Differential symptomology of possible and confirmed Ebola virus disease infection in the Democratic Republic of the Congo: a retrospective cohort study.

BACKGROUND: In its earliest phases, Ebola virus disease's rapid-onset, high fever, and gastrointestinal symptoms are largely indistinguishable from other infectious illnesses. We aimed to characterise the clinical indicators associated with Ebola virus disease to improve outbreak response. METHODS: In this retrospective analysis, we assessed routinely collected data from individuals with possible Ebola virus disease attending 30 Ebola health facilities in two provinces of the Democratic Republic of the Congo between Aug 1, 2018, and Aug 28, 2019. We used logistic regression analysis to model the probability of Ebola infection across 34 clinical variables and four types of possible Ebola virus disease exposures: contact with an individual known to have Ebola virus disease, attendance at any funeral, health facility consultation, or consultation with an informal health practitioner. FINDINGS: Data for 24 666 individuals were included. If a patient presented to care in the early symptomatic phase (ie, days 0-2), Ebola virus disease positivity was most associated with previous exposure to an individual with Ebola virus disease (odds ratio [OR] 11·9, 95% CI 9·1-15·8), funeral attendance (2·1, 1·6-2·7), or health facility consultations (2·1, 1·6-2·8), rather than clinical parameters. If presentation occurred on day 3 or later (after symptom onset), bleeding at an injection site (OR 33·9, 95% CI 12·7-101·3), bleeding gums (7·5, 3·7-15·4), conjunctivitis (2·4, 1·7-3·4), asthenia (1·9, 1·5-2·3), sore throat (1·8, 1·3-2·4), dysphagia (1·8, 1·4-2·3), and diarrhoea (1·6, 1·3-1·9) were additional strong predictors of Ebola virus disease. Some Ebola virus disease-specific signs were less prevalent among vaccinated individuals who were positive for Ebola virus disease when compared with the unvaccinated, such as dysphagia (-47%, p=0·0024), haematemesis (-90%, p=0·0131), and bleeding gums (-100%, p=0·0035). INTERPRETATION: Establishing the exact time an individual first had symptoms is essential to assessing their infection risk. An individual's exposure history remains of paramount importance, especially in the early phase. Ebola virus disease vaccination reduces symptom severity and should also be considered when assessing the likelihood of infection. These findings about symptomatology should be translated into practice during triage and should inform testing and quarantine procedures. FUNDING: Médecins Sans Frontières and its research affiliate Epicentre.

COVID-19 in French nursing homes during the second pandemic wave: a mixed-methods cross-sectional study.

INTRODUCTION: French nursing homes were deeply affected by the first wave of the COVID-19 pandemic, with 38% of all residents infected and 5% dying. Yet, little was done to prepare these facilities for the second pandemic wave, and subsequent outbreak response strategies largely duplicated what had been done in the spring of 2020, regardless of the unique needs of the care home environment. METHODS: A cross-sectional, mixed-methods study using a retrospective, quantitative data from residents of 14 nursing homes between November 2020 and mid-January 2021. Four facilities were purposively selected as qualitative study sites for additional in-person, in-depth interviews in January and February 2021. RESULTS: The average attack rate in the 14 participating nursing facilities was 39% among staff and 61% among residents. One-fifth (20) of infected residents ultimately died from COVID-19 and its complications. Failure to thrive syndrome (FTTS) was diagnosed in 23% of COVID-19-positive residents. Those at highest risk of death were men (HR=1.78; 95% CI: 1.18 to 2.70; p=0.006), with FTTS (HR=4.04; 95% CI: 1.93 to 8.48; p<0.001) or in facilities with delayed implementation of universal FFP2 masking policies (HR=1.05; 95% CI: 1.02 to 1.07; p<0.001). The lowest mortality was found in residents of facilities with a partial (HR=0.30; 95% CI: 0.18 to 0.51; p<0.001) or full-time physician on staff (HR=0.20; 95% CI: 0.08 to 0.53; p=0.001). Significant themes emerging from qualitative analysis centred on (1) the structural, chronic neglect of nursing homes, (2) the negative effects of the top-down, bureaucratic nature of COVID-19 crisis response, and (3) the counterproductive effects of lockdowns on both residents and staff. CONCLUSION: Despite high resident mortality during the first pandemic wave, French nursing homes were ill-prepared for the second, with risk factors (especially staffing, lack of medical support, isolation/quarantine policy, etc) that affected case fatality and residents' and caregivers' overall well-being and mental health.

Severe acute malnutrition and mortality in children in the community: Comparison of indicators in a multi-country pooled analysis.

OBJECTIVES: This study aims to describe the mortality risk of children in the community who had severe acute malnutrition (SAM) defined by either a mid-upper arm circumference (MUAC) <115mm, a low weight-for-height Z-score (WHZ) <-3 or both criteria. METHODS: We pooled individual-level data from children aged 6-59 months enrolled in 3 community-based studies in the Democratic Republic of the Congo (DRC), Senegal and Nepal. We estimate the mortality hazard using Cox proportional hazard models in groups defined by either anthropometric indicator. RESULTS: In total, we had 49,001 time points provided by 15,060 children available for analysis, summing to a total of 143,512 person-months. We found an increasing death rate with a deteriorating nutritional status for all anthropometrical indicators. Children identified as SAM only by a low MUAC (<115mm) and those identified only by a low WHZ (Z-score <-3) had a similar mortality hazard which was about 4 times higher than those without an anthropometric deficit. Having both a low MUAC and a low WHZ was associated with an 8 times higher hazard of dying compared to children within the normal range. The 2 indicators identified a different set of children; the proportion of children identified by both indicators independently ranged from 7% in the DRC cohort, to 35% and 37% in the Senegal and the Nepal cohort respectively. CONCLUSION: In the light of an increasing popularity of using MUAC as the sole indicator to identify SAM children, we show that children who have a low WHZ, but a MUAC above the cut-off would be omitted from diagnosis and treatment despite having a similar risk of death.

Severely malnourished children with a low weight-for-height have similar mortality to those with a low mid-upper-arm-circumference: II. Systematic literature review and meta-analysis.

BACKGROUND: The WHO recommended criteria for diagnosis of sever acute malnutrition (SAM) are weight-for-height/length Z-score (WHZ) of <- 3Z of the WHO2006 standards, a mid-upper-arm circumference (MUAC) of < 115 mm, nutritional oedema or any combination of these parameters. A move to eliminate WHZ as a diagnostic criterion has been made on the assertion that children with a low WHZ are healthy, that MUAC is a "superior" prognostic indicator of mortality and that adding WHZ to the assessment does not improve the prediction of death. Our objective was to examine the literature comparing the risk of death of SAM children admitted by WHZ or MUAC criteria. METHODS: We conducted a systematic search for reports which examined the relationship of WHZ and MUAC to mortality for children less than 60 months. The WHZ, MUAC, outcome and programmatic variables were abstracted from the reports and examined. Individual study's case fatality rates were compared by chi-squared analysis and random effects meta-analyses for combined data. RESULTS: Twenty-one datasets were reviewed. All the patient studies had an ascertainment bias. Most were inadequate because they had insufficient deaths, used obsolete standards, combined oedematous and non-oedematous subjects, did not report the proportion of children with both deficits or the deaths occurred remotely after anthropometry. The meta-analyses showed that the mortality risks for children who have SAM by MUAC < 115 mm only and those with SAM by WHZ < -3Z only are not different. CONCLUSIONS: As the diagnostic criteria identify different children, this analysis does not support the abandonment of WHZ as an important independent diagnostic criterion for the diagnosis of SAM. Failure to identify such children will result in their being denied treatment and unnecessary deaths from SAM.

Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: III. Effect of case-load on malnutrition related mortality- policy implications.

BACKGROUND: Severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <-3Z of the WHO2006 standards, or a mid-upper-arm circumference (MUAC) of < 115 mm or there is nutritional oedema. Although there has been a move to eliminate WHZ as a diagnostic criterion we have shown that children with a low WHZ have at least as high a mortality risk as those with a low MUAC. Here we take the estimated case fatality rates and published case-loads to estimate the proportion of total SAM related deaths occurring in children that would be excluded from treatment with a MUAC-only policy. METHODS: The effect of varying case-load and mortality rates on the proportion of all deaths that would occur in admitted children was examined. We used the same calculations to estimate the proportion of all SAM-related deaths that would be excluded with a MUAC-only policy in 48 countries with very different relative case loads for SAM by only MUAC, only WHZ and children with both deficits. The case fatality rates (CFR) are taken from simulations, empirical data and the literature. RESULTS: The relative number of cases of SAM by MUAC alone, WHZ alone and those with both criteria have a dominant effect on the proportion of all SAM-related deaths that would occur in children excluded from treatment by a MUAC-only program. Many countries, particularly in the Sahel, West Africa and South East Asia would fail to identify the majority of SAM-related deaths if a MUAC only program were to be implemented. Globally, the estimated minimum number of deaths that would occur among children excluded from treatment in our analyses is 300,000 annually. CONCLUSIONS: The number, proportion or attributable fraction of children excluded from treatment with any change of current policy are the correct indicators to guide policy change. CRFs alone should not be used to guide policy in choosing whether or not to drop WHZ as a diagnostic for SAM. All the criteria for diagnosis of malnutrition need to be retained. It is critical that methods are found to identify those children with a low WHZ, but not a low MUAC, in the community so that they will not remain undetected.

Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: I. Empirical data demonstrates Simpson's paradox.

BACKGROUND: According to WHO childhood severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <-3Z of the WHO2006 standards, the mid-upper-arm circumference (MUAC) is < 115 mm, there is nutritional oedema or any combination of these parameters. Recently there has been a move to eliminate WHZ as a diagnostic criterion on the assertion that children meeting the WHZ criterion are healthy, that MUAC is universally a superior prognostic indicator of mortality and that adding WHZ to the assessment does not improve the prediction; these assertions have lead to a controversy concerning the role of WHZ in the diagnosis of SAM. METHODS: We examined the mortality experience of 76,887 6-60 month old severely malnourished children admitted for treatment to in-patient, out-patient or supplementary feeding facilities in 18 African countries, of whom 3588 died. They were divided into 7 different diagnostic categories for analysis of mortality rates by comparison of case fatality rates, relative risk of death and meta-analysis of the difference between children admitted using MUAC and WHZ criteria. RESULTS: The mortality rate was higher in those children fulfilling the WHO2006 WHZ criterion than the MUAC criterion. This was the case for younger as well as older children and in all regions except for marasmic children in East Africa. Those fulfilling both criteria had a higher mortality. Nutritional oedema increased the risk of death. Having oedema and a low WHZ dramatically increased the mortality rate whereas addition of the MUAC criterion to either oedema-alone or oedema plus a low WHZ did not further increase the mortality rate. The data were subject to extreme confounding giving Simpson's paradox, which reversed the apparent mortality rates when children fulfilling both WHZ and MUAC criteria were included in the estimation of the risk of death of those fulfilling either the WHZ or MUAC criteria alone. CONCLUSIONS: Children with a low WHZ, but a MUAC above the SAM cut-off point are at high risk of death. Simpson's paradox due to confounding from oedema and mathematical coupling may make previous statistical analyses which failed to distinguish the diagnostic groups an unreliable guide to policy. WHZ needs to be retained as an independent criterion for diagnosis of SAM and methods found to identify those children with a low WHZ, but not a low MUAC, in the community.

Change in quality of malnutrition surveys between 1986 and 2015.

BACKGROUND: Representative surveys collecting weight, height and MUAC are used to estimate the prevalence of acute malnutrition. The results are then used to assess the scale of malnutrition in a population and type of nutritional intervention required. There have been changes in methodology over recent decades; the objective of this study was to determine if these have resulted in higher quality surveys. METHODS: In order to examine the change in reliability of such surveys we have analysed the statistical distributions of the derived anthropometric parameters from 1843 surveys conducted by 19 agencies between 1986 and 2015. RESULTS: With the introduction of standardised guidelines and software by 2003 and their more general application from 2007 the mean standard deviation, kurtosis and skewness of the parameters used to assess nutritional status have each moved to now approximate the distribution of the WHO standards when the exclusion of outliers from analysis is based upon SMART flagging procedure. Where WHO flags, that only exclude data incompatible with life, are used the quality of anthropometric surveys has improved and the results now approach those seen with SMART flags and the WHO standards distribution. Agencies vary in their uptake and adherence to standard guidelines. Those agencies that fully implement the guidelines achieve the most consistently reliable results. CONCLUSIONS: Standard methods should be universally used to produce reliable data and tests of data quality and SMART type flagging procedures should be applied and reported to ensure that the data are credible and therefore inform appropriate intervention. Use of SMART guidelines has coincided with reliable anthropometric data since 2007.

Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo.

BACKGROUND: Cash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months. METHODS: We conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat. RESULTS: The hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group. CONCLUSIONS: CTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02460848 . Registered on 27 May 2015.

The Effect of Random Error on Diagnostic Accuracy Illustrated with the Anthropometric Diagnosis of Malnutrition.

BACKGROUND: It is often thought that random measurement error has a minor effect upon the results of an epidemiological survey. Theoretically, errors of measurement should always increase the spread of a distribution. Defining an illness by having a measurement outside an established healthy range will lead to an inflated prevalence of that condition if there are measurement errors. METHODS AND RESULTS: A Monte Carlo simulation was conducted of anthropometric assessment of children with malnutrition. Random errors of increasing magnitude were imposed upon the populations and showed that there was an increase in the standard deviation with each of the errors that became exponentially greater with the magnitude of the error. The potential magnitude of the resulting error of reported prevalence of malnutrition were compared with published international data and found to be of sufficient magnitude to make a number of surveys and the numerous reports and analyses that used these data unreliable. CONCLUSIONS: The effect of random error in public health surveys and the data upon which diagnostic cut-off points are derived to define "health" has been underestimated. Even quite modest random errors can more than double the reported prevalence of conditions such as malnutrition. Increasing sample size does not address this problem, and may even result in less accurate estimates. More attention needs to be paid to the selection, calibration and maintenance of instruments, measurer selection, training & supervision, routine estimation of the likely magnitude of errors using standardization tests, use of statistical likelihood of error to exclude data from analysis and full reporting of these procedures in order to judge the reliability of survey reports.

Comparison of weight-for-height and mid-upper arm circumference (MUAC) in a therapeutic feeding programme in South Sudan: is MUAC alone a sufficient criterion for admission of children at high risk of mortality?

OBJECTIVE: The present study was performed to describe the operational implications of using mid-upper arm circumference (MUAC) as a single admission criterion for treatment of severe acute malnutrition in South Sudan. DESIGN: We performed a retrospective analysis of routine programme data of children with severe acute malnutrition aged 6-59 months admitted to a therapeutic feeding programme using weight-for-height Z-score (WHZ) and/or MUAC. To understand the implications of using MUAC as a single admission criterion, we compared patient characteristics and treatment outcomes for children admitted with MUAC<115 mm (irrespective of WHZ) v. children admitted with WHZ<-3 and MUAC≥115 mm. RESULTS: Of 2205 children included for analysis, 719 (32·6 %) were admitted to the programme with MUAC<115 mm and 1486 (67·4 %) with WHZ<-3 and MUAC≥115 mm. Children who would have been admitted using a single MUAC<115 mm criterion were more severely malnourished and more likely to be female and younger. Compared with children admitted with WHZ<-3 and MUAC≥115 mm, children who would have been admitted using MUAC<115 mm were less likely to recover (54 % v. 69 %) and had higher risk of death (4 % v. 1 %), but responded to treatment with greater weight and MUAC gains. MUAC<115 mm would have failed to identify 33 % of deaths, while 98 % were identified by WHZ<-3 alone and 100 % by MUAC<130 mm. CONCLUSIONS: The study shows that MUAC<115 mm identified more severely malnourished children with a higher risk of mortality but failed to identify a third of the children who died. Admission criteria for therapeutic feeding should be adapted to the programmatic context with consideration for both operational and public health implications.

Local discrepancies in measles vaccination opportunities: results of population-based surveys in Sub-Saharan Africa.

BACKGROUND: The World Health Organization recommends African children receive two doses of measles containing vaccine (MCV) through routine programs or supplemental immunization activities (SIA). Moreover, children have an additional opportunity to receive MCV through outbreak response immunization (ORI) mass campaigns in certain contexts. Here, we present the results of MCV coverage by dose estimated through surveys conducted after outbreak response in diverse settings in Sub-Saharan Africa. METHODS: We included 24 household-based surveys conducted in six countries after a non-selective mass vaccination campaign. In the majority (22/24), the survey sample was selected using probability proportional to size cluster-based sampling. Others used Lot Quality Assurance Sampling. RESULTS: In total, data were collected on 60,895 children from 2005 to 2011. Routine coverage varied between countries (>95% in Malawi and Kirundo province (Burundi) while <35% in N'Djamena (Chad) in 2005), within a country and over time. SIA coverage was <75% in most settings. ORI coverage ranged from >95% in Malawi to 71.4% [95% CI: 68.9-73.8] in N'Djamena (Chad) in 2005.In five sites, >5% of children remained unvaccinated after several opportunities. Conversely, in Malawi and DRC, over half of the children eligible for the last SIA received a third dose of MCV. CONCLUSIONS: Control pre-elimination targets were still not reached, contributing to the occurrence of repeated measles outbreak in the Sub-Saharan African countries reported here. Although children receiving a dose of MCV through outbreak response benefit from the intervention, ensuring that programs effectively target hard to reach children remains the cornerstone of measles control.

Observational bias during nutrition surveillance: results of a mixed longitudinal and cross-sectional data collection system in Northern Nigeria.

BACKGROUND: The Sahel is subject to seasonal hungry periods with increasing rates of malnutrition. In Northern Nigeria, there is no surveillance system and surveys are rare. The objectives were to analyse possible observational bias in a sentinel surveillance system using repeated mixed longitudinal/cross-sectional data and estimate the extent of seasonal variation. METHODS: Thirty clusters were randomly selected using probability proportional to size (PPS) sampling from Kazaure Local Government Area, Jigawa State. In each cluster, all the children aged 6-59 months within 20 randomly selected households had their mid-upper arm circumference measured and were tested for oedema. The surveys were repeated every 2 or 4 weeks. At each survey round, three of the clusters were randomly selected to be replaced by three new clusters chosen at random by PPS. The seasonal variation of acute malnutrition was assessed using cyclical regression. The effect of repeated visits to the same cluster was examined using general linear mixed effects models adjusted for the seasonal change. RESULTS: There was a significant seasonal fluctuation of Global Acute Malnutrition (GAM) with a peak in October. With each repeat survey of a cluster, the prevalence of GAM decreased by 1.6% (95% CI: 0.4 to 2.7; p = 0.012) relative to the prevalence observed during the previous visit after adjusting for seasonal change. CONCLUSIONS: Northern Nigeria has a seasonal variation in the prevalence of acute malnutrition. Repeated surveys in the same cluster-village, even if different children are selected, lead to a progressive improvement of the nutritional status of that village. Sentinel site surveillance of nutritional status is prone to observational bias, with the sentinel site progressively deviating from that of the community it is presumed to represent.

Effect of mass supplementation with ready-to-use supplementary food during an anticipated nutritional emergency.

BACKGROUND: Previous studies have shown the benefits of ready-to-use supplementary food (RUSF) distribution in reducing the incidence and prevalence of severe acute malnutrition. METHODS AND FINDINGS: To compare the incidence of wasting, stunting and mortality between children aged 6 to 23 mo participating and not participating in distributions of RUSF, we implemented two exhaustive prospective cohorts including all children 60 cm to 80 cm, resident in villages of two districts of Maradi region in Niger (n = 2238). Villages (20) were selected to be representative of the population. All registered children were eligible for the monthly distributions between July and October 2010. Age, sex, height, weight, and Mid-Upper Arm Circumference (MUAC) were measured at baseline and two weeks after each distribution; the amount and type of distribution and the amount shared and remaining were also assessed. We compared the incidence of wasting, stunting, and mortality among children participating in the distribution (intervention) of RUSF versus children not participating in the distribution (comparison).The absolute rate of wasting was 1.59 events per child-year (503 events/315.3 child-year) in the intervention group and 1.78 events per child-year (322 events/180.4 child-year) in the comparison group [corrected].The intervention group had a small but higher weight-for-length Z-score gain (-0.2 z vs. -0.3 z) and less loss of MUAC than the comparison group (-2.8 vs. -4.0 mm). There was no difference in length gain (2.7 vs. 2.8 cm). Mortality was lower for children whose households received the intervention than those who did not (adjusted HR 0.55, 95% CI: 0.32-0.98). CONCLUSIONS: Short-term distribution with RUSF for children 6 to 23 months improve the nutritional status of children at risk for malnutrition. Fewer children who participated in the RUSF distribution died than those who did not.

Violence against civilians and access to health care in North Kivu, Democratic Republic of Congo: three cross-sectional surveys.

BACKGROUND: The province of North Kivu in the Democratic Republic of Congo has been afflicted by conflict for over a decade. After months of relative calm, offences restarted in September 2008. We did an epidemiological study to document the impact of violence on the civilian population and orient pre-existing humanitarian aid. METHODS: In May 2009, we conducted three cross-sectional surveys among 200 000 resident and displaced people in North Kivu (Kabizo, Masisi, Kitchanga). The recall period covered an eight month period from the beginning of the most recent offensives to the survey date. Heads of households provided information on displacement, death, violence, theft, and access to fields and health care. RESULTS: Crude mortality rates (per 10 000 per day) were below emergency thresholds: Kabizo 0.2 (95% CI: 0.1-0.4), Masisi 0.5 (0.4-0.6), Kitchanga 0.7 (0.6-0.9). Violence was the reported cause in 39.7% (27/68) and 35.8% (33/92) of deaths in Masisi and Kitchanga, respectively. In Masisi 99.1% (897/905) and Kitchanga 50.4% (509/1020) of households reported at least one member subjected to violence. Displacement was reported by 39.0% of households (419/1075) in Kitchanga and 99.8% (903/905) in Masisi. Theft affected 87.7% (451/514) of households in Masisi and 57.4% (585/1019) in Kitchanga. Access to health care was good: 93.5% (359/384) of the sick in Kabizo, 81.7% (515/630) in Masisi, and 89.8% (651/725) in Kitchanga received care, of whom 83.0% (298/359), 87.5% (451/515), and 88.9% (579/651), respectively, did not pay. CONCLUSIONS: Our results show the impact of the ongoing war on these civilian populations: one third of deaths were violent in two sites, individuals are frequently subjected to violence, and displacements and theft are common. While humanitarian aid may have had a positive impact on disease mortality and access to care, the population remains exposed to extremely high levels of violence.

Learning lessons from field surveys in humanitarian contexts: a case study of field surveys conducted in North Kivu, DRC 2006-2008.

Survey estimates of mortality and malnutrition are commonly used to guide humanitarian decision-making. Currently, different methods of conducting field surveys are the subject of debate among epidemiologists. Beyond the technical arguments, decision makers may find it difficult to conceptualize what the estimates actually mean. For instance, what makes this particular situation an emergency? And how should the operational response be adapted accordingly. This brings into question not only the quality of the survey methodology, but also the difficulties epidemiologists face in interpreting results and selecting the most important information to guide operations. As a case study, we reviewed mortality and nutritional surveys conducted in North Kivu, Democratic Republic of Congo (DRC) published from January 2006 to January 2009. We performed a PubMed/Medline search for published articles and scanned publicly available humanitarian databases and clearinghouses for grey literature. To evaluate the surveys, we developed minimum reporting criteria based on available guidelines and selected peer-review articles. We identified 38 reports through our search strategy; three surveys met our inclusion criteria. The surveys varied in methodological quality. Reporting against minimum criteria was generally good, but presentation of ethical procedures, raw data and survey limitations were missed in all surveys. All surveys also failed to consider contextual factors important for data interpretation. From this review, we conclude that mechanisms to ensure sound survey design and conduct must be implemented by operational organisations to improve data quality and reporting. Training in data interpretation would also be useful. Novel survey methods should be trialled and prospective data gathering (surveillance) employed wherever feasible.