Evaluation of Early Warning, Alert and Response System for Ebola Virus Disease, Democratic Republic of the Congo, 2018-2020.

The 10th and largest Ebola virus disease epidemic in the Democratic Republic of the Congo (DRC) was declared in North Kivu Province in August 2018 and ended in June 2020. We describe and evaluate an Early Warning, Alert and Response System (EWARS) implemented in the Beni health zone of DRC during August 5, 2018-June 30, 2020. During this period, 194,768 alerts were received, of which 30,728 (15.8%) were validated as suspected cases. From these, 801 confirmed and 3 probable cases were detected. EWARS showed an overall good performance: sensitivity and specificity >80%, nearly all (97%) of alerts investigated within 2 hours of notification, and good demographic representativeness. The average cost of the system was US $438/case detected and US $1.8/alert received. The system was stable, despite occasional disruptions caused by political insecurity. Our results demonstrate that EWARS was a cost-effective component of the Ebola surveillance strategy in this setting.

Predictors of exceeding emergency under-five mortality thresholds using small-scale survey data from humanitarian settings (1999 - 2020): considerations for measles vaccination, malnutrition, and displacement status.

BACKGROUND: Quantifying the effect of measles containing vaccine (MCV) coverage and the prevalence of global acute malnutrition (GAM) on mortality levels in populations of displaced and crisis-affected resident children is important for intervention programming in humanitarian emergencies. METHODS: A total of 1597 surveys containing data on under-five death rate, population status (internally displaced, refugee, or crisis-affected resident), measles containing vaccine coverage, and global acute malnutrition were extracted from the Complex Emergency Database (CE-DAT). Under-five mortality rates were dichotomized to those exceeding critical levels or otherwise. A Bayesian multivariable mixed-effect logistic regression model was used to assess the association between an under-five death rate (U5DR) exceeding this threshold and population status (i.e., internally displaced, refugees or residents), GAM prevalence (proxy for food security), and MCV coverage. RESULTS: The prevalence of GAM, MCV and U5DR were higher in internally displaced children (IDC) with values of 14.6%, 69.9% and 2.07 deaths per 10 000 per day, respectively. Refugee populations had lower average under-five mortality rate (0.89 deaths per 10 000 per day), GAM of 12.0% and the highest measles containing vaccine coverage (80.0%). In crisis-affected residents the prevalence of GAM, MCV and average U5DR are 11.1%, 65.5% and 1.20 deaths per 10 000 per day respectively. In mixed-effect logistic model taking 2 deaths per 10 000 children less than five years old per as emergency threshold (Model III); MCV (AOR = 0.66, 95% Highest Density Interval (HDI): 0.57, 0.78), GAM (AOR = 1.79, 95% HDI: 1.52, 2.12) were associated with a reduction of the odds of U5DR exceeding critical level accounting for country-specific levels of variability. The odds of U5DR exceeding critical level (2/10000/day) in crisis-affected resident children and refugees were 0.36 (95% HDI: 0.22, 0.58) and 0.25(95% HDI: 0.11, 0.55) less than amongst IDP children adjusting for GAM and MCV. In considering country specific yearly median U5DR (model IV) the odds of U5DR exceeding twice the median U5DR were associated with MCV (AOR = 0.72, 95% HDI: 0.64, 0.82), GAM (AOR = 1.53, 95%HDI: 1.34, 1.76). The odds of U5DR exceeding critical level in crisis-affected resident children was 0.30(95% HDI: 0.20, 0.45) less than IDP children, after adjusting for MCV and GAM. We found no difference between the odds of U5DR exceeding twice the country level median U5DR in the refugee population compared to the IDPs. CONCLUSIONS: In this study vaccination coverage and global acute malnutrition (proxy for food security) were associated with U5DR exceeding critical level. The emergency threshold for IDPs and affected residents is significantly different and consistent across the different outcomes, whereas the result is inconsistent for IDPs and refugees. Continued improvement in measles vaccination coverage and reduction of malnutrition in humanitarian emergencies have the potential to minimize the deterioration of mortality level amongst children in emergency settings. To generate a robust understanding of the critical level of child mortality in displaced and affected resident populations, studies accounting for the impact of the duration of displacement, contextual factors in humanitarian settings, and the level of humanitarian assistance provided are needed.

Civil war and death in Yemen: Analysis of SMART survey and ACLED data, 2012-2019.

Conflict in Yemen has displaced millions and destroyed health infrastructure, resulting in the world's largest humanitarian disaster. The objective of this paper is to examine mortality in Yemen to determine whether it has increased significantly since the conflict began in 2015 compared to the preceding period. We analysed 91 household surveys using the Standardized Monitoring and Assessment of Relief and Transitions methodology, covering 2,864 clusters undertaken from 2012-2019, and deaths from Armed Conflict Location & Event Data Project database covering the conflict period 2015-2019. We used a Poisson-Gamma model to estimate pre-conflict (µp, baseline value) and conflict period (µc) mean death rates using household survey data from 2012-2019. To analyse changes in the distribution of deaths and estimate nationwide excess deaths, we applied pre- and post-conflict death rates to total population numbers. Further, we tested for association between excess death and security levels by governorate. The national estimated crude death rate/10,000 in the conflict period was 0.20 (95% CI: 0.17, 0.24), which is meaningfully higher than the estimated baseline rate of 0.19 (95% CI: 0.17, 0.22). Applying the conflict period rate to the Yemeni population, we estimated 168,212 excess deaths that occurred between 2015 and 2019. There was an 17.8% increase in overall deaths above the baseline during the conflict period. A large share (67.2%) of the excess deaths were due to combat-related violence. At the governorate level, posterior crude death rate varied across the country, ranging from 0.03 to 0.63 per 10,000 per day. Hajjah, Ibb, and Al Jawf governorates presented the highest total excess deaths. Insecurity level was not statistically associated with excess deaths. The health situation in Yemen was poor before the crisis in 2015. During the conflict, intentional violence from air and ground strikes were responsible for more deaths than indirect or non-violent causes. The provision of humanitarian aid by foreign agencies may have helped contain increases in indirect deaths from the conflict.

Measuring mental health burden in humanitarian settings: a critical review of assessment tools.

BACKGROUND: The effects of disasters and conflicts are widespread and heavily studied. While attention to disasters' impacts on mental health is growing, mental health effects are not well understood due to inconsistencies in measurement. OBJECTIVE: The purpose of this study is to review mental health assessment tools and their use in populations affected by disasters and conflicts. METHOD: Tools that assess posttraumatic stress disorder, depression, substance use disorder, and general mental health were examined. This review began with a search for assessment tools in PubMed, PsycINFO, and Google Scholar. Next, validation studies for the tools were obtained through snowball sampling. A final search was conducted for scientific studies using the selected tools in humanitarian settings to collect the data for analysis. The benefits and limitations described for each tool were compiled into a complete table. RESULTS: Twelve assessment tools were included, with 88 studies using them. The primary findings indicate that half of the studies used the Impact of Events Scale-Revised. The most common limitation discussed is that self-report tools inaccurately estimate the prevalence of mental health problems. This inaccuracy is further exacerbated by a lack of cultural appropriateness of the tools, as many are developed for Western contexts. CONCLUSION: It is recommended that researchers and humanitarian workers reflect on the effectiveness of the mental health assessment tool they use to accurately represent the populations under study in emergency settings. In addition, mental health assessment should be coupled with action.

Human Stampedes: An Updated Review of Current Literature.

Human stampedes are a major cause of mortality in mass gatherings, but they have received limited scientific attention. While the number of publications has increased, there is no recent review of new study results. This study compiles and reviews available literature on stampedes, their prevention, preparedness, and response.A search for peer-reviewed and grey literature in PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Google Scholar (Google Inc.; Mountain View, California USA), Web of Science (Thomson Reuters; New York, New York USA), the World Health Organization Library Database (WHOLIS; World Health Organization; Geneva, Switzerland), and ReliefWeb (UN Office for the Coordination of Humanitarian Affairs; Geneva, Switzerland) was conducted, and papers were selected according to pre-defined eligibility criteria. Included items were read and results were compiled and summarized. A total of 64 publications were included, of which, 34 were published between 2013-2016. The most studied events were Germany's Love Parade stampede in 2010 (Duisburg, Germany; n = 6) and the United Kingdom (UK) Hillsborough Stadium stampede in 1989 (Sheffield, England; n = 4). Conflicting definitions of human stampedes were found. The common belief that they result from an irrational and panicking crowd has progressively been replaced by studies suggesting that successive systemic failures are main underlying causes. There is a lack of systematic reporting, making news reports often the only source available. Prevention measures are mainly related to crowd management and venue design, but their effectiveness has not been studied. Drills are recommended in the preparedness phase to improve coordination and communication. Delay in decisions, poor triage, or loss of medical records are common problems in the response, which may worsen the outcome.Stampedes are complex phenomenon that remain incompletely understood, hampering formulation of evidence-based strategies for their prevention and management. Documentation comes mostly from high-profile events and findings are difficult to extrapolate to other settings. More research from different disciplines is warranted to address these gaps in order to prevent and mitigate future events. A start would be to decide on a common definition of stampedes. Moitinho de AlmeidaM, von SchreebJ. Human stampedes: an updated review of current literature. Prehosp Disaster Med. 2019;34(1):82-88.

PALTEM: What Parameters Should Be Collected in Disaster Settings to Assess the Long-Term Outcomes of Famine?

Evidence suggests that nutritional status during fetal development and early life leaves an imprint on the genome, which leads to health outcomes not only on a person as an adult but also on his offspring. The purpose of this study is to bring forth an overview of the relevant parameters that need to be collected to assess the long-term and transgenerational health outcomes of famine. A literature search was conducted for the most pertinent articles on the epigenetic effects of famine. The results were compiled, synthesized and discussed with an expert in genetics for critical input and validation. Prenatal and early life exposure to famine was associated with metabolic, cardiovascular, respiratory, reproductive, neuropsychiatric and oncologic diseases. We propose a set of parameters to be collected in disaster settings to assess the long-term outcomes of famine: PALTEM (parameters to assess long-term effects of malnutrition).