Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria.

BACKGROUND: Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited. METHODS AND FINDINGS: We conducted a prospective observational cohort study in 3 conflict-affected states in Nigeria in 2021. Enumerators within rapid response teams observed CATI implementation during a cholera outbreak and collected data on household demographics; existing water, sanitation, and hygiene (WASH) infrastructure; and CATI interventions. Descriptive statistics showed that CATIs were delivered to 46,864 case and neighbor households, with 80.0% of cases and 33.5% of neighbors receiving all intended supplies and activities, in a context with operational challenges of population density, supply stock outs, and security constraints. We then applied prospective Poisson space-time scan statistics (STSS) across 3 models for each state: (1) an unadjusted model with case and population data; (2) an environmentally adjusted model adjusting for distance to cholera treatment centers and existing WASH infrastructure (improved water source, improved latrine, and handwashing station); and (3) a fully adjusted model adjusting for environmental and CATI variables (supply of Aquatabs and soap, hygiene promotion, bedding and latrine disinfection activities, ring coverage, and response timeliness). We ran the STSS each day of our study period to evaluate the space-time dynamics of the cholera outbreaks. Compared to the unadjusted model, significant cholera clustering was attenuated in the environmentally adjusted model (from 572 to 18 clusters) but there was still risk of cholera transmission. Two states still yielded significant clusters (range 8-10 total clusters, relative risk of 2.2-5.5, 16.6-19.9 day duration, including 11.1-56.8 cholera cases). Cholera clustering was completely attenuated in the fully adjusted model, with no significant anomalous clusters across time and space. Associated measures including quantity, relative risk, significance, likelihood of recurrence, size, and duration of clusters reinforced the results. Key limitations include selection bias, remote data monitoring, and the lack of a control group. CONCLUSIONS: CATIs were associated with significant reductions in cholera clustering in Northeast Nigeria despite operational challenges. Our results provide a strong justification for rapid implementation and scale-up CATIs in cholera-response, particularly in conflict settings where WASH access is often limited.

Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan.

OBJECTIVE: We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. DESIGN: Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). SETTING: Study was conducted as part of a bigger evaluation study in South Sudan. PARTICIPANTS: International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. RESULTS: The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. CONCLUSIONS: Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.

Multi-purpose cash transfers and health among vulnerable Syrian refugees in Lebanon: a prospective cohort study.

BACKGROUND: Multipurpose cash transfers (MPCs) are used on a widespread basis in the Syrian refugee response; however, there is little to no evidence as to how they affect health in humanitarian crises. METHODS: A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the impact of MPCs on health care-seeking and expenditures for child, adult acute, and adult chronic illness by Syrian refugees in Lebanon. Households receiving MPCs from UNHCR were compared to control households not receiving UNHCR MPCs. RESULTS: Care-seeking for childhood illness was consistently high in both MPC and non-MPC households. An increased proportion of households did not receive all recommended care due to cost; this increase was 19.3% greater among MPC recipients than controls (P = 0.002). Increases in child hospitalizations were significantly smaller among MPC recipients than controls (DiD -6.1%; P = 0.037). For adult acute illnesses, care-seeking increased among MPC recipients but decreased in controls (adjusted DiD 11.3%; P = 0.057); differences in change for other utilization outcomes were not significant. The adjusted difference in change in the proportion of MPC households not receiving recommended chronic illness care due to cost compared to controls was - 28.2% (P = 0.073). Access to medication for adult chronic illness also marginally significantly improved for MPC households relative to controls. The proportion of MPC recipients reporting expenses for the most recent child and adult acute illness increased significantly, as did the [log] total visit cost. Both MPC and control households reported significant increases in borrowing to pay for health expenses over the year study period, but differences in change in borrowing or asset sales were not significant, indicating that MPC was not protective against for household financial risks associated with health. CONCLUSIONS: While MPC may have shown some positive effects, findings were mixed and MPC appears insufficient on its own to address health utilization and expenditures. A broader strategy addressing Syrian refugee health in Lebanon is needed of which MPC should be incorporated, with additional support such as additional conditional cash transfers for health.

Venezuela's public health crisis: a regional emergency.

The economic crisis in Venezuela has eroded the country's health-care infrastructure and threatened the public health of its people. Shortages in medications, health supplies, interruptions of basic utilities at health-care facilities, and the emigration of health-care workers have led to a progressive decline in the operational capacity of health care. The effect of the crisis on public health has been difficult to quantify since the Venezuelan Ministry of Health stopped publishing crucial public health statistics in 2016. We prepared a synthesis of health information, beyond what is available from other sources, and scholarly discussion of engagement strategies for the international community. Data were identified through searches in MEDLINE, PubMed, and the grey literature, through references from relevant articles, and governmental and non-governmental reports, and publicly available databases. Articles published in English and Spanish until Dec 1, 2018, were included. Over the past decade, public health measures in Venezuela have substantially declined. From 2012 to 2016, infant deaths increased by 63% and maternal mortality more than doubled. Since 2016, outbreaks of the vaccine-preventable diseases measles and diphtheria have spread throughout the region. From 2016 to 2017, Venezuela had the largest rate of increase of malaria in the world, and in 2015, tuberculosis rates were the highest in the country in 40 years. Between 2017 and 2018, most patients who were infected with HIV interrupted therapy because of a lack of medications. The Venezuelan economic crisis has shattered the health-care system and resulted in rising morbidity and mortality. Outbreaks and expanding epidemics of infectious diseases associated with declines in basic public health services are threatening the health of the country and the region.

Maternal mental health symptoms are positively associated with child dietary diversity and meal frequency but not nutritional status in Eastern Democratic Republic of Congo.

OBJECTIVE: The objective was to examine the association between symptoms of maternal mental health problems and child diet and nutritional status in South Kivu, Democratic Republic of Congo. DESIGN: Maternal depression and anxiety symptoms were measured by the Hopkins Symptom Checklist-25 (HSCL-25), and post-traumatic stress was measured by the Harvard Trauma Questionnaire (HTQ). Participants were classified as having high psychological distress if their mean item score was in the upper quartile of both measures. Dependent variables included child dietary diversity, meal frequency, height-for-age z score (HAZ), weight-for-age z score (WAZ), weight-for-height z score (WHZ), stunting and underweight. Bivariate and multivariate regression analyses were conducted. SETTING: The study was nested in a larger quasi-experimental study evaluating Jenga Jamaa II, a food and nutrition assistance project in Uvira and Fizi territories. PARTICIPANTS: In total, 812 mother-child pairs participated. Children ranged from 2·6 to 5·6 years of age. RESULTS: HSCL-25 (ß: 0·18, P < 0·05) and HTQ (ß: 0·19, P < 0·05) were statistically significantly associated with higher dietary diversity scores, and all maternal mental health measures were associated with higher meal frequency (HSCL-25: ß: 0·13, P = 0·001; HTQ: ß: 0·12, P = 0·001; high distress: ß: 0·15, P < 0·05) and consumption of at least three meals/snacks per day (HSCL-25: OR: 2·06, HTQ: OR: 1·93, high distress: OR: 2·68, P < 0·001 for all). No significant associations were found with HAZ, WAZ, WHZ, stunting or underweight indicators. CONCLUSIONS: More severe symptoms of maternal mental health problems were positively associated with child diet, but not anthropometry indicators. More research is needed to understand the role of maternal mental health in child feeding practices in food insecure and resource-poor settings.

Mental health symptoms and their relations with dietary diversity and nutritional status among mothers of young children in eastern Democratic Republic of the Congo.

BACKGROUND: In developing countries, maternal mental health problems have been linked to sub-optimal child feeding practices and child underweight and stunting, but little is known about how maternal mental health is associated with mothers' own diets and nutritional status. The objective of the study was to investigate the association between mental health symptoms and diet and nutritional status of mothers of young children in South Kivu, DR Congo. METHODS: Participants were 828 mothers of young children enrolled in a larger, quasi-experimental study evaluating a multi-year food security and nutrition project. The present analysis was conducted with cross-sectional data collected from 2015 to 2016. We assessed symptoms of anxiety and depression using the Hopkins Symptom Checklist-25 (HSCL-25) and post-traumatic stress disorder (PTSD) with the Harvard Trauma Questionnaire (HTQ), using a four-point Likert scale. Mean scale scores were calculated ranging from one to four. A variable was created for high distress (participants scoring in the upper quartile of both measures). Dietary diversity scores were calculated from the number of food groups (range zero to ten) consumed the previous day, identified from an open recall. Nutritional status was measured by body mass index (BMI) and underweight (BMI < 18.5 kg/m2, or mid-upper arm circumference < 23 cm for pregnant women). Bivariate and multivariate (adjusting for parent study intervention group, education, age, health, parity, livelihoods zone, and territory of origin) regression analyses were conducted. RESULTS: Maternal mental health measures were positively and statistically significantly associated with higher dietary diversity scores in adjusted analyses (HSCL-25: ß= 0.18, p = 0.002, HTQ: ß= 0.12, p = 0.029, High Distress: ß= 0.47, p < 0.001). Mental health symptoms were not significantly associated with BMI (HSCL-25: ß = - 0.04, p = 0.824; HTQ: ß = 0.02, p = 0.913; High distress: ß= - 0.02, p = 0.938) or underweight (HSCL 25: OR = 0.91, p = 0.640; HTQ: OR = 1.03, p = 0.866; High distress: OR = 0.78, p = 0.489). CONCLUSIONS: More severe maternal mental health symptoms were associated with higher dietary diversity but not nutritional status, and the reasons for these findings are not clear from available data. More research is needed to identify underlying factors that could influence mental health symptomatology and diet quality among food insecure and extremely resource-limited populations.

Cash and voucher assistance and children's nutrition status in Somalia.

To address ongoing food insecurity and acute malnutrition in Somalia, a broad range of assistance modalities are used, including in-kind food, food vouchers, and cash transfers. Evidence of the impact of cash and voucher assistance (CVA) on prevention of acute malnutrition is limited in humanitarian and development settings. This study examined the impact of CVA on prevention of child acute malnutrition in 2017/2018 in the context of the Somalia food crisis. Changes in diet and acute malnutrition were measured over a 4-month period among children age 6-59 months from households receiving household transfers of approximately US$450 delivered either as food vouchers or a mix of in-kind food, vouchers, and cash. Baseline to endline change in children's dietary diversity, meal frequency, minimum acceptable diet (MAD), mid-upper arm circumference (MUAC), and acute malnutrition (MUAC < 12.5 cm) were compared using difference-in-difference analysis with inverse probability weighting. There were no statistically significant changes in dietary diversity, meal frequency, or the proportion of children with MAD for either intervention group. Adjusted change in mean MUAC showed increases of 0.5 cm (confidence interval [CI; 0.0, 0.7 cm]) in the food voucher group and 0.1 cm (CI [-0.1, 0.4]) in the mixed transfer group. In adjusted analysis, prevalence of acute malnutrition among children under 5 years increased by 0.7% (CI [-13.4, 14.4%]) among food voucher recipients and decreased by 4.8% (CI [-9.9, 8.1%]) in mixed transfer recipients. The change over time in both mean MUAC and acute malnutrition prevalence was similar for both interventions, suggesting that cash and vouchers had similar effects on child nutrition status.

Evaluating interventions to improve child nutrition in Eastern Democratic Republic of Congo.

OBJECTIVE: The prevention of malnutrition in children under two approach (PM2A), women's empowerment and agricultural interventions have not been widely evaluated in relation to child diet and nutrition outcomes. The present study evaluated the effectiveness of PM2A, women's empowerment groups (WEG), farmer field schools (FFS) and farmer-to-farmer training (F2F). DESIGN: Community-matched quasi-experimental design; outcome measures included children's dietary diversity, stunting and underweight. SETTING: Communities in South Kivu, Democratic Republic of the Congo.ParticipantsA total of 1312 children from 1113 households. RESULTS: Achievement of minimum dietary diversity ranged from 22·9 to 39·7 % and was significantly greater in the PM2A and FFS groups (P<0·05 for both comparisons). Fewer than 7·6 and 5·8 % of children in any group met minimum meal frequency and acceptable diet targets; only the PM2A group differed significantly from controls (P<0·05 for both comparisons). The endline stunting prevalence ranged from 54·7 % (PM2A) to 69·1 % (F2F) and underweight prevalence from 22·3 % (FFS) to 34·4 % (F2F). No significant differences were found between intervention groups and controls for nutrition measures; however, lower prevalences of stunting (PM2A, -4 %) and underweight (PM2A and FFS, -7 %) suggest potential impact on nutrition outcomes. CONCLUSIONS: Children in the PM2A and FFS groups had better child diet measures and nutrition outcomes with the best results among PM2A beneficiaries. Interventions that address multiple aspects nutrition education, health, ration provision and income generation may be more effective in improving child diet and nutrition in resource-poor settings than stand-alone approaches.

Point-of-use water treatment improves recovery rates among children with severe acute malnutrition in Pakistan: results from a site-randomized trial.

OBJECTIVE: To evaluate effectiveness of point-of-use water treatment in improving treatment of children affected by severe acute malnutrition (SAM). DESIGN: Programme sites were randomized to one of four intervention arms: (i) standard SAM treatment; (ii) SAM treatment plus flocculent/disinfectant water treatment; (iii) SAM treatment plus chlorine disinfectant; or (iv) SAM treatment plus ceramic water filter. Outcome measures were calculated based on participant status upon exit or after 120d of enrolment, whichever came first. Child anthropometric data were collected during weekly monitoring at programme sites. Child caregivers were interviewed at enrolment and exit. Use of water treatment products was assessed in a home visit 4-6 weeks after enrolment. SETTING: Dadu District, Sindh Province, Pakistan. SUBJECTS: Children (n 901) aged 6-59 months with SAM and no medical complications. RESULTS: Recovery rates were 16·7-22·2 % higher among children receiving water treatment compared with the control group. The adjusted odds of recovery were approximately twice as high for those receiving water treatment compared with controls. Mean length of stay until recovery was 73 (sd 24·6) d and mean rate of weight gain was 4·7 (sd 3·0) g/kg per d. Differences in recovery rate, length of stay and rate of weight gain between intervention groups were not statistically significant. CONCLUSIONS: Incorporating point-of-use water treatment into outpatient treatment programmes for children with SAM increased nutritional recovery rates. No significant differences in recovery rates were observed between the different intervention groups, indicating that different water treatment approaches were equally effective in improving recovery.

Humanitarian Needs Among Displaced and Female-Headed Households in Government-Controlled Areas of Syria.

OBJECTIVES: To identify unmet needs and assistance priorities of displaced and female-headed households in government-controlled areas of Syria. METHODS: In mid-2016, we undertook a survey of accessible areas, largely urban and government-controlled, to identify unmet needs and assistance priorities. We used a cluster design with probability sampling to attain a final sample of 2405 households from 10 of 14 governorates; 31 of 65 (47.7%) districts were included that are home to 38.1% of people in need. RESULTS: Displaced and female-headed households were more vulnerable than nondisplaced and male-headed households in numerous sectors. Despite approximately half of surveyed households reporting receipt of humanitarian assistance in the preceding month and apparently effective targeting of assistance by vulnerability, unmet needs were nearly ubiquitous. CONCLUSIONS: The humanitarian situation in inaccessible areas of Syria is likely to be considerably worse; thus, findings presented here likely underestimate humanitarian needs. Efforts to expand support to Syria's most vulnerable households are desperately needed as are innovative targeting and modalities that enable more efficient and effective assistance.

Maternal Health Care Utilization Among Syrian Refugees in Lebanon and Jordan.

Purpose The influx of Syrian refugees into Jordan and Lebanon over the last 5 years presents an immense burden to national health systems. This study was undertaken to assess utilization of maternal health services among Syrian refugees in both countries. Description A cross-sectional survey of Syrian refugees living in urban and rural (non-camp) settings was conducted using a two-stage cluster survey design with probability proportional to size sampling in 2014-2015. Eighty-six percent of surveyed households in Lebanon and 88% of surveyed households in Jordan included women with a live birth in the last year. Information from women in this sub-set of households was analyzed to understand antenatal and intrapartum health service utilization. Assessment A majority of respondents reported seeking antenatal care, 82% and 89% in Jordan and Lebanon, respectively. Women had an average of at least six antenatal care visits. Nearly all births (98% in Jordan and 94% in Lebanon) took place in a health facility. Cesarean rates were similar in both countries; approximately one-third of all births were cesarean deliveries. A substantial proportion of women incurred costs for intrapartum care; 33% of Syrian women in Jordan and 94% of Syrian women in Lebanon reported paying out of pocket for their deliveries. The proportion of women incurring costs for intrapartum care was higher in Jordan both countries for women with cesarean deliveries compared to those with vaginal deliveries; however, this difference was not statistically significant in either country (Jordan p-value = 0.203; Lebanon p-value = 0.099). Conclusion Syrian refugees living in Jordan and Lebanon had similar levels of utilization of maternal health services, despite different health systems and humanitarian assistance provisions. As expected, a substantial proportion of households incurred out-of-pocket costs for essential maternal and newborn health services, making cost a major factor in care-seeking decisions and locations. As health financing policies shift to account for the continued burden of refugee hosting on the health system, sustained attention to the availability and quality of essential maternal and newborn health services is needed to protect both refugee and host populations women's rights to health and health care during pregnancy, childbirth, and the postpartum period.

Health service access and utilization among Syrian refugees in Jordan.

BACKGROUND: The influx of Syrian refugees into Jordan presents an immense burden to the Jordanian health system. Changing lifestyles and aging populations are shifting the global disease burden towards increased non-infectious diseases including chronic conditions, co-morbidities, and injuries which are more complicated and costly to manage. The strain placed on health systems threatens the ability to ensure the health needs of both refugees and host country populations are adequately addressed. In light of the increasing challenges facing host governments and humanitarian actors to meet health needs of Syrian refugees and affected host communities, this study was undertaken to assess utilization of health services among Syrian refugees in non-camp settings. METHODS: A survey of Syrian refugees in Jordan was undertaken in June 2014 to characterize health seeking behaviors and issues related to accessing care. A cluster design with probability proportional to size sampling was used to attain a nationally representative sample of 1550 non-camp Syrian refugee households. Differences in household characteristics by geographic region, facility type, and sector utilized were examined using chi-square and t-test methods. RESULTS: Care-seeking was high with 86.1 % of households reporting an adult sought medical care the last time it was needed. Approximately half (51.5 %) of services were sought from public sector facilities, 38.7 % in private facilities, and 9.8 % in charity/NGO facilities. Among adult care seekers, 87.4 % were prescribed medication during the most recent visit, 89.8 % of which obtained the medication. Overall, 51.8 % of households reported out-of-pocket expenditures for the consultation or medications at the most recent visit (mean US$39.9, median US$4.2). CONCLUSIONS: Despite high levels of care-seeking, cost was an important barrier to health service access for Syrian refugees in Jordan. The cessation of free access to health care since the time of the survey is likely to have worsened health equity for refugees. Dependence of refugees on the public facilities for primary and specialist care has placed a great burden on the Jordanian health system. To improve accessibility and affordability of health services in an equitable manner for both refugees and Jordanian host communities, strategies that should be considered going forward include shifting resources for non-communicable diseases and other traditional hospital services to the primary level and creating strong health promotion programs emphasizing prevention and self-care are strategies.

Health service utilization and access to medicines among Syrian refugee children in Jordan.

BACKGROUND: With over one million Syrian refugee children in the region, we undertook this study to characterize care-seeking behaviors and health service utilization for child refugees with the aim of informing humanitarian programming for non-camp settings in Jordan. METHODS: A survey of Syrian refugees living outside of camps in Jordan was conducted using a 125 × 12 cluster design with probability proportional to size sampling to obtain a representative sample. The questionnaire focused on access to health services, including a module on care seeking for children. RESULTS: Care seeking was high with 90.9% of households with a child less than 18 years seeking medical care the last time it was needed. Households most often sought care for children in the public sector (54.6%), followed by private (36.5%) and charity sectors (8.9%). Among child care seekers, 88.6% were prescribed medication during the most recent visit, 90.6% of which obtained the medication. Overall, 49.4% of households reported out-of-pocket expenditures for either the consultation or prescribed medications at the most recent visit (mean $US21.1 and median $US0). CONCLUSIONS: Syrian refugees had good access to care for their sick children at the time of the survey; however, this has likely deteriorated since the survey because of the withdrawal of free access for refugees. The number of refugees in Jordan and relative accessibility of care has resulted in a large burden on the health system; the Jordanian government will require additional support if current levels of health access are to be maintained for Syrian refugees.

Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan.

BACKGROUND: There are currently more people displaced by conflict than at any time since World War II. The profile of displaced populations has evolved with displacement increasingly occurring in urban and middle-income settings. Consequently, an epidemiological shift away from communicable diseases that have historically characterized refugee populations has occurred. The high prevalence of non-communicable diseases (NCDs) poses a challenge to in terms of provision of appropriate secondary and tertiary services, continuity of care, access to medications, and costs. In light of the increasing burden of NCDs faced by refugees, we undertook this study to characterize the prevalence of NCDs and better understand issues related to care-seeking for NCDs among Syrian refugees in non-camp settings in Jordan. METHODS: A cross-sectional survey of 1550 refugees was conducted using a multi-stage cluster design with probability proportional to size sampling to obtain a nationally representative sample of Syrian refugees outside of camps. To obtain information on chronic conditions, respondents were asked a series of questions about hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and arthritis. Differences by care-seeking for these conditions were examined using chi-square and t-test methods and characteristics of interest were included in the adjusted logistic regression model. RESULTS: Among adults, hypertension prevalence was the highest (9.7%, CI: 8.8-10.6), followed by arthritis (6.8%, CI: 5.9-7.6), diabetes (5.3%, CI: 4.6-6.0), chronic respiratory diseases (3.1%, CI: 2.4-3.8), and cardiovascular disease (3.7%, CI: 3.2, 4.3). Of the 1363 NCD cases, 84.7% (CI: 81.6-87.3) received care in Jordan; of the five NCDs assessed, arthritis cases had the lowest rates of care seeking at 65%, (CI:0-88, p = 0.005). Individuals from households in which the head completed post-secondary and primary education, respectively, had 89% (CI: 22-98) and 88% (CI: 13-98) lower odds of seeking care than those with no education (p = 0.028 and p = 0.037, respectively). Refugees in North Jordan were most likely to seek care for their condition; refugees in Central Jordan had 68% (CI: 1-90) lower odds of care-seeking than those in the North (p = 0.047). CONCLUSION: More than half of Syrian refugee households in Jordan reported a member with a NCD. A significant minority did not receive care, citing cost as the primary barrier. As funding limitations persist, identifying the means to maintain and improve access to NCD care for Syrian refugees in Jordan is essential.

Measuring impact: a cross-sectional multi-stage cluster survey to assess the attainment of durable solutions in post-tsunami Aceh, Indonesia.

BACKGROUND: There exists little agreement on the choice of indicators to be used to assess the impact of humanitarian assistance. The 2004 Indian Ocean tsunami led to significant mortality and displacement in Aceh Province, Indonesia, as well as a nearly unprecedented humanitarian response. Six years after the disaster we conducted an impact assessment of humanitarian services rendered in Aceh using a comprehensive set of rights-based indicators and sought to determine modifiable predictors of improved outcomes in disaster-affected households. METHODS: A sample of 597 returned and non-returned households in Banda Aceh and Meulaboh was selected using a multistage stratified cluster survey design. We employed principle components analysis and the Framework on Durable Solutions for Internally Displaced Persons to develop a comprehensive and rights-based approach to humanitarian impact measurement using multivariate regression models. RESULTS: The attainment of durable solutions was equivalent in both returned households 100.1 [CI] 97.63-102.5) and households that integrated elsewhere (99.37 [CI] 95.43-103.3, P = 0.781). Standard of living as well as education and health facility satisfaction increased significantly whereas monthly income decreased after the tsunami, from 2585241 IDR ([CI] 2357202-2813279 IDR) to 2038963 ([CI] 1786627-2291298 IDR, P < 0.001). Shelter (P = 0.007) and legal assistance (P < 0.001) were both significantly associated with positive durable solutions outcomes, whereas prolonged displacement duration was significantly associated with poorer outcomes (P < 0.001). Livelihood assistance received after one year was associated with higher odds of increasing or maintaining pre-tsunami income levels (OR = 3.02, P = 0.008), whereas livelihood assistance received within one year was associated with lower odds of attaining pre-tsunami income (OR = 0.52, P = 0.010). CONCLUSIONS: We find that after adjusting for pre-tsunami conditions and tsunami-related damages, the impact of sectoral responses can be assessed. The duration of displacement was the strongest negative predictive factor for the attainment of durable solutions, suggesting that measures to reduce displacement time may be effective in mitigating the long-term effects of disaster on households. The durable solutions framework is a novel and effective impact measurement tool and can be used to identify factors amenable to intervention and inform future disaster recovery efforts.

A comparison of the medium-term impact and recovery of the Pakistan floods and the Haiti earthquake: objective and subjective measures.

INTRODUCTION: The 2010 Haiti earthquake and Pakistan floods were similar in their massive human impact. Although the specific events were very different, the humanitarian response to disasters is supposed to achieve the same ends. This paper contrasts the disaster effects and aims to contrast the medium-term response. METHODS: In January 2011, similarly structured population-based surveys were carried out in the most affected areas using stratified cluster designs (80×20 in Pakistan and 60×20 in Haiti) with probability proportional to size sampling. RESULTS: Displacement persisted in Haiti and Pakistan at 53% and 39% of households, respectively. In Pakistan, 95% of households reported damage to their homes and loss of income or livelihoods, and in Haiti, the rates were 93% and 85%, respectively. Frequency of displacement, and income or livelihood loss, were significantly higher in Pakistan, whereas disaster-related deaths or injuries were significantly more prevalent in Haiti. CONCLUSION: Given the rise in disaster frequency and costs, and the volatility of humanitarian funding streams as a result of the recent global financial crisis, it is increasingly important to measure the impact of humanitarian response against the goal of a return to normalcy.

Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study.

BACKGROUND: As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes. METHODS: A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols. RESULTS: Very few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI - 30.2, - 26.5) and 5.1 days (CI - 6.2, - 4.0); the full adapted protocol had a decrease of 3.0 (CI - 5.1, - 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18-3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45-2.19); and fully adapted protocol AOR = 2.41 (CI 1.69-3.45). CONCLUSIONS: This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing.

Caregiver use of MUAC tapes in South Sudan: a three-group prospective comparison.

Introduction: Nutrition program modifications occurred globally in response to the COVID-19 pandemic. Within community management of acute malnutrition (CMAM), community screenings for acute malnutrition were replaced by caregivers monitoring child mid-upper arm circumference (MUAC), but questions remain about different MUAC tapes' performance and acceptability for caregiver use. Methods: The study was conducted in Central Equatoria and Warrap States, South Sudan, between March 2022 and January 2023. A three-group prospective non-randomized design was used to compare the performance of three MUAC tapes (UNICEF 2009, UNICEF 2020, and GOAL MAMI) used by caregivers. The primary outcome was the false negative rate (i.e., the proportion of children not identified as wasted by the caregiver but classified as wasted by enumerators). Caregivers with children aged 5-53 months were assigned to and trained on the use of 1 of the 3 tapes and followed for 8 months, including three monitoring visits and baseline/endline surveys. Results: Of the 2,893 enrolled children, 2,401 (83.0%) completed baseline, endline, and two or more monitoring visits. Only 3.7% of children were identified as wasted by caregivers and 3.8% by study team measurement. Cumulative measurement agreement between caregivers and enumerators was similar by tape. False negative and false positive rates were both <0.5% overall and similar among the tapes. There were differences in training needs and durability between the tapes, but all three were acceptable and performed equally well. Discussion: Caregiver measurement of child MUAC is feasible in South Sudan. The three MUAC tapes were acceptable, and caregivers could measure accurately with minimal support. All tapes performed similarly and are appropriate for use in Family MUAC programs in South Sudan. There were indications that the UNICEF 2020 tape may be less durable; the GOAL MAMI tape has the added benefit of being suitable for assessments of infants <6 months of age.

Mortality following the Haitian earthquake of 2010: a stratified cluster survey.

INTRODUCTION: Research that seeks to better understand vulnerability to earthquakes and risk factors associated with mortality in low resource settings is critical to earthquake preparedness and response efforts. This study aims to characterize mortality and associated risk factors in the 2010 Haitian earthquake. METHODS: In January 2011, a survey of the earthquake affected Haitian population was conducted in metropolitan Port-au-Prince. A stratified 60x20 cluster design (n = 1200 households) was used with 30 clusters sampled in both camp and neighborhood locations. Households were surveyed regarding earthquake impact, current living conditions, and unmet needs. RESULTS: Mortality was estimated at 24 deaths (confidence interval [CI]: 20-28) per 1,000 in the sample population. Using two approaches, extrapolation of the survey mortality rate to the exposed population yielded mortality estimates ranging from a low of 49,033 to a high of 86,555. No significant difference in mortality was observed by sex (p = .786); however, age was significant with adults age 50+ years facing increased mortality risk. Odds of death were not significantly higher in camps, with 27 deaths per 1,000 (CI: 22-34), compared to neighborhoods, where the death rate was 19 per 1,000 (CI: 15-25; p = 0.080). Crowding and residence in a multistory building were also associated with increased risk of death. CONCLUSIONS: Haiti earthquake mortality estimates are widely varied, though epidemiologic surveys conducted to date suggest lower levels of mortality than officially reported figures. Strategies to mitigate future mortality burden in future earthquakes should consider improvements to the built environment that are feasible in urban resource-poor settings.