A typology of social network interactions in sub-Saharan Africa: Evidence from a rural population in Senegal.

Social isolation/marginalization in sub-Saharan Africa is under-researched, despite increasing evidence of weakening traditional community-based social support. This paper aims to develop a typology of social networks capable of accounting for social marginalization in a rural community in Western Senegal and to describe the socio-demographic characteristics of network profiles. Building on prior qualitative work, we carry out a latent profile analysis using a unique and extensive social network data set, identifying four different network profiles: Locally integrated, Constrained relationships, Locally marginalized, and Local elites. This paper provides the first empirically supported classification of social integration and marginalization in social networks in rural sub-Saharan Africa. In doing so, it can serve as a reference for future research seeking to understand both the broader scope of social integration and marginalization and the consequences of differential access to social capital through social networks on access to health resources and well-being.

COVID-19-specific metabolic imprint yields insights into multiorgan system perturbations.

Corona disease 2019 (COVID-19) affects multiple organ systems. Recent studies have indicated perturbations in the circulating metabolome linked to COVID-19 severity. However, several questions pertain with respect to the metabolome in COVID-19. We performed an in-depth assessment of 1129 unique metabolites in 27 hospitalized COVID-19 patients and integrated results with large-scale proteomic and immunology data to capture multiorgan system perturbations. More than half of the detected metabolic alterations in COVID-19 were driven by patient-specific confounding factors ranging from comorbidities to xenobiotic substances. Systematically adjusting for this, a COVID-19-specific metabolic imprint was defined which, over time, underwent a switch in response to severe acute respiratory syndrome coronavirus-2 seroconversion. Integration of the COVID-19 metabolome with clinical, cellular, molecular, and immunological severity scales further revealed a network of metabolic trajectories aligned with multiple pathways for immune activation, and organ damage including neurological inflammation and damage. Altogether, this resource refines our understanding of the multiorgan system perturbations in severe COVID-19 patients.

Activation and Kinetics of Circulating T Follicular Helper Cells, Specific Plasmablast Response, and Development of Neutralizing Antibodies following Yellow Fever Virus Vaccination.

A single dose of the replication-competent, live-attenuated yellow fever virus (YFV) 17D vaccine provides lifelong immunity against human YFV infection. The magnitude, kinetics, and specificity of B cell responses to YFV 17D are relatively less understood than T cell responses. In this clinical study, we focused on early immune events critical for the development of humoral immunity to YFV 17D vaccination in 24 study subjects. More specifically, we studied the dynamics of several immune cell populations over time and the development of neutralizing Abs. At 7 d following vaccination, YFV RNA in serum as well as several antiviral proteins were detected as a sign of YFV 17D replication. Activation of Th1-polarized circulating T follicular helper cells followed germinal center activity, the latter assessed by the surrogate marker CXCL13 in serum. This coincided with a plasmablast expansion peaking at day 14 before returning to baseline levels at day 28. FluoroSpot-based analysis confirmed that plasmablasts were specific to the YFV-E protein. The frequencies of plasmablasts correlated with the magnitude of neutralizing Ab titers measured at day 90, suggesting that this transient B cell subset could be used as an early marker of induction of protective immunity. Additionally, YFV-specific memory B cells were readily detectable at 28 and 90 d following vaccination, and all study subjects tested developed protective neutralizing Ab titers. Taken together, these studies provide insights into key immune events leading to human B cell immunity following vaccination with the YFV 17D vaccine.

Does social integration really protect against loneliness? Gender determinants in a rural population in Senegal / L'intégration sociale protège-t-elle vraiment contre la solitude ? Déterminants genrés dans une population rurale du Sénégal

Introduction: This study aims to test a measure of loneliness and to document its determinants among rural men and women in Senegal. Methods: Data from the Niakhar Social Networks and Health Project were used. The analysis sample was composed of 1261 residents aged 16 years and older. Analyses were stratified by gender. Associations between loneliness and its determinants (socio-demographic characteristics and level of social integration) were examined with multivariate logistic regressions. Results: Loneliness affects almost one in three people. Its prevalence is more significant for women. Multivariate analyses indicate that for both men and women, older age intensifies loneliness and recent migration experience protects against loneliness. Other factors act differently according to gender. Widowhood or divorce for men, and residential isolation for women, worsen the experience of loneliness. Social integration protects men against loneliness, but this relationship is not found for women. Finally, the effect of the level of social integration on loneliness varies with age. Conclusions: This study, which documents a phenomenon which is often neglected by misconceptions about social solidarities in these societies, suggests that loneliness is not linked to the same issues for men and women. For men, being socially integrated and being in a union are protective, whereas for women, poor social integration does not appear to be a clear source of loneliness, unlike residential isolation.

Introduction: Cette étude vise à tester une mesure de la solitude et à documenter ses déterminants chez les hommes et les femmes en milieu rural au Sénégal. Méthodes: Les données du Niakhar Social Networks and Health Project sont utilisées. L'échantillon d'analyse est composé de 1 261 résidents âgés de 16 ans et plus. Les analyses sont stratifiées par sexe. Les associations entre la solitude et ses déterminants (caractéristiques socio-démographiques et niveau d'intégration sociale) sont examinées à l'aide de régressions logistiques multivariées. Résultats: La solitude touche près d'un individu sur trois et sa prévalence est plus grande chez les femmes. Les analyses multivariées indiquent que, pour les hommes et les femmes, l'âge avancé favorise la solitude, et l'expérience migratoire récente protège contre la solitude. D'autres facteurs agissent de manière différente selon le sexe. La situation de veuvage ou de divorce pour les hommes, et l'isolement résidentiel pour les femmes, entrainent l'expérience de solitude. L'intégration sociale protège les hommes contre la solitude, mais cette relation ne se retrouve pas pour les femmes. Enfin, l'effet du niveau d'intégration sociale sur la solitude varie selon l'âge. Conclusion: Cette étude suggère que la solitude ne répond pas aux mêmes enjeux pour les hommes et pour les femmes et documente ce phénomène souvent occulté par les idées reçues relatives aux solidarités sociales dans ces sociétés. Pour les hommes, être intégrés socialement et être en union sont des éléments protecteurs, alors que pour les femmes, une faible intégration sociale n'apparait pas clairement comme une source de solitude, contrairement à l'isolement résidentiel.

Expansion of SARS-CoV-2-Specific Antibody-Secreting Cells and Generation of Neutralizing Antibodies in Hospitalized COVID-19 Patients.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in late 2019 and has since become a global pandemic. Pathogen-specific Abs are typically a major predictor of protective immunity, yet human B cell and Ab responses during COVID-19 are not fully understood. In this study, we analyzed Ab-secreting cell and Ab responses in 20 hospitalized COVID-19 patients. The patients exhibited typical symptoms of COVID-19 and presented with reduced lymphocyte numbers and increased T cell and B cell activation. Importantly, we detected an expansion of SARS-CoV-2 nucleocapsid protein-specific Ab-secreting cells in all 20 COVID-19 patients using a multicolor FluoroSpot Assay. Out of the 20 patients, 16 had developed SARS-CoV-2-neutralizing Abs by the time of inclusion in the study. SARS-CoV-2-specific IgA, IgG, and IgM Ab levels positively correlated with SARS-CoV-2-neutralizing Ab titers, suggesting that SARS-CoV-2-specific Ab levels may reflect the titers of neutralizing Abs in COVID-19 patients during the acute phase of infection. Last, we showed that IL-6 and C-reactive protein serum concentrations were higher in patients who were hospitalized for longer, supporting the recent observations that IL-6 and C-reactive protein could be used as markers for COVID-19 severity. Altogether, this study constitutes a detailed description of clinical and immunological parameters in 20 COVID-19 patients, with a focus on B cell and Ab responses, and describes tools to study immune responses to SARS-CoV-2 infection and vaccination.

Who Matters Most? Migrant Networks, Tie Strength, and First Rural-Urban Migration to Dakar.

Social networks' influence on migration has long been explored largely through the lenses of cumulative causation and social capital theory. This article aims to reconceptualize elements of these theories for the case of rural-urban migration and test their utility in explaining first-migration timing. We use a uniquely extensive social network survey linked to prospectively collected migration data in rural Senegal. We decompose migrant networks into return migrants, current migrants, and nonmigrant residents of the destination to capture heterogeneity in migration-relevant social capital. As expected, the number of nonmigrant alters living in the capital, Dakar, has an outsized association with the migration hazard, the number of current migrants from the village living in Dakar has a smaller association, and the number of return migrants has little association. Drawing on social capital theory, we test the influence of (1) subjectively assessed tie strength between the ego and their network alters and (2) structurally weak ties measured through second-order ("friend of a friend") connections. Weak and strong subjective ties to current migrants and nonmigrant Dakar residents are positively associated with the first-migration hazard. Structurally weak ties to current migrants are too, but only for individuals with no direct ties to current migrants.

A distress-continuum, disorder-threshold model of depression: a mixed-methods, latent class analysis study of slum-dwelling young men in Bangladesh.

BACKGROUND: Binary categorical approaches to diagnosing depression have been widely criticized due to clinical limitations and potential negative consequences. In place of such categorical models of depression, a 'staged model' has recently been proposed to classify populations into four tiers according to severity of symptoms: 'Wellness;' 'Distress;' 'Disorder;' and 'Refractory.' However, empirical approaches to deriving this model are limited, especially with populations in low- and middle-income countries. METHODS: A mixed-methods study using latent class analysis (LCA) was conducted to empirically test non-binary models to determine the application of LCA to derive the 'staged model' of depression. The study population was 18 to 29-year-old men (n = 824) from an urban slum of Bangladesh, a low resource country in South Asia. Subsequently, qualitative interviews (n = 60) were conducted with members of each latent class to understand experiential differences among class members. RESULTS: The LCA derived 3 latent classes: (1) Severely distressed (n = 211), (2) Distressed (n = 329), and (3) Wellness (n = 284). Across the classes, some symptoms followed a continuum of severity: 'levels of strain', 'difficulty making decisions', and 'inability to overcome difficulties.' However, more severe symptoms such as 'anhedonia', 'concentration issues', and 'inability to face problems' only emerged in the severely distressed class. Qualitatively, groups were distinguished by severity of tension, a local idiom of distress. CONCLUSIONS: The results indicate that LCA can be a useful empirical tool to inform the 'staged model' of depression. In the findings, a subset of distress symptoms was continuously distributed, but other acute symptoms were only present in the class with the highest distress severity. This suggests a distress-continuum, disorder-threshold model of depression, wherein a constellation of impairing symptoms emerge together after exceeding a high level of distress, i.e., a tipping point of tension heralds a host of depression symptoms.

A latent class analysis of attitudes concerning the acceptability of intimate partner violence in rural Senegal.

BACKGROUND: Research concerning the causes and consequences of intimate partner violence (IPV), particularly in less developed areas of the world, has become prominent in the last two decades. Although a number of potential causal factors have been investigated the current consensus is that attitudes toward IPV on the individual level, likely representing perceptions of normative behavior, and the normative acceptability of IPV on the aggregate level likely play key roles. Measurement of both is generally approached through either binary indicators of acceptability of any type of IPV or additive composite indexes of multiple indicators. Both strategies imply untested assumptions which potentially have important implications for both research into the causes and consequences of IPV as well as interventions aimed to reduce its prevalence. METHODS: Using survey data from rural Senegal collected in 2014, this analysis estimates latent class measurement models of attitudes concerning the acceptability of IPV. We investigate the dimensional structure of IPV ideation and test the parallel indicator assumption implicit in common measurement strategies, as well as structural and measurement invariance between men and women. RESULTS: We find that a two-class model of the acceptability of IPV in which the conditional probability of class membership is allowed to vary between the sexes is preferred for both men and women. Though the assumption of structural invariance between men and women is supported, measurement invariance and the assumption of parallel indicators (or equivalence of indicators used) are not. CONCLUSIONS: Measurement strategies conventionally used to operationalize the acceptability of IPV, key to modeling perceptions of norms around IPV, are a poor fit to the data used here. Research concerning the measurement characteristics of IPV acceptability is a precondition for adequate investigation of its causes and consequences, as well as for intervention efforts aimed at reducing or eliminating IPV.

Modeling the relationship between women's perceptions and future intention to use institutional maternity care in the Western Highlands of Guatemala.

BACKGROUND: Despite global gains, women in hard-to-reach areas are at a relatively higher risk of death and disability related to childbirth. Traditional methods of measuring satisfaction may mask negative experiences (such as disrespect and abuse) that can drive down demand for institutional care. Better measurement of women's perceptions of care quality, especially among marginalized populations with historically low utilization of institutional care, are needed to inform how to improve services and foster greater utilization of (potentially life-saving) clinical care. METHODS: A population-based household survey was conducted in 15 purposively selected villages in the rural Western Highlands of Guatemala among women who gave birth to a child within the last 5 years. Demographic and health information including experiences and perceptions of maternity care were collected. Two sets of nested multivariate logistic regression models were estimated to identify factors associated with future intention to give birth in a health facility, separately among women who gave birth to their last child at home and women who gave birth to their last child in a facility. The independent variables of interest were access to care, perceived need for maternity care, and two measures of perceived quality: satisfaction with last birth and disrespect and abuse (perceived or experienced). Thematic analysis was performed on open-ended responses. RESULTS: Perceived need for facility-based childbirth services and satisfaction with last childbirth experience, either at home or in a facility, emerged as the key factors influencing intention to give birth in a health institution in the future. Among the facility birth group, reporting disrespect and abuse is a deterrent to seeking facility-based care in the future. However, select perceptions of disrespect and abuse did not have an association with future intention (among the home birth group). CONCLUSIONS: Women's perceptions of care quality influence care-seeking. Women who feel they were mistreated in health facilities are more likely to avoid or delay seeking care in the future. Health systems need to reinforce trust and positive perceptions of respectful care. Developing better measures of women's perceptions of maternity care experiences among indigenous populations in Guatemala can inform improvements in care provision.

A novel approach for the development of tiered use biological criteria for rivers and streams in an ecologically diverse landscape.

Water resource protection goals for aquatic life are often general and can result in under protection of some high quality water bodies and unattainable expectations for other water bodies. More refined aquatic life goals known as tiered aquatic life uses (TALUs) provide a framework to designate uses by setting protective goals for high quality water bodies and establishing attainable goals for water bodies altered by legally authorized legacy activities (e.g., channelization). Development of biological criteria or biocriteria typically requires identification of a set of least- or minimally-impacted reference sites that are used to establish a baseline from which goals are derived. Under a more refined system of stream types and aquatic life use goals, an adequate set of reference sites is needed to account for the natural variability of aquatic communities (e.g., landscape differences, thermal regime, and stream size). To develop sufficient datasets, Minnesota employed a reference condition approach in combination with an approach based on characterizing a stream's response to anthropogenic disturbance through development of a Biological Condition Gradient (BCG). These two approaches allowed for the creation of ecologically meaningful and consistent biocriteria within a more refined stream typology and solved issues related to small sample sizes and poor representation of minimally- or least-disturbed conditions for some stream types. Implementation of TALU biocriteria for Minnesota streams and rivers will result in consistent and protective goals that address fundamental differences among waters in terms of their potential for restoration.

Safety and immunogenicity following co-administration of Yellow fever vaccine with Tick-borne encephalitis or Japanese encephalitis vaccines: Results from an open label, non-randomized clinical trial.

BACKGROUND: Flavivirus infections pose a significant global health burden underscoring the need for the development of safe and effective vaccination strategies. Available flavivirus vaccines are from time to time concomitantly delivered to individuals. Co-administration of different vaccines saves time and visits to health care units and vaccine clinics. It serves to provide protection against multiple pathogens in a shorter time-span; e.g., for individuals travelling to different endemic areas. However, safety and immunogenicity-related responses have not been appropriately evaluated upon concomitant delivery of these vaccines. Therefore, we performed an open label, non-randomized clinical trial studying the safety and immunogenicity following concomitant delivery of the yellow fever virus (YFV) vaccine with tick-borne encephalitis virus (TBEV) and Japanese encephalitis virus (JE) virus vaccines. METHODS AND FINDINGS: Following screening, healthy study participants were enrolled into different cohorts receiving either TBEV and YFV vaccines, JEV and YFV vaccines, or in control groups receiving only the TBEV, JEV, or YFV vaccine. Concomitant delivery was given in the same or different upper arms for comparison in the co-vaccination cohorts. Adverse effects were recorded throughout the study period and blood samples were taken before and at multiple time-points following vaccination to evaluate immunological responses to the vaccines. Adverse events were predominantly mild in the study groups. Four serious adverse events (SAE) were reported, none of them deemed related to vaccination. The development of neutralizing antibodies (nAbs) against TBEV, JEV, or YFV was not affected by the concomitant vaccination strategy. Concomitant vaccination in the same or different upper arms did not significantly affect safety or immunogenicity-related outcomes. Exploratory studies on immunological effects were additionally performed and included studies of lymphocyte activation, correlates associated with germinal center activation, and plasmablast expansion. CONCLUSIONS: Inactivated TBEV or JEV vaccines can be co-administered with the live attenuated YFV vaccine without an increased risk of adverse events and without reduced development of nAbs to the respective viruses. The vaccines can be delivered in the same upper arm without negative outcome. In a broader perspective, the results add valuable information for simultaneous administration of live and inactivated flavivirus vaccines in general. TRIAL REGISTRATION: Eudra CT 2017-002137-32.

Renal transplantation in infants and small children.

There are still concerns about renal transplantation in small children. The aim of this study was to identify prenatal data, underlying diseases, patient and graft survival, graft function and growth in young renal transplant recipients at our center. A retrospective analysis was performed on 50 kidney transplants performed during the period 1981-2008 in children weighing <13 kg. Their median age at transplantation was 1.4 (range 0.4-3.7) years and the median weight was 9.5 (3.4-12.1) kg. The underlying diseases were congenital in 88% of the patients and acquired in 12%. Ten-year patient survival was 88% (82% before 1998 and 95% since 1998). Ten-year graft survival was 82% (75 and 95%, respectively). Graft function (glomerular filtration rate) deteriorated from a mean of 75-48 ml/min/1.73 m(2) within 10 years. There was rapid catch-up growth within the first years post-transplant, from a median height of -2.44 standard deviation score (SDS) at transplantation to -0.74 SDS after 3 years. In small children, patient and graft survival were as good as those in older children. Renal function deteriorated during the first years post-transplant but stabilized within a few years. In most children, there was a substantial improvement in growth within the first years after transplantation.

Acute effects of antagonist stretching on jump height, torque, and electromyography of agonist musculature.

Although there has been substantial research on the acute effects of static stretching on subsequent force and power development, the outcome after stretching of the antagonist musculature has not been examined. The purpose of this study was to investigate the effects of static stretching of antagonist musculature on multiple strength and power measures. Sixteen trained men were tested for vertical jump height and isokinetic peak torque production during knee extension at 60°.s (SlowKE) and 300°.s (FastKE). Electromyography was recorded for the vastus lateralis and the biceps femoris muscles during isokinetic knee extension. Subjects performed these tests in a randomized counterbalanced order with and without prior stretching of the antagonist musculature. Paired samples t-tests indicated significantly greater torque production during the FastKE when preceded by stretching of the antagonist musculature vs. the nonstretch trial (102.2 vs. 93.5 N.m; p = 0.032). For SlowKE, torque production was not significantly different between the trials (176.7 vs. 162.9 N.m; p = 0.086). Vertical jump height (59.8 vs. 58.6 cm; p = 0.011) and power (8571 vs. 8487 W; p = 0.005) were significantly higher after the stretching trial vs. the nonstretching trial. Electromyography responses were similar between the trials. These results suggest that static stretching of the antagonist hamstrings before high-speed isokinetic knee extension increases the torque production. Furthermore, stretching the hip flexors (emphasis on single-joint hip flexors) and dorsiflexors, the antagonists of the hip extensors and plantarflexors, may enhance jump height and power, although the effect sizes were small.

Innovative vaccine approaches-a Keystone Symposia report.

The rapid development of COVID-19 vaccines was the result of decades of research to establish flexible vaccine platforms and understand pathogens with pandemic potential, as well as several novel changes to the vaccine discovery and development processes that partnered industry and governments. And while vaccines offer the potential to drastically improve global health, low-and-middle-income countries around the world often experience reduced access to vaccines and reduced vaccine efficacy. Addressing these issues will require novel vaccine approaches and platforms, deeper insight how vaccines mediate protection, and innovative trial designs and models. On June 28-30, 2021, experts in vaccine research, development, manufacturing, and deployment met virtually for the Keystone eSymposium "Innovative Vaccine Approaches" to discuss advances in vaccine research and development.

Individual, Community, and Social Network Influences on Beliefs Concerning the Acceptability of Intimate Partner Violence in Rural Senegal.

Intimate partner violence (IPV) is a pressing international public health and human rights concern. Recent scholarship concerning causes of IPV has focused on the potentially critical influence of social learning and influence in interpersonal interaction through social norms. Using sociocentric network data from all individuals aged 16 years and above in a rural Senegalese village surveyed as part of the Niakhar Social Networks and Health Project (n = 1,274), we estimate a series of nested linear probability models to test the association between characteristics of respondents' social networks and residential compounds (including educational attainment, health ideation, socioeconomic status, and religion) and whether respondents are classified as finding IPV acceptable, controlling for individual characteristics. We also test for direct social learning effects, estimating the association between IPV acceptability among network members and co-residents and respondents' own, net of these factors. We find individual, social network, and residential compound factors are all associated with IPV acceptability. On the individual level, these include gender, traditional health ideation, and household agricultural investment. Residential compound-level associations are largely explained in the presence of the individual and network characteristics, except for that concerning educational attainment. We find that network alters' IPV acceptability is strongly positively associated with respondents' own, net of individual and compound-level characteristics. A 10% point higher probability of IPV acceptability in respondents' networks is estimated to be associated with a 4.5% point higher likelihood of respondents being classified as finding IPV acceptable. This research provides compelling evidence that social interaction through networks exerts an important, potentially normative, influence on whether individuals in this population perceive IPV as acceptable or not. It also suggests that interventions targeting individuals most likely to perceive IPV as acceptable may have a multiplier effect, influencing the normative context of others they interact with through their social networks.

SARS-CoV-2-specific humoral and cellular immunity persists through 9 months irrespective of COVID-19 severity at hospitalisation.

OBJECTIVES: Humoral and cellular immunity to SARS-CoV-2 following COVID-19 will likely contribute to protection from reinfection or severe disease. It is therefore important to characterise the initiation and persistence of adaptive immunity to SARS-CoV-2 amidst the ongoing pandemic. METHODS: Here, we conducted a longitudinal study on hospitalised moderate and severe COVID-19 patients from the acute phase of disease into convalescence at 5 and 9 months post-symptom onset. Utilising flow cytometry, serological assays as well as B cell and T cell FluoroSpot assays, we assessed the magnitude and specificity of humoral and cellular immune responses during and after human SARS-CoV-2 infection. RESULTS: During acute COVID-19, we observed an increase in germinal centre activity, a substantial expansion of antibody-secreting cells and the generation of SARS-CoV-2-neutralising antibodies. Despite gradually decreasing antibody levels, we show persistent, neutralising antibody titres as well as robust specific memory B cell responses and polyfunctional T cell responses at 5 and 9 months after symptom onset in both moderate and severe COVID-19 patients. CONCLUSION: Our findings describe the initiation and, importantly, persistence of cellular and humoral SARS-CoV-2-specific immunological memory in hospitalised COVID-19 patients long after recovery, likely contributing towards protection against reinfection.

The relationship between armed conflict and reproductive, maternal, newborn and child health and nutrition status and services in northeastern Nigeria: a mixed-methods case study.

BACKGROUND: Armed conflict between the militant Islamist group Boko Haram, other insurgents, and the Nigerian military has principally affected three states of northeastern Nigeria (Borno, Adamawa, Yobe) since 2002. An intensification of the conflict in 2009 brought the situation to increased international visibility. However, full-scale humanitarian intervention did not occur until 2016. Even prior to this period of armed conflict, reproductive, maternal, neonatal, and child health indicators were extremely low in the region. The presence of local and international humanitarian actors, in the form of United Nations agencies and non-governmental organizations, working in concert with concerned federal, state, and local entities of the Government of Nigeria, were able to prioritize and devise strategies for the delivery of health services that resulted in marked improvement of health status in the subset of the population in which this could be measured. Prospects for the future remain uncertain. METHODS: Interviews were conducted with more than 60 respondents from government, United Nations agencies, and national and international non-governmental organizations. Quantitative data on intervention coverage indicators from publicly available national surveys (Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS)), National Nutrition and Health Surveys (NNHS)) were descriptively analyzed. RESULTS: Overall, indicators of low reproductive, maternal, neonatal, and child health (RMNCH) status and intervention coverage were found in the pre-intervention period (prior to 2016) and important improvements were noted following the arrival of international humanitarian assistance, even while armed conflict and adverse conditions persisted. Security issues, workforce limitations, and inadequate financing were frequently cited obstacles. CONCLUSION: It is assumed that armed conflict would have a negative impact on the health status of the affected population, but pre-conflict indicators can be so depressed that this effect is difficult to measure. When this is the case, health sector intervention by the international community can often result in marked improvements in the accessible population. What might happen upon the departure of the humanitarian organizations cannot be predicted with an appreciable degree of certainty.