Haloperidol (oral) versus olanzapine (oral) for people with schizophrenia and schizophrenia-spectrum disorders.

BACKGROUND: Schizophrenia is often a severe and disabling psychiatric disorder. Antipsychotics remain the mainstay of psychotropic treatment for people with psychosis. In limited resource and humanitarian contexts, it is key to have several options for beneficial, low-cost antipsychotics, which require minimal monitoring. We wanted to compare oral haloperidol, as one of the most available antipsychotics in these settings, with a second-generation antipsychotic, olanzapine. OBJECTIVES: To assess the clinical benefits and harms of haloperidol compared to olanzapine for people with schizophrenia and schizophrenia-spectrum disorders. SEARCH METHODS: We searched the Cochrane Schizophrenia study-based register of trials, which is based on monthly searches of CENTRAL, CINAHL, ClinicalTrials.gov, Embase, ISRCTN, MEDLINE, PsycINFO, PubMed and WHO ICTRP. We screened the references of all included studies. We contacted relevant authors of trials for additional information where clarification was required or where data were incomplete. The register was last searched on 14 January 2023. SELECTION CRITERIA: Randomised clinical trials comparing haloperidol with olanzapine for people with schizophrenia and schizophrenia-spectrum disorders. Our main outcomes of interest were clinically important change in global state, relapse, clinically important change in mental state, extrapyramidal side effects, weight increase, clinically important change in quality of life and leaving the study early due to adverse effects. DATA COLLECTION AND ANALYSIS: We independently evaluated and extracted data. For dichotomous outcomes, we calculated risk ratios (RR) and their 95% confidence intervals (CI) and the number needed to treat for an additional beneficial or harmful outcome (NNTB or NNTH) with 95% CI. For continuous data, we estimated mean differences (MD) or standardised mean differences (SMD) with 95% CIs. For all included studies, we assessed risk of bias (RoB 1) and we used the GRADE approach to create a summary of findings table. MAIN RESULTS: We included 68 studies randomising 9132 participants. We are very uncertain whether there is a difference between haloperidol and olanzapine in clinically important change in global state (RR 0.84, 95% CI 0.69 to 1.02; 6 studies, 3078 participants; very low-certainty evidence). We are very uncertain whether there is a difference between haloperidol and olanzapine in relapse (RR 1.42, 95% CI 1.00 to 2.02; 7 studies, 1499 participants; very low-certainty evidence). Haloperidol may reduce the incidence of clinically important change in overall mental state compared to olanzapine (RR 0.70, 95% CI 0.60 to 0.81; 13 studies, 1210 participants; low-certainty evidence). For every eight people treated with haloperidol instead of olanzapine, one fewer person would experience this improvement. The evidence suggests that haloperidol may result in a large increase in extrapyramidal side effects compared to olanzapine (RR 3.38, 95% CI 2.28 to 5.02; 14 studies, 3290 participants; low-certainty evidence). For every three people treated with haloperidol instead of olanzapine, one additional person would experience extrapyramidal side effects. For weight gain, the evidence suggests that there may be a large reduction in the risk with haloperidol compared to olanzapine (RR 0.47, 95% CI 0.35 to 0.61; 18 studies, 4302 participants; low-certainty evidence). For every 10 people treated with haloperidol instead of olanzapine, one fewer person would experience weight increase. A single study suggests that haloperidol may reduce the incidence of clinically important change in quality of life compared to olanzapine (RR 0.72, 95% CI 0.57 to 0.91; 828 participants; low-certainty evidence). For every nine people treated with haloperidol instead of olanzapine, one fewer person would experience clinically important improvement in quality of life. Haloperidol may result in an increase in the incidence of leaving the study early due to adverse effects compared to olanzapine (RR 1.99, 95% CI 1.60 to 2.47; 21 studies, 5047 participants; low-certainty evidence). For every 22 people treated with haloperidol instead of olanzapine, one fewer person would experience this outcome. Thirty otherwise relevant studies and several endpoints from 14 included studies could not be evaluated due to inconsistencies and poor transparency of several parameters. Furthermore, even within studies that were included, it was often not possible to use data for the same reasons. Risk of bias differed substantially for different outcomes and the certainty of the evidence ranged from very low to low. The most common risks of bias leading to downgrading of the evidence were blinding (performance bias) and selective reporting (reporting bias). AUTHORS' CONCLUSIONS: Overall, the certainty of the evidence was low to very low for the main outcomes in this review, making it difficult to draw reliable conclusions. We are very uncertain whether there is a difference between haloperidol and olanzapine in terms of clinically important global state and relapse. Olanzapine may result in a slightly greater overall clinically important change in mental state and in a clinically important change in quality of life. Different side effect profiles were noted: haloperidol may result in a large increase in extrapyramidal side effects and olanzapine in a large increase in weight gain. The drug of choice needs to take into account side effect profiles and the preferences of the individual. These findings and the recent inclusion of olanzapine alongside haloperidol in the WHO Model List of Essential Medicines should increase the likelihood of it becoming more easily available in low- and middle- income countries, thereby improving choice and providing a greater ability to respond to side effects for people with lived experience of schizophrenia. There is a need for additional research using appropriate and equivalent dosages of these drugs. Some of this research needs to be done in low- and middle-income settings and should actively seek to account for factors relevant to these. Research on antipsychotics needs to be person-centred and prioritise factors that are of interest to people with lived experience of schizophrenia.

Xpert-Ultra Assay in Stool and Urine Samples to Improve Tuberculosis Diagnosis in Children: The Médecins Sans Frontières Experience in Guinea-Bissau and South Sudan.

Background: More than half of childhood tuberculosis cases remain undiagnosed yearly. The World Health Organization recommends the Xpert-Ultra assay as a first pediatric diagnosis test, but microbiological confirmation remains low. We aimed to determine the diagnostic performance of Xpert-Ultra with stool and urine samples in presumptive pediatric tuberculosis cases in 2 high-tuberculosis-burden settings. Methods: This Médecins Sans Frontières cross-sectional multicentric study took place at Simão Mendes Hospital, Guinea-Bissau (July 2019 to April 2020) and in Malakal Hospital, South Sudan (April 2021 to June 2023). Children aged 6 months to 15 years with presumptive tuberculosis underwent clinical and laboratory assessment, with 1 respiratory and/or extrapulmonary sample (reference standard [RS]), 1 stool, and 1 urine specimen analyzed with Xpert-Ultra. Results: A total of 563 children were enrolled in the study, 133 from Bissau and 400 from Malakal; 30 were excluded. Confirmation of tuberculosis was achieved in 75 (14.1%), while 248 (46.5%) had unconfirmed tuberculosis. Of 553 with an RS specimen, the overall diagnostic yield was 12.4% (66 of 533). A total of 493 stool and 524 urine samples were used to evaluate the performance of Xpert-Ultra with these samples. Compared with the RS, the sensitivity and specificity of Xpert-Ultra were 62.5% (95% confidence interval, 49.4%-74%) and 98.3% (96.7%-99.2%), respectively, with stool samples, and 13.9% (7.5%-24.3%) and 99.4% (98.1%-99.8%) with urine samples. Nine patients were positive with stool and/or urine samples but negative with the RS. Conclusions: Xpert-Ultra in stool samples showed moderate to high sensitivity and high specificity compared with the RS and an added diagnostic yield when RS results were negative. Xpert-Ultra in stool samples was useful in extrapulmonary cases. Xpert-Ultra in urine samples showed low test performance. Clinical Trials Registration: NCT06239337.

Association between severity of symptoms and minimum mental health treatment duration in humanitarian contexts: a retrospective observational study.

Background: Understanding and optimising mental health and psychosocial support (MHPSS) interventions in humanitarian crises is crucial, particularly for the most prevalent mental health conditions in conflict settings: anxiety, depression, and post-traumatic stress disorder. However, research on what is the most appropriate length of psychological intervention is lacking in this setting. We aimed to establish which factors are most closely related to improvement and to determine the required number of consultations needed to achieve this improvement. Methods: We retrospectively analysed records from 9028 patients allocated to treatment for anxiety, depression, and post-traumatic symptoms from the MHPSS programme in Borno State, Nigeria, from January 2018 to December 2019. Patient characteristics, severity (Clinical Global Impression of Severity Scale, CGI-S scale), and clinical improvement were assessed by an attending counsellor (CGI-I scale) and by the patient (Mental Health Global State, MHGS scale). Improvement was defined as scores 1, 2, and 3 in the Clinical Global Impression of Improvement (CGI-I) scale, and as a decrease of at least 4 points in the MHGS scale. We investigated the associations between the category of symptoms, the severity of illness, and improvement of symptoms using multivariable logistic regression. We used Kaplan-Meier (KM) curves to assess the number of consultations (i.e., time of treatment) needed to achieve improvement of symptoms, by symptom category and symptom severity. Findings: The patients included were referred to treatment for anxiety (n = 3462), depression (n = 3970), or post-traumatic symptoms (n = 1596). Median age was 31 years (range 16-103), and 84.3% were female. Patients categorised as severe were less likely to present improvement according to the CGI-I scale (OR 0.11, 95% CI 0.05-0.25), while none of the other categories of symptoms showed significant results. Overall, three or more consultations were associated with improvement in both scales (OR 3.55, 95% CI 1.47-8.57 for CGI-I; and OR 3.04, 95% CI 2.36-3.90 for MHGS). KM curves for the category of symptoms showed that around 90% of patients with anxiety, depression, or post-traumatic symptoms, as well as those with mild or moderate severity, presented improvement after three consultations, compared with six consultations for those with severe symptoms. Interpretation: Classification by severity among patients with anxiety, depression, or post-traumatic symptoms could predict the probability of improvement, whereas classification by symptoms could not. Our study highlights the importance of classifying patient severity in MHPSS programmes to plan and implement the appropriate duration of care. A major limitation was the number of patients lost to follow up after the first consultation and excluded from the logistic regression and KM analysis. Funding: The study was funded and staffed entirely by Médicos Sin Fronteras (Médecins Sans Frontières), Spain.

Point-of-care ultrasound for tuberculosis diagnosis in children: a Médecins Sans Frontières cross-sectional study in Guinea-Bissau.

OBJECTIVE: Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB. DESIGN: Cross-sectional study (July 2019 to April 2020). SETTING: Simão Mendes hospital in Bissau, a setting with high TB, HIV, and malnutrition burdens. PARTICIPANTS: Patients aged between 6 months and 15 years with presumptive TB. INTERVENTIONS: Participants underwent clinical, laboratory and unblinded clinician-performed POCUS assessments, to assess subpleural nodules (SUNs), lung consolidation, pleural and pericardial effusion, abdominal lymphadenopathy, focal splenic and hepatic lesions and ascites. Presence of any sign prompted a POCUS positive result. Ultrasound images and clips were evaluated by expert reviewers and, in case of discordance, by a second reviewer. Children were categorised as confirmed TB (microbiological diagnosis), unconfirmed TB (clinical diagnosis) or unlikely TB. Ultrasound findings were analysed per TB category and risk factor: HIV co-infection, malnutrition and age. RESULTS: A total of 139 children were enrolled, with 62 (45%) women and 55 (40%) aged <5 years; 83 (60%) and 59 (42%) were severely malnourished (SAM) and HIV-infected, respectively. TB confirmation occurred in 27 (19%); 62 (45%) had unconfirmed TB and 50 (36%) had unlikely TB. Children with TB were more likely to have POCUS-positive results (93%) compared with children with unlikely TB (34%). Common POCUS signs in patients with TB were: lung consolidation (57%), SUNs (55%) and pleural effusion (30%), and focal splenic lesions (28%). In children with confirmed TB, POCUS sensitivity was 85% (95% CI) (67.5% to 94.1%). In those with unlikely TB, specificity was 66% (95% CI 52.2% to 77.6%). Unlike HIV infection and age, SAM was associated with a higher POCUS-positivity. Cohen's kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9. CONCLUSIONS: We found a high prevalence of POCUS signs in children with TB compared with children with unlikely TB. POCUS-positivity was dependent on nutritional status but not on HIV status or age. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children. TRIAL REGISTRATION NUMBER: NCT05364593.

Severity, symptomatology, and treatment duration for mental health disorders: a retrospective analysis from a conflict-affected region of northern Nigeria.

BACKGROUND: Mental Health and psychosocial support (MHPSS) programs are essential during humanitarian crises and in conflict settings, like Nigeria's Borno State. However, research on how types of traumatic stress and symptom severity affect clinical improvement is lacking in these contexts, as is consensus over how long these patients must engage in mental health care to see results. METHODS: Records from 11,709 patients from the MHPSS program in Pulka and Gwoza local government areas in Borno State, Nigeria from 2018 and 2019 were retrospectively analyzed. Patient information, symptoms, stress type, severity (CGI-S scale), and clinical improvement (CGI-I and MHGS scales) were assessed by the patient and counselor. Associations between variables were investigated using logistic regression models. RESULTS: Clinical improvement increased with consultation frequency (OR: 2.5, p < 0.001 for CGI-I; OR: 2, p < 0.001 for MHGS), with patients who received three to six counseling sessions were most likely to improve, according to severity. Survivors of sexual violence, torture, and other conflict/violence-related stressors were nearly 20 times as likely to have posttraumatic stress disorder (PTSD) (OR: 19.7, p < 0.001), and depression (OR: 19.3, p < 0.001) symptomatology. Children exposed to conflict-related violence were also almost 40 times as likely to have PTSD (OR: 38.2, p = 0.002). Most patients presented an improvement in outcome at discharge, per both counselors (92%, CGI-I) and self-rating scores (73%, MHGS). CONCLUSION: We demonstrate a threshold at which patients were most likely to improve (3 sessions for mild or moderate patients; 6 sessions for severe). In addition, we identify the specific types of stress and symptom severity that affected the number of sessions needed to achieve successful outcomes, and highlight that some stress types (especially torture or having a relative killed) were specifically linked to PTSD and depression. Therefore, we emphasize the importance of classifying patient stress type and severity to identify the appropriate duration of care needed.

Cervical cancer screening coverage and its related knowledge in southern Malawi.

BACKGROUND: Cervical cancer (CC) is the fourth most common cancer among women worldwide and Malawi has the world's highest rate of cervical cancer related mortality. Since 2016 the National CC Control Strategy has set a screening coverage target at 80% of 25-49-year-old women. The Ministry of Health and Médecins Sans Frontières (MSF) set up a CC program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas. This population-based survey aimed to estimate CC screening coverage and to understand why women were or were not screened. METHODS: A population-based survey was conducted in 2019. All resident consenting eligible women aged 25-49 years were interviewed (n = 1850) at households selected by two-stage cluster sampling. Screening and treatment coverage and facilitators and barriers to screening were calculated stratified by age, weighted for survey design. Chi square and design-based F tests were used to assess relationship between participant characteristics and screening status. RESULTS: The percentage of women ever screened for CC was highest in Blantyre at 40.2% (95% CI 35.1-45.5), 38.9% (95% CI 32.8-45.4) in Chiradzulu with supported CC screening services, and lowest in Chiradzulu without supported CC screening services at 25.4% (95% CI 19.9-31.8). Among 623 women screened, 49.9% (95% CI 44.0-55.7) reported that recommendation in the health facility was the main reason they were screened and 98.5% (95% CI 96.3-99.4) recommended CC screening to others. Among 1227 women not screened, main barriers were lack of time (26.0%, 95% CI 21.9-30.6), and lack of motivation (18.3%, 95% CI 14.1-23.3). Overall, 95.6% (95% CI 93.6-97.0) of women reported that they had some knowledge about CC. Knowledge of CC symptoms was low at 34.4% (95% CI 31.0-37.9) and 55.1% (95% CI 51.0-59.1) of participants believed themselves to be at risk of CC. CONCLUSION: Most of the survey population had heard about CC. Despite this knowledge, fewer than half of eligible women had been screened for CC. Reasons given for not attending screening can be addressed by programs. To significantly reduce mortality due to CC in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment.

Shifting to Tele-Mental Health in humanitarian and crisis settings: an evaluation of Médecins Sans Frontières experience during the COVID-19 pandemic.

BACKGROUND: 'Tele-Mental Health (MH) services,' are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its MH activities across humanitarian and resource-constrained settings to remote format. METHODS: From June-July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of tele-MH services. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews occurred. RESULTS: Respondents in 44 countries (6 geographic regions), mostly from Sub-Saharan Africa (39.5%), the Middle East and North Africa (18.5%) and Asia (13.6%) participated. Most tele-MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using these interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using telecommunication platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought tele-MH services had some degree of usefulness, notably improved access to care (37.7%) and time efficiency (32.8%). Qualitative results outlined a myriad of challenges, notably in establishing therapeutic alliance, providing care for vulnerable populations and those inherent to the communications infrastructure. CONCLUSION: Tele-MH services were perceived to be a feasible alternative solution to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering tele-MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.

Seroprevalence and risk factors of exposure to COVID-19 in homeless people in Paris, France: a cross-sectional study.

BACKGROUND: During the COVID-19 lockdown period from March 17 to May 11, 2020, French authorities in Paris and its suburbs relocated people experiencing recurrent homelessness to emergency shelters, hotels, and large venues. A serological survey was done at some of these locations to assess the COVID-19 exposure prevalence in this group. METHODS: We did a cross-sectional seroprevalence study at food distribution sites, emergency shelters, and workers' residences that were provided medical services by Médecins Sans Frontières in Paris and Seine-Saint-Denis in the Ile-de-France region. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody seropositivity was detected by Luciferase-Linked Immunosorbent Assay and Pseudo Neutralization Test. Sociodemographic and exposure related information was collected via a verbal questionnaire to analyse risk factors and associations with various COVID-19 symptoms. FINDINGS: Between June 23 and July 2, 2020, 426 (52%) of 818 individuals recruited tested positive in 14 sites. Seroprevalence varied significantly by type of recruitment site (χ2 p<0·0001), being highest among those living in workers' residences (88·7%, 95% CI 81·8-93·2), followed by emergency shelters (50·5%, 46·3-54·7), and food distribution sites (27·8%, 20·8-35·7). More than two thirds of COVID-19 seropositive individuals (68%, 95% CI 64·2-72·2; 291 of 426) did not report any symptoms during the recall period. COVID-19 seropositivity was strongly associated with overcrowding (medium density: adjusted odds ratio [aOR] 2·7, 95% CI 1·5-5·1, p=0·0020; high density: aOR 3·4, 1·7-6·9, p<0·0001). INTERPRETATION: These results show high exposure to SARS-CoV-2 with important variations between those at different study sites. Living in crowded conditions was the strongest factor associated with exposure level. This study underscores the importance of providing safe, uncrowded accommodation, alongside adequate testing and public health information. FUNDING: Médecins Sans Frontières, Epicentre, Institut Pasteur's URGENCE nouveau coronavirus fund, Total Foundation.

Development of a patient rated scale for mental health global state for use during humanitarian interventions.

OBJECTIVE: We present the results of a cross-cultural validation of the Mental Health Global State (MHGS) scale for adults and adolescents (<14 years old). METHODS: We performed two independent studies using mixed methods among 103 patients in Hebron, Occupied Palestinian Territories and 106 in Cauca, Colombia. The MHGS was analyzed psychometrically, sensitivity and specificity, ability to detect clinically meaningful change, compared to the Clinical Global Impression-Severity scale (CGI-S). Principal component analysis was used to reduce the number of questions after data collection. RESULTS: The scale demonstrated good internal consistency, with a Cronbach alpha score of 0.80 in both settings. Test retest reliability was high, ICC 0.70 (95% CI [0.41-0.85]) in Hebron and 0.87 (95% CI [0.76-0.93]) in Cauca; inter-rater reliability was 0.70 (95% CI [0.42-0.85]) in Hebron and 0.76 (95% CI [0.57-0.88]) in Cauca. Psychometric properties were also good, and the tool demonstrated a sensitivity of 85% in Hebron and 100% in Cauca, with corresponding specificity of 80% and 79%, when compared to CGI-S. CONCLUSIONS: The MHGS showed promising results to assess global mental health thereby providing an additional easy to use tool in humanitarian interventions. Additional work should focus on validation in at least one more context, to adhere to best practices in transcultural validation.

Utility of Clinical and Laboratory Decision Rules in Identifying Bacterial Meningitis Among Children with Suspicion of Central Nervous System Infections in a Malaria-Endemic Area, Mbarara, Uganda.

Several decision rules combining clinical and biological parameters have been proposed to distinguish bacterial from aseptic meningitis, but have not been evaluated in Africa. In children hospitalized with suspected central nervous system infections in Uganda, we found that the Bacterial Meningitis Score and Meningitest showed lower performance than in European children, and that a decision rule designed specifically using parameters associated with bacterial meningitis also showed inadequate diagnostic performance for clinical use.

Neighborhood-targeted and case-triggered use of a single dose of oral cholera vaccine in an urban setting: Feasibility and vaccine coverage.

INTRODUCTION: In June 2015, a cholera outbreak was declared in Juba, South Sudan. In addition to standard outbreak control measures, oral cholera vaccine (OCV) was proposed. As sufficient doses to cover the at-risk population were unavailable, a campaign using half the standard dosing regimen (one-dose) targeted high-risk neighborhoods and groups including neighbors of suspected cases. Here we report the operational details of this first public health use of a single-dose regimen of OCV and illustrate the feasibility of conducting highly targeted vaccination campaigns in an urban area. METHODOLOGY/PRINCIPAL FINDINGS: Neighborhoods of the city were prioritized for vaccination based on cumulative attack rates, active transmission and local knowledge of known cholera risk factors. OCV was offered to all persons older than 12 months at 20 fixed sites and to select groups, including neighbors of cholera cases after the main campaign ('case-triggered' interventions), through mobile teams. Vaccination coverage was estimated by multi-stage surveys using spatial sampling techniques. 162,377 individuals received a single-dose of OCV in the targeted neighborhoods. In these neighborhoods vaccine coverage was 68.8% (95% Confidence Interval (CI), 64.0-73.7) and was highest among children ages 5-14 years (90.0%, 95% CI 85.7-94.3), with adult men being less likely to be vaccinated than adult women (Relative Risk 0.81, 95% CI: 0.68-0.96). In the case-triggered interventions, each lasting 1-2 days, coverage varied (range: 30-87%) with an average of 51.0% (95% CI 41.7-60.3). CONCLUSIONS/SIGNIFICANCE: Vaccine supply constraints and the complex realities where cholera outbreaks occur may warrant the use of flexible alternative vaccination strategies, including highly-targeted vaccination campaigns and single-dose regimens. We showed that such campaigns are feasible. Additional work is needed to understand how and when to use different strategies to best protect populations against epidemic cholera.

Retrospective mortality among refugees from the Central African Republic arriving in Chad, 2014.

BACKGROUND: The Central African Republic has known long periods of instability. In 2014, following the fall of an interim government installed by the Séléka coalition, a series of violent reprisals occurred. These events were largely directed at the country's Muslim minority and led to a massive displacement of the population. In 2014, we sought to document the retrospective mortality among refugees arriving from the CAR into Chad by conducting a series of surveys. METHODS: The Sido camp was surveyed exhaustively in March-April 2014 and a systematic sampling strategy was used in the Goré camp in October 2014. The survey recall period began November 1, 2013, just before the major anti-Balaka offensive. Heads of households were asked to describe their household composition at the beginning of and throughout the recall period. For household members reported as dying, further information about the date and circumstances of death was obtained. RESULTS: In Sido, 3449 households containing 25 353 individuals were interviewed. A total of 2599 deaths were reported, corresponding to a crude mortality rate of 6.0/10000 persons/day, and 8% of the population present at the beginning of the recall period died. Most (82.4%) deaths occurred among males, most deaths occurred in December 2013 and January 2014, and 92% were due to violence in the CAR. In Goré, 1383 households containing 8614 individuals were interviewed. A total of 1203 deaths were reported, corresponding to a crude mortality rate of 3.7/10000 persons/day [95%CI 3.5-3.9], and 12% of the population present at the beginning of the recall period died. Most (77.1%) deaths occurred among males. As in Sido, most deaths occurred in December 2013 and January 2014, and 86% of all deaths were due to violence in the CAR. CONCLUSIONS: The results of these two surveys describe a part of the toll of the violent events of December 2013 and January 2014 in the Central African Republic.

A two-phase approach for the identification of refugees with priority need for mental health care in Lebanon: a validation study.

BACKGROUND: Time and resource efficient mental disorder screening mechanisms are not available to identify the growing number of refugees and other forcibly displaced persons in priority need for mental health care. The aim of this study was to identify efficient screening instruments and mechanisms for the detection of moderate and severe mental disorders in a refugee setting. METHODS: Lay interviewers applied a screening algorithm to detect individuals with severe distress or mental disorders in randomly selected households in a Palestinian refugee camp in Beirut, Lebanon. The method included household informant and individual level interviews using a Vignettes of Local Terms and Concepts for mental disorders (VOLTAC), individual and household informant portions of the field-test version of the WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS) and the WHO Self Reporting Questionnaire (SRQ-20). A subset of participants were then reappraised utilizing the Mini International Neuropsychiatric Interview (MINI), WHO Disability Assessment Schedule II, and the Global Assessment of Functioning. The study constitutes a secondary analysis of interview data from 283 randomly selected households (n = 748 adult residents) who participated in a mental health disorders prevalence study in 2010. RESULTS: The 5-item household informant portion of WASSS was the most efficient instrument among those tested. It detected adults with severe mental disorders with 95% sensitivity and 71% specificity (Area Under Curve (AUC) = 0.85) and adults with moderate or severe mental disorder with 85.1% sensitivity and 74.8% specificity (AUC = 0.82). The complete screening algorithm demonstrated 100% sensitivity and 58% specificity. CONCLUSIONS: Our results suggest that a two phase, screen-confirm approach is likely a useful strategy to detect incapacitating mental disorders in humanitarian contexts where mental health specialists are scarce, and that in the context of a multi-step screen confirm mechanism, the household informant portion of field-test version of the WASSS may be an efficient screening tool to identify adults in greatest need for mental health care in humanitarian settings.

Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study.

BACKGROUND: Oral cholera vaccines represent a new effective tool to fight cholera and are licensed as two-dose regimens with 2-4 weeks between doses. Evidence from previous studies suggests that a single dose of oral cholera vaccine might provide substantial direct protection against cholera. During a cholera outbreak in May, 2015, in Juba, South Sudan, the Ministry of Health, Médecins Sans Frontières, and partners engaged in the first field deployment of a single dose of oral cholera vaccine to enhance the outbreak response. We did a vaccine effectiveness study in conjunction with this large public health intervention. METHODS: We did a case-cohort study, combining information on the vaccination status and disease outcomes from a random cohort recruited from throughout the city of Juba with that from all the cases detected. Eligible cases were those aged 1 year or older on the first day of the vaccination campaign who sought care for diarrhoea at all three cholera treatment centres and seven rehydration posts throughout Juba. Confirmed cases were suspected cases who tested positive to PCR for Vibrio cholerae O1. We estimated the short-term protection (direct and indirect) conferred by one dose of cholera vaccine (Shanchol, Shantha Biotechnics, Hyderabad, India). FINDINGS: Between Aug 9, 2015, and Sept 29, 2015, we enrolled 87 individuals with suspected cholera, and an 898-person cohort from throughout Juba. Of the 87 individuals with suspected cholera, 34 were classified as cholera positive, 52 as cholera negative, and one had indeterminate results. Of the 858 cohort members who completed a follow-up visit, none developed clinical cholera during follow-up. The unadjusted single-dose vaccine effectiveness was 80·2% (95% CI 61·5-100·0) and after adjusting for potential confounders was 87·3% (70·2-100·0). INTERPRETATION: One dose of Shanchol was effective in preventing medically attended cholera in this study. These results support the use of a single-dose strategy in outbreaks in similar epidemiological settings. FUNDING: Médecins Sans Frontières.

Physiotherapy for poliomyelitis: a descriptive study in the Republic of Congo.

BACKGROUND: A large poliomyelitis outbreak occurred in 2010 in the Republic of Congo. This paper describes the demographic and clinical characteristics of poliomyelitis cases and their outcomes following physiotherapy. FINDINGS: Demographic and clinical data were collected on 126 individuals between November 23, 2010 and March 23, 2011. The male/female ratio was 2.5 and the median age was 19 years (IQR: 13.5-23). The most severe forms of the disease were more common in older patients, 81 of the 126 patients (64.3%) had multiple evaluations of muscle strength. Among patients with multiple evaluations, 38.1% had improved strength at final evaluation, 48.3% were stable and 13.6% had decreased strength. CONCLUSIONS: Most acute poliomyelitis patients receiving physiotherapy had improved or stable muscle strength at their final evaluation. These descriptive results highlight the need for further research into the potential benefits of physiotherapy in polio affected patients.

Time is (still) of the essence: quantifying the impact of emergency meningitis vaccination response in Katsina State, Nigeria.

BACKGROUND: In 2009, a large meningitis A epidemic affected a broad region of northern Nigeria and southern Niger, resulting in more than 75 000 cases and 4000 deaths. In collaboration with state and federal agencies, Médecins Sans Frontières (MSF) intervened with a large-scale vaccination campaign using polysaccharide vaccine. Here the authors analyze the impact (cases averted) of the vaccination response as a function of the timing and coverage achieved. METHODS: Phenomenological epidemic models were fitted to replicate meningitis surveillance data from the Nigerian Ministry of Health/WHO surveillance system and from reinforced surveillance conducted by MSF in both vaccinated and unvaccinated areas using a dynamic, state-space framework to account for under-reporting of cases. RESULTS: The overall impact of the vaccination campaigns (reduction in meningitis cases) in Katsina State, northern Nigeria, ranged from 4% to 12%. At the local level, vaccination reduced cases by as much as 50% when campaigns were conducted early in the epidemic. CONCLUSIONS: Reactive vaccination with polysaccharide vaccine during meningitis outbreaks can significantly reduce the case burden when conducted early and comprehensively. Introduction of the conjugate MenAfriVac vaccine has reduced rates of disease caused by serogroup A Neisseria meningitidis in the region. Despite this, reactive campaigns with polysaccharide vaccine remain a necessary and important tool for meningitis outbreak response.

Lowenstein-Jensen selective medium for reducing contamination in Mycobacterium tuberculosis culture.

We compared Mycobacterium tuberculosis sputum culture recovery and contamination rates between Lowenstein-Jensen medium (LJ) containing the following decontaminants and LJ alone: (i) PANTA (n = 299), (ii) Selectatab-MB (n = 299), and (iii) penicillin G (n = 234). The contamination rate for LJ alone was approximately 31%, versus 5.0% for PANTA-containing, 2% for Selectatab-containing, and 9% for penicillin-containing media (P < 0.001). M. tuberculosis isolation rates were 9.8%, 17%, 18%, and 12% for standard LJ, PANTA, Selectatab, and penicillin cultures, respectively.

Mental disorders, disability and treatment gap in a protracted refugee setting.

BACKGROUND: Studies have shown high levels of distress and mental disorder among people living in refugee camps, yet none has confirmed diagnosis through clinical reappraisal. AIMS: To estimate the prevalence of mental disorders, related disability and treatment gap in adult refugees living in the Burj el-Barajneh camp. METHOD: Randomly selected participants were screened by household representative (n = 748) and individual (n = 315) interviews; clinical reappraisal was performed on a subset (n = 194) of 326 selected participants. Weighted prevalence estimates and 95% confidence intervals were calculated. RESULTS: The prevalence of current mental disorders was 19.4% (95% CI 12.6-26.2); depression was the most common diagnosis (8.3%, 95% CI 4.4-12.2) and multiple diagnoses were common (42%) among the 88 persons with mental disorder. Lifetime prevalence of psychosis was 3.3% (95% CI 1.0-5.5). Mental disorders were associated with moderate to severe dysfunction (odds ratio = 8.8, 95% CI 4.5-17.4). The treatment gap was 96% (95% CI 92-100). CONCLUSIONS: A range of mental disorders and associated disability are common in this long-term refugee setting. Combined with an important treatment gap, findings support the current consensus-based policy to prioritise availability of mental health treatment in refugee camps, especially for the most severe and disabling conditions.

Brief mental health interventions in conflict and emergency settings: an overview of four Médecins Sans Frontières - France programs.

INTRODUCTION: Mental health problems, particularly anxiety and mood disorders, are prevalent in the setting of humanitarian emergencies, both natural and man-made disasters. Evidence regarding best strategies for therapeutic interventions is sparse. Médecins Sans Frontières has been providing mental health services during emergencies for over two decades, and here we compare data from four programs. PROGRAM OVERVIEW: In China, 564 patients were followed for an average of 7 sessions after a major earthquake. The most common diagnoses were PTSD and other anxiety disorders. Between program entry and exit, the median global assessment of functioning increased from 65 to 80. At program entry, 58% were considered moderately, markedly or severely ill; a proportion which fell to 14% at program exit. In Colombia in the setting of chronic violence, 2411 patients were followed for a median of two sessions. Anxiety disorders and major depression were the most common diagnoses, and 76% of patients were moderately or severely ill at program entry. 91% had symptomatic improvement at program exit. In Gaza, 1357 patients were followed for a median of 9 sessions; a majority was under age 15. PTSD and other anxiety disorders were the most common diagnoses, and 91% were moderately or severely ill at entry. 89% had improved symptoms at program exit. In the West Bank, the 1478 patients had similar characteristics to those enrolled in Gaza. 88% were moderately or severely ill at entry; 88% had improved at exit. DISCUSSION AND EVALUATION: It was feasible to implement brief yet effective mental health interventions in a wide variety of humanitarian contexts - post-natural disaster, during acute violent conflict and during chronic violent conflict. The most common diagnoses were PTSD, other anxiety disorders and mood disorders. The use of local specially-trained counselors who were focused on coping skills and improving functionality over a brief time period, likely contributed to the symptomatic improvement seen in a large majority of patients across the four sites. CONCLUSIONS: Mental health is an essential part of a health care response to humanitarian emergencies. In a variety of settings, we show the positive results of brief interventions. Further research is needed to improve and evaluate mental health interventions in crises.

Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11.

The diagnostic concepts of post-traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro- and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD-11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non-specific symptoms; a new complex PTSD category that comprises three clusters of intra- and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of "adjustment disorder" involving increased specification of symptoms; and a conceptualization of "acute stress reaction" as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low- and high-income countries.