Drought, armed conflict and population mortality in Somalia, 2014-2018: A statistical analysis.

During 2010-2012, extreme food insecurity and famine in Somalia were estimated to account for 256,000 deaths. Since 2014 Somalia has experienced recurrent below-average rainfall, with consecutive failed rains in late 2016 and 2017 leading to large-scale drought, displacement and epidemics. We wished to estimate mortality across Somalia from 2014 to 2018, and measure the excess death toll attributable to the 2017-2018 drought-triggered crisis. We used a statistical approach akin to small-area estimation, and relying solely on existing data. We identified and re-analysed 91 household surveys conducted at the district level and estimating the crude (CDR) and under 5 years death rate (U5DR) over retrospective periods of 3-4 months. We captured datasets of candidate predictors of mortality with availability by district and month. We also reconstructed population denominators by district-month combining alternative census estimates and displacement data. We combined these data inputs into predictive models to estimate CDR and U5DR and combined the predictions with population estimates to project death tolls. Excess mortality was estimated by constructing counterfactual no-crisis scenarios. Between 2013 and 2018, Somalia's population increased from 12.0 to 13.5 million, and internally displaced people or returnees reached 20% of the population. We estimated an excess death toll of 44,700 in the most likely counterfactual scenario, and as high as 163,800 in a pessimistic scenario. By contrast to 2010-2012, excess deaths were widespread across Somalia, including central and northern regions. This analysis suggests that the 2017-2018 crisis had a lower, albeit still very substantial, mortality impact than its 2010-2012 predecessor. Despite modest elevations in death rate, crisis conditions were widespread and affected a population of millions. Humanitarian response to drought-related crises in Somalia needs to be strengthened, target the most vulnerable and emphasise very early interventions.

COVID-19 in French nursing homes during the second pandemic wave: a mixed-methods cross-sectional study.

INTRODUCTION: French nursing homes were deeply affected by the first wave of the COVID-19 pandemic, with 38% of all residents infected and 5% dying. Yet, little was done to prepare these facilities for the second pandemic wave, and subsequent outbreak response strategies largely duplicated what had been done in the spring of 2020, regardless of the unique needs of the care home environment. METHODS: A cross-sectional, mixed-methods study using a retrospective, quantitative data from residents of 14 nursing homes between November 2020 and mid-January 2021. Four facilities were purposively selected as qualitative study sites for additional in-person, in-depth interviews in January and February 2021. RESULTS: The average attack rate in the 14 participating nursing facilities was 39% among staff and 61% among residents. One-fifth (20) of infected residents ultimately died from COVID-19 and its complications. Failure to thrive syndrome (FTTS) was diagnosed in 23% of COVID-19-positive residents. Those at highest risk of death were men (HR=1.78; 95% CI: 1.18 to 2.70; p=0.006), with FTTS (HR=4.04; 95% CI: 1.93 to 8.48; p<0.001) or in facilities with delayed implementation of universal FFP2 masking policies (HR=1.05; 95% CI: 1.02 to 1.07; p<0.001). The lowest mortality was found in residents of facilities with a partial (HR=0.30; 95% CI: 0.18 to 0.51; p<0.001) or full-time physician on staff (HR=0.20; 95% CI: 0.08 to 0.53; p=0.001). Significant themes emerging from qualitative analysis centred on (1) the structural, chronic neglect of nursing homes, (2) the negative effects of the top-down, bureaucratic nature of COVID-19 crisis response, and (3) the counterproductive effects of lockdowns on both residents and staff. CONCLUSION: Despite high resident mortality during the first pandemic wave, French nursing homes were ill-prepared for the second, with risk factors (especially staffing, lack of medical support, isolation/quarantine policy, etc) that affected case fatality and residents' and caregivers' overall well-being and mental health.

Can we predict the burden of acute malnutrition in crisis-affected countries? Findings from Somalia and South Sudan.

BACKGROUND: Sample surveys are the mainstay of surveillance for acute malnutrition in settings affected by crises but are burdensome and have limited geographical coverage due to insecurity and other access issues. As a possible complement to surveys, we explored a statistical approach to predict the prevalent burden of acute malnutrition for small population strata in two crisis-affected countries, Somalia (2014-2018) and South Sudan (2015-2018). METHODS: For each country, we sourced datasets generated by humanitarian actors or other entities on insecurity, displacement, food insecurity, access to services, epidemic occurrence and other factors on the causal pathway to malnutrition. We merged these with datasets of sample household anthropometric surveys done at administrative level 3 (district, county) as part of nutritional surveillance, and, for each of several outcomes including binary and continuous indices based on either weight-for-height or middle-upper-arm circumference, fitted and evaluated the predictive performance of generalised linear models and, as an alternative, machine learning random forests. RESULTS: We developed models based on 85 ground surveys in Somalia and 175 in South Sudan. Livelihood type, armed conflict intensity, measles incidence, vegetation index and water price were important predictors in Somalia, and livelihood, measles incidence, rainfall and terms of trade (purchasing power) in South Sudan. However, both generalised linear models and random forests had low performance for both binary and continuous anthropometric outcomes. CONCLUSIONS: Predictive models had disappointing performance and are not usable for action. The range of data used and their quality probably limited our analysis. The predictive approach remains theoretically attractive and deserves further evaluation with larger datasets across multiple settings.

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews.

BACKGROUND: Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth. METHODS: We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data. RESULTS: We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering. CONCLUSION: Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise.

BACKGROUND: An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas. METHOD: A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions. FINDINGS: The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention. DISCUSSION: These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting. CONCLUSION: This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change.

The Forgotten Agenda of Wasting in Southeast Asia: Burden, Determinants and Overlap with Stunting: A Review of Nationally Representative Cross-Sectional Demographic and Health Surveys in Six Countries.

Childhood wasting is among the most prevalent forms of undernutrition globally. The Southeast Asia region is home to many wasted children, but wasting is not recognized as a public health problem and its epidemiology is yet to be fully examined. This analysis aimed to determine the burden of wasting, its predictors, and the level of wasting and stunting concurrence. Datasets from Demographic and Health Surveys and Multiple Indicator Cluster Surveys in six countries in the region were analyzed. The pooled weighted prevalence for wasting and concurrent wasting and stunting among children 0-59 months in the six countries was 8.9%, 95% CI (8.0-9.9) and 1.6%, 95% CI (1.5-1.8), respectively. This prevalence is approximately 12-fold higher than the 0.7% prevalence of high-income countries; and translated into an absolute number of 1,088,747 children affected by wasting and 272,563 concurrent wasting and stunting. Wasting prevalence was 50 percent higher in the 0-23-month age group. Predictors for wasting included source of drinking water, wealth index, urban residence, child's age and history of illness and mother's body mass index. In conclusion, our analysis showed that wasting is a serious public health problem in the region that should be addressed urgently using both preventive and curative approaches.

Informing the management of acute malnutrition in infants aged under 6 months (MAMI): risk factor analysis using nationally-representative demographic & health survey secondary data.

BACKGROUND: Tackling malnutrition is a global health priority, helping children both survive and thrive. Acute malnutrition (wasting) in infants aged under 6 months (u6m) is often neglected. Worldwide, some 8.5 million infants u6m are affected yet recent World Health Organization malnutrition guidelines highlight numerous evidence gaps on how to best manage them. To inform future research, policy and programming, we aimed to identify risk factors associated with infant u6m wasting. METHODS: We did secondary data analysis of nationally representative, cross sectional Demographic and Health Surveys conducted in the last 10 years. We compared wasted infants u6m (weight-for-length <-2 z-scores) vs. non-wasted (weight-for-length ≥-2 z-score). We used simple and adjusted (for infant age, sex, socio-economic status) logistic regression to calculate odds of wasting associated with risk factors spanning three broad categories: household-related; maternal-related; infant-related. RESULTS: We analysed 16,123 infants u6m from 20 countries. Multiple risk factors were statistically associated with wasting. These included: poverty (Odds ratio, OR 1.22 (95% CI [1.01-1.48], p = 0.04)); low maternal body mass index (adjusted OR 1.53(1.29-1.80, p < 0.001); small infant size at birth (aOR 1.32(1.10-1.58, p < 0.01)); delayed start of breastfeeding (aOR 1.31(1.13-1.51, p < 0.001)); prelacteal feed (aOR 1.34(1.18-1.53, p < 0.001)); recent history of diarrhoea (aOR 1.37(1.12-1.67, p < 0.01)); mother disempowered (experiences violence; does not make decisions about health issues; does not engage with health services such as antenatal care, does not give birth in a health facility). 'Protective' factors associated with significantly decreased odds of infant u6m wasting included: educated mother (OR 0.64(0.54-0.76, p < 0.001)); mother in work (OR 0.82(0.72-0.94, p < 0.01)); currently breastfed (aOR 0.62(0.42-0.91, p = 0.02)), exclusively breastfed (aOR 0.84(0.73-0.97, p = 0.02). DISCUSSION: Infant u6m wasting is a complex, multifactorial problem associated with many risk factors; knowing them will help shape international and national management strategies. Whilst our observational study cannot prove causation, many factors identified are biologically plausible and/or socially important. They should be considered when assessing and managing infants u6m. Although supporting breastfeeding is core to future interventions, this alone is unlikely to be sufficient; strategies should involve multiple sectors, beyond just health and nutrition. By noting our results, future intervention studies could focus resources and maximise chances of achieving impact.

MUAC as the sole discharge criterion from community-based management of severe acute malnutrition in Burkina Faso.

The use of mid upper arm circumference (MUAC) measurement to screen and determine eligibility for admission to therapeutic feeding programs has been established, but evidence and programmatic experience to inform guidance on the use of MUAC as a discharge criterion is limited. We present results from a large-scale nutritional program using MUAC for admission and discharge and compare program outcomes and response to treatment when determining eligibility for discharge by proportional weight gain versus discharge by MUAC. The study population included all children admitted to the Ministry of Health therapeutic feeding program supported by Médecins Sans Frontières in northern Burkina Faso from September 2007 to December 2011 (n = 50,841). Recovery was high overall using both discharge criteria, with low risks of death, nonresponse, and transfer to inpatient care and high daily gains in weight, MUAC, weight-for-height Z score, and height. When discharge was made by MUAC only, recovery increased, while all adverse program outcomes and length of stay decreased, with increasing MUAC on admission. MUAC-based programming, where MUAC is integrated into program screening, admission, and discharge, is one of several new approaches that can be used to target resources to the most at-risk malnourished children and improve program efficiency and coherency. This analysis provides additional programmatic experience on the use of MUAC-based discharge criterion, but more work may be needed to inform optimal discharge thresholds across settings.

Does the Humanitarian Sector Use Evidence-informed Standards? A Review of the 2011 Sphere Indicators for Wash, Food Security and Nutrition, and Health Action.

BACKGROUND: In 1997, the pursuit of greater accountability and effectiveness in humanitarian response prompted a multi-stakeholder collaboration to develop a set of indicators and standards to guide humanitarian practitioners, published later in the form of the Sphere Handbook. Twenty years after the first edition of the Handbook was developed, and in order to guide the 2018 revision, an assessment of the evidence base for current Water, Sanitation and Hygiene (WASH), Food Security and Nutrition, and Health Action indicators, as compared to evidence collated by the 2015 LSHTM Humanitarian Health Evidence Review (HHER), was conducted. METHODOLOGY: In order to assess the utility of the Sphere indicators as a tool with which to monitor and evaluate humanitarian activities, indicators from the WASH, Food Security and Nutrition, and Health Action chapters of the Sphere Handbook were analysed and classified according to the SMART criteria. Each indicator was then assessed based on existing evidence related to the effectiveness of humanitarian health interventions as compiled in the HHER. RESULTS: Of the 159 Sphere indicators intended to guide humanitarian response, only 2 met all of the SMART criteria. The remaining 157 did not provide any time indication for the measurement of the indicator. Furthermore, only 11 standards (23%) and 14 indicators (8%) are supported in part by 33 studies identified in the HHER. Less than one third of studies captured by HHER that explore interventions related to WASH, nutrition, or health could be linked to existing Sphere indicators. CONCLUSION: It is not possible to adequately link the 2011 Sphere indicators and standards to their sources in their current constitution, and they are not sufficiently evidence-informed. In the absence of clear measurement definitions, they do not provide necessarily detailed guidance. While recognising that a number of indicators have emerged as a combination of empirical evidence, expert experience, and "common sense", a focus on fewer indicators, each better defined, is likely to enhance the practical application of the Sphere Handbook in humanitarian settings.

A novel, efficient method for estimating the prevalence of acute malnutrition in resource-constrained and crisis-affected settings: A simulation study.

INTRODUCTION: The assessment of the prevalence of acute malnutrition in children under five is widely used for the detection of emergencies, planning interventions, advocacy, and monitoring and evaluation. This study examined PROBIT Methods which convert parameters (mean and standard deviation (SD)) of a normally distributed variable to a cumulative probability below any cut-off to estimate acute malnutrition in children under five using Middle-Upper Arm Circumference (MUAC). METHODS: We assessed the performance of: PROBIT Method I, with mean MUAC from the survey sample and MUAC SD from a database of previous surveys; and PROBIT Method II, with mean and SD of MUAC observed in the survey sample. Specifically, we generated sub-samples from 852 survey datasets, simulating 100 surveys for eight sample sizes. Overall the methods were tested on 681 600 simulated surveys. RESULTS: PROBIT methods relying on sample sizes as small as 50 had better performance than the classic method for estimating and classifying the prevalence of acute malnutrition. They had better precision in the estimation of acute malnutrition for all sample sizes and better coverage for smaller sample sizes, while having relatively little bias. They classified situations accurately for a threshold of 5% acute malnutrition. Both PROBIT methods had similar outcomes. CONCLUSIONS: PROBIT Methods have a clear advantage in the assessment of acute malnutrition prevalence based on MUAC, compared to the classic method. Their use would require much lower sample sizes, thus enable great time and resource savings and permit timely and/or locally relevant prevalence estimates of acute malnutrition for a swift and well-targeted response.

Evidence on public health interventions in humanitarian crises.

Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.

Is Middle-Upper Arm Circumference "normally" distributed? Secondary data analysis of 852 nutrition surveys.

BACKGROUND: Wasting is a major public health issue throughout the developing world. Out of the 6.9 million estimated deaths among children under five annually, over 800,000 deaths (11.6 %) are attributed to wasting. Wasting is quantified as low Weight-For-Height (WFH) and/or low Mid-Upper Arm Circumference (MUAC) (since 2005). Many statistical procedures are based on the assumption that the data used are normally distributed. Analyses have been conducted on the distribution of WFH but there are no equivalent studies on the distribution of MUAC. METHODS: This secondary data analysis assesses the normality of the MUAC distributions of 852 nutrition cross-sectional survey datasets of children from 6 to 59 months old and examines different approaches to normalise "non-normal" distributions. RESULTS: The distribution of MUAC showed no departure from a normal distribution in 319 (37.7 %) distributions using the Shapiro-Wilk test. Out of the 533 surveys showing departure from a normal distribution, 183 (34.3 %) were skewed (D'Agostino test) and 196 (36.8 %) had a kurtosis different to the one observed in the normal distribution (Anscombe-Glynn test). Testing for normality can be sensitive to data quality, design effect and sample size. Out of the 533 surveys showing departure from a normal distribution, 294 (55.2 %) showed high digit preference, 164 (30.8 %) had a large design effect, and 204 (38.3 %) a large sample size. Spline and LOESS smoothing techniques were explored and both techniques work well. After Spline smoothing, 56.7 % of the MUAC distributions showing departure from normality were "normalised" and 59.7 % after LOESS. Box-Cox power transformation had similar results on distributions showing departure from normality with 57 % of distributions approximating "normal" after transformation. Applying Box-Cox transformation after Spline or Loess smoothing techniques increased that proportion to 82.4 and 82.7 % respectively. CONCLUSION: This suggests that statistical approaches relying on the normal distribution assumption can be successfully applied to MUAC. In light of this promising finding, further research is ongoing to evaluate the performance of a normal distribution based approach to estimating the prevalence of wasting using MUAC.

Malnutrition and Childhood Disability in Turkana, Kenya: Results from a Case-Control Study.

BACKGROUND: Children with disabilities may be particularly vulnerable to malnutrition, as a result of exclusions and feeding difficulties. However, there is limited evidence currently available on this subject. METHODS: A population-based case-control study was conducted in Turkana County, Kenya, between July and August 2013. Key informants in the community identified children aged 6 months to 10 years who they believed may have a disability. These children were screened by a questionnaire (UNICEF-Washington Group) and assessed by a paediatrician to confirm whether they had a disability and the type. Two controls without disabilities were selected per case: A sibling control (sibling nearest in age) and a neighbourhood control (nearest neighbour within one year of age). The caregiver completed a questionnaire on behalf of the child (e.g. information on feeding, poverty, illness, education), and anthropometric measures were taken. We undertook multivariable logistic and linear regression analyses to estimate the relationship between disability and malnutrition. RESULTS: The study included 311 cases with disabilities, 196 sibling controls and 300 neighbour controls. Children with disabilities were more likely to report a range of feeding difficulties. They were 1.6-2.9 times more likely to have malnutrition in comparison to neighbour controls or family controls, including general malnutrition (low weight for age), stunting (low height for age), low body mass index (BMI) or low mid upper arm circumference (MUAC) for age. Children with disabilities were almost twice as likely to have wasting (low weight for height) in comparison to neighbour controls (OR = 1.9, 95% CI 1.1-3.2), but this difference was not apparent compared with siblings (OR = 1.5, 95% CI 0.8-2.7). Children with disabilities also faced other exclusions. For instance those aged 5+ were much more likely not to attend school than neighbour controls (OR = 8.5, 95% CI 4.3-16.9). CONCLUSIONS: Children with disabilities were particularly vulnerable to malnutrition, even within this area of food insecurity and widespread malnutrition. Efforts need to be made to include children with disabilities within food supplementation programmes, and school based programmes alone may be inadequate to meet this need. Exclusion of children with disabilities from education is also a priority area to be addressed.

Omitting edema measurement: how much acute malnutrition are we missing?

BACKGROUND: Acute malnutrition is a major public health issue in low-income countries. It includes both wasting and edematous malnutrition, but the terms wasting and acute malnutrition are often used interchangeably. Little is known about the burden of edematous malnutrition, and few large-scale surveys measure it. OBJECTIVE: Most acute malnutrition might be captured by the measurement of wasting alone, but this is unknown. This article aims to fill this gap. DESIGN: This article presents a secondary data analysis of 852 nutrition cross-sectional survey data sets of children aged 6-59 mo. The data sets assembled included surveys from East, West, South, and Central Africa; the Caribbean; and Asia. The overlap between edematous malnutrition and wasting was assessed, and the impact of including/excluding edema on acute malnutrition prevalence estimates was evaluated. RESULTS: The prevalence of edematous malnutrition varied from 0% to 32.9%, and children were more likely to have bilateral edema in Central and South Africa (OR: 4; 95% CI: 2.8, 5.6). A large proportion of children with edematous malnutrition were not wasted [62% and 66% based on midupper arm circumference (MUAC) and weight-for-height (WFH), respectively], and most were not severely wasted (83% and 86% based on MUAC and WFH, respectively). When wasting and global acute malnutrition prevalence estimates as well as severe wasting and severe acute malnutrition prevalence estimates overall were compared, the differences between estimates were small (median of 0.0% and mean of 0.3% based on WFH and MUAC for global estimates and slightly higher median of 0.1% and mean of 0.4% based on MUAC and WFH, respectively, for the severe forms), but the picture was different at the regional level. CONCLUSIONS: The terms acute malnutrition and wasting should not be used interchangeably. The omission of the measurement of edema can have important repercussions, especially at the nutrition program level.