The effect of internal displacement due to armed conflict on tuberculosis treatment outcomes in northwest Syria, 2019-2020.

Background: Northwest Syria accounts for over 4 million people of whom more than half are internally displaced persons (IDPs). More than 1 million IDPs reside in camps and many more live in settings which are overcrowded and poorly ventilated. Suboptimal social living conditions leave these populations susceptible to tuberculosis (TB) morbidity and mortality. This study aimed to assess the effect of internal displacement due to armed conflict on the risk of unsuccessful treatment outcomes among TB patients in northwest Syria. Methods: All patients registered to start TB treatment at three centres in northwest Syria between the 1st June 2019 to the 31st December 2020 were included. Unsuccessful TB treatment outcome was defined as a composite outcome combining the WHO TB treatment outcomes of treatment failure, loss to follow-up, and death. We assessed the association between internal displacement and unsuccessful TB treatment outcomes using multivariable logistic regression. We also explored the risk of an unsuccessful treatment outcome by internal displacement setting (camp, village or city). Results: Of the total 737 registered patients included in the analysis, 400 (54%) were documented as internally displaced. The median age of IDPs was 30 (IQR: 21.5-48) and the median age of residents was 34 (IQR:22-50). A significantly higher percentage of those who were IDPs had an unsuccessful treatment outcome compared to residents (40% vs 18%, p<0.001). After adjustment for confounders, the relative risk of having unsuccessful TB treatment was two-fold higher in internally displaced TB patients compared to residents (95% CI: 1.5-2.6). IDPs living in villages had a 30% lower risk of an unsuccessful treatment outcome compared to IDPs living in camps (RR 95% CI: 0.50-0.91), and IDPs living in cities had a 13% lower risk of an unsuccessful treatment outcome (RR 95% CI: 0.57-1.18). Conclusion: This is one of few studies which aims to quantify the effect of internal displacement on TB treatment outcomes during times of conflict. Our findings starkly highlight how social determinants contribute to poor TB outcomes and act as a starting point for much needed research on how best to manage TB in humanitarian crisis settings.

A snapshot of the practicality and barriers to COVID-19 interventions: Public health and healthcare workers' perceptions in high and low- and middle-income countries.

BACKGROUND: In response to the COVID-19 pandemic, governments have implemented a range of non-pharmaceutical interventions (NPIs) and pharmaceutical interventions (PIs) to reduce transmission and minimise morbidity and mortality, whilst maintaining social and economic activities. The perceptions of public health workers (PHWs) and healthcare workers (HCWs) are essential to inform future COVID-19 strategies as they are viewed as trusted sources and are at the forefront of COVID-19 response. The objectives of this study were to 1) describe the practicality of implementing NPIs and PIs and 2) identify potential barriers to implementation, as perceived by HCWs and PHWs. METHODS: We conducted a cross-sectional study of PHWs and HCWs perceptions of the implementation, practicality of, and barriers to implementation of NPIs and PIs using an online survey (28/9/2020-1/11/2020) available in English, French and Portuguese. We used descriptive statistics and thematic analysis to analyse quantitative and qualitative responses. RESULTS: In total, 226 respondents (67 HCWs and 159 PHWs) from 52 countries completed the survey and 222 were included in the final analysis. Participants from low and middle-income countries (LMICs) accounted for 63% of HCWs and 67% of PHWs, with the remaining from high-income (HICs). There was little difference between the perceptions of PHWs and HCWs in HICs and LMICs, with the majority regarding a number of common NPIs as difficult to implement. However, PHWs in HICs perceived restrictions on schools and educational institutions to be more difficult to implement, with a lack of childcare support identified as the main barrier. Additionally, most contact tracing methods were perceived to be more difficult to implement in HICs than LMICs, with a range of barriers reported. A lack of public support was the most commonly reported barrier to NPIs overall across both country income and professional groups. Similarly, public fear of vaccine safety and lack of vaccine supply were the main reported barriers to implementing a COVID-19 vaccine. However, PHWs and HCWs in LMICs perceived a lack of financial support and the vaccine being manufactured in another country as additional barriers. CONCLUSION: This snapshot provides insight into the difficulty of implementing interventions as perceived by PHWs and HCWs. There is no one-size-fits-all solution to implementing interventions, and barriers in different contexts do vary. Barriers to implementing a vaccine programme expressed here by HCWs and PHCWs have subsequently come to the fore internationally.

On the ferries: the unmet health care needs of transiting refugees in Greece.

Background: In 2015, over 850 000 refugees, asylum seekers and migrants arrived in Greece. In response to an overwhelming need for access to healthcare for them, Doctors of the World established the Refugee Ferry Project, which comprised of a clinic providing primary health care, and integrated mental health and psychosocial support on board a commercial ferry. Methods: Of the 1405 service users, 87.5% (1229/1405) originated from Syria, Afghanistan and Iraq. The majority were women 801/1405 (57%) and children 511/1405 (36%), including 50 pregnant women and 19 unaccompanied minors. Results: The most common diagnoses were respiratory tract infections, dehydration, nausea and vomiting, and musculoskeletal pain with 39.4% of the disease burden being classified as non-communicable. Exposure to violence was associated with an increased risk of developing mental health issues. Conclusions: Humanitarian actors face huge challenges trying to respond to the needs of transiting populations. It is only by continuous reassessment and having the capacity to mobilize and adapt to an ever-evolving situation that we can try to meet these needs. Having an integrated, flexible and multidisciplinary approach remains crucial, despite the shift from a transit to static population. With over 62 000 refugees stranded in Greece, the need to develop innovative ways to respond to their needs is greater than ever.