit it may have in discrete terms.

2: The second major point is around your data and results. You have a very small N number, which is 25. This is outright far too small to publish as a discrete and useful data set. You are not able to present this as reliable or useful primary data, and you certainly cannot draw any conclusion from this. This does practically make your results section, and much of your discussion, unfortunately nullified. You can’t attempt any correlations and you can’t compare your data with other studies as you have done.

Equally important are the questions and presentation of questions and data you’ve supplied. This is really very unclear. First, the bulk of your data given in Table 1 is of households overall and not the U5s. This would be fine, if then the U5 divided data was presented, which it is not. You have two tables on household (=15) and then total people (=85) data but your single table on actual U5s primarily around feeding is first of all not attempted to be correlated with anything, and second of all not even discussed. I’m not sure what’s happened there, but it makes it very difficult to then read paragraphs in results (e.g. “ A strong…retrieve water”).

It doesn’t necessarily matter since the N number is probably too low to present anyway, but were you to re-write this section I would want a much clearer and more precise presentation of particular data around the U5s and what data sets you are able to aim to correlate, which is entirely missing. In both the n-number and data tables presented, you are unable to attempt any analysis.

From a medical point of view, I would have concern over your exploration of health and illness. In your introduction you highlight respiratory and gastrointestinal infectious diseases as predominant burdens of diseases and emphasise this. I do not see any detailed assessment of illness in your data gathering or illness. You are very vague when it comes to symptoms and illness, and the sole phrases used are: “evidence of infection / cough / fever”. This really does need more qualification.  I don’t know of anyone under 5 who doesn’t cough, and while fever is relevant, you are not going to fund and execute a high-end longitudinal cohort study where your most central data point is only ‘fever’ in order to critically appraise and understand U5 illness.

3: Similarly, and moving into the third major point which is around your conclusions and discussion, you have not presented data on several areas you try to draw conclusions from: vaccination status, nutritional status, distance from water, finance, etc. (Again, just to come back to the first point, and this is a run-through theme, what exactly are you trying to argue with such data – we know that vaccinations prevent certain infections, as does nutritional status, finance, etc.). The consequence of all of this is that when you do state in your discussion something similar to “Treatment seeking behaviour was primarily from private facilities with low vaccination compliance. This reflects the marked dependence of slum dwellers on the private health system and the intrinsic weakness of the public health care system in promoting immunization awareness.” it becomes very hard to appreciate the point and justification. The crux here is that if you want to argue something, you are necessarily going to have to dive into a far more full critical analysis of the public/private availability and outreach of care in these settings. Further, once you have done that and once again, what is your proposed intervention and change based on your results? Again if the point of this whole study is just to more strongly argue for the need for public provision of vaccination, I’m not sure that justifies the study.

Your next discussion point is: Future consortium studies involving culture and culture independent sampling to identify pathogens in the presence of infection symptoms will address this limitation. I’m not sure what this exactly is meant to mean, but it sounds like the future project intends to base diagnosis on microbiological lab results. This is obviously far better than the current survey methodology I’ve already critiqued, but I would question it’s reasonability. It’s entirely for you to decide whether or not it’s possible, and if it is then that’s very strong, but first of all I’m not sure of the widespread availability and accuracy of broad microbiological testing, and also you will very likely miss out many substantial respiratory and GI infections that do not end up growing anything in culture.

4: There are several other more minor points (inclusion of AMR, choice and analysis of survey questions) but I think I will just leave for now because that’s quite a lot. I’m mindful this does sound like asking for an entire revamp of this paper, and while that is what I think is needed, there is significant potential here. If there is a genuine need for such a longitudinal study in this setting then I think that’s fantastic and the basis of a genuinely excellent paper. If you take away all the primary data, which really doesn’t do very much, and instead focus on the critical literature appraisal of U5 morbidity and mortality in slum settings, that’s something that would be very worthwhile to read. Your consortium is clearly investing a great deal of time, effort and money into this, so there must be a solid idea of what is missing in the world of child health.

I would want a critical appraisal of current approaches to child health in these settings. What is the history, what is happening now, who is involved, where is the research, what is the data, what are the interventions; all of this in critical detail. I would want the knowledge or intervention gap. You have all looked at this setting and decided there is some gap somewhere: what is it? Give an equal appraisal of what is missing and why it is important. If it is knowledge that’s missing, why is it important, and what would some actor do with it. If it is intervention alone that’s missing, the same questions apply, in which case why is your study not a feasibility study for intervention? And if it’s both, give the whole analysis. I would want a far fuller critical analysis of One Health and its applicability and usefulness, and in particular how you have used it to inform your study. It’s more or less superficially obvious, but since you attribute such emphasis on it, I would want it critically justified. And I would want a more detailed analysis of potential change to intervention and significant expansion of what you mean by intervention. You could consider this a separate review and appraisal of interventions around child health in slum settings and how they have fared, and where you think the weaknesses lie.

In short, switch this from a preliminary study that presents un-useful data into a sweeping critical appraisal that qualitatively justifies a future longitudinal study with proposed methodology. I think that would be a very interesting piece to read and a far stronger basis for your study than what you have currently.