High levels of mortality, exposure to violence and psychological distress experienced by the internally displaced population of Ein Issa camp prior to and during their displacement in Northeast Syria, November 2017.

BACKGROUND: War in Syria has lasted for more than eight years, causing population displacement, collapse of medical and public health services, extensive violence and countless deaths. Since November 2016, military operations in Northeast Syria intensified. In October 2017 a large influx of internally displaced persons (IDPs) arrived to Ein Issa camp, Raqqa governate. Médecins Sans Frontières (MSF) assessed the health status of recently arrived IDPs in Ein Issa camp. METHODS: MSF carried out a cross-sectional survey using simple random sampling between 8 and 18 November 2017, enrolling households who had arrived to Ein Issa camp since 1 October 2017. A questionnaire collected data on demographics, history of displacement, retrospective one-year mortality, two-week morbidities, non-communicable diseases, exposure to violence in the last year and two-week psychological distress symptoms among all household members as well as vaccination status in children aged 6 to 59 months. The latter were also screened for malnutrition. Prevalence estimates and mortality rates were calculated with their 95% confidence interval. Mortality rates were calculated as the number of deaths/10,000 persons/day using the individual person-day contribution of all household members. RESULTS: MSF surveyed 257 households (1482 participants). They reported 31 deaths in the previous year, resulting in a crude mortality rate of 0.56 deaths/10,000 persons/day (95%CI: 0.39-0.80). Conflict-related violence was the most frequently reported cause of death (64.5%). In the previous year, 31.7% (95%CI: 29.4-34.2) of the participants experienced at least one violent episode. The most frequent type of violence reported was witnessing atrocities (floggings, executions or public body displays); 18.9% (95%CI: 17.0-21.0) of the population and 9.8% (95%CI: 7.9-12.0) of the children under 15 years had witnessed such atrocities. In men over 14 years, 15.8% (95%CI: 11.9-20.8) were detained/kidnapped and 11.3% (95%CI: 8.0-15.8) tortured/beaten/attacked. In the two weeks prior to interview, 14.4% (95%CI: 10.6-19.3) of the respondents felt so hopeless that they did not want to carry on living most of the time. CONCLUSIONS: High levels of mortality, exposure to violence and psychological distress were reported. These survey results increase understanding of the impact of the conflict on the IDP population in Northeast Syria.

The blast wounded of Raqqa, Syria: observational results from an MSF-supported district hospital.

BACKGROUND: In June 2017, the U.S.-backed Syrian Democratic Forces (SDF) launched a military operation to retake the city of Raqqa, Syria, from the so-called Islamic State. The city population incurred mass numbers of wounded. In the post-offensive period, the population returned to a city (Raqqa) contaminated with improvised explosive devices (IEDs) and explosive remnants of war (ERWs), resulting in a second wave of wounded patients. Médecins Sans Frontières (MSF) supported a hospital in Tal-Abyad (north of Raqqa) and scaled up operations in response to this crisis. We describe the cohort of blast-wounded cases admitted to this hospital in order help prepare future humanitarian responses. METHODS: We retrospectively extracted data from clinical charts in the MSF-supported hospital. We included all new admissions for blast-wounded patients with key data elements documented. We performed comparative analyses from the offensive period (June 6, 2017 to October 17, 2017) and the post-offensive period (October 18, 2017 to March 17, 2018). RESULTS: We included 322 blast related injuries. There were more than twice the number of cases with blast injuries in the post-offensive period as the offensive period (225 vs. 97, p = <.001). The offensive period saw a significantly higher proportion of female patients (32.0%, n = 31 vs. 11.1%, n = 25, p < 0.001) and paediatric patients (42.3%, n = 41 vs 24.9%, n = 56, p = 0.002). Blast-injured patients in the post-offensive period included more cases with multiple traumatic injuries (65.8%, n = 148 vs. 39.2%, n = 38, p < 0.001). The treatment of the blast-injured cases in the post-offensive period was more labor intensive with those patients having a higher median number of interventions (2 vs 1, p = <0.001) and higher median number of days in hospital (7 vs 4, p = < 0.001). CONCLUSIONS: In the wake of the Raqqa offensive, the MSF-supported district hospital received an unpredicted second, larger and more complex wave of blast-wounded cases as the population returned to a city strewn with IEDs and ERWs. These findings indicate the high risk of traumatic injury to the population even after warring factions have vacated conflict zones. Medical humanitarian actors should be prepared for a continued and scaled up response in areas known to be highly contaminated with explosive ordnance.

Seroprevalence and risk factors of recent infection with hepatitis E virus during an acute outbreak in an urban setting in Chad, 2017.

BACKGROUND: From September 2016-April 2017, Am Timan, Chad, experienced a large HEV outbreak in an urban setting with a limited impact in terms of morbidity and mortality. To better understand HEV epidemiology in this context, we estimated the seroprevalence of anti-HEV antibodies (IgM and IgG) and assessed the risk factors for recent HEV infections (positive anti-HEV IgM) during this outbreak. METHODS: A serological survey using simple random sampling was implemented in Am Timan at the tail-end of the outbreak (sample size aim = 384 household). Household members provided us with blood samples and household heads answered questions around water, sanitation and hygiene practices and animal ownership. Blood samples were tested for HEV IgG and IgM antibodies using Enzyme-Immune-Assay (EIA). We calculated weighted prevalence estimates and prevalence ratios (PRs) for possible risk factors for recent infection using multivariate Cox regression. RESULTS: We included 241 households (1529 participants). IgM prevalence decreased with age: 12.6% (< 5 years) to 4.3% (> 15 years). IgG prevalence increased with age: 23.5% (< 5 years) to 75.9% (> 15 years). Risk factors for recent HEV infections included: sharing the sanitation facility with other HHs (PR 1.72; 95%CI: 1.08-2.73), not systematically using soap for HW (PR 1.85; 95%CI: 1.30-2.63) and having animals sleeping inside the compound (PR 1.69; 95%CI: 1.15-2.50). CONCLUSIONS: Evidence suggests that Am Timan was already highly endemic for HEV before the outbreak, potentially explaining the limited extent of the outbreak. Recent infection with HEV was linked to household level exposures. Future HEV outbreak response must include ensuring access to safe water, and reducing household level transmission through active hygiene and sanitation promotion activities.

A large outbreak of Hepatitis E virus genotype 1 infection in an urban setting in Chad likely linked to household level transmission factors, 2016-2017.

BACKGROUND: In September 2016, three acutely jaundiced (AJS) pregnant women were admitted to Am Timan Hospital, eastern Chad. We described the outbreak and conducted a case test-negative study to identify risk factors for this genotype of HEV in an acute outbreak setting. METHODS: Active case finding using a community based surveillance network identified suspected AJS cases. Pregnant or visibly ill AJS cases presenting at hospital were tested with Assure® IgM HEV rapid diagnostic tests (RDTs) and some with Polymerase Chain Reaction (PCR) in Amsterdam; confirmed cases were RDT-positive and controls were RDT-negative. All answered questions around: demographics, household makeup, area of residence, handwashing practices, water collection behaviour and clinical presentation. We calculated unadjusted odds ratios (ORs) and 95% confidence intervals (95% CI). RESULTS: Between September and April 2017, 1443 AJS cases (1293 confirmed) were detected in the town(attack rate: 2%; estimated 65,000 population). PCR testing confirmed HEV genotype 1e. HEV RDTs were used for 250 AJS cases; 100 (40%) were confirmed. Risk factors for HEV infection, included: having at least two children under the age of 5 years (OR 2.1, 95%CI 1.1-4.3), having another household member with jaundice (OR 2.4, 95%CI 0.90-6.3) and, with borderline significance, living in the neighbourhoods of Riad (OR 3.8, 95%CI 1.0-1.8) or Ridina (OR 3.3, 95%CI 1.0-12.6). Cases were more likely to present with vomiting (OR 3.2, 9%CI 1.4-7.9) than controls; possibly due to selection bias. Cases were non-significantly less likely to report always washing hands before meals compared with controls (OR 0.33, 95%CI 0.1-1.1). DISCUSSION: Our study suggests household factors and area of residence (possibly linked to access to water and sanitation) play a role in HEV transmission; which could inform future outbreak responses. Ongoing sero-prevalence studies will elucidate more aspects of transmission dynamics of this virus with genotype 1e.