Child Health During War and Disasters: Building Resilience.

Children face unique risks resulting from disasters and conflicts. Broadly, complex emergencies create new and augment existing health risks to children. Direct, conflict-related injuries and deaths - such as those resulting from exposure to chemical weapons and blast injuries - not only have immediate impact but also have long-term impacts on the health and wellbeing of children. Lapses in vaccination coverage, changes in vector patterns, and widespread malnutrition, contribute to new and re-emerging infectious diseases among children. Understanding risks resulting from disasters and conflicts is critical for implementing timely and appropriate public health programs to reduce the negative health effects on children.

Chickenpox Outbreaks in Three Refugee Camps on Mainland Greece, 2016-2017: A Retrospective Study.

INTRODUCTION: Displaced populations face disproportionately high risk of communicable disease outbreaks given the strains of travel, health care circumstances in their country of origin, and limited access to health care in receiving countries. STUDY OBJECTIVE: Understanding the role of demographic characteristics in outbreaks is important for timely and efficient control measures. Accordingly, this study assesses chickenpox outbreaks in three large refugee camps on mainland Greece from 2016 - 2017, using clinical line-list data from Médecins du Monde (MdM) clinics. METHODS: Clinical line-list data from MdM clinics operating in Elliniko, Malakasa, and Raidestos camps in mainland Greece were used to characterize chickenpox outbreaks in these camps. Logistic regression was used to compare the odds of chickenpox by sex, camp, and yearly increase in age. Incidences were calculated for age categories and for sex for each camp outbreak. RESULTS: Across camps, the median age was 19 years (IQR: 7.00 - 30.00 years) for all individuals and five years (IQR: 2.00 - 8.00 years) for cases. Males were 55.94% of the total population and 51.32% of all cases. There were four outbreaks of chickenpox across Elliniko (n = 1), Malakasa (n = 2), and Raidestos (n = 1) camps. The odds of chickenpox when controlling for age and sex was lower for Malakasa (OR = 0.46; 95% CI, 0.38 - 0.78) and Raidestos (OR = 0.36; 95% CI, 0.24 - 0.56) when compared Elliniko. Odds of chickenpox were comparable between Malakasa and Raidestos (OR = 1.49; 95% CI, 0.92 - 2.42). Across all camps, the highest incidence was among children zero-to-five years of age. The sex-specific incidence chickenpox was higher for males than females in Elliniko and Malakasa, while the incidence was higher among females in Raidestos. CONCLUSION: As expected, individuals five years of age and under made up the majority of chickenpox cases. However, 12% of cases were teenagers or older, highlighting the need to consider atypical age groups in vaccination strategies and control measures. To support both host and displaced populations, it is important to consider risk-reduction needs for both groups. Including host communities in vaccination campaigns and activities can help reduce the population burden of disease for both communities.

Disease burden among refugees in camps on mainland Greece, 2016-2017: a retrospective cross-sectional study.

BACKGROUND: Despite the importance of baseline health data for evidence-informed decision-making, these data are rarely available for displaced populations. At the height of the European refugee crisis, most of those seeking asylum in Europe were from regions with high prevalences of communicable and non-communicable diseases. To create an epidemiologic profile for refugees in camps on mainland Greece, this study assessed the prevalence of 11 communicable and non-communicable diseases among refugees utilizing Médecins du Monde (MdM) in-camp clinics. METHODS: The proportional morbidity of selected diseases among individuals utilizing MdM services were determined from data collected at refugee camp clinics on mainland Greece from April 2016 - July 2017. Overall and age-specific proportional morbidities were reported. Differences in disease burden among refugees from the largest sending countries - Afghanistan and Syria - were compared using proportional morbidity ratios and 95% confidence intervals. Patterns in results were compared with disease burden estimates in sending countries and with findings from comparable settings. RESULTS: Respiratory tract infections (RTIs) were the most prevalent outcome. Among RTIs, upper RTIs were most common, with a proportional morbidity of nearly 40%; throughout the study period, over 46% of children under 18 years had at least one upper RTI consultation. Musculoskeletal conditions (3.64%), were the most prevalent non-communicable outcome, followed by hypertension (2.21%) and asthma (1.28%). Afghans were 31.68% more likely than Syrians to have a consultation for at least one condition (PR: 1.32; 95% CI: 1.25, 1.39). The proportional morbidity of RTIs was comparable to sending countries, but there was a comparatively lower burden of other conditions among refugees than literature estimates from sending countries. CONCLUSION: Refugees utilizing MdM clinics in camps had higher burdens of communicable diseases - predominantly RTIs - relative to non-communicable diseases. Non-communicable disease burdens were comparatively lower than reported prevalences from in-country populations. These findings can be attributed to a range of considerations including differences in demographic profiles between sending countries and refugee populations and missed opportunities for utilizing clinical care. Further investment is needed to capture the health profiles of displaced populations to support evidence-informed decision-making processes in humanitarian emergency responses.

Ensuring Access to Opioid Treatment Program Services Among Delawareans Vulnerable to Flooding.

Objective: To quantify potential flood-related access disruptions to medication-assisted treatment for opioid use disorder (OUD) among Delawareans. Methods: Spatial flood risk maps and infrastructure, services, and hazard risk, transportation networks, opioid treatment programs (OTPs) for the State of Delaware were integrated to visually display the relationship between these layers. A complex network theory-based simulation model was used to assess both direct (e.g., inundation with flood water) and indirect (e.g., isolation) impacts of floods. Results: Delaware is at increasing risk from flooding associated with storms and sea-level rise, which can lead to sunny day flooding during high tides. Of the 18 OTPs in Delaware, 4 are expected to be flooded in a 100-year flood and 7 are expected to be severely disrupted, increasing to 9 by 2035 and to 10 by 2050, with service reachability less than 15 square miles due to flood-induced isolation. Conclusions: Individuals utilizing OTPs for OUDs must be able to access treatment programs regardless of external disruptors like floods. Because these programs require consistent treatment adherence and in-person oversight by clinicians, timely restoration of services and continuity of operations for treatment facilities in post-disaster settings is critical for treatment compliance. Policy Implications: The State of Delaware has the third highest rate of drug overdose mortality in the U.S., with three-quarters of all drug-related deaths involving opioids. Impeded access to opioid treatment during a flood disaster can lead to relapse, overdose, and death. Hazard planning must develop policies and practices to address these risks.

Correction: Civil war and death in Yemen: Analysis of SMART survey and ACLED data, 2012-2019.

[This corrects the article DOI: 10.1371/journal.pgph.0000581.].

Predictors of exceeding emergency under-five mortality thresholds using small-scale survey data from humanitarian settings (1999 - 2020): considerations for measles vaccination, malnutrition, and displacement status.

BACKGROUND: Quantifying the effect of measles containing vaccine (MCV) coverage and the prevalence of global acute malnutrition (GAM) on mortality levels in populations of displaced and crisis-affected resident children is important for intervention programming in humanitarian emergencies. METHODS: A total of 1597 surveys containing data on under-five death rate, population status (internally displaced, refugee, or crisis-affected resident), measles containing vaccine coverage, and global acute malnutrition were extracted from the Complex Emergency Database (CE-DAT). Under-five mortality rates were dichotomized to those exceeding critical levels or otherwise. A Bayesian multivariable mixed-effect logistic regression model was used to assess the association between an under-five death rate (U5DR) exceeding this threshold and population status (i.e., internally displaced, refugees or residents), GAM prevalence (proxy for food security), and MCV coverage. RESULTS: The prevalence of GAM, MCV and U5DR were higher in internally displaced children (IDC) with values of 14.6%, 69.9% and 2.07 deaths per 10 000 per day, respectively. Refugee populations had lower average under-five mortality rate (0.89 deaths per 10 000 per day), GAM of 12.0% and the highest measles containing vaccine coverage (80.0%). In crisis-affected residents the prevalence of GAM, MCV and average U5DR are 11.1%, 65.5% and 1.20 deaths per 10 000 per day respectively. In mixed-effect logistic model taking 2 deaths per 10 000 children less than five years old per as emergency threshold (Model III); MCV (AOR = 0.66, 95% Highest Density Interval (HDI): 0.57, 0.78), GAM (AOR = 1.79, 95% HDI: 1.52, 2.12) were associated with a reduction of the odds of U5DR exceeding critical level accounting for country-specific levels of variability. The odds of U5DR exceeding critical level (2/10000/day) in crisis-affected resident children and refugees were 0.36 (95% HDI: 0.22, 0.58) and 0.25(95% HDI: 0.11, 0.55) less than amongst IDP children adjusting for GAM and MCV. In considering country specific yearly median U5DR (model IV) the odds of U5DR exceeding twice the median U5DR were associated with MCV (AOR = 0.72, 95% HDI: 0.64, 0.82), GAM (AOR = 1.53, 95%HDI: 1.34, 1.76). The odds of U5DR exceeding critical level in crisis-affected resident children was 0.30(95% HDI: 0.20, 0.45) less than IDP children, after adjusting for MCV and GAM. We found no difference between the odds of U5DR exceeding twice the country level median U5DR in the refugee population compared to the IDPs. CONCLUSIONS: In this study vaccination coverage and global acute malnutrition (proxy for food security) were associated with U5DR exceeding critical level. The emergency threshold for IDPs and affected residents is significantly different and consistent across the different outcomes, whereas the result is inconsistent for IDPs and refugees. Continued improvement in measles vaccination coverage and reduction of malnutrition in humanitarian emergencies have the potential to minimize the deterioration of mortality level amongst children in emergency settings. To generate a robust understanding of the critical level of child mortality in displaced and affected resident populations, studies accounting for the impact of the duration of displacement, contextual factors in humanitarian settings, and the level of humanitarian assistance provided are needed.

Civil war and death in Yemen: Analysis of SMART survey and ACLED data, 2012-2019.

Conflict in Yemen has displaced millions and destroyed health infrastructure, resulting in the world's largest humanitarian disaster. The objective of this paper is to examine mortality in Yemen to determine whether it has increased significantly since the conflict began in 2015 compared to the preceding period. We analysed 91 household surveys using the Standardized Monitoring and Assessment of Relief and Transitions methodology, covering 2,864 clusters undertaken from 2012-2019, and deaths from Armed Conflict Location & Event Data Project database covering the conflict period 2015-2019. We used a Poisson-Gamma model to estimate pre-conflict (µp, baseline value) and conflict period (µc) mean death rates using household survey data from 2012-2019. To analyse changes in the distribution of deaths and estimate nationwide excess deaths, we applied pre- and post-conflict death rates to total population numbers. Further, we tested for association between excess death and security levels by governorate. The national estimated crude death rate/10,000 in the conflict period was 0.20 (95% CI: 0.17, 0.24), which is meaningfully higher than the estimated baseline rate of 0.19 (95% CI: 0.17, 0.22). Applying the conflict period rate to the Yemeni population, we estimated 168,212 excess deaths that occurred between 2015 and 2019. There was an 17.8% increase in overall deaths above the baseline during the conflict period. A large share (67.2%) of the excess deaths were due to combat-related violence. At the governorate level, posterior crude death rate varied across the country, ranging from 0.03 to 0.63 per 10,000 per day. Hajjah, Ibb, and Al Jawf governorates presented the highest total excess deaths. Insecurity level was not statistically associated with excess deaths. The health situation in Yemen was poor before the crisis in 2015. During the conflict, intentional violence from air and ground strikes were responsible for more deaths than indirect or non-violent causes. The provision of humanitarian aid by foreign agencies may have helped contain increases in indirect deaths from the conflict.

Challenges in public health and epidemiology research in humanitarian settings: experiences from the field.

BACKGROUND: Humanitarian settings often present unique scientific challenges and conditions that distinguish them from standard research settings. While a number of these challenges are faced in both standard settings and humanitarian settings, factors unique to humanitarian settings such as inaccessibility and time sensitivities further exacerbate the effects of these challenges. This analysis focuses on experiences in post-disaster contexts such as Indonesia and India following the 2004 Indian Ocean Tsunami, the Philippines following Typhoon Haiyan in 2013, and Nepal following the 2015 earthquake. DISCUSSION: Particular issues that we faced in undertaking research in post-disaster settings include challenges with uncharted ethical and cultural considerations, non-standardised administrative methods for record keeping, data sharing and dissemination. While these issues are not unique to post-disaster humanitarian settings, the time-sensitive nature of our work exacerbated the effects of these concerns. Relying on local partners and making quick decisions to tackle issues is imperative for navigating both foreseen and unforeseen challenges. While pre-emptive action to address these concerns is the most efficient means to expedite research protocols, adaptability and contingency planning are key components of practical research implementation in dynamic situations. CONCLUSIONS: Research is not always a priority in humanitarian settings, so innovative methods are necessary to conduct meaningful and situationally appropriate research in these venues. By understanding available resources, local culture, and political considerations and working efficiently and decisively, we can begin to jump hurdles associated with epidemiologic research in humanitarian settings.