Programmatic implications for promotion of handwashing behavior in an internally displaced persons camp in North Kivu, Democratic Republic of Congo.

BACKGROUND: Diarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings. METHODS: We conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing. RESULTS: At the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as "maintaining a good image" and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene. CONCLUSIONS: Hygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp's existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps.

An evaluation of a tuberculosis case-finding and treatment program among Syrian refugees-Jordan and Lebanon, 2013-2015.

BACKGROUND: The displacement crisis in Syria poses challenges for tuberculosis (TB) control across the region. Since 2012 in Jordan and 2013 in Lebanon, the International Organization for Migration (IOM) has supported the National TB Program (NTP) in detecting and treating TB among Syrian refugees. In December 2016, IOM asked US Centers for Disease Control and Prevention (CDC) staff to evaluate its program of support to Jordan and Lebanon's NTPs for TB control among Syrian refugees. This manuscript focuses on case-finding, including contact investigations, and treatment components of the IOM program during 2013-2015 in Jordan and 2015 in Lebanon. METHODS: The evaluation consisted of a retrospective review of de-identified Jordan and Lebanon line lists of TB cases and of investigated contacts (Lebanon only). Syrian refugee TB cases were categorized by sex, age group (age < 5 years, 5-14 years, ≥15 years), TB type (pulmonary versus extra-pulmonary), and additionally in Jordan, by refugee camp status (residence in versus outside a refugee camp), to evaluate differences in treatment completion and contact investigation. RESULTS: In Jordan, Syrian refugee cases represented 24.4% of TB cases in 2013, when Syrian refugees made up 6.8% of the country's population, and 13.8% of TB cases in 2015, when Syrians made up 8.3% of the total population. In Lebanon in 2015, Syrian refugee cases represented 21.4% of TB cases, when Syrians made up 20.1% of the total population. In Jordan, the proportion of Syrian TB cases residing in refugee camps (29.3%) was higher than the proportion of Syrians refugees residing in camps (17.1%). Of Syrian TB cases in 2015, 94.8% in Jordan and 87.8% in Lebanon completed treatment. In Lebanon, among Syrian TB cases with household contacts listed, contact investigation was completed for 77.8% of cases. CONCLUSION: IOM's program of NTP support provides critical TB services for Syrian refugees with high treatment completion rates. More community and health practitioner outreach for enhanced active case finding among community-based Syrian refugees in Jordan may improve TB case detection in populations outside of refugee camps. Thorough contact investigations need continued emphasis, including completely recording investigations in both countries, to find active TB cases.

TB control in humanitarian emergencies: Lessons from the Syria displacement crisis.

The TB care for communities in emergency contexts satellite session at the 2017 48th Union World Conference on Lung Health discussed the impact of the Syrian displacement crisis on regional tuberculosis (TB) control. At the session, representatives of the affected countries and of international organizations reviewed the epidemiologic impact of Syrian displacement on regional TB control, as well as challenges and successes seen in TB control during this displacement. This discussion offered several lessons for TB control in other humanitarian emergencies. TB control in humanitarian emergencies requires increasing awareness of TB symptoms and services among healthcare workers and the affected populations. It also requires performing standardized symptom screening at borders or registration, while leveraging more widely available radiographic and diagnostic tools to find cases in high-burden settings that may be missed using symptom screening alone. Additionally, treatment completion rates can be maintained and improved through dedication of sufficient resources and innovative strategies to keep mobile populations on treatment. Finally, sustained commitment, including funding, from the international humanitarian community is necessary to improve TB control, and ultimately end TB, both in the Syria crisis and other humanitarian emergencies worldwide.

Cost-effectiveness of birth-dose hepatitis B vaccination among refugee populations in the African region: a series of case studies.

BACKGROUND: Hepatitis B affects 257 million people worldwide. Mother-to-child hepatitis B virus (HBV) transmission is a preventable cause of substantial morbidity and mortality and poses greatest risk for developing chronic HBV infection. The World Health Organization recommends that all countries institute universal hepatitis B birth dose (HepB BD) vaccination during the first 24 h of life, followed by timely completion of routine immunization. The objective of this analysis was to assess the cost-effectiveness of adding HepB BD vaccination among sub-Saharan African refugee populations where the host country's national immunization policy includes HepB BD. METHODS: We performed a cost-effectiveness analysis of three hepatitis B vaccination strategy scenarios for camp-based refugee populations in the African Region (AFR): routine immunization (RI), RI plus universal HepB BD, and RI plus HepB BD only for newborns of hepatitis B surface antigen-positive mothers identified through rapid diagnostic testing (RDT). We focused analyses on refugee populations living in countries that include HepB BD in national immunization schedules: Djibouti, Algeria and Mauritania. We used a decision tree model to estimate costs of vaccination and testing, and costs of life-years lost due to complications of chronic hepatitis B. RESULTS: Compared with RI alone, addition of HepB BD among displaced Somali refugees in Djibouti camps would save 9807 life-years/year, with an incremental cost-effectiveness ratio (ICER) of 0.15 USD (US dollars) per life-year saved. The RI plus HepB BD strategy among Western Saharan refugees in Algerian camps and Malian refugees in Mauritania camps would save 27,108 life-years/year with an ICER of 0.11 USD and 18,417 life-years/year with an ICER of 0.16 USD, respectively. The RI plus RDT-directed HepB BD was less cost-effective than RI plus delivery of universal HepB BD vaccination or RI alone. CONCLUSIONS: Based on our model, addition of HepB BD vaccination is very cost-effective among three sub-Saharan refugee populations, using relative life-years saved. This analysis shows the potential benefit of implementing HepB BD vaccination among other camp-based refugee populations as more AFR countries introduce national HepB BD policies.

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

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

Public health implications of complex emergencies and natural disasters.

BACKGROUND: During the last decade, conflict or natural disasters have displaced unprecedented numbers of persons. This leads to conditions prone to outbreaks that imperil the health of displaced persons and threaten global health security. Past literature has minimally examined the association of communicable disease outbreaks with complex emergencies (CEs) and natural disasters (NDs). METHODS: To examine this association, we identified CEs and NDs using publicly available datasets from the Center for Research on the Epidemiology of Disasters and United Nations Flash and Consolidated Appeals archive for 2005-2014. We identified outbreaks from World Health Organization archives. We compared findings to identify overlap of outbreaks, including their types (whether or not of a vaccine-preventable disease), and emergency event types (CE, ND, or Both) by country and year using descriptive statistics and measure of association. RESULTS: There were 167 CEs, 912 NDs, 118 events linked to 'Both' types of emergencies, and 384 outbreaks. Of CEs, 43% were associated with an outbreak; 24% NDs were associated with an outbreak; and 36% of 'Both' types of emergencies were associated with an outbreak. Africa was disproportionately affected, where 67% of total CEs, 67% of 'Both' events (CE and ND), and 46% of all outbreaks occurred for the study period. The odds ratio of a vaccine-preventable outbreak occurring in a CE versus an ND was 4.14 (95% confidence limits 1.9, 9.4). CONCLUSIONS: CEs had greater odds of being associated with outbreaks compared with NDs. Moreover, CEs had high odds of a vaccine-preventable disease causing that outbreak. Focusing on better vaccine coverage could reduce CE-associated morbidity and mortality by preventing outbreaks from spreading.

Real-Time Surveillance in Emergencies Using the Early Warning Alert and Response Network.

Humanitarian emergencies often result in population displacement and increase the risk for transmission of communicable diseases. To address the increased risk for outbreaks during humanitarian emergencies, the World Health Organization developed the Early Warning Alert and Response Network (EWARN) for early detection of epidemic-prone diseases. The US Centers for Disease Control and Prevention has worked with the World Health Organization, ministries of health, and other partners to support EWARN through the implementation and evaluation of these systems and the development of standardized guidance. Although protocols have been developed for the implementation and evaluation of EWARN, a need persists for standardized training and additional guidance on supporting these systems remotely when access to affected areas is restricted. Continued collaboration between partners and the Centers for Disease Control and Prevention for surveillance during emergencies is necessary to strengthen capacity and support global health security.

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

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

Evaluation of the Field Performance of ImmunoCard STAT!® Rapid Diagnostic Test for Rotavirus in Dadaab Refugee Camp and at the Kenya-Somalia Border.

AbstractRotavirus commonly causes diarrhea in children, leading to hospitalization and even death. Rapid diagnostic tests are feasible alternatives for determining rotavirus outbreaks in refugee camps that have inadequate laboratory capacity. We evaluated the field performance of ImmunoCard STAT!® Rotavirus (ICS-RV) in Dadaab Refugee Camp and at the Kenya-Somalia border. From May to December 2014, we prospectively enrolled children aged < 5 years hospitalized with acute diarrhea, defined as ≥ 3 episodes of loose stool in 24 hours for < 7 days. Stool samples were collected and tested by trained surveillance clerks using ICS-RV per manufacturer's instructions. The field performance characteristics of ICS-RV were evaluated against the gold standard test, Premier™ Rotaclone® enzyme immunoassay. The operational characteristics were evaluated using World Health Organization (WHO) ASSURED criteria to determine whether ICS-RV is appropriate as a point-of-care test by administering a standard questionnaire and observing surveillance clerks performing the test. We enrolled 213 patients with a median age of 10 months (range = 1-48); 58.2% were male. A total of 71 (33.3%) and 60 (28.2%) patients tested positive for rotavirus infection by immunoassay and ICS-RV, respectively. The sensitivity, specificity, and positive and negative predictive values of ICS-RV compared with the immunoassay were 83.1% (95% confidence interval [CI] = 72.3-91.0), 99.3% (95% CI = 96.1-100), 98.3% (95% CI = 91.1-100), and 92.1% (95% CI = 86.6-95.5), respectively. The ICS-RV fulfilled the WHO ASSURED criteria for point-of-care testing. ICS-RV is a field-ready point-of-care test with good field performance and operational characteristics. It can be useful in determining rotavirus outbreaks in resource-limited settings.

Pneumonia prevention: Cost-effectiveness analyses of two vaccines among refugee children aged under two years, Haemophilus influenzae type b-containing and pneumococcal conjugate vaccines, during a humanitarian emergency, Yida camp, South Sudan.

By September 2013, war between Sudan and South Sudan resulted in >70,000 Sudanese refugees and high pneumonia incidence among the 20,000 refugees in Yida camp, South Sudan. Using Médecins Sans Frontières (MSF)-provided data and modifying our decision-tree models, we estimated if administering Haemophilus influenzae type b (Hib)-containing (pentavalent vaccine, also with diphtheria pertussis and tetanus [DPT] and hepatitis B) and pneumococcal conjugate (PCV) vaccines were cost-effective against hospitalized pneumonia. Among children <2years old, compared with no vaccination, one- and two-doses of combined Hib-containing and PCV would avert an estimated 118 and 125 pneumonia cases, and 8.5 and 9.1 deaths, respectively. The cost per Disability-Adjusted-Life-Year averted for administering combined one- and two-doses was US$125 and US$209, respectively. MSF demonstrated that it was possible to administer these vaccines during an emergency and our analysis found it was highly cost-effective, even with just one-dose of either vaccine. Despite unknown etiology, there is strong field and now economic rationale for administering Hib and PCV during at least one humanitarian emergency.

Partnerships that Facilitate a Refugee's Journey to Wellbeing.

The current global refugee crisis involves 65.3 million persons who have been displaced from their homes or countries of origin. While escaping immediate harm may be their first priority, displaced people go on to face numerous health risks, including trauma and injuries, malnutrition, infectious diseases, exacerbation of existing chronic diseases, and mental health conditions. This crisis highlights the importance of building capacity among health-care providers, scientists, and laboratorians to understand and respond to the health needs of refugees. The November 2016 American Society of Tropical Medicine and Hygiene (ASTMH) conference in Atlanta will feature an interactive exhibit entitled "The Refugee Journey to Wellbeing" and three symposia about refugee health. The symposia will focus on tropical disease challenges in refugee populations, careers in refugee health, and recent experiences of governmental agencies and nongovernmental organizations in responding to the global refugee crisis. We invite ASTMH attendees to attend the exhibit and symposia and consider contributions they could make to improve refugee health through tropical disease research or clinical endeavors.

Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan.

BACKGROUND: Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County. METHODS: We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission. RESULTS: Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available "always" or "sometimes". Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including "before eating" (80 % rinsing vs. 7 % washing with soap) and "before preparing/cooking food" (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone. CONCLUSIONS: Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.

Etiology and Incidence of Viral Acute Respiratory Infections Among Refugees Aged 5 Years and Older in Hagadera Camp, Dadaab, Kenya.

We used the Centers for Disease Control and Prevention-Kenya Medical Research Institute Acute Respiratory Infection (ARI) Surveillance System data to estimate severe acute respiratory infection (SARI) hospitalization rates, viral etiology, and associated complaints of influenza-like illnesses (ILI) and SARI conditions among those aged 5 years and older in Hagadera, Dadaab refugee camp, Kenya, for 2010-2012. A total of 471 patients aged ≥ 5 years met the case definition for ILI or SARI. SARI hospitalization rates per 10,000 person-years were 14.7 (95% confidence interval [CI] = 9.1, 22.2) for those aged 5-14 years; 3.4 (95% CI = 1.6, 7.2) for those aged 15-24 year; and 3.8 (95% CI = 1.6, 7.2) for those aged ≥ 25 years. Persons between the ages of 5 and 14 years had 3.5 greater odds to have been hospitalized as a result of SARI than those aged ≥ 25 years (odds ratio [OR] = 3.5, P < 0.001). Among the 419 samples tested, 169 (40.3%) were positive for one or more virus. Of those samples having viruses, 36.9% had influenza A; 29.9% had adenovirus; 20.2% had influenza B; and 14.4% had parainfluenza 1, 2, or 3. Muscle/joint pain was associated with influenza A (P = 0.002), whereas headache was associated with influenza B (P = 0.019). ARIs were responsible for a substantial disease burden in Hagadera camp.

Pneumonia Prevention during a Humanitarian Emergency: Cost-effectiveness of Haemophilus Influenzae Type B Conjugate Vaccine and Pneumococcal Conjugate Vaccine in Somalia.

BACKGROUND: Pneumonia is a leading cause of death among children less than five years old during humanitarian emergencies. Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae are the leading causes of bacterial pneumonia. Vaccines for both of these pathogens are available to prevent pneumonia. Problem This study describes an economic analysis from a publicly funded health care system perspective performed on a birth cohort in Somalia, a country that has experienced a protracted humanitarian emergency. METHODS: An impact and cost-effectiveness analysis was performed comparing: no vaccine, Hib vaccine only, pneumococcal conjugate vaccine 10 (PCV10) only, and both together administered through supplemental immunization activities (SIAs). The main summary measure was the incremental cost per disability-adjusted life-years (DALYs) averted. One-way sensitivity analysis was conducted for uncertainty in parameter values. RESULTS: Each SIA would avert a substantial number of cases and deaths. Compared with no vaccine, the DALYs averted by two SIAs for two doses of Hib vaccine was US $202.93 (lower and upper limits: $121.80-$623.52), two doses of PCV10 was US $161.51 ($107.24-$227.21), and two doses of both vaccines was US $152.42 ($101.20-$214.42). Variables that influenced the cost-effectiveness for each strategy most substantially were vaccine effectiveness, case fatality rates (CFRs), and disease burden. CONCLUSIONS: The World Health Organization (WHO) defines a cost-effective intervention as costing one to three times the per capita gross domestic product (GDP; in 2011, for Somalia=US $112). Based on the presented model, Hib vaccine alone, PCV10 alone, or Hib vaccine and PCV10 given together in SIAs are cost-effective interventions in Somalia. The WHO/Strategic Advisory Group of Experts decision-making factors for vaccine deployment appear to have all been met: the disease burden is large, the vaccine-related risk is low, prevention in this setting is more feasible than treatment, the vaccine duration probably is sufficient for the vulnerable period of the child's life, cost is reasonable, and herd immunity is possible.

"Impact of and response to increased tuberculosis prevalence among Syrian refugees compared with Jordanian tuberculosis prevalence: case study of a tuberculosis public health strategy".

INTRODUCTION: By the summer of 2014, the Syrian crisis resulted in a regional humanitarian emergency with 2.9 million refugees, including 608,000 in Jordan. These refugees access United Nations High Commissioner for Refugees (UNHCR)-sponsored clinics or Jordan Ministry of Health clinics, including tuberculosis diagnosis and treatment. Tuberculosis care in Syria has deteriorated with destroyed health infrastructure and drug supply chain. Syrian refugees may have undiagnosed tuberculosis; therefore, the UNHCR, the International Organization for Migration (IOM), the National Tuberculosis Program (NTP), and the Centers for Disease Control and Prevention developed the Public Health Strategy for Tuberculosis among Syrian Refugees in Jordan. This case study presents that strategy, its impact, and recommendations for other neighboring countries. CASE DESCRIPTION: UNHCR determined that World Health Organization (WHO) criteria for implementing a tuberculosis program in an emergency were met for the Syrian refugees in Jordan. Jordan NTP assessed their tuberculosis program and found that access to Syrian refugees was the one component of their program missing. Therefore, a strategy for tuberculosis control among Syrian refugees was developed. Since that development through work with IOM, UNHCR, and NTP, tuberculosis case detection among Syrian refugees is almost 40 % greater (74 cases/12 months or 1.01/100,000 monthly through June 2014 vs. 56 cases/16 months or 0.73/100,000 monthly through June 2013) using estimated population figures; more than two fold the 2012 Jordan tuberculosis incidence. Additionally, the WHO objective of curing ≥85 % of newly identified infectious tuberculosis cases was met among Syrian refugees. DISCUSSION AND EVALUATION: Tuberculosis (TB) rates among displaced persons are high, but increased detection is possible. High TB rates were found among Syrian refugees through active screening and will probably persist as the Syrian crisis continues. Active screening can detect tuberculosis early and reduce risk for transmission. However, this strategy needs sustainable funding to continue and all activities have not been realized. CONCLUSIONS: Initial assessment found that tuberculosis among Syrian refugees was at a high incidence rate. Through partnership, a cohesive Jordanian tuberculosis strategy was developed for Syrian refugees and it has potential to inform treatment and control efforts for other regional countries impacted by the Syrian crisis.

Comparison of impact and cost-effectiveness of rotavirus supplementary and routine immunization in a complex humanitarian emergency, Somali case study.

BACKGROUND: A humanitarian emergency involves a complete breakdown of authority that often disrupts routine health care delivery, including immunization. Diarrheal diseases are a principal cause of morbidity and mortality among children during humanitarian emergencies. The objective of this study was to assess if vaccination against rotavirus, the most common cause of severe diarrhea among children, either as an addition to routine immunization program (RI) or supplemental immunization activity (SIA) would be cost-effective during a humanitarian emergency to decrease diarrhea morbidity and mortality, using Somalia as a case study. METHODS: An impact and cost-effectiveness analysis was performed comparing no vaccine; two-dose rotavirus SIA and two-dose of RI for the 424,592 births in the 2012 Somali cohort. The main summary measure was the incremental cost per disability-adjusted life-year (DALY) averted. Univariate sensitivity analysis examined the extent to which the uncertainty in the variables affected estimates. RESULTS: If introduced in Somalia, a full-series rotavirus RI and SIA would save 908 and 359 lives, respectively, and save US$63,793 and US$25,246 in direct medical costs, respectively. The cost of a RI strategy would be US$309,458. Because of the high operational costs, a SIA strategy would cost US$715,713. US$5.30 per DALY would be averted for RI and US$37.62 per DALY averted for SIA. Variables that most substantially influenced the cost-effectiveness for both RI and SIA were vaccine program costs, mortality rate, and vaccine effectiveness against death. CONCLUSIONS: Based on our model, rotavirus vaccination appears to be a cost-effective intervention as either RI or SIA, as defined by the World Health Organization as one to three times the per capita Gross Domestic Product (Somalia $112 in 2011). RI would have greater health impact and is more cost effective than SIA, assuming feasibility of reaching the target population. However, given the lack of infrastructure, whether RI is realistic in this setting remains unanswered, and alternative approaches like SIA should be further examined.

Measles outbreak response among adolescent and adult Somali refugees displaced by famine in Kenya and Ethiopia, 2011.

BACKGROUND: The refugee complexes of Dadaab, Kenya, and Dollo-Ado, Ethiopia, experienced measles outbreaks during June-November 2011, following a large influx of refugees from Somalia. METHODS: Line-lists from health facilities were used to describe the outbreak in terms of age, sex, vaccination status, arrival date, attack rates (ARs), and case fatality ratios (CFRs) for each camp. Vaccination data and coverage surveys were reviewed. RESULTS: In Dadaab, 1370 measles cases and 32 deaths (CFR, 2.3%) were reported. A total of 821 cases (60.1%) were aged ≥15 years, 906 (82.1%) arrived to the camps in 2011, and 1027 (79.6%) were unvaccinated. Camp-specific ARs ranged from 212 to 506 cases per 100 000 people. In Dollo-Ado, 407 cases and 23 deaths (CFR, 5.7%) were reported. Adults aged ≥15 years represented 178 cases (43.7%) and 6 deaths (26.0%). Camp-specific ARs ranged from 21 to 1100 cases per 100 000 people. Immunization activities that were part of the outbreak responses initially targeted children aged 6 months to 14 years and were later expanded to include individuals up to 30 years of age. CONCLUSIONS: The target age group for outbreak response-associated immunization activities at the start of the outbreaks was inconsistent with the numbers of cases among unvaccinated adolescents and adults in the new population. In displacement of populations from areas affected by measles outbreaks, health authorities should consider vaccinating adults in routine and outbreak response activities.

Malnourished children in refugee camps and lack of connection with services after US resettlement.

Identifying and addressing malnutrition among US-bound refugee children is an important human rights issue. Failure to address childhood malnutrition can impair cognitive development and productivity. The target population was children aged 6-59 months, originating from eight countries representing 51 % of US-resettled refugees for 2005-2011, living in 22 camps prior to potential US-resettlement. The corresponding camp-level nutritional survey data were evaluated. State Refugee Health Coordinators were surveyed on nutritional assessment, reporting and referrals for their US-refugee medical screenings. From 2004 to 2010, half of the camps (63 total surveys) had global acute malnutrition prevalence over 15 % at least once (surveys not done annually) and anemia prevalence greater than 40 %. The majority of US-refugee medical screenings included height and weight measurements but few used national or WHO standards to evaluate presence or level of malnutrition. Improve overseas camp monitoring and link these nutritional data to US-resettling refugee children to inform potential nutritional interventions. Domestically, use WHO or US growth standards for anthropometrics to determine presence of malnutrition and need for corrective action.

Risk factors for measles mortality among hospitalized Somali refugees displaced by famine, Kenya, 2011.

BACKGROUND: Measles among displaced, malnourished populations can result in a high case fatality ratio. In 2011, a large measles outbreak occurred in Dadaab, Kenya, among refugees fleeing famine and conflict in Somalia. The aim of this study was to identify predictors of measles deaths among hospitalized patients during the outbreak. METHODS: A retrospective cohort study design was used to investigate measles mortality among hospitalized measles patients with a date of rash onset during 6 June-10 September 2011. Data were abstracted from medical records and a measles case was defined as an illness with fever, maculopapular rash, and either cough, coryza or conjunctivitis. Vaccination status was determined by patient or parental recall. Independent predictors of mortality were identified using logistic regression analysis. RESULTS: Of 388 hospitalized measles patients, 188 (49%) were from hospital X, 70 (18%) from hospital Y, and 130 (34%) from hospital Z; median age was 22 years, 192 (50%) were 15-29 years of age, and 22 (6%) were vaccinated. The mean number of days from rash onset to hospitalization varied by hospital (hospital X = 5, hospital Y = 3, hospital Z = 6; P < .0001). Independent risk factors for measles mortality were neurological complications (odds ratio [OR], 12.8; 95% confidence interval [CI], 3.1-52.4), acute malnutrition (OR, 7.6; 95% CI, 1.3-44.3), and admission to hospital Z (OR, 4.2; 95% CI, 1.3-13.2). CONCLUSIONS: Among Somali refugees, in addition to timely vaccination at border crossing points, early detection and treatment of acute malnutrition and proper management of measles cases may reduce measles mortality.