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.

Infant and young child feeding practices in refugee settings across 203 population-based surveys from 2013-2019.

Infant and young child feeding (IYCF) plays a crucial role in early childhood growth and development. This study summarizes recent IYCF practices in multiple refugee settings and compares them to those in the host countries. We analyzed 203 surveys conducted among refugees residing in 15 countries and 120 unique sites and assessed eight IYCF indicators available from those surveys. A total of 146 surveys were conducted in Eastern and Southern Africa (ESA) and 50 in Western and Central Africa (WCA) regions. The median prevalence across surveys of all four indicators describing intake of breast milk was relatively high: 96.6% for ever breastfed, 81.2% for initiation of breastfeeding within 1 h of birth, 76.9% for exclusive breastfeeding 0-5 months, and 75.0% for continued breastfeeding 12-23 months. The median prevalence of early initiation and exclusive breastfeeding was markedly higher in ESA than in WCA (85.0% vs. 37.5% and 83.5% vs. 56.1%, respectively). Conversely, the overall median prevalence of timely introduction of solid and semisolid foods and flesh food consumption was low: 51.8% and 16.1%, respectively. Flesh food consumption was higher in WCA than in ESA (27.4% vs. 11.6%). The median prevalence of mixed milk feeding at 0-5 months and bottle feeding was very low: 2.4% and 3.8%, respectively. Indicators describing breast milk intake were generally either similar or higher in refugees than in the host country populations, whereas the other indicators were generally higher in the host populations than in refugees. The low prevalence of timely introduction of solids and of flesh food consumption in refugees is concerning and requires substantial improvement.

A Prospective Comparison of Standard and Modified Acute Malnutrition Treatment Protocols during COVID-19 in South Sudan.

A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan's standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6-59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP -10.0; TSFP -7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored.

Acute malnutrition recovery rates improve with COVID-19 adapted nutrition treatment protocols in South Sudan: a mixed methods study.

BACKGROUND: Globally, emergency nutrition program adaptations were implemented as part of COVID-19 mitigation strategies, but the implications of the adoption of all protocol changes at scale in the context of deteriorating food security are not yet well characterized. With ongoing conflict, widespread floods, and declining food security, the secondary impacts of COVID-19 on child survival in South Sudan is of great concern. In light of this, the present study aimed to characterize the impact of COVID-19 on nutrition programming in South Sudan. METHODS: A mixed methods approach including a desk review and secondary analysis of facility-level program data was used to analyze trends in program indicators over time and compare two 15-month periods prior to the onset of COVID-19 (January 2019 - March 2020; "pre-COVID period") and after the start of the pandemic (April 2020 - June 2021; "COVID" period) in South Sudan. RESULTS: The median number of reporting Community Management of Acute Malnutrition sites increased from 1167 pre-COVID to 1189 during COVID. Admission trends followed historic seasonal patterns in South Sudan; however, compared to pre-COVID, declines were seen during COVID in total admissions (- 8.2%) and median monthly admissions (- 21.8%) for severe acute malnutrition. For moderate acute malnutrition, total admissions increased slightly during COVID (1.1%) while median monthly admissions declined (- 6.7%). Median monthly recovery rates improved for severe (92.0% pre-COVID to 95.7% during COVID) and moderate acute malnutrition (91.5 to 94.3%) with improvements also seen in all states. At the national level, rates also decreased for default (- 2.4% for severe, - 1.7% for moderate acute malnutrition) and non-recovery (- 0.9% for severe, - 1.1% for moderate acute malnutrition), with mortality rates remaining constant at 0.05-0.15%. CONCLUSIONS: Within the context of the ongoing COVID-19 pandemic in South Sudan, improved recovery, default, and non-responder rates were observed following adoption of changes to nutrition protocols. Policymakers in South Sudan and other resource-constrained settings should consider if simplified nutrition treatment protocols adopted during COVID-19 improved performance and should be maintained in lieu of reverting to standard treatment protocols.

Outcomes after Acute Malnutrition Program Adaptations to COVID-19, Uganda, Ethiopia, and Somalia.

At the onset of the COVID-19 pandemic, protocols for community-based management of acute malnutrition (CMAM) were implemented to support continuity of essential feeding services while mitigating COVID-19 transmission. To assess correlations between adaptation timing and CMAM program indicators, we evaluated routine program data in Uganda, Ethiopia, and Somalia for children 6-59 months of age. We specifically analyzed facility-level changes in total admissions, average length of stay (ALOS), total children screened for admission, and recovery rates before and after adaptations. We found no statistically significant changes in program indicators after adaptations. For Somalia, we also analyzed child-level changes in ALOS and in weight and mid-upper arm circumference at admission and discharge. ALOS significantly increased immediately after adaptations and then decreased to preadaptation levels. We found no meaningful changes in either weight or mid-upper arm circumference at admission or discharge. These findings indicate that adapted CMAM programs can remain effective.

Risk factors for hospitalisation and death from COVID-19: a prospective cohort study in South Sudan and Eastern Democratic Republic of the Congo.

OBJECTIVES: Our study described demographic characteristics, exposures and symptoms, and comorbidities to evaluate risk factors of hospitalisation and mortality among cases in Juba, South Sudan (SSD) and North and South Kivu in eastern Democratic Republic of the Congo (DRC). DESIGN: Prospective observational cohort of COVID-19 cases. METHODS: Individuals presenting for care at one of five study facilities in SSD (n=1) or DRC (n=4) or referred from home-based care by mobile medical teams between December 2020 and June 2021 were eligible for enrolment. Demographic characteristics, COVID-19 exposures, symptoms at presentation, as well as acute and chronic comorbidities, were evaluated using a standard questionnaire at enrolment. Disease progression was characterised by location of care using mixed-effects regression models. RESULTS: 751 individuals were eligible for enrolment. Among cases followed to discharge or death (n=519), 375 were enrolled outpatients (75.7%). A similar number of cases were enrolled in DRC (n=262) and SSD (n=257). Overall mortality was 4.8% (95% CI: 3.2% to 6.9%); there were no outpatient deaths. Patients presenting with any symptoms had higher odds of hospitalisation (adjusted OR (AOR) 2.78, 95% CI 1.47 to 5.27) and all deaths occurred among symptomatic individuals. Odds of both hospitalisation and mortality were greatest among cases with respiratory symptoms; presence of low oxygen levels on enrolment was strongly associated with both hospitalisation (AOR 7.77, 95% CI 4.22 to 14.29) and mortality (AOR 25.29, 95% CI 6.42 to 99.54). Presence of more than one chronic comorbidity was associated with 4.96 (95% CI 1.51 to 16.31) times greater odds of death; neither infectious comorbidities evaluated, nor malnutrition, were significantly associated with increased mortality. CONCLUSIONS: Consistent with prior literature, older age, low oxygen level, other respiratory symptoms and chronic comorbidities were all risk factors for mortality. Patients presenting with these characteristics were more likely to be hospitalised, providing evidence of effective triage and referral. TRIAL REGISTRATION NUMBER: NCT04568499.

Clinical progression and outcomes of patients hospitalized with COVID-19 in humanitarian settings: A prospective cohort study in South Sudan and Eastern Democratic Republic of the Congo.

Little information is available on COVID-19 in Africa and virtually none is from humanitarian and more resource-constrained settings. This study characterizes hospitalized patients in the African humanitarian contexts of Juba, South Sudan and North and South Kivu in Eastern Democratic Republic of the Congo. This observational cohort was conducted between December 2020 and June 2021. Patients presenting for care at five facilities or referred from home-based care by mobile medical teams were eligible for enrollment and followed until death or recovery. Disease progression was characterized for hospitalized patients using survival analysis and mixed effects regression model to estimate survival odds for patient characteristics and treatments received. 144 COVID-19 cases enrolled as hospitalized patients were followed to recovery/death. The observed mortality proportion among hospitalized patients was 16.7% (CI: 11.2-23.3%); mortality was three times higher in South Sudan, where patients presented later after symptom onset and in worse conditions. Age and diabetes history were the only patient characteristics associated with decreased survival; clinical status indicators associated with decreased survival included fever, low oxygen level, elevated respiratory and pulse rates. The only therapy associated with survival was non-invasive oxygen; invasive oxygen therapies and other specialized treatments were rarely received. Improving availability of oxygen monitoring and proven COVID-19 therapies in humanitarian and resource-poor settings is critical for health equity. Customizing training to reflect availability of specific medications, therapies and operational constraints is particularly important given the range of challenges faced by providers in these settings.

Accuracy of Fully Automated 3D Imaging System for Child Anthropometry in a Low-Resource Setting: Effectiveness Evaluation in Malakal, South Sudan.

BACKGROUND: Adoption of 3D imaging systems in humanitarian settings requires accuracy comparable with manual measurement notwithstanding additional constraints associated with austere settings. OBJECTIVE: This study aimed to evaluate the accuracy of child stature and mid-upper arm circumference (MUAC) measurements produced by the AutoAnthro 3D imaging system (third generation) developed by Body Surface Translations Inc. METHODS: A study of device accuracy was embedded within a 2-stage cluster survey at the Malakal Protection of Civilians site in South Sudan conducted between September 2021 and October 2021. All children aged 6 to 59 months within selected households were eligible. For each child, manual measurements were obtained by 2 anthropometrists following the protocol used in the 2006 World Health Organization Child Growth Standards study. Scans were then captured by a different enumerator using a Samsung Galaxy 8 phone loaded with a custom software, AutoAnthro, and an Intel RealSense 3D scanner. The scans were processed using a fully automated algorithm. A multivariate logistic regression model was fit to evaluate the adjusted odds of achieving a successful scan. The accuracy of the measurements was visually assessed using Bland-Altman plots and quantified using average bias, limits of agreement (LoAs), and the 95% precision interval for individual differences. Key informant interviews were conducted remotely with survey enumerators and Body Surface Translations Inc developers to understand challenges in beta testing, training, data acquisition and transmission. RESULTS: Manual measurements were obtained for 539 eligible children, and scan-derived measurements were successfully processed for 234 (43.4%) of them. Caregivers of at least 10.4% (56/539) of the children refused consent for scan capture; additional scans were unsuccessfully transmitted to the server. Neither the demographic characteristics of the children (age and sex), stature, nor MUAC were associated with availability of scan-derived measurements; team was significantly associated (P<.001). The average bias of scan-derived measurements in cm was -0.5 (95% CI -2.0 to 1.0) for stature and 0.7 (95% CI 0.4-1.0) for MUAC. For stature, the 95% LoA was -23.9 cm to 22.9 cm. For MUAC, the 95% LoA was -4.0 cm to 5.4 cm. All accuracy metrics varied considerably by team. The COVID-19 pandemic-related physical distancing and travel policies limited testing to validate the device algorithm and prevented developers from conducting in-person training and field oversight, negatively affecting the quality of scan capture, processing, and transmission. CONCLUSIONS: Scan-derived measurements were not sufficiently accurate for the widespread adoption of the current technology. Although the software shows promise, further investments in the software algorithms are needed to address issues with scan transmission and extreme field contexts as well as to enable improved field supervision. Differences in accuracy by team provide evidence that investment in training may also improve performance.

Anemia design effects in cluster surveys of women and young children in refugee settings.

BACKGROUND: Nutrition surveys in many refugee settings routinely estimate anemia prevalence in high-risk population groups. Given the lack of information on anemia design effects (DEFF) observed in surveys in these settings, the goal of this paper is to better understand the magnitude and distribution of DEFFs and intracluster correlation coefficients (ICCs) in order to inform future survey design. METHODS: Two-stage cluster surveys conducted during 2013-2016 were included if they measured hemoglobin in refugee children aged 6-59 months and/or non-pregnant women aged 15-49 years. Prevalence of anemia, anemia DEFFs and ICCs, mean cluster size, number of clusters, and total sample size were calculated per-survey for non-pregnant women and children. Non-parametric tests were used to assess differences and correlations of ICC and DEFF between women and children and inter-regional differences. RESULTS: Eighty-seven unique cluster surveys from nine countries were included in this analysis. More than 90% of all surveys had ICC values for anemia below 0.10. Median ICC for children was 0.032 (IQR: 0.015-0.048), not significantly different from that observed for non-pregnant women for whom the median was 0.024 (IQR: -0.002-0.055). DEFFs were significantly higher for children [1.54 (IQR: 1.21-1.82)] versus women [1.20 (IQR: 0.99-1.46)]. Regional differences in DEFFs and ICCs were observed. CONCLUSIONS: Both ICCs and DEFF were relatively small for both non-pregnant women and preschool children and fall in a narrow range. Differences in ICCs between women and children were non-significant, suggesting similar inter-cluster distributions of anemia; significant differences in DEFF were likely attributable to differing cluster sizes. Given regional differences in both ICCs and DEFFs, location-specific values are preferred. However, in the absence of other context-specific information, we suggest using DEFFs of 1.4-1.8 if mean cluster size is around 20, and DEFFs of 1.2-1.4 if mean cluster size is around 10.

COVID-19 Trends Among Persons Aged 0-24 Years - United States, March 1-December 12, 2020.

Coronavirus disease 2019 (COVID-19) case and electronic laboratory data reported to CDC were analyzed to describe demographic characteristics, underlying health conditions, and clinical outcomes, as well as trends in laboratory-confirmed COVID-19 incidence and testing volume among U.S. children, adolescents, and young adults (persons aged 0-24 years). This analysis provides a critical update and expansion of previously published data, to include trends after fall school reopenings, and adds preschool-aged children (0-4 years) and college-aged young adults (18-24 years) (1). Among children, adolescents, and young adults, weekly incidence (cases per 100,000 persons) increased with age and was highest during the final week of the review period (the week of December 6) among all age groups. Time trends in weekly reported incidence for children and adolescents aged 0-17 years tracked consistently with trends observed among adults since June, with both incidence and positive test results tending to increase since September after summer declines. Reported incidence and positive test results among children aged 0-10 years were consistently lower than those in older age groups. To reduce community transmission, which will support schools in operating more safely for in-person learning, communities and schools should fully implement and strictly adhere to recommended mitigation strategies, especially universal and proper masking, to reduce COVID-19 incidence.

Child nutritional status as screening tool for identifying undernourished mothers: an observational study of mother-child dyads in Mogadishu, Somalia, from November 2019 to March 2020.

BACKGROUND: Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible to undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves. METHODS: The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6-59 months, parity and gestational status for women aged 19-50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <-2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m2 for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status. RESULTS: A total of 93.6% (2142/2288) of enrolled dyads met inclusion criteria. Wasting was observed among 57.5% of children; 20.2% of pregnant mothers, 20.0% of lactating mothers and 7.95% of non-PLMs were undernourished. Models suggest significant, positive associations between child and maternal anthropometrics; a one-unit increase in WHZ and a 1 cm increase in child MUAC were associated with 0.22 kg/m2 (95% CI 0.22 to 0.24) and 0.19 kg/m2 (95% CI 0.16 to 0.21) increases in maternal BMI, respectively, and 0.20 cm (95% CI 0.18 to 0.22) and 0.24 cm (95% CI 0.23 to 0.25) increases in maternal MUAC, respectively. Adjusted R2 values were low (range 0.06-0.10). CONCLUSIONS: Undernutrition among non-PLMs illustrates the importance of expanding screening. However, while significant, the strength of association between mother and child anthropometrics does not support child nutritional status as a screening tool for identifying at-risk mothers.

Comparison of anthropometric data quality in children aged 6-23 and 24-59 months: lessons from population-representative surveys from humanitarian settings.

BACKGROUND: Ensuring the quality of anthropometry data is paramount for getting accurate estimates of malnutrition prevalence among children aged 6-59 months in humanitarian and refugee settings. Previous reports based on data from Demographic and Health Surveys suggested systematic differences in anthropometric data quality between the younger and older groups of preschool children. METHODS: We analyzed 712 anthropometric population-representative field surveys from humanitarian and refugee settings conducted during 2011-2018. We examined and compared the quality of five anthropometric indicators in children aged 6-23 months and children aged 24-59 months: weight for height, weight for age, height for age, body mass index for age and mid-upper arm circumference (MUAC) for age. Using the z-score distribution of each indicator, we calculated the following parameters: standard deviation (SD), percentage of outliers, and measures of distribution normality. We also examined and compared the quality of height, weight, MUAC and age measurements using missing data and rounding criteria. RESULTS: Both SD and percentage of flags were significantly smaller on average in older than in younger age group for all five anthropometric indicators. Differences in SD between age groups did not change meaningfully depending on overall survey quality or on the quality of age ascertainment. Over 50% of surveys overall did not deviate significantly from normality. The percentage of non-normal surveys was higher in older than in the younger age groups. Digit preference score for weight, height and MUAC was slightly higher in younger age group, and for age slightly higher in the older age group. Children with reported exact date of birth (DOB) had much lower digit preference for age than those without exact DOB. SD, percentage flags and digit preference scores were positively correlated between the two age groups at the survey level, such as those surveys showing higher anthropometry data quality in younger age group also tended to show higher quality in older age group. CONCLUSIONS: There should be an emphasis on increased rigor of training survey measurers in taking anthropometric measurements in the youngest children. Standardization test, a mandatory component of the pre-survey measurer training and evaluation, of 10 children should include at least 4-5 children below 2 years of age.

Adoption of Strategies to Mitigate Transmission of COVID-19 During a Statewide Primary Election - Delaware, September 2020.

Elections occurring during the coronavirus disease 2019 (COVID-19) pandemic have been affected by notable changes in the methods of voting, the number and type of polling locations, and in-person voting procedures (1). To mitigate transmission of COVID-19 at polling locations, jurisdictions have adopted changes to protocols and procedures, informed by CDC's interim guidance, developed in collaboration with the Election Assistance Commission (2). The driving principle for this guidance is that voting practices with lower infection risk will be those which reduce the number of voters who congregate indoors in polling locations by offering a variety of methods for voting and longer voting periods. The guidance for in-person voting includes considerations for election officials, poll workers, and voters to maintain healthy environments and operations. To assess knowledge and adoption of mitigation strategies, CDC collaborated with the Delaware Department of Health and Social Services and the Delaware State Election Commission on a survey of poll workers who served during the statewide primary election on September 15, 2020. Among 522 eligible poll workers, 93% correctly answered all three survey questions about COVID-19 transmission. Respondents noted that most voters and poll workers wore masks. However, masks were not always worn correctly (i.e., covering both the nose and mouth). Responses suggest that mitigation measures recommended for both poll workers and voters were widely adopted and feasible, but also highlighted gaps in infection prevention control efforts. Strengthening of measures intended to minimize the risk of poll workers acquiring COVID-19 from ill voters, such as additional training and necessary personal protective equipment (PPE), as well as support for alternative voting options for ill voters, are needed. Adherence to mitigation measures is important not only to protect voters but also to protect poll workers, many of whom are older adults, and thus at higher risk for severe COVID-19-associated illness. Enhanced attention to reducing congregation in polling locations, correct mask use, and providing safe voting options for ill voters are critical considerations to minimize risk to voters and poll workers. Evidence from the Delaware election supports the feasibility and acceptability of implementing current CDC guidance for election officials, poll workers, and voters for mitigating COVID-19 transmission at polling locations (2).

Assessment of immunity to polio among Rohingya children in Cox's Bazar, Bangladesh, 2018: A cross-sectional survey.

BACKGROUND: We performed a cross-sectional survey in April-May 2018 among Rohingya in Cox's Bazar, Bangladesh, to assess polio immunity and inform vaccination strategies. METHODS AND FINDINGS: Rohingya children aged 1-6 years (younger group) and 7-14 years (older group) were selected using multi-stage cluster sampling in makeshift settlements and simple random sampling in Nayapara registered camp. Surveyors asked parents/caregivers if the child received any oral poliovirus vaccine (OPV) in Myanmar and, for younger children, if the child received vaccine in any of the 5 campaigns delivering bivalent OPV (serotypes 1 and 3) conducted during September 2017-April 2018 in Cox's Bazar. Dried blood spot (DBS) specimens were tested for neutralizing antibodies to poliovirus types 1, 2, and 3 in 580 younger and 297 older children. Titers ≥ 1:8 were considered protective. Among 632 children (335 aged 1-6 years, 297 aged 7-14 years) enrolled in the study in makeshift settlements, 51% were male and 89% had arrived after August 9, 2017. Among 245 children (all aged 1-6 years) enrolled in the study in Nayapara, 54% were male and 10% had arrived after August 9, 2017. Among younger children, 74% in makeshift settlements and 92% in Nayapara received >3 bivalent OPV doses in campaigns. Type 1 seroprevalence was 85% (95% CI 80%-89%) among younger children and 91% (95% CI 86%-95%) among older children in makeshift settlements, and 92% (88%-95%) among younger children in Nayapara. Type 2 seroprevalence was lower among younger children than older children in makeshift settlements (74% [95% CI 68%-79%] versus 97% [95% CI 94%-99%], p < 0.001), and was 69% (95% CI 63%-74%) among younger children in Nayapara. Type 3 seroprevalence was below 75% for both age groups and areas. The limitations of this study are unknown routine immunization history and poor retention of vaccination cards. CONCLUSIONS: Younger Rohingya children had immunity gaps to all 3 polio serotypes and should be targeted by future campaigns and catch-up routine immunization. DBS collection can enhance the reliability of assessments of outbreak risk and vaccination strategy impact in emergency settings.

Malnutrition trends in Rohingya children aged 6-59 months residing in informal settlements in Cox's Bazar District, Bangladesh: An analysis of cross-sectional, population-representative surveys.

BACKGROUND: More than 700,000 ethnic Rohingya have crossed the border from Rakhine State, Myanmar to Cox's Bazar District, Bangladesh, following escalated violence by Myanmar security forces. The majority of these displaced Rohingya settled in informal sites on previously forested land, in areas without basic infrastructure or access to services. METHODS AND FINDINGS: Three cross-sectional population-representative cluster surveys were conducted, including all informal settlements of Rohingya refugees in the Ukhia and Teknaf Upazilas of Cox's Bazar District. The first survey was conducted during the acute phase of the humanitarian response (October-November 2017), and the second and third surveys were conducted 6 (April-May 2018) and 12 (October-November 2018) months later. Anthropometric indices (weight, height, mid-upper arm circumference [MUAC], oedema) and haemoglobin (Hb) were measured in children aged 6-59 months following standard procedures. Final samples for survey rounds 1, 2, and 3 (R1, R2, and R3) included 1,113, 628, and 683 children, respectively, of which approximately half were male (50.7%-53.5% per round) and a third were 6-23 months of age (32.4%-33.3% per round). Prevalence of global acute malnutrition (GAM) as assessed by weight for height in R2 (12.1%, 95% CI: 9.6-15.1) and R3 (11.0%, 95% CI: 8.4-14.2) represent a significant decline from the observed prevalence in R1 (19.4%, 95% CI: 16.8-22.3) (p < 0.001 for both comparisons). Overall, the prevalence of anaemia significantly declined (p < 0.001) between the first 2 rounds (47.9%, 95% CI: 44.1-51.7 and 32.3%, 95% CI: 27.8-37.1, respectively); prevalence increased significantly (p = 0.04) to 39.8% (95% CI, 34.1-45.4) during R3 but remained below R1 levels. Reported receipt of both fortified blended foods (12.8%) and micronutrient powders (10.3%) were low during R1 but increased significantly (p < 0.001 for both) within the first 6 months to 49.8% and 29.9%, respectively. Although findings demonstrate improvement in anthropometric indicators during a period in which nutrition programme coverage increased, causation cannot be determined from the cross-sectional design. CONCLUSIONS: These data document significant improvements in both acute and micronutrient malnutrition among Rohingya children in makeshift settlements. These declines coincide with a scaleup of services aimed at prevention and treatment of malnutrition. Ongoing activities to improve access to nutritional services may facilitate further reductions in malnutrition levels to sustained below-crisis levels.

Vaccination coverage survey and seroprevalence among forcibly displaced Rohingya children, Cox's Bazar, Bangladesh, 2018: A cross-sectional study.

BACKGROUND: During August 2017-January 2018, more than 700,000 forcibly displaced Rohingyas crossed into Cox's Bazar, Bangladesh. In response to measles and diphtheria cases, first documented in September and November 2017, respectively, vaccination campaigns targeting children <15 years old were mobilized during September 2017-March 2018. However, in a rapidly evolving emergency situation, poor sanitation, malnutrition, overcrowding, and lack of access to safe water and healthcare can increase susceptibility to infectious diseases, particularly among children. We aimed to estimate population immunity to vaccine-preventable diseases (VPDs) after vaccination activities in the camps to identify any remaining immunity gaps among Rohingya children. METHODS AND FINDINGS: We conducted a cross-sectional serologic and vaccination coverage survey in Nayapara Registered Refugee Camp ("Nayapara") and makeshift settlements (MSs) April 28, 2018 to May 31, 2018, among 930 children aged 6 months to 14 years. MSs are informal, self-settled areas with a population of more than 850,000, the majority of whom arrived after August 2017, whereas Nayapara is a registered camp and has better infrastructure than MSs, including provision of routine immunization services. Households were identified using simple random sampling (SRS) in Nayapara and multistage cluster sampling in MSs (because household lists were unavailable). Dried blood spots (DBSs) were collected to estimate seroprotection against measles, rubella, diphtheria, and tetanus, using Luminex multiplex bead assay (MBA). Caregiver interviews assessed vaccination campaign participation using vaccination card or recall. In Nayapara, 273 children aged 1 to 6 years participated; 46% were female and 88% were registered refugees. In MSs, 358 children aged 1 to 6 years and 299 children aged 7 to 14 years participated; 48% of all children in MSs were female, and none were registered refugees. In Nayapara, estimated seroprotection among 1- to 6-year-olds was high for measles, rubella, diphtheria, and tetanus (91%-98%; 95% confidence interval [CI] 87%-99%); children >6 years were not assessed. In MSs, measles seroprotection was similarly high among 1- to 6-year-olds and 7- to 14-year-olds (91% [95% CI 86%-94%] and 99% [95% CI 96%-100%], respectively, p < 0.001). Rubella and diphtheria seroprotection in MSs were significantly lower among 1- to 6-year-olds (84% [95% CI 79%-88%] and 63% [95% CI 56%-70%]) compared to 7- to 14-year-olds (96% [95% CI 90%-98%] and 77% [95% CI 69%-84%]) (p < 0.001). Tetanus seroprevalence was similar among 1- to 6-year-olds and 7- to 14-year-olds (76% [95% CI 69%-81%] and 84% [95% CI 77%-89%], respectively; p = 0.07). Vaccination campaign coverage was consistent with seroprotection in both camps. However, nonresponse, the main limitation of the study, may have biased the seroprotection and campaign coverage results. CONCLUSIONS: In this study, we observed that despite multiple vaccination campaigns, immunity gaps exist among children in MSs, particularly for diphtheria, which requires serial vaccinations to achieve maximum protection. Therefore, an additional tetanus-diphtheria campaign may be warranted in MSs to address these remaining immunity gaps. Rapid scale-up and strengthening of routine immunization services to reach children and to deliver missed doses to older children is also critically needed to close immunity gaps and prevent future outbreaks.

Comparing hemoglobin distributions between population-based surveys matched by country and time.

BACKGROUND: Valid measurement of hemoglobin is important for tracking and targeting interventions. This study compares hemoglobin distributions between surveys matched by country and time from The Demographic and Health Survey (DHS) Program and the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. METHODS: Four pairs of nationally representative surveys measuring hemoglobin using HemoCue® with capillary (DHS) or venous (BRINDA) blood were matched by country and time. Data included 17,719 children (6-59 months) and 21,594 non-pregnant women (15-49 y). Across paired surveys, we compared distributional statistics and anemia prevalence. RESULTS: Surveys from three of the four countries showed substantial differences in anemia estimates (9 to 31 percentage point differences) which were consistently lower in BRINDA compared to DHS (2 to 31 points for children, 1 to 16 points for women). CONCLUSION: We identify substantial differences in anemia estimates from surveys of similar populations. Further work is needed to identify the cause of these differences to improve the robustness of anemia estimates for comparing populations and tracking improvements over time.

Correction to: Injury-related deaths before and during the Islamic State insurgency - Baghdad, Iraq, 2010-2015.

[This corrects the article DOI: 10.1186/s13031-020-0252-7.].