Health profile of pediatric Special Immigrant Visa holders arriving from Iraq and Afghanistan to the United States, 2009-2017: A cross-sectional analysis.

BACKGROUND: The United States has admitted over 80,000 Special Immigrant Visa holders (SIVH), which include children. Despite the increase in the proportion of SIVH admissions to the US over recent years, little is known about health conditions in SIV children. We report the frequency of selected diseases identified overseas and assess differences in selected conditions between SIV children from Iraq and Afghanistan. METHODS AND FINDINGS: We analyzed 15,729 overseas medical exam data in Centers for Disease Control and Prevention's Electronic Disease Notification system (EDN) for children less than 18 years of age from Iraq (29.1%) and Afghanistan (70.9%) who were admitted to the US from April 2009 through December 2017 in a cross-sectional analysis. Variables included age, sex, native language, measured height and weight, and results of the overseas medical examination. From our analysis, less than 1% of SIV children (Iraqi: 0.1%; Afghan: 0.12%) were reported to have abnormal tuberculosis test findings, less than 1% (Iraqi: 0.3%; Afghan: 0.7%) had hearing abnormalities, and about 4% (Iraqi: 6.0% Afghan: 2.9%) had vision abnormalities, with a greater prevalence of vision abnormalities noted in Iraqis (OR: 1.9, 95% CI 1.6-2.2, p <0.001). Seizure disorders were noted in 46 (0.3%) children, with Iraqis more likely to have a seizure disorder (OR: 7.6, 95% CI 3.8-15.0, p < 0.001). On average, children from Afghanistan had a lower mean height-for-age z-score (Iraqi: -0.28; Afghan: -0.68). Only the data quality assessment for height for age for children ≥5 years fell within WHO recommendations. Limitations included the inability to obtain all SIVH records and self-reported medical history of noncommunicable diseases. CONCLUSION: In this investigation, we found that less than 1% of SIV children were reported to have abnormal tuberculosis test findings and 4% of SIV children had reported vision abnormalities. Domestic providers caring for SIVH should follow the US Centers for Disease Control and Prevention (CDC) Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees, including an evaluation for malnutrition. Measurement techniques and anthropometric equipment used in panel site clinics should be assessed, and additional training in measurement techniques should be considered. Future analyses could further explore the health of SIV children after resettlement in the US.

Serious psychological distress and disability among older persons living in conflict affected areas in eastern Ukraine: a cluster-randomized cross-sectional household survey.

BACKGROUND: Older persons are often unable to leave conflict areas; however, little is known about the mental and physical health among this population. Our objective was to determine the prevalence of and whether there was an association between psychological distress and disability among older persons affected by conflict in eastern Ukraine. METHODS: We conducted a cluster-randomized cross-sectional household survey of persons aged ≥60 years in government and non-government controlled areas (GCA and NGCA) of Donetsk and Luhansk regions in January-March 2016. Psychological distress and dependency (degree of disability) were measured using the Kessler K6 Psychological Distress Scale and Katz Index of Independence in Activities of Daily Living, respectively. Association between psychological distress and dependency was assessed using logistic regression adjusting for demographic and socioeconomic characteristics. RESULTS: Final sample included 758 and 418 persons in GCA and NGCA, respectively. Prevalence of serious psychological distress was 33.6% (95% Confidence Interval (CI), 28.0-39.7%) in GCA and 42.5% (95%CI, 36.1-49.2%) in NGCA. Overall, 32.2% (95%CI, 27.9-36.7%) of independent persons and 74.0% (95%CI, 65.2-81.2%) of moderately/severely dependent persons reported serious psychological distress (P < .0001). Being dependent, a woman, and having a chronic disease were all significantly associated with psychological distress in a logistic regression model. CONCLUSIONS: Prevalence of serious psychological distress was very high compared with rates reported from developed countries and was highly associated with disability. Health services for the disabled, including psychological as well as physical support, could help in reducing the proportion of people needing mental health services not normally identified.

Assessment of Anthropometric Data Following Investments to Ensure Quality: Kenya Demographic Health Surveys Case Study, 2008 to 2009 and 2014.

BACKGROUND: Evidence-based nutrition programs depend on accurate estimates of malnutrition derived from data collected in population representative surveys. The feasibility of obtaining accurate anthropometric data as part of national, multisectoral surveys has been a debated issue. OBJECTIVES: The study aimed to evaluate changes in anthropometric data quality corresponding to investments by the Kenya Ministry of Health and nutrition sector partners for the 2014 Kenya Demographic Health Survey. METHODS: Anthropometric data collected during the 2008 to 2009 and 2014 Kenya surveys were reanalyzed to assess standard parameters of quality: standard deviation, skewness, and kurtosis of z-score values for 3 anthropometric indicators (weight for height, height for age, and weight for age), percentage of children with missing measurements and outlier values, digit preference, and heaping of age. RESULTS: A total of 9936 households were selected in 2008 to 2009, and 39 679 households were selected in 2014. Standard deviation of z-scores for all 3 indicators was smaller in 2014 than in 2008 to 2009. Applying original Demographic and Health Survey exclusion criteria, weight for height z-scores were 1.16 in 2014, 10.1% narrower than 2008 to 2009. The percentage of outlying values declined significantly from 2008 to 2009 to 2014 for both height for age and weight for height ( P < .001). Digit preference scores in 2014 improved for both weight ( P = .011) and height ( P < .001) suggesting less rounding of terminal digits. CONCLUSIONS: All tests of data quality suggest an improvement in 2014 relative to 2008 to 2009, despite the complexity implied by the larger sample. This improvement corresponds with efforts to enhance training and supervision of anthropometry, suggesting a positive effect of these enhancements.

Risk factors for unsafe behaviors toward grenades among rural populations affected by explosive devices in Colombia.

BACKGROUND: Following decades of armed conflict, Colombia remains highly affected by explosive device (ED) contamination, especially in rural areas. Many victims are injured by EDs despite knowing their dangers. Determining risk factors for unsafe behaviors toward EDs, including grenades, is critical for preventing injuries. METHODS: In 2012, CDC assisted Colombian partners in conducting a multi-stage knowledge, attitudes, and practices survey in rural ED-affected areas. Within each of 40 clusters, 28 households were selected, and participants aged 10 years or older were asked about behaviors toward EDs. Participants reported actual behaviors toward past EDs encountered and theoretical behaviors toward EDs not encountered. Behaviors were a priori classified as unsafe or safe. This analysis focuses on behaviors toward the most commonly encountered device, grenades. RESULTS: Of 928 adult and 562 child participants, 488 (52.5%) adults and 249 (43.9%) children encountered ED, while 121 (13.7%) adults and 148 (26.9%) children received mine risk education (MRE). Among the 430 (46.7%) adults who encountered grenades, 113 (25.7%) reported unsafe behaviors; multivariable analysis showed that unsafe behavior was associated with working outdoors (adjusted odds ratio [aOR]: 1.7, 95% confidence interval [CI]: 1.1-2.7). Among the 429 (46.5%) adults who did not encounter ED, 61 (14.6%) described unsafe theoretical behaviors toward grenades; multivariable analysis showed that unsafe behavior was associated with older age (aOR: 1.02, 95% confidence limit [CL]: 1.00-1.05) and black or Afro-Colombian identity (aOR: 2.5, 95% CI 1.3-5.1). Among the 181 (32.0%) children who encountered grenades, 41 (23.8%) reported unsafe behaviors, while among the 311 (55.9%) children who did not encounter ED, 30 (10.2%) reported unsafe behavior. In both groups of children, multivariable analysis showed that unsafe behavior was associated with lower mean score on knowledge of ED, with aOR: 0.7, 95% CL: 0.6-0.9, and aOR: 0.8, 95% CL: 0.6-0.98, respectively. CONCLUSIONS: Participants reported frequent ED exposure but low receipt of MRE. Our findings should guide MRE improvement in ED-affected areas by strengthening the connection between ED knowledge and avoiding unsafe behavior, with a particular focus on people working outdoors. MRE should promote knowledge of ED risks but should also recognize socioeconomic factors that lead to engaging in unsafe behaviors.

Suboptimal infant and young child feeding practices among internally displaced persons during conflict in eastern Ukraine.

OBJECTIVE: To determine current status, areas for improvement and effect of conflict on infant and young child feeding (IYCF) practices among internally displaced persons (IDP) in eastern Ukraine. DESIGN: Cross-sectional household survey, June 2015. SETTING: Kharkiv, Dnipropetrovsk and Zaporizhia oblasts (Ukrainian administrative divisions) bordering conflict area in Ukraine. SUBJECTS: Randomly selected IDP households with children aged <2 years registered with local non-governmental organizations. Questions based on the WHO IYCF assessment questionnaire were asked for 477 children. Mid-upper arm circumference was measured in 411 children aged 6-23 months. RESULTS: Exclusive breast-feeding prevalence for infants aged <6 months was 25·8 (95 % CI 15·8, 38·0) %. Percentage of mothers continuing breast-feeding when their child was aged 1 and 2 years was 53·5 (95 % CI 43·2, 63·6) % and 20·6 (95 % CI 11·5, 32·7) %, respectively. Bottle-feeding was common for children aged <2 years (68·1 %; 95 % CI 63·7, 72·3 %). Almost all infants aged 6-8 months received solid foods (98·6 %; 95 % CI 88·5, 99·9 %). Mothers who discontinued breast-feeding before their infant was 6 months old more often listed stress related to conflict as their primary reason for discontinuation (45·7 %) compared with mothers who discontinued breast-feeding when their child was aged 6-23 months (14·3 %; P<0·0001). CONCLUSIONS: To mitigate the effects of conflict and improve child health, humanitarian action is needed focused on helping mothers cope with stress related to conflict and displacement while supporting women to adhere to recommended IYCF practices if possible and providing appropriate support to women when adherence is not feasible.

Centers for Disease Control and Prevention Public Health Response to Humanitarian Emergencies, 2007-2016.

Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB's responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB's multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.

Fatalities from Firearm-Related Injuries in Selected Governorates of Iraq, 2010-2013.

BACKGROUND: In Iraq, where Islamic State of Iraq and Syria (ISIS) and other groups have contributed to escalating violence in recent years, understanding the epidemiology of intentional firearm-related fatalities is essential for public health action. METHODS: The Iraqi Ministry of Health (MoH; Baghdad, Iraq) compiles surveillance of fatal injuries in eight of Iraq's 18 governorates (Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya). Information is collected from coroner's reports and interviews with family members. Analysis was performed on intentional firearm-related injuries, excluding injuries from intentional self-harm or negligent discharges, that occurred during 2010-2013, a subset of all fatal injuries, and compared to previously published explosive-related fatalities. RESULTS: Overall, the dataset included 7,985 firearm-related fatalities. Yearly fatalities were: 2010=1,706; 2011=1,642; 2012=1,662; and 2013=2,975. Among fatalities, 86.0% were men and 13.7% women; 83.4% were adults and 6.2% children <18 years of age. Where age and sex were both known, men aged 20-39 years accounted for 56.3% of fatalities. Three "high-burden" governorates had the highest fatality rate per 100,000 population-Baghdad (12.9), Ninevah (17.0), and Al-Anbar (14.6)-accounting for 85.9% of fatalities recorded in the eight governorates. Most fatalities occurred in the street (56.3%), followed by workplace (12.2%), home (11.3%), and farm/countryside (8.4%). Comparing the ratio of firearm-related fatalities to explosives-related fatalities revealed an overall ratio of 2.8:1. The ratio in Baghdad more than doubled from 2.9 in 2010 to 6.1 in 2013; the highest ratios were seen outside the high-burden governorates. CONCLUSIONS: Firearm-related fatalities remained relatively stable throughout 2010-2012, and almost doubled in 2013, correlating with increased ISIS activity. Three governorates contributed the majority of fatalities and experienced the highest fatality rates; these saw high levels of conflict. Firearm-related fatalities disproportionately affected younger men, who historically are over-represented as victims and perpetrators of violence. More than one-half of fatalities occurred in the street, indicating this as a common environment for conflict involving firearms. Firearms appear to account for more fatalities in Iraq than explosives and largely accounted for escalating violence in Baghdad during the study period. The high ratio observed outside the high-burden governorates is reflective of very low numbers of explosives-related fatalities; thus, violence in these governorates is likely non-conflict-related. These observations provide valuable public health information for targeted intervention to prevent violence. Nerlander MP , Leidman E , Hassan A , Sultan ASS , Hussain SJ , Browne LB , Bilukha OO . Fatalities from firearm-related injuries in selected governorates of Iraq, 2010-2013. Prehosp Disaster Med. 2017;32(5):548-555.

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.

Nutritional situation among Syrian refugees hosted in Iraq, Jordan, and Lebanon: cross sectional surveys.

BACKGROUND: Ongoing armed conflict in Syria has caused large scale displacement. Approximately half of the population of Syria have been displaced including the millions living as refugees in neighboring countries. We sought to assess the health and nutrition of Syrian refugees affected by the conflict. METHODS: Representative cross-sectional surveys of Syrian refugees were conducted between October 2 and November 30, 2013 in Lebanon, April 12 and May 1, 2014 in Jordan, and May 20 and 31, 2013 in Iraq. Surveys in Lebanon were organized in four geographical regions (North, South, Beirut/Mount Lebanon and Bekaa). In Jordan, independent surveys assessed refugees residing in Za'atri refugee camp and refugees residing among host community nationwide. In Iraq, refugees residing in Domiz refugee camp in the Kurdistan region were assessed. Data collected on children aged 6 to 59 months included anthropometric indicators, morbidity and feeding practices. In Jordan and Lebanon, data collection also included hemoglobin concentration for children and non-pregnant women aged 15 to 49 years, anthropometric indicators for both pregnant and non-pregnant women, and household level indicators such as access to safe water and sanitation. RESULTS: The prevalence of global acute malnutrition among children 6 to 59 months of age was less than 5 % in all samples (range 0.3-4.4 %). Prevalence of acute malnutrition among women 15 to 49 years of age, defined as mid-upper arm circumference less than 23.0 cm, was also relatively low in all surveys (range 3.5-6.5 %). For both children and non-pregnant women, anemia prevalence was highest in Za'atri camp in Jordan (48.4 % and 44.8 %, respectively). Most anemia was mild or moderate; prevalence of severe anemia was less than or equal to 1.1 % in all samples of children and women. CONCLUSIONS: Despite the ongoing conflict, results from all surveys indicate that global acute malnutrition is relatively low in the assessed Syrian refugee populations. However, prevalence of anemia suggests a serious public health problem among women and children, especially in Za'atri camp. Based on these findings, nutrition partners in the region have reprioritized response interventions, focusing on activities to address micronutrient deficiencies such as food fortification.

Injury-related fatalities in selected governorates of Iraq from 2010 to 2013: Prospective surveillance.

OBJECTIVE: After several years of relative stability in Iraq, the emergence of the Islamic State militant group has spurred a resurgence of violence. This study explores the impact of the conflict on the overall injury profile to estimate the proportion of injury fatalities related to conflict and better understand how violence has affected nonconflict-related injuries. DESIGN: Routine prospective injury surveillance operated by the Iraqi Ministry of Health. SETTING: Surveillance data were collected from coroner offices in eight pilot governorates: Al-Anbar, Baghdad, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. PARTICIPANTS: We analyzed all fatalities from external injury causes recorded between January 1, 2010 and December 31, 2013. Analysis included 32,664 fatal injuries. RESULTS: Of all injury fatalities reported, 27.1 percent were conflict-related fatalities, approximately the same proportion as road traffic-related fatalities (24.4 percent) and other unintentional injuries (27.5 percent). The proportion of fatalities from conflict was approximately three times higher among males than females (33.0 percent and 10.3 percent, respectively) and four times higher among adults than children (29.8 percent and 7.3 percent, respectively). The total number of injury fatalities remained stable between 2010 and 2012; an increase in injury fatalities in 2013 was driven primarily by increases in fatalities from both interpersonal violence and conflict. CONCLUSIONS: From 2010 to 2013, nearly one in four injury fatalities in Iraq was attributable to conflict, a notably higher proportion than other conflict-affected countries in the region. The overall profile of nonconflict injuries in Iraq is also distinct from other countries of similar socioeconomic level that have not experienced violence.

Road traffic fatalities in selected governorates of Iraq from 2010 to 2013: prospective surveillance.

BACKGROUND: The insurgency tactics that characterize modern warfare, such as suicide car bombs and roadside bombs, have the potential to significantly impact road traffic injuries in conflict affected-countries. As road traffic incidents are one of the top ten causes of death in Iraq, changes in incidence have important implications for the health system. We aimed to describe patterns of road traffic fatalities for all demographic groups and types of road users in Iraq during a period characterized by a resurgence in insurgency activity. METHODS: Iraqi Ministry of Health routine prospective injury surveillance collects information on all fatal injuries in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. From all injury fatalities documented at the coroner office, we analyzed only those attributed to road traffic that occurred between 1 January 2010 and 31 December 2013. Coroners ascertain information from physical examinations, police reports and family members. RESULTS: Analysis included 7,976 road traffic fatalities. Overall, 6,238 (78.2 %) fatalities were male and 2,272 (28.5 %) were children under 18 years of age. The highest numbers of road traffic fatalities were among males 15 to 34 years of age and children of both sexes under 5 years of age. 49.2 % of fatalities occurred among pedestrians. Among children and females, the majority of road traffic fatalities were pedestrians, 69.0 % and 56.6 %, respectively. Fatalities among motorcyclists (3.7 %) and bicyclists (0.4 %) were least common. Rates of road traffic fatalities ranged from 8.6 to 10.7 per 100,000 population. CONCLUSIONS: The injury surveillance system provides the first data from a conflict-affected country on road traffic fatalities disaggregated by type of road user. The highest numbers of fatalities were among children and young men. Nearly half of fatalities were pedestrians, a proportion nearly double that of any neighboring country. As insurgency activity increased in 2013, the number of road traffic fatalities declined.

Deaths due to Intentional Explosions in Selected Governorates of Iraq from 2010 to 2013: Prospective Surveillance.

INTRODUCTION: The aim of this study was to describe the most recent trends and epidemiologic patterns of fatal injuries resulting from explosions in Iraq, one of the countries most affected by violence from explosive devices. METHODS: Iraqi Ministry of Health (MoH) routine prospective injury surveillance collects information on all fatal injuries recorded by coroners from physical examinations, police reports, and family members in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. This study analyzed explosive-related fatal injuries that occurred from January 1, 2010 through December 31, 2013. RESULTS: Analysis included 2,803 fatal injuries. The number of fatal injuries declined from 2010 through 2012, followed by an increase in 2013. One-thousand one-hundred and one explosion-related fatalities were documented in 2013, more than twice as many as in 2012 or in 2011. Most fatalities were among men aged 20-39 years. Of all causalities, 194 (6.9%) were among females and 302 (10.8%) were among children aged less than 18 years. The majority of fatalities were caused by improvised explosive devices (IEDs): car bombs (15.3%), suicide bombs (4.0%), and other IEDs (29.6%). The highest number of fatalities occurred in streets and roads. Of all deaths, 95.6% occurred in three governorates: Baghdad, Ninevah, and Al-Anbar. CONCLUSIONS: Explosives continue to result in a high number of fatal injuries in Iraq. Following a period of declining violence from explosives, in 2013, fatalities increased. Most explosion-related injuries resulted from IEDs; males aged 20-39 years were at greatest risk.

Notes from the field: malnutrition and elevated mortality among refugees from South Sudan - Ethiopia, June-July 2014.

As a result of armed civil conflict in South Sudan that started in mid-December of 2013, an estimated 1.1 million persons were internally displaced, and approximately 400,000 refugees fled South Sudan to neighboring countries (primarily to Ethiopia, Uganda, Sudan, and Kenya). Refugees from South Sudan arriving in Ethiopia are sheltered in three refugee camps located in Gambella region: Leitchuor, Kule, and Tierkidi. The camps were established during January-May 2014 and have estimated refugee populations of 47,000, 51,000, and 50,000, respectively. Reports from health clinics and humanitarian agencies providing assistance to refugees suggested poor nutritional status of arriving refugees and elevated mortality rates. To assess the nutritional status of refugee children aged 6-59 months and mortality rates (crude [all ages] and aged <5 years), the Administration for Refugee and Returnee Affairs (an Ethiopian government aid agency), the United Nations High Commissioner for Refugees, World Food Programme, and United Nations Children's Fund, in collaboration with CDC, conducted cross-sectional population-representative surveys in Leitchuor, Kule, and Tierkidi camps during June-July 2014. Anthropometric measurements in children were taken using standard procedures, and nutritional status was classified based on 2006 World Health Organization (WHO) growth standards. Hemoglobin was measured using HemoCue Hb 301. Anemia was diagnosed according to WHO thresholds. Retrospective mortality rates in Leitchuor and Kule were measured using a household census method.

Nutritional status of women and child refugees from Syria-Jordan, April-May 2014.

As a result of civil war, an estimated 2.8 million refugees have fled Syria and reside in neighboring countries, mainly Lebanon, Turkey, Jordan, and Iraq. The largest Syrian refugee camp in the region is Zaatari camp in Jordan, with approximately 79,000 refugees; another estimated 500,000 Syrian refugees live in Jordanian cities, towns, and villages, mostly in the capital (Amman) and in four northern governorates (Irbid, Mafraq, Jarash, and Zarqa). Although all registered refugees in Jordan receive food vouchers from the World Food Programme (WFP) and vulnerable refugees receive cash assistance from the United Nations High Commissioner for Refugees (UNHCR) and nongovernmental organizations, the nutritional status of some refugees might be compromised because of dislocation, lack of income, and limited access to nutritious foods. To assess the nutritional status of Syrian refugees, UNHCR, WFP, the United Nations Children's Fund (UNICEF), Medair International (a nongovernmental organization), and CDC, in collaboration with the United Nations Population Fund and the World Health Organization (WHO), conducted cross-sectional, population-representative cluster surveys in Zaatari camp and among refugees residing in the host community. The surveys were conducted during April-May 2014 with the principal objective of assessing nutritional status of refugee children aged 6-59 months and nonpregnant women of reproductive age (15-49 years). Preliminary findings indicated a high prevalence of anemia in Zaatari camp among both children and women (48.4% and 44.8%, respectively). Nutrition policies aimed at ensuring optimal child and maternal micronutrient status and addressing the underlying risk factors for anemia are likely to result in improved health outcomes and a reduction in anemia.

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.

Fatal and non-fatal injuries due to intentional explosions in Nepal, 2008-2011: analysis of surveillance data.

BACKGROUND: Nepal is one of the post-conflict countries affected by violence from explosive devices. We undertook this study to assess the magnitude of injuries due to intentional explosions in Nepal during 2008-2011 and to describe time trends and epidemiologic patterns for these events. METHODS: We analyzed surveillance data on fatal and non-fatal injuries due to intentional explosions in Nepal that occurred between 1 January 2008 and 31 December 2011. The case definition included casualties injured or killed by explosive devices knowingly activated by an individual or a group of individuals with the intent to harm, hurt or terrorize. Data were collected through media-based and active community-based surveillance. RESULTS: Analysis included 437 casualties injured or killed in 131 intentional explosion incidents. A decrease in the number of incidents and casualties between January 2008 and June 2009 was followed by a pronounced increase between July 2010 and June 2011. Eighty-four (19.2%) casualties were among females and 40 (9.2%) were among children under 18 years of age. Fifty-nine (45.3%) incidents involved one casualty, 47 (35.9%) involved 2 to 4 casualties, and 6 involved more than 10 casualties. The overall case-fatality ratio was 7.8%. The highest numbers of incidents occurred in streets or at crossroads, in victims' homes, and in shops or markets. Incidents on buses and near stadiums claimed the highest numbers of casualties per incident. Socket, sutali, and pressure cooker bombs caused the highest numbers of incidents. CONCLUSIONS: Intentional explosion incidents still pose a threat to the civilian population of Nepal. Most incidents are caused by small homemade explosive devices and occur in public places, and males aged 20 to 39 account for a plurality of casualties. Stakeholders addressing the explosive device problem in Nepal should continue to use surveillance data to plan interventions.

Injuries and deaths due to victim-activated improvised explosive devices, landmines and other explosive remnants of war in Nepal.

BACKGROUND: Following more than a decade of civil conflict, Nepal is among the countries affected by landmines, victim-activated improvised explosive devices (IED) and other explosive remnants of war (ERW). OBJECTIVES: To assess the magnitude of injuries due to landmines, victim-activated IED and other ERW in Nepal and to describe epidemiological patterns and risk factors for these events. METHODS: Analysis of surveillance data on civilian injuries due to landmines, victim-activated IED and other ERW between July 2006 and June 2010. Data were collected through active community-based prospective surveillance. RESULTS: Of 307 total casualties, 94 (31%) were female and 169 (55%) were children under 18 years of age. The case-fatality ratio was 14%. The highest number of casualties was in the age group 10-14 years. 233 (76%) injuries were caused by victim-activated IED, 13 (4%) by landmines and 44 (14%) by other ERW. Two types of IED, sutali and socket bombs, caused the majority of injuries (28% and 31%, respectively). 117 (38%) of all injuries occurred in victims' homes and 152 (50%) occurred while victims were tampering with explosive devices. CONCLUSIONS: Substantial numbers of civilians, including women and children, were injured and killed following implementation of the Comprehensive Peace Agreement in 2006. The government of Nepal and humanitarian organisations should continue their efforts to reach communities at highest risk through targeted interventions and nationwide media campaigns to convey the risks of tampering with explosive devices or suspicious objects.

Interpreting results of cluster surveys in emergency settings: is the LQAS test the best option?

Cluster surveys are commonly used in humanitarian emergencies to measure health and nutrition indicators. Deitchler et al. have proposed to use Lot Quality Assurance Sampling (LQAS) hypothesis testing in cluster surveys to classify the prevalence of global acute malnutrition as exceeding or not exceeding the pre-established thresholds. Field practitioners and decision-makers must clearly understand the meaning and implications of using this test in interpreting survey results to make programmatic decisions. We demonstrate that the LQAS test--as proposed by Deitchler et al.--is prone to producing false-positive results and thus is likely to suggest interventions in situations where interventions may not be needed. As an alternative, to provide more useful information for decision-making, we suggest reporting the probability of an indicator's exceeding the threshold as a direct measure of "risk". Such probability can be easily determined in field settings by using a simple spreadsheet calculator. The "risk" of exceeding the threshold can then be considered in the context of other aggravating and protective factors to make informed programmatic decisions.

Old and new cluster designs in emergency field surveys: in search of a one-fits-all solution.

INTRODUCTION: Cluster surveys are frequently used to measure key nutrition and health indicators in humanitarian emergencies. The survey design of 30 clusters of 7 children (30 x 7) was initially proposed by the World Health Organization for measuring vaccination coverage, and later a design of 30 clusters of 30 children (30 x 30) was introduced to measure acute malnutrition in emergency settings. Recently, designs of 33 clusters of 6 children (33 x 6) and 67 clusters of 3 children (67 x 3) have been proposed as alternatives that enable measurement of several key indicators with sufficient precision, while offering substantial savings in time. This paper explores expected effects of using 67 x 3, 33 x 6, or 30 x 7 designs instead of a "standard" 30 x 30 design on precision and accuracy of estimates, and on time required to complete the survey. ANALYSIS: The 67 x 3, 33 x 6, and 30 x 7 designs are expected to be more statistically efficient for measuring outcomes having high design effects (e.g., vaccination coverage, vitamin A distribution coverage, or access to safe water sources), and less efficient for measuring outcomes with more within-cluster variability, such as global acute malnutrition or anemia. Because of small sample sizes, these designs may not provide sufficient levels of precision to measure crude mortality rates. Given the small number (3 to 7) of survey subjects per cluster, it may be hard to select representative samples of subjects within clusters.The smaller sample size in these designs will likely result in substantial time savings. The magnitude of the savings will depend on several factors, including the average travel time between clusters. The 67 x 3 design will provide the least time savings. The 33 x 6 and 30 x 7 designs perform similarly to each other, both in terms of statistical efficiency and in terms of time required to complete the survey. CONCLUSION: Cluster designs discussed in this paper may offer substantial time and cost savings compared to the traditional 30 x 30 design, and may provide acceptable levels of precision when measuring outcomes that have high intracluster homogeneity. Further investigation is required to determine whether these designs can consistently provide accurate point estimates for key outcomes of interest. Organizations conducting cluster surveys in emergency settings need to build their technical capacity in survey design to be able to calculate context-specific sample sizes individually for each planned survey.

The lasting legacy of war: epidemiology of injuries from landmines and unexploded ordnance in Afghanistan, 2002-2006.

INTRODUCTION: Due to several decades of armed conflict and civil unrest, Afghanistan is one of the countries most affected by landmines and unexploded ordnance worldwide. OBJECTIVE: The study was performed to assess the magnitude of injuries due to landmines and unexploded ordnance in Afghanistan during 2002-2006 and to describe epidemiological patterns and potential risk factors for these events. METHODS: Surveillance data including 5,471 injuries caused by landmines and unexploded ordnance in Afghanistan during 2002-2006 were analyzed. The International Committee of the Red Cross collects data on such injuries from 490 reporting health facilities and volunteers throughout the country. These surveillance data were used to describe injury trends, victim demographics, injury types, risk behaviors, and explosive types related to landmine and unexploded ordnance accidents. RESULTS: The largest number of injuries (1,706) occurred in 2002. The number declined sharply to 1,049 injuries in 2003, and remained relatively stable with slight decline thereafter. Overall, 92% of victims were civilians, 91% were males, and 47% were children <18 years of age. The case-fatality ratio was 17%. Approximately 50% of all injuries were caused by unexploded ordnance and 42% by landmines. Among children, 65% of injuries were caused by unexploded ordnance and only 27% by landmines, whereas in adults, most injuries (56%) were caused by landmines. The most common risk behaviors among children were tending animals, playing, and tampering with explosive devices. In adults, most common risk behaviors were traveling, performing activities of economic necessity, and tampering with explosives. Twenty-eight percent of the surviving victims who received mine awareness training and 2% of those who did not receive such training reported that the area where event occurred was marked. CONCLUSIONS: The large number of injuries and high proportion of child victims suggest that clearance and risk education activities fall short of achieving their goals, and must be substantially improved or expanded. Especially concerning is the high proportion of injuries caused by unexploded ordnance, and the high number of injuries sustained while tampering with explosive devices. Because unexploded ordnance is more visible than are landmines, and ordnance-contaminated areas are cheaper to clear than are minefields, these injuries are highly preventable and should be a priority for clearance and risk education efforts.