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  • In the wake of these

    2019-06-29

    In the wake of these commitments comes a reminder of the enormity of the task at hand. In , Alexandre Delamou and colleagues present data on the lasting effect of the Ebola virus disease epidemic on maternal and child health-care services in the rural Forest region of Guinea—the location of approximately two of every three reported deaths from Ebola virus disease in the country. They analysed aggregated monthly service use data from health systems in six districts, using an interrupted time series analysis to estimate trends in antenatal care, facility-based (institutional) delivery, and receipt of five childhood vaccinations (polio, pentavalent, yellow fever, measles, and tuberculosis) across three periods: pre-epidemic (January, 2013, to February, 2014), epidemic (March, 2014, to February, 2015), and post-epidemic (March, 2015, to February, 2016). Delamou and colleagues showed that trends in both maternal and child health indicators significantly dropped during the epidemic—a tragic but unsurprising finding, and one in agreement with similar reports from Liberia and Sierra Leone. But less well described, and perhaps more concerning, is their finding of durable, detrimental effects on basic health-care delivery up to a year after the epidemic ended in Guinea. Indeed, they estimate persistently stagnant or negative trends in all health indicators assessed through the end of their observation period in March, 2016. These estimates correspond to thousands of missed opportunities for prenatal care, safe deliveries, and preventable early life infections—the cornerstones of maternal and child health.
    How is it possible that lychee, a deliciously sweet tropical fruit, could induce a fatal hypoglycemic encephalopathy in children? The answer is straightforward: the edible fruit (aril) of lychee or litchi (), and other members of the Soapberry family (Sapindaceae), contains unusual NSC 66811 structure that disrupt gluconeogenesis and β-oxidation of fatty acids. This is well established in relation to both litchi fruit and, more particularly, fruit of its cousin, the ackee plant (), a member of the Sapindaceae originating in west Africa and transplanted in the 18th century to the Caribbean. Ingestion of immature ackee fruit has been known for decades in Jamaica to cause a toxic hypoglycaemic encephalopathy (Jamaican vomiting sickness) in children. This knowledge has been slow to reach certain parts of Asia where the so-called mysterious litchi disease has been attributed to various causes (fruit colouring, heat stroke) in Bihar, India, to an unidentified pesticide in northwest Bangladesh and, after an exhaustive negative virological search, to a yet-to-be-discovered neurotropic virus in northeast Vietnam. However, the illness evolves far too quickly to be a viral disorder, with a median time of 20 h from health to death in Bangladeshi children. In , Aakash Shrivastava and colleagues\' study of Indian children with litchi-associated encephalopathy unequivocally pins the blame on the litchi fruit itself, as predicted by previous Indian investigators and by us. Like most, if not all, neurotoxic factors, the separation between chemical-induced health and illness depends on dosage and individual susceptibility, which in this case translates to the number of litchi fruit consumed and the concentration of hypoglycaemic amino acids, as well as the children\'s age and state of nourishment. Shrivastava and colleagues report that, akin to ackee, the unripe fruit of litchi has a higher concentration of hypoglycin A and its lower homologue, α-(methylenecyclopropyl)glycine; the reported absence of a significant difference between the two probably arises from the small number of fruit samples tested (n=6 per batch of ripe and unripe fruit). Unfortunately, the study did not compare litchi-associated cases with controls drawn from the community and, strangely, cases were compared with sick controls lacking neurological disease and no history in the previous 3 months of altered mental status or seizures, and admitted to a case-surveillance hospital less than 7 days from admission of the case.