Can severity of a humanitarian crisis be quantified? Assessment of the INFORM severity index.

BACKGROUND: Those responding to humanitarian crises have an ethical imperative to respond most where the need is greatest. Metrics are used to estimate the severity of a given crisis. The INFORM Severity Index, one such metric, has become widely used to guide policy makers in humanitarian response decision making. The index, however, has not undergone critical statistical review. If imprecise or incorrect, the quality of decision making for humanitarian response will be affected. This analysis asks, how precise and how well does this index reflect the severity of conditions for people affected by disaster or war? RESULTS: The INFORM Severity Index is calculated from 35 publicly available indicators, which conceptually reflect the severity of each crisis. We used 172 unique global crises from the INFORM Severity Index database that occurred January 1 to November 30, 2019 or were ongoing by this date. We applied exploratory factor analysis (EFA) to determine common factors within the dataset. We then applied a second-order confirmatory factor analysis (CFA) to predict crisis severity as a latent construct. Model fit was assessed via chi-square goodness-of-fit statistic, Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA). The EFA models suggested a 3- or 4- factor solution, with 46 and 53% variance explained in each model, respectively. The final CFA was parsimonious, containing three factors comprised of 11 indicators, with reasonable model fit (Chi-squared = 107, with 40 degrees of freedom, CFI = 0.94, TLI = 0.92, RMSEA = 0.10). In the second-order CFA, the magnitude of standardized factor-loading on the 'societal governance' latent construct had the strongest association with the latent construct of 'crisis severity' (0.73), followed by the 'humanitarian access/safety' construct (0.56). CONCLUSIONS: A metric of crisis-severity is a critical step towards improving humanitarian response, but only when it reflects real life conditions. Our work is a first step in refining an existing framework to better quantify crisis severity.

Smoke Alarms and Carbon Monoxide Alarms in Households With Children, Puerto Rico, 2010.

In 2017, Puerto Rico sustained extensive damage from Hurricane Maria, increasing the risk of fires and carbon monoxide (CO) poisonings. Using a population-based, in-person survey of households with children less than 6 years old in Puerto Rico, we collected data in 2010 concerning the presence of smoke alarms and CO alarms in these households. We generated national estimates by extrapolating the number of households in each stratum using data from the 2010 Census. We determined which household characteristics predicted the presence of these alarms. Of 355 households analyzed, 31% had functional smoke alarms, or an estimated 109,773 households territory wide. The presence of smoke alarms was associated with living in multifamily housing and no child in the household receiving government medical insurance. Public housing or publicly subsidized housing, as compared to owner-occupied housing and unsubsidized rental housing, was associated with having a functional smoke alarm in households with children aged less than 6 years. Based on only six houses having CO alarms, we estimated only 7685 (2%) households had CO alarms. The low prevalence of functional smoke or CO alarms 7 years before Hurricane Maria is unfortunate and should be remedied by ensuring that such alarms are widely installed in current rebuilding activities.

The burden of non-communicable diseases and their related risk factors in the country of Georgia, 2015.

BACKGROUND: Non-communicable diseases (NCDs), mainly cardiovascular diseases, are a substantial cause of mortality in the country of Georgia, accounting for approximately 93% of all deaths (standardized mortality rate 630.7 deaths per 100,000 persons per year) and an important threat to health security. We conducted a nationally representative survey examining the prevalence of NCDs and their risk factors as part of a 2015 Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV) serosurvey. METHODS: We conducted a cross-sectional serosurvey among adults aged ≥18 years using a stratified, multi-stage cluster design (n = 7000). We asked participants standardized questions from the Global Adult Tobacco Survey and the WHO STEPwise approach to Surveillance (STEPS) Survey. We also measured blood pressure and Body Mass Index for each participant. Weighted frequencies were computed for NCD and risk factor prevalence and compared to 2010 STEPS results. RESULTS: Georgians reported high rates of smoking, alcohol use, elevated blood pressure, obesity, diabetes and cardiovascular disease. An estimated 27.1% (95% confidence interval [CI]: 25.3, 28.8%) of adults (51.5% of men and 6.0% of women) reported daily use of tobacco products and 27.5% (95% CI: 25.7, 29.2%) of adults (52.1% of men and 7.0% of women) reported binge drinking within the last 30 days. Physical measurements revealed that 37.5% (95% CI: 35.8, 39.3%) of adults had elevated blood pressure and 33.4% (95% CI: 31.8, 35.0%) had obesity. 5.4% (95% CI: 4.6, 6.2%) of adults had self-reported diagnosed diabetes and 15.3% (95% CI: 14.1, 16.6%) had self-reported diagnosed cardiovascular disease. From 2010 to 2015, the prevalence of obesity increased by 8.3 percentage points (95% CI: 5.9, 10.7%; p < 0.01) and the prevalence of elevated blood pressure increased by 4.1 percentage points (95% CI: 1.4, 6.8%; p < 0.01). CONCLUSIONS: Georgia has a high NCD burden, and results from the survey showed an increase in obesity and elevated blood pressure since 2010. The prevalence of other major NCDs have remained near levels reported in the 2010 STEPs survey. Comprehensive public health interventions are needed to control the heath security threats of major NCDs and their risk factors in the future.

Hepatitis C prevalence and risk factors in Georgia, 2015: setting a baseline for elimination.

BACKGROUND: The country of Georgia launched the world's first Hepatitis C Virus (HCV) Elimination Program in 2015 and set a 90% prevalence reduction goal for 2020. We conducted a nationally representative HCV seroprevalence survey to establish baseline prevalence to measure progress toward elimination over time. METHODS: A cross-sectional seroprevalence survey was conducted in 2015 among adults aged ≥18 years using a stratified, multi-stage cluster design (n = 7000). Questionnaire variables included demographic, medical, and behavioral risk characteristics and HCV-related knowledge. Blood specimens were tested for antibodies to HCV (anti-HCV) and HCV RNA. Frequencies were computed for HCV prevalence, risk factors, and HCV-related knowledge. Associations between anti-HCV status and potential risk factors were calculated using logistic regression. RESULTS: National anti-HCV seroprevalence in Georgia was 7.7% (95% confidence interval (CI) = 6.7, 8.9); HCV RNA prevalence was 5.4% (95% CI = 4.6, 6.4). Testing anti-HCV+ was significantly associated with male sex, unemployment, urban residence, history of injection drug use (IDU), incarceration, blood transfusion, tattoos, frequent dental cleanings, medical injections, dialysis, and multiple lifetime sexual partners. History of IDU (adjusted odds ratio (AOR) = 21.4, 95% CI = 12.3, 37.4) and blood transfusion (AOR = 4.5, 95% CI = 2.8, 7.2) were independently, significantly associated with testing anti-HCV+ after controlling for sex, age, urban vs. rural residence, and history of incarceration. Among anti-HCV+ participants, 64.0% were unaware of their HCV status, and 46.7% did not report IDU or blood transfusion as a risk factor. CONCLUSIONS: Georgia has a high HCV burden, and a majority of infected persons are unaware of their status. Ensuring a safe blood supply, implementing innovative screening strategies beyond a risk-based approach, and intensifying prevention efforts among persons who inject drugs are necessary steps to reach Georgia's HCV elimination goal.

Oral Cholera Vaccine Coverage during an Outbreak and Humanitarian Crisis, Iraq, 2015.

During November-December 2015, as part of the 2015 cholera outbreak response in Iraq, the Iraqi Ministry of Health targeted ≈255,000 displaced persons >1 year of age with 2 doses of oral cholera vaccine (OCV). All persons who received vaccines were living in selected refugee camps, internally displaced persons camps, and collective centers. We conducted a multistage cluster survey to obtain OCV coverage estimates in 10 governorates that were targeted during the campaign. In total, 1,226 household and 5,007 individual interviews were conducted. Overall, 2-dose OCV coverage in the targeted camps was 87% (95% CI 85%-89%). Two-dose OCV coverage in the 3 northern governorates (91%; 95% CI 87%-94%) was higher than that in the 7 southern and central governorates (80%; 95% CI 77%-82%). The experience in Iraq demonstrates that OCV campaigns can be successfully implemented as part of a comprehensive response to cholera outbreaks among high-risk populations in conflict settings.

Parameters associated with design effect of child anthropometry indicators in small-scale field surveys.

BACKGROUND: Cluster surveys provide rapid but representative estimates of key nutrition indicators in humanitarian crises. For these surveys, an accurate estimate of the design effect is critical to calculate a sample size that achieves adequate precision with the minimum number of sampling units. This paper describes the variability in design effect for three key nutrition indicators measured in small-scale surveys and models the association of design effect with parameters hypothesized to explain this variability. METHODS: 380 small-scale surveys from 28 countries conducted between 2006 and 2013 were analyzed. We calculated prevalence and design effect of wasting, underweight, and stunting for each survey as well as standard deviations of the underlying continuous Z-score distribution. Mean cluster size, survey location and year were recorded. To describe design effects, median and interquartile ranges were examined. Generalized linear regression models were run to identify potential predictors of design effect. RESULTS: Median design effect was under 2.00 for all three indicators; for wasting, the median was 1.35, the lowest among the indicators. Multivariable linear regression models suggest significant, positive associations of design effect and mean cluster size for all three indicators, and with prevalence of wasting and underweight, but not stunting. Standard deviation was positively associated with design effect for wasting but negatively associated for stunting. Survey region was significant in all three models. CONCLUSIONS: This study supports the current field survey guidance recommending the use of 1.5 as a benchmark for design effect of wasting, but suggests this value may not be large enough for surveys with a primary objective of measuring stunting or underweight. The strong relationship between design effect and region in the models underscores the continued need to consider country- and locality-specific estimates when designing surveys. These models also provide empirical evidence of a positive relationship between design effect and both mean cluster size and prevalence, and introduces standard deviation of the underlying continuous variable (Z-scores) as a previously unexplored factor significantly associated with design effect. The magnitude and directionality of this association differed by indicator, underscoring the need for further investigation into the relationship between standard deviation and design effect.

Prevalence of Elevated Blood Lead Levels and Risk Factors Among Residents Younger Than 6 Years, Puerto Rico--2010.

CONTEXT: Limited data exist about blood lead levels (BLLs) and potential exposures among children living in Puerto Rico. The Puerto Rico Department of Health has no formal blood lead surveillance program. OBJECTIVES: We assessed the prevalence of elevated BLLs (≥5 micrograms of lead per deciliter of blood), evaluated household environmental lead levels, and risk factors for BLL among children younger than 6 years of age living in Puerto Rico in 2010. METHODS: We used a population-based, cross-sectional sampling strategy to enroll an island-representative sample of Puerto Rican children younger than 6 years. We estimated the island-wide weighted prevalence of elevated BLLs and conducted bivariable and multivariable linear regression analyses to ascertain risk factors for elevated BLLs. RESULTS: The analytic data set included 355 households and 439 children younger than 6 years throughout Puerto Rico. The weighted geometric mean BLL of children younger than 6 years was 1.57 µg/dL (95% confidence interval [CI], 1.27-1.88). The weighted prevalence of children younger than 6 years with BLLs of 5 µg/dL or more was 3.18% (95% CI, 0.93-5.43) and for BLLs of 10 µg/dL or more was 0.50% (95% CI, 0-1.31). Higher mean BLLs were significantly associated with data collection during the summer months, a lead-related activity or hobby of anyone in the residence, and maternal education of less than 12 years. Few environmental lead hazards were identified. CONCLUSIONS: The prevalence of elevated BLLs among Puerto Rican children younger than 6 years is comparable with the most recent (2007-2010) US national estimate (BLLs ≥5 µg/dL = 2.6% [95% CI = 1.6-4.0]). Our findings suggest that targeted screening of specific higher-risk groups of children younger than 6 years can replace island-wide or insurance-specific policies of mandatory blood lead testing in Puerto Rico.

Prevalence of nodding syndrome--Uganda, 2012-2013.

Nodding syndrome (NS) is a seizure disorder of unknown etiology, predominately affecting children aged 3-18 years in three sub-Saharan countries (Uganda, South Sudan, and Tanzania), with the primary feature of episodic head nodding. These episodes are thought to be one manifestation of a syndrome that includes neurologic deterioration, cognitive impairment, and additional seizure types. NS investigations have focused on clinical features, progression, and etiology; however, none have provided a population-based prevalence assessment using a standardized case definition. In March 2013, CDC and the Ugandan Ministry of Health (MOH) conducted a single-stage cluster survey to perform the first systematic assessment of prevalence of NS in Uganda using a new consensus case definition, which was modified during the course of the investigation. Based on the modified definition, the estimated number of probable NS cases in children aged 5-18 years in three northern Uganda districts was 1,687 (95% confidence interval [CI] = 1,463-1,912), for a prevalence of 6.8 (CI = 5.9-7.7) probable NS cases per 1,000 children aged 5-18 years in the three districts. These findings can guide the MOH to understand and provide the health-care resources necessary to address NS in northern Uganda, and provide a basis for future studies of NS in Uganda and in other areas affected by NS.

The PROBIT approach in estimating the prevalence of wasting: revisiting bias and precision.

BACKGROUND: The PROBIT methodology was presented in the 1995 World Health Organization Technical Report on Anthropometry as an alternative to the standard prevalence based method of measuring malnutrition in children. Theoretically the PROBIT method will always give a smaller standard error than the standard prevalence method in measuring malnutrition. A recent article by Dale et al. assessed the PROBIT method for measuring global acute malnutrition measure and found that the method was biased and the precision was superior only for sample sizes less than 150 when compared to the standard method. In a manner similar to Dale, our study further investigated the bias and precision of the PROBIT method for different sample sizes using simulated populations. RESULTS: The PROBIT method showed bias for each of the ten simulated populations, but the direction and magnitude of the average bias was changed depending on the simulated population. For a given simulated population, the average bias was relatively constant for all sample sizes drawn. The 95% half-width confidence interval was lower for the PROBIT method than the standard prevalence method regardless of the sample size or simulated population. The absolute difference in the confidence limits showed the most gains for the PROBIT method for the smaller samples sizes, but the ratio of confidence intervals was relatively constant across all sample sizes. CONCLUSIONS: The PROBIT method will provide gains in precision regardless of the sample size, but the method may be biased. The direction and magnitude of the bias depends on the population it is drawn from.

Mental health survey among landmine survivors in Siem Reap province, Cambodia.

Many survivors of the Khmer Rouge period in Cambodia and the subsequent war with Vietnam have now returned to Cambodia. In this two-stage household cluster survey in Siem Reap Province in Cambodia, we explored the mental health consequences on 166 landmine injury survivors selected from 1000 household in 50 clusters and an oversample of all landmine survivors. We found a prevalence of anxiety of 62% for all respondents, 74% for depression, and 34% for post-traumatic stress disorder (PTSD). These prevalences were statistically significantly higher than among the adult population who had not been injured by landmines. These data underscore the importance of providing mental health care services for the people in Siem Reap Province in Cambodia who have been injured by landmines.

Using Small Area Prevalence Survey Methods to Conduct Blood Lead Assessments among Children.

INTRODUCTION: Prevalence surveys conducted in geographically small areas such as towns, zip codes, neighborhoods or census tracts are a valuable tool for estimating the extent to which environmental risks contribute to children's blood lead levels (BLLs). Population-based, cross-sectional small area prevalence surveys assessing BLLs can be used to establish a baseline lead exposure prevalence for a specific geographic region. MATERIALS AND METHODS: The required statistical methods, biological and environmental sampling, supportive data, and fieldwork considerations necessary for public health organizations to rapidly conduct child blood lead prevalence surveys at low cost using small area, cluster sampling methodology are described. RESULTS: Comprehensive small area prevalence surveys include partner identification, background data collection, review of the assessment area, resource availability determinations, sample size calculations, obtaining the consent of survey participants, survey administration, blood lead analysis, environmental sampling, educational outreach, follow-up and referral, data entry/analysis, and report production. DISCUSSION: Survey results can be used to estimate the geographic distribution of elevated BLLs and to investigate inequitable lead exposures and risk factors of interest. CONCLUSIONS: Public health officials who wish to assess child and household-level blood lead data can quickly apply the data collection methodologies using this standardized protocol here to target resources and obtain assistance with these complex procedures. The standardized methods allow for comparisons across geographic areas and over time.

Risk factors and genotype distribution of hepatitis C virus in Georgia: A nationwide population-based survey.

In preparation for the National Hepatitis C Elimination Program in the country of Georgia, a nationwide household-based hepatitis C virus (HCV) seroprevalence survey was conducted in 2015. Data were used to estimate HCV genotype distribution and better understand potential sex-specific risk factors that contribute to HCV transmission. HCV genotype distribution by sex and reported risk factors were calculated. We used explanatory logistic regression models stratified by sex to identify behavioral and healthcare-related risk factors for HCV seropositivity, and predictive logistic regression models to identify additional variables that could help predict the presence of infection. Factors associated with HCV seropositivity in explanatory models included, among males, history of injection drug use (IDU) (aOR = 22.4, 95% CI = 12.7, 39.8) and receiving a blood transfusion (aOR = 3.6, 95% CI = 1.4, 8.8), and among females, history of receiving a blood transfusion (aOR = 4.0, 95% CI 2.1, 7.7), kidney dialysis (aOR = 7.3 95% CI 1.5, 35.3) and surgery (aOR = 1.9, 95% CI 1.1, 3.2). The male-specific predictive model additionally identified age, urban residence, and history of incarceration as factors predictive of seropositivity and were used to create a male-specific exposure index (Area under the curve [AUC] = 0.84). The female-specific predictive model had insufficient discriminatory performance to support creating an exposure index (AUC = 0.61). The most prevalent HCV genotype (GT) nationally was GT1b (40.5%), followed by GT3 (34.7%) and GT2 (23.6%). Risk factors for HCV seropositivity and distribution of HCV genotypes in Georgia vary substantially by sex. The HCV exposure index developed for males could be used to inform targeted testing programs.

An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan.

BACKGROUND: From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, a case-control study was conducted in June 2019. METHODS: For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression. RESULTS: The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician [adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79]. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400). DISCUSSION: Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.

Prevalence of Crimean-Congo Hemorrhagic Fever Virus among Livestock and Ticks in Zhambyl Region, Kazakhstan, 2017.

Crimean-Congo hemorrhagic fever (CCHF) is a highly fatal zoonotic disease endemic to Kazakhstan. Previous work estimated the seroprevalence of CCHF virus (CCHFV) among livestock owners in the Zhambyl region of southern Kazakhstan at 1.2%. To estimate CCHFV seroprevalence among cattle and sheep, we selected 15 villages with known history of CCHFV circulation (endemic) and 15 villages without known circulation (nonendemic) by cluster sampling with probability proportional to livestock population size. We collected whole blood samples from 521 sheep and 454 cattle from randomly selected households within each village and collected ticks found on the animals. We tested livestock blood for CCHFV-specific IgG antibodies by ELISA; ticks were screened for CCHFV RNA by real-time reverse transcription polymerase chain reaction and CCHFV antigen by antigen-capture ELISA. We administered questionnaires covering animal demographics and livestock herd characteristics to an adult in each selected household. Overall weighted seroprevalence was 5.7% (95% CI: 3.1, 10.3) among sheep and 22.5% (95% CI: 15.8, 31.2) among cattle. CCHFV-positive tick pools were found on two sheep (2.4%, 95% CI: 0.6, 9.5) and three cattle (3.8%, 95% CI: 1.2, 11.5); three CCHFV-positive tick pools were found in nonendemic villages. Endemic villages reported higher seroprevalence among sheep (15.5% versus 2.8%, P < 0.001) but not cattle (25.9% versus 20.1%, P = 0.42). Findings suggest that the current village classification scheme may not reflect the geographic distribution of CCHFV in Zhambyl and underscore that public health measures must address the risk of CCHF even in areas without a known history of circulation.

Risk factors associated with sexual violence towards girls in Swaziland.

OBJECTIVE: To explore risk factors for sexual violence in childhood in a nationally representative sample of females aged 13 to 24 years in Swaziland. METHODS: During a household survey respondents were asked to report any experiences of sexual violence before the age of 18 years. The association between childhood sexual violence and several potential demographic and social risk factors was explored through bivariate and multivariate logistic regression. FINDINGS: Participants totalled 1244. Compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence (crude odds ratio, COR: 1.89; 95% CI: 1.14-3.14), as did those who had had no relationship with her at all (COR: 1.93; 95% CI: 1.34-2.80). In addition, greater odds of childhood sexual violence were noted among respondents who were not attending school at the time of the survey (COR: 2.26; 95% CI: 1.70-3.01); who were emotionally abused as children (COR: 2.04; 95% CI: 1.50-2.79); and who knew of another child who had been sexually assaulted (COR: 1.77; 95% CI: 1.31-2.40) or was having sex with a teacher (COR: 2.07; 95% CI: 1.59-2.69). Childhood sexual violence was positively associated with the number of people the respondent had lived with at any one time (COR: 1.03; 95% CI: 1.01-1.06). CONCLUSION: Inadequate supervision or guidance and an unstable environment put girls at risk of sexual violence. Greater educational opportunities and an improved mother-daughter relationship could help prevent it.

Prevalence of war-related mental health conditions and association with displacement status in postwar Jaffna District, Sri Lanka.

CONTEXT: Nearly 2.7 million individuals worldwide are internally displaced (seeking refuge in secure areas of their own country) annually by armed conflict. Although the psychological impact of war has been well documented, less is known about the mental health symptoms of forced displacement among internally displaced persons. OBJECTIVES: To estimate the prevalence of the most common war-related mental health conditions, symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression, and to assess the association between displacement status and these conditions in postwar Jaffna District, Sri Lanka. DESIGN, SETTING, AND PARTICIPANTS: Between July and September 2009, a cross-sectional multistage cluster sample survey was conducted among 1517 Jaffna District households including 2 internally displaced persons camps. The response rate was 92% (1448 respondents, 1409 eligible respondents). Two percent of participants (n = 80) were currently displaced, 29.5% (n = 539) were recently resettled, and 68.5% (n = 790) were long-term residents. Bivariable analyses followed by multivariable logistic regression models were performed to determine the association between displacement status and mental health. MAIN OUTCOME MEASURES: Symptom criteria of PTSD, anxiety, and depression as measured by the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25. RESULTS: The overall prevalences of symptoms of PTSD, anxiety, and depression were 7.0% (95% confidence interval [CI], 5.1%-9.7%), 32.6% (95% CI, 28.5%-36.9%), and 22.2% (95% CI, 18.2%-26.5%), respectively. Currently displaced participants were more likely to report symptoms of PTSD (odds ratio [OR], 2.71; 95% CI, 1.28-5.73), anxiety (OR, 2.91; 95% CI, 1.89-4.48), and depression (OR, 4.55; 95% CI, 2.47-8.39) compared with long-term residents. Recently resettled residents were more likely to report symptoms of PTSD (OR, 1.96; 95% CI, 1.11-3.47) compared with long-term residents. However, displacement was no longer associated with mental health symptoms after controlling for trauma exposure. CONCLUSION: Among residents of Jaffna District in Sri Lanka, prevalence of symptoms of war-related mental health conditions was substantial and significantly associated with displacement status and underlying trauma exposure.

Acceptability of urine diversion dry toilets in Dollo Ado refugee camp, Ethiopia.

Given the increasing frequency and duration of humanitarian emergencies worldwide, there is a need to identify a greater range of effective and contextually appropriate water, sanitation and hygiene (WASH) interventions. Typical sanitation systems may be poorly suited for some of the conditions in which humanitarian emergencies can occur, such as in drought-prone regions. Urine-diversion dry toilets (UDDTs) are one potential alternative sanitation option which can be used in these conditions. Between 2014 and 2016, the U.S. Centers for Disease Control and Prevention (CDC) partnered with local agencies to evaluate the acceptability of UDDTs in a refugee camp in Ethiopia. The overall goals were to provide evidence regarding the level of adoption and satisfaction with UDDTs in this emergency context and the factors associated with satisfaction. Two cross-sectional surveys were conducted 18-months apart, using a stratified design to sample UDDT and latrine users for comparison. The proportion who reported to use their UDDT consistently was 88.8% (95% CI 85.1-92.5) in the first survey and 93.4% (95% CI 90.6-96.2) in the second survey. Reported satisfaction levels were significantly higher among respondents in the second survey (p < 0.0001), where 97.0% (95% CI 95.1-98.9) of respondents stated either that they were mostly or very satisfied with their UDDT. There was no significant difference detected in satisfaction between UDDT and latrine users (p = 0.28). Using a multivariable logistic regression model, we identified several factors associated with a higher level of satisfaction with UDDTs. Those who had previously (before coming to the camp) used a pit latrine (AOR = 4.2; 95% CI 1.4-12.7) or had no sanitation system (AOR = 2.4; 95% CI 1.3-4.4) relative to a pour-flush toilet, had a clean UDDT (AOR = 2.8; 95% CI 1.7-4.6), had been in the camp for a longer time period (AOR = 2.3; 95% CI 1.7-3.0), did not share their UDDT (AOR = 1.8; 95% CI 1.0-3.0) and had used their UDDT for a longer time period (AOR = 1.7; 95% CI 1.2-2.4) had higher odds of satisfaction. The findings demonstrate that UDDTs have been effectively introduced and utilized in this context and this may have implications for other humanitarian settings where they can be similarly managed.

SARS-CoV-2 antibody prevalence in Sierra Leone, March 2021: a cross-sectional, nationally representative, age-stratified serosurvey.

INTRODUCTION: As of 26 March 2021, the Africa Centres for Disease Control and Prevention had reported 4 159 055 cases of COVID-19 and 111 357 deaths among the 55 African Union member states; however, no country has published a nationally representative serosurvey as of October 2021. Such data are vital for understanding the pandemic's progression on the continent, evaluating containment measures, and policy planning. METHODS: We conducted a cross-sectional, nationally representative, age-stratified serosurvey in Sierra Leone in March 2021 by randomly selecting 120 Enumeration Areas throughout the country and 10 randomly selected households in each of these. One to two persons per selected household were interviewed to collect information on sociodemographics, symptoms suggestive of COVID-19, exposure history to laboratory-confirmed COVID-19 cases, and history of COVID-19 illness. Capillary blood was collected by fingerstick, and blood samples were tested using the Hangzhou Biotest Biotech RightSign COVID-19 IgG/IgM Rapid Test Cassette. Total seroprevalence was estimated after applying sampling weights. RESULTS: The overall weighted seroprevalence was 2.6% (95% CI 1.9% to 3.4%). This was 43 times higher than the reported number of cases. Rural seropositivity was 1.8% (95% CI 1.0% to 2.5%), and urban seropositivity was 4.2% (95% CI 2.6% to 5.7%). DISCUSSION: Overall seroprevalence was low compared with countries in Europe and the Americas (suggesting relatively successful containment in Sierra Leone). This has ramifications for the country's third wave (which started in June 2021), during which the average number of daily reported cases was 87 by the end of the month:this could potentially be on the order of 3700 actual infections per day, calling for stronger containment measures in a country with only 0.2% of people fully vaccinated. It may also reflect significant under-reporting of incidence and mortality across the continent.

SARS-CoV-2 antibody prevalence in Sierra Leone, March 2021: a cross-sectional, nationally representative, age-stratified serosurvey.

Background As of 26 March 2021, the Africa CDC had reported 4,159,055 cases of COVID-19 and 111,357 deaths among the 55 African Union Member States; however, no country has published a nationally representative serosurvey as of May 2021. Such data are vital for understanding the pandemic's progression on the continent, evaluating containment measures, and policy planning. Methods We conducted a cross-sectional, nationally representative, age-stratified serosurvey in Sierra Leone in March 2021 by randomly selecting 120 Enumeration Areas throughout the country and 10 randomly selected households in each of these. One to two persons per selected household were interviewed to collect information on socio-demographics, symptoms suggestive of COVID-19, exposure history to laboratory-confirmed COVID-19 cases, and history of COVID-19 illness. Capillary blood was collected by fingerstick, and blood samples were tested using the Hangzhou Biotest Biotech RightSign COVID-19 IgG/IgM Rapid Test Cassette. Total seroprevalence was was estimated after applying sampling weights. Findings The overall weighted seroprevalence was 2.6% (95% CI 1.9-3.4). This is 43 times higher than the reported number of cases. Rural seropositivity was 1.8% (95% CI 1.0-2.5), and urban seropositivity was 4.2% (95% CI 2.6-5.7). Interpretation Although overall seroprevalence was low compared to countries in Europe and the Americas (suggesting relatively successful containment in Sierra Leone), our findings indicate enormous underreporting of active cases. This has ramifications for the country's third wave (which started in June 2021), where the average number of daily reported cases was 87 by the end of the month: this could potentially be on the order of 3,700 actual infections, calling for stronger containment measures in a country with only 0.2% of people fully vaccinated. It may also reflect significant underreporting of incidence and mortality across the continent.

Sexual violence and its health consequences for female children in Swaziland: a cluster survey study.

BACKGROUND: Despite concern, few studies have been done about sexual violence against girls younger than 18 years of age in sub-Saharan Africa. We report the prevalence and circumstances of sexual violence in girls in Swaziland, and assess the negative health consequences. METHODS: We obtained data from a nationally representative sample of girls and women aged 13-24 years from selected households in Swaziland between May 15, 2007, and June 16, 2007, with a two-stage cluster design. The questionnaire examined demographics, type of sexual violence that took place before the respondent was 18 years of age, circumstances of the incident, and health-related conditions. Information was gathered from 1244 women and girls (response rate 96.3%), of whom 1242 provided retrospective responses to questions about sexual violence. We used regression models adjusted for relevant demographics to estimate the odds ratios for the associations between sexual violence and health-related conditions. FINDINGS: 33.2% (95% CI 29.9-36.7) of respondents reported an incident of sexual violence before they reached 18 years of age. The most common perpetrators of the first incident were men or boys from the respondent's neighbourhood (32.3% [28.8-36.1]) and boyfriends or husbands (26.2% [22.2-30.7]). The first incident most often took place in the respondent's own home (26.1% [21.6-31.2]). Sexual violence was associated with reported lifetime experience of sexually transmitted diseases (adjusted OR 3.69 [95% CI 1.78-7.66]), pregnancy complications or miscarriages (3.54 [1.47-8.55]), unwanted pregnancy (2.92 [1.87-4.55]), and self-report of feeling depressed (2.30 [1.70-3.11]). INTERPRETATION: Knowledge of the high prevalence of sexual violence against girls in Swaziland and its associated serious health-related conditions and behaviours should be used to develop effective prevention strategies. FUNDING: UNICEF.