Food Environments, Food Security, and Household Food Availability of Circular Migrant Families: A Mixed-Methods Study Among Brick Kiln Laborers in Bihar, India.

BACKGROUND: Circular migration is the dominant pattern of movement in India and is a livelihood strategy used by many food insecure rural households. Repeated shifts in food environments have important implications on household food security and dietary patterns but have not been studied. OBJECTIVE: To explore differences in the food environment, food security, and food availability between home and destination spaces. METHODS: Mixed-methods research was conducted among circular migrant families working and residing on brick kilns in the state of Bihar. Utilizing stratified cluster sampling, 2 rounds of cross-sectional data were collected from 2564 families. Additionally, 25 in-depth interviews were conducted with circular migrant parents, kiln owners, and labor contractors. The Food Insecurity Experience Scale was validated for use in our study population. Bivariate analyses were conducted to estimate the association of food insecurity with sociodemographic variables. Qualitative data were analyzed using descriptive thematic methods. RESULTS: Seventy percent of respondents utilized at least one nonmarket source of food at the origin; at the destination, sources of food were limited to the private market. Despite higher food prices at the destination, perceived food affordability was higher during periods of migration, resulting in improved food security. Tubers, rice, and wheat were typically available in the household daily, whereas fruits, eggs, and dairy were typically unavailable during the week. CONCLUSIONS: Circular migration can enable short-term food security by improving food affordability. Policy frameworks must address the root causes of chronic food insecurity, especially among rural-to-rural circular migrant families.

Early life migration and undernutrition among circular migrant children: An observational study in the brick kilns of Bihar, India.

BACKGROUND: India holds the world's largest burden of chronic and acute child undernutrition. Poverty and systemic inequities are basic causes of undernutrition that also drive households to engage in circular migration for livelihood. Short-term, temporary movement of the whole family, including young children, is common; yet, the nutritional implications of recurrent movements beginning in early life has not been studied. We sought to estimate the association of repeat and early life migration with stunting and wasting outcomes among circular migrant children under three. METHODS: Using a stratified cluster design, we conducted two waves of primary data collection among 2564 randomly selected circular migrant children under three years of age temporarily residing across 1156 brick kilns in Bihar, India. We conducted multilevel modeling to estimate the association of the number of migration episodes and age at first migration with stunting (<-2 standard deviations (SD) height-for-age z scores (HAZ)) and wasting (<-2 SD weight-for-height z-scores (WHZ)) and examined the determinants of nutrition status among migrant children, including diet, illness, food security and the health environment. RESULTS: The overall prevalence of stunting was 51.6%. Among children who were either born during migration or first migrated before six months of age, those who experienced multiple episodes of migration were more likely to be stunted compared to those who migrated once (adjusted odds ratio (aOR) = 2.10; 95% confidence interval (CI) = 1.30-3.41). Children were over three times as likely to be wasted in the summer compared to the winter (aOR = 3.28; 95% CI = 2.68-4.01); in the summer, the overall prevalence of wasting was 38.8%. Public health access indicators such as interaction with frontline health workers at the destination was low (5.3%), whereas feeding indicators such as exclusive breastfeeding among 0-5 months was high (81.1%). CONCLUSIONS: Policy efforts should ensure continuity of social protection and welfare entitlements between home and destinations for circular migrant families, with an explicit focus on rural-to-rural movement.

Agreement between dried blood spots and HemoCue in Tamil Nadu, India.

India retains the world's largest burden of anemia despite decades of economic growth and anemia prevention programming. Accurate screening and estimates of anemia prevalence are critical for successful anemia control. Evidence is mixed on the performance of HemoCue, a point-of-care testing device most widely used for large-scale surveys. The use of dried blood spots (DBS) to assess hemoglobin (Hb) concentration is a potential alternative, particularly in field settings. The objective of this study is to assess Hb measurement agreement between capillary HemoCue and DBS among two age groups, children 6-59 months and females age 12-40 years. We analyzed data from the baseline round of a cluster randomized rice fortification intervention in Cuddalore district of Tamil Nadu, India. Capillary blood was collected from a subset of participants for Hb assessment by HemoCue 301 and DBS methods. We calculated Lin's concordance correlation coefficient, and tested bias by conducting paired t-tests of Hb concentration. Independence of the bias and Hb magnitude was examined visually using Bland-Altman plots and statistically tested by Pearson's correlation. We assessed differences in anemia classification using McNemar's test of marginal homogeneity. Concordance between HemoCue and DBS Hb measures was moderate for both children 6-59 months (ρc = 0.67; 95% CI 0.65, 0.71) and females 12-40 years (ρc = 0.67: 95% CI 0.64, 0.69). HemoCue measures were on average 0.06 g/dL higher than DBS for children (95% CI 0.002, 0.12; p = 0.043) and 0.29 g/dL lower than DBS for females (95% CI - 0.34, - 0.23; p < 0.0001). 50% and 56% of children were classified as anemic according to HemoCue and DBS, respectively (p < 0.0001). 55% and 47% of females were classified as anemic according to HemoCue and DBS, respectively (p < 0.0001). There is moderate statistical agreement of Hb concentration between HemoCue and DBS for both age groups. The choice of Hb assessment method has important implications for individual anemia diagnosis and population prevalence estimates. Further research is required to understand factors that influence the accuracy and reliability of DBS as a methodology for Hb assessment.

The natural history of acute Ebola Virus Disease among patients managed in five Ebola treatment units in West Africa: A retrospective cohort study.

INTRODUCTION: Previous studies of Ebola Virus Disease (EVD) have focused on clinical symptoms and Ebola virus (EBOV) cycle threshold (CT) values recorded at patient triage. Our study explores EVD symptoms and EBOV CT values from onset of illness to recovery or death in a diverse population of patients. METHODOLOGY/PRINCIPAL FINDINGS: We analyzed clinical care data from EBOV positive patients admitted to five Ebola treatment units in West Africa from 2014-2015. Prevalence of clinical signs/symptoms and CT values were explored using descriptive statistics. Logistic regression was used to examine their association with mortality. Survival was analyzed using Kaplan-Meier estimators from symptom onset date to death. During the first week of illness, dyspnea (OR = 2.44, 95% CI: 1.07-5.85) and tachycardia (OR = 10.22, 95% CI: 2.20-56.71) were associated with higher odds of mortality. Dyspnea (OR = 2.33, 95% CI: 1.210-4.581), bleeding (OR = 2.51, 95% CI: 1.219-5.337), and diarrhoea (OR = 2.79, 95% CI: 1.171-6.970) at any point during the illness course were associated with higher odds of mortality. Higher initial (OR = 0.85, 95% CI: 0.81-0.89) and mean (OR = 0.60, 95% CI: 0.53-0.66) CT values were associated with lower odds of mortality. CT values reached their nadir after 3-5 days of illness and then rose in both survivors and non-survivors until recovery or death. CONCLUSIONS/SIGNIFICANCE: Our study demonstrates the population prevalence of clinical signs/symptoms and EBOV CT values over time in a large, diverse cohort of patients with EVD, as well as associations between symptoms/EBOV CT values and mortality. These findings have implications on surveillance, operational planning, and clinical care for future EVD outbreaks.

Ebola Virus Disease and Pregnancy: A Retrospective Cohort Study of Patients Managed at 5 Ebola Treatment Units in West Africa.

BACKGROUND: Reliable data are lacking on pregnancy outcomes during Ebola virus disease (EVD) epidemics. We aimed to characterize symptoms and outcomes among pregnant women admitted to Ebola treatment units (ETUs) with suspected and confirmed EVD to better inform obstetric management. METHODS: We analyzed a retrospective cohort of reproductive-aged women presenting to 5 West African ETUs from September 2014 to September 2015. We compared clinical symptoms, risk of EVD diagnosis, and mortality between pregnant and nonpregnant women. RESULTS: Of 729 reproductive-aged women admitted to study ETUs, 44 (6%) reported pregnancy. Thirteen of 44 pregnant women (30%) tested EVD positive; 6 of 13 (46%) died. Pregnant women were less likely than nonpregnant women to report anorexia, asthenia, diarrhea, fever, myalgias/arthralgias, nausea, or vomiting (P < .05) at admission. Pregnant women with suspected EVD had the same risk, however, of laboratory-confirmed EVD (30% vs 24%, P = .38). While pregnant women with confirmed EVD had similar Ebola viral loads on presentation to nonpregnant women, as measured by initial cycle threshold (26.4 vs 23.2, P = .16), they were less likely to have myalgias/arthralgias (P< .001) and vomiting (P = .02). Both all-cause mortality (14% vs 19%, P = .39) and EVD-specific mortality (46% vs 54%, P = .60) were not significantly different between pregnant and nonpregnant women. Two neonates born live in the ETU died within 8 days. CONCLUSIONS: We find no evidence to support a difference in the risk of death between pregnant women with suspected or confirmed EVD compared to nonpregnant women. Limited data suggest poor fetal and neonatal outcomes in EVD-affected pregnancies.

Successful Implementation of a Multicountry Clinical Surveillance and Data Collection System for Ebola Virus Disease in West Africa: Findings and Lessons Learned.

BACKGROUND: The 2014 outbreak of Ebola virus disease (EVD) in West Africa was the largest ever recorded. Starting in September 2014, International Medical Corps (IMC) managed 5 Ebola treatment units (ETUs) in Liberia and Sierra Leone, which cumulatively cared for about 2,500 patients. We conducted a retrospective cohort study of patient data collected at the 5 ETUs over 1 year of operations. METHODS: To collect clinical and epidemiological data from the patient care areas, each chart was either manually copied across the fence between the high-risk zone and low-risk zone, imaged across the fence, or imaged in the high-risk zone. Each ETU's data were entered into a separate electronic database, and these were later combined into a single relational database. Lot quality assurance sampling was used to ensure data quality, with reentry of data with high error rates from imaged records. RESULTS: The IMC database contains records on 2,768 patient presentations, including 2,351 patient admissions with full follow-up data. Of the patients admitted, 470 (20.0%) tested positive for EVD, with an overall case fatality ratio (CFR) of 57.0% for EVD-positive patients and 8.1% for EVD-negative patients. Although more men were admitted than women (53.4% vs. 46.6%), a larger proportion of women were diagnosed EVD positive (25.6% vs. 15.2%). Diarrhea, red eyes, contact with an ill person, and funeral attendance were significantly more common in patients with EVD than in those with other diagnoses. Among EVD-positive patients, age was a significant predictor of mortality: the highest CFRs were among children under 5 (89.1%) and adults over 55 (71.4%). DISCUSSION: While several prior reports have documented the experiences of individual ETUs, this study is the first to present data from multiple ETUs across 2 countries run by the same organization with similar clinical protocols. Our experience demonstrates that even in austere settings under difficult conditions, it is possible for humanitarian organizations to collect high-quality clinical and epidemiologic data during a major infectious disease outbreak.

Age at arrival and risk of obesity among US immigrants.

Although immigrants are a rapidly growing subgroup, little is known about overweight/obesity among the foreign-born in the United States, especially regarding the effect of age at arrival. This study determined whether overweight/obesity prevalence is associated with age at arrival of immigrants to the United States. We analyzed data on 6,421 adult immigrants from the New Immigrant Survey (NIS), a study that is nationally representative of adult immigrants with newly acquired legal permanent residence (LPR). Multiple regression analyses tested the effects of duration of residence and age at arrival on overweight/obesity, defined by BMI of > or = 25 kg/m(2), and self-reported dietary change score. We found the relationship between duration of residence and overweight/obesity prevalence varied by age at arrival (P < 0.001). Immigrants < or = 20-years old at arrival who had resided in the United States > or = 15 years were 11 times (95% confidence interval: 5.33, 22.56) more likely to be overweight/obese than immigrants < 20-years old at arrival who had resided in the United States < or = 1 year. By comparison, there was no difference in overweight/obesity prevalence by duration among immigrants who arrived at >50 years of age. Higher self-reported dietary change is also associated with overweight/obesity. In conclusion, immigrants younger than 20 at arrival in the United States may be at higher risk of overweight/obesity with increasing duration of residence than those who arrive at later ages. Obesity prevention among young US immigrants should be a priority.