Prospective Outcomes of Noma Facial Reconstructive Surgery in Sokoto, Nigeria

Background: Noma is a gangrenous infection of the face that results in severe facial deformity, occurring primarily in malnourished and impoverished populations. Objective: To assess clinician- and patient-reported outcomes (PROs) before and after reconstructive surgery for patients with noma in northwest Nigeria. Methods: Objective outcomes were recorded using the noma-specific NOITULP (nose, outer cheek, inner cheek, trismus, upper/lower lip, particularities) classification system. PROs were recorded using a locally developed tool. Postsurgical changes were assessed by Wilcoxon signed-rank testing. Linear regression was used to look for associated risk factors. The inter-rater reliability (IRR) of the NOITULP score was assessed using the weighted kappa statistic. Results: Forty-nine patients (median age 25 years, 71% male) underwent local/regional flap reconstruction and/or trismus release. Twelve complications were reported. Univariate analysis showed a 3.20 change in PRO score (95% confidence interval 0.59 to 5.81, p = 0.018) per kilogram the patient underwent at time of surgery. The NOITULP score improved from a presurgery median of 3.5 to 2.3 (p < 0.0001), however, the IRR was poor (kappa = 0.0894, p < 0.0001). The PRO score also improved from a median of 7.0 to 12.0 (p < 0.0001). Conclusions: Facial reconstructive surgery improves the NOITULP score and PROs in patients with noma in northwest Nigeria. Clinical Trial Registration: OCA017-63.

Correction: Translating drug resistant tuberculosis treatment guidelines to reality in war-torn Kandahar, Afghanistan: A retrospective cohort study

[This corrects the article DOI: 10.1371/journal.pone.0237787.].

Correction: Evaluation of community based surveillance in the Rohingya refugee camps in Cox's Bazar, Bangladesh, 2019

[This corrects the article DOI: 10.1371/journal.pone.0244214.].

Correction: Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018

[This corrects the article DOI: 10.1371/journal.pone.0269385.].

Correction: Exploring factors influencing patient mortality and loss to follow-up in two paediatric hospital wards in Zamfara, North-West Nigeria, 2016-2018

[This corrects the article DOI: 10.1371/journal.pone.0262073.].

Proportion of paediatric admissions with any stage of noma at the Anka General Hospital, northwest Nigeria

INTRODUCTION

Noma is a rapidly spreading infection of the oral cavity which mainly affects young children. Without early treatment, it can have a high mortality rate. Simple gingivitis is a warning sign for noma, and acute necrotizing gingivitis is the first stage of noma. The epidemiology of noma is not well understood. We aimed to understand the prevalence of all stages of noma in hospitalised children.

METHODS

We conducted a prospective observational study from 1st June to 24th October 2021, enrolling patients aged 0 to 12 years who were admitted to the Anka General Hospital, Zamfara, northwest Nigeria. Consenting parents/ guardians of participants were interviewed at admission. Participants had anthropometric and oral examinations at admission and discharge.

FINDINGS

Of the 2346 patients, 58 (2.5%) were diagnosed with simple gingivitis and six (n = 0.3%) with acute necrotizing gingivitis upon admission. Of those admitted to the Inpatient Therapeutic Feeding Centre (ITFC), 3.4% (n = 37, CI 2.5-4.7%) were diagnosed with simple gingivitis upon admission compared to 1.7% of those not admitted to the ITFC (n = 21, CI 1.1-2.6%) (p = 0.008). Risk factors identified for having simple gingivitis included being aged over two years (2 to 6 yrs old, odds ratio (OR) 3.4, CI 1.77-6.5; 7 to 12 yrs OR 5.0, CI 1.7-14.6; p = <0.001), being admitted to the ITFC (OR 2.1; CI 1.22-3.62) and having oral health issues in the three months prior to the assessment (OR 18.75; CI 10.65, 33.01). All (n = 4/4) those aged six months to five years acute necrotizing gingivitis had chronic malnutrition.

CONCLUSION

Our study showed a small proportion of children admitted to the Anka General Hospital had simple or acute necrotizing gingivitis. Hospital admission with malnutrition was a risk factor for both simple and acute necrotizing gingivitis. The lack of access to and uptake of oral health care indicates a strong need for oral examinations to be included in routine health services. This provision could improve the oral status of the population and decrease the chance of patients developing noma.

Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study

BACKGROUND

The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known.

METHODS

We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition.

RESULTS

Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU.

CONCLUSIONS

Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.

Retrospective analysis of fungemia among children in Anka General Hospital, Nigeria, from October 2018 to November 2021: a case series

Yeast-related bloodstream infections (BSIs) in pediatric patients are associated with severe acute malnutrition (SAM), hematological/oncological malignancies and admission to an intensive care unit. These infections are rarely described from low- and middle-income countries. We describe a case series of pediatric patients diagnosed with severe sepsis and yeast isolated from their blood culture in a conflict-affected area of Nigeria from October 2018 to November 2021. We identified 20 patients with yeast BSIs, among whom 17 were also diagnosed with SAM. We recommend the inclusion of antifungal treatment for empiric treatment guidelines for children with SAM and severe sepsis in similar settings.

Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018

In low-resource settings, detection of healthcare-acquired outbreaks in neonatal units relies on astute clinical staff to observe unusual morbidity or mortality from sepsis as microbiological diagnostics are often absent. We aimed to generate reliable (and automated) early warnings for potential clusters of neonatal late onset sepsis using retrospective data that could signal the start of an outbreak in an NCU in Port au Prince, Haiti, using routinely collected data on neonatal admissions. We constructed smoothed time series for late onset sepsis cases, late onset sepsis rates, neonatal care unit (NCU) mortality, maternal admissions, neonatal admissions and neonatal antibiotic consumption. An outbreak was defined as a statistical increase in any of these time series indicators. We created three outbreak alarm classes: 1) thresholds: weeks in which the late onset sepsis cases exceeded four, the late onset sepsis rates exceeded 10% of total NCU admissions and the NCU mortality exceeded 15%; 2) differential: late onset sepsis rates and NCU mortality were double the previous week; and 3) aberration: using the improved Farrington model for late onset sepsis rates and NCU mortality. We validated pairs of alarms by calculating the sensitivity and specificity of the weeks in which each alarm was launched and comparing each alarm to the weeks in which a single GNB positive blood culture was reported from a neonate. The threshold and aberration alarms were the strongest predictors for current and future NCU mortality and current LOS rates (p<0.0002). The aberration alarms were also those with the highest sensitivity, specificity, negative predictive value, and positive predictive value. Without microbiological diagnostics in NCUs in low-resource settings, applying these simple algorithms to routinely collected data show great potential to facilitate early warning for possible healthcare-acquired outbreaks of LOS in neonates. The methods used in this study require validation across other low-resource settings.

Exploring factors influencing patient mortality and loss to follow-up in two paediatric hospital wards in Zamfara, North-West Nigeria, 2016-2018

INTRODUCTION

Child mortality has been linked to infectious diseases, malnutrition and lack of access to essential health services. We investigated possible predictors for death and patients lost to follow up (LTFU) for paediatric patients at the inpatient department (IPD) and inpatient therapeutic feeding centre (ITFC) of the Anka General Hospital (AGH), Zamfara State, Nigeria, to inform best practices at the hospital.

METHODS

We conducted a retrospective cohort review study using routinely collected data of all patient admissions to the IPD and ITFC with known hospital exit status between 2016 and 2018. Unadjusted and adjusted rate ratios (aRR) and respective 95% confidence intervals (95% CI) were calculated using Poisson regression to estimate the association between the exposure variables and mortality as well as LTFU.

RESULTS

The mortality rate in IPD was 22% lower in 2018 compared to 2016 (aRR 0.78; 95% CI 0.66-0.93) and 70% lower for patients coming from lead-affected villages compared to patients from other villages (aRR 0.30; 95% CI 0.19-0.48). The mortality rate for ITFC patients was 41% higher during rainy season (aRR 1.41; 95% CI 1.2-1.6). LTFU rates in ITFC increased in 2017 and 2018 when compared to 2016 (aRR 1.6; 95% CI 1.2-2.0 and aRR 1.4; 95% CI 1.1-1.8) and patients in ITFC had 2.5 times higher LTFU rates when coming from a lead-affected village.

CONCLUSIONS

Our data contributes clearer understanding of the situation in the paediatric wards in AGH in Nigeria, but identifying specific predictors for the multifaceted nature of mortality and LTFU is challenging. Mortality in paediatric patients in IPD of AGH improved during the study period, which is likely linked to better awareness of the hospital, but still remains high. Access to healthcare due to seasonal restrictions contributes to mortalities due to late presentation. Increased awareness of and easier access to healthcare, such as for patients living in lead-affected villages, which are still benefiting from an MSF lead poisoning intervention, decreases mortalities, but increases LTFU. We recommend targeted case audits and qualitative studies to better understand the role of health-seeking behaviour, and social and traditional factors in the use of formal healthcare in this part of Nigeria and potentially similar settings in other countries.

Noma (cancrum oris): A scoping literature review of a neglected disease (1843 to 2021)

Background

Noma (cancrum oris) is an ancient but neglected and poorly understood preventable disease, afflicting the most disenfranchised populations in the world. It is a devastating and often fatal condition that requires urgent and intensive clinical and surgical care, often difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and identify research gaps that need to be addressed to evolve our understanding of how to address this disease.

Methods

We searched 11 databases and collected primary peer reviewed articles on noma in all languages, the final search was conducted on 24^th August 2021. The oldest manuscript identified was from 28^th March 1843 and the most recently published manuscript was from 3^rd June 2021. Search terms included cancrum oris and noma. Data was extracted using a standardised data extraction tool and key areas of interest were identified. The Preferred Reporting Items for Systemic review and Meta-Analyses requirements were followed.

Results

The review included 147 articles, the majority of the studies (n = 94, 64%) were case reports. Most manuscripts (n = 81, 55%) were published in the 2000s, 49 (33%) were from the 1900s and 17 (12%) from the 1800s. The main areas of interest identified were the history and epidemiology of the disease, noma’s clinical progression and aetiology, treatment regimens, mortality rates and the risk factors for the development of noma.

Conclusions

Noma has been reported in the literature for hundreds of years; however important gaps in our understanding of the disease remain. Future research should focus on determining the burden and distribution of disease; the true mortality rate, pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.

Noma is a devastating and often fatal condition that mainly affects children in severely disenfranchised communities. Noma is preventable and requires urgent basic medical care in the early stages of disease. Once the disease reaches the last stage, sequelae, survivors require expert surgical care, usually difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and to identify research priorities that will evolve our understanding of how to eradicate this disease. Our review showed that noma has been reported in the literature for hundreds of years; however several major gaps in knowledge still exist. There is appreciation among the small community of clinicians and researchers involved in noma care and research that these gaps in knowledge impact on the ability to develop and implement sound evidence-based policies and activities aimed at eradicating noma from communities that continue to be afflicted by this ancient disease. The main focus of future research should be to study the burden and distribution of disease; the true mortality rate, and the pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti

Objectives.

To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-)eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes.

Methods.

We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services.

Results.

A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55–6.55) and low birthweight (OR 1.40; 95% CI 1.05–1.86) for women with complicated pregnancies.

Conclusion.

To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended.

Model of care, Noma Children's Hospital, northwest Nigeria

The Nigerian Ministry of Health has been offering care for noma patients for many years at the Noma Children’s Hospital (NCH) in Sokoto, northwest Nigeria, and Médecins Sans Frontières has supported these initiatives since 2014. The comprehensive model of care consists of four main components: acute care, care for noma sequelae, integrated hospital‐based services and community‐based services. The model of care is based on the limited evidence available for prevention and treatment of noma and follows WHO’s protocols for acute patients and best practice guidelines for the surgical treatment of noma survivors. The model is updated continually as new evidence becomes available, including evidence generated through the operational research studies performed at NCH. By describing the model of care, we wish to share the lessons learned with other actors working in the noma and neglected tropical disease sphere in the hope of guiding programme development.

Predictors of virological failure among people living with HIV receiving first line antiretroviral treatment in Myanmar: retrospective cohort analysis

Background

Progress toward the global target for 95% virological suppression among those on antiretroviral treatment (ART) is still suboptimal. We describe the viral load (VL) cascade, the incidence of virological failure and associated risk factors among people living with HIV receiving first-line ART in an HIV cohort in Myanmar treated by the Médecins Sans Frontières in collaboration with the Ministry of Health and Sports Myanmar.

Methods

We conducted a retrospective cohort study, including adult patients with at least one HIV viral load test result and having received of at least 6 months’ standard first-line ART. The incidence rate of virological failure (HIV viral load ≥ 1000 copies/mL) was calculated. Multivariable Cox’s regression was performed to identify risk factors for virological failure.

Results

We included 25,260 patients with a median age of 33.1 years (interquartile range, IQR 28.0–39.1) and a median observation time of 5.4 years (IQR 3.7–7.9). Virological failure was documented in 3,579 (14.2%) participants, resulting in an overall incidence rate for failure of 2.5 per 100 person-years of follow-up. Among those who had a follow-up viral load result, 1,258 (57.1%) had confirmed virological failure, of which 836 (66.5%) were switched to second-line treatment. An increased hazard for failure was associated with age ≤ 19 years (adjusted hazard ratio, aHR 1.51; 95% confidence intervals, CI 1.20–1.89; p < 0.001), baseline tuberculosis (aHR 1.39; 95% CI 1.14–1.49; p < 0.001), a history of low-level viremia (aHR 1.60; 95% CI 1.42–1.81; p < 0.001), or a history of loss-to-follow-up (aHR 1.24; 95% CI 1.41–1.52; p = 0.041) and being on the same regimen (aHR 1.37; 95% CI 1.07–1.76; p < 0.001). Cumulative appointment delay was not significantly associated with failure after controlling for covariates.

Conclusions

VL monitoring is an important tool to improve programme outcomes, however limited coverage of VL testing and acting on test results hampers its full potential. In our cohort children and adolescents, PLHIV with history of loss-to-follow-up or those with low-viremia are at the highest risk of virological failure and might require more frequent virological monitoring than is currently recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00336-0.

Growth and neurodevelopment in low birth weight versus normal birth weight infants from birth to 24 months, born in an obstetric emergency hospital in Haiti, a prospective cohort study

BACKGROUND

Low birthweight (LBW) infants are at higher risk of mortality and morbidity (growth, chronic disease and neurological problems) during their life. Due to the high incidence of (pre-) eclampsia in Haiti, LBW infants are common. We assessed the anthropometric growth (weight and length) and neurodevelopmental delay in LBW and normal birthweight (NBW) infants born at an obstetric emergency hospital in Port au Prince, Haiti, between 2014 and 2017.

METHODS

Infants were followed at discharge and 3, 6, 12, 15, 18, 21 and 24 months of corrected gestational age. At each visit they underwent a physical checkup (weight, length, physical abnormalities, identification of morbidities). At 6, 12, 18 and 24 months they underwent a neurodevelopmental assessment using the Bayley Scale III (motor, cognitive and communication skills). We modelled the trajectories between birth and 24 months of age of NBW compared to LBW infants for weight, length, and raw scores for Bayley III assessments using mixed linear models.

RESULTS

In total 500 LBW and 210 NBW infants were recruited of which 333 (46.7%) were followed up for 24 months (127 NBW; 60.5% and 206 LBW; 41.2%) and 150 died (LBW = 137 and NBW = 13). LBW and NBW babies gained a mean 15.8 g and 11.4 g per kg of weight from discharge per day respectively. The speed of weight gain decreased rapidly after 3 months in both groups. Both groups grow rapidly up to 6 months of age. LBW grew more than the NBW group during this period (22.8 cm vs. 21.1 cm). Both groups had WHZ scores <- 2 up to 15 months. At 24 months NBW babies scored significantly higher on the Bayley scales for gross motor, cognitive and receptive and expressive communication skills. There was no difference between the groups for fine motor skills.

CONCLUSION

LBW babies that survive neonatal care in urban Haiti and live up to 24 months of age, perform similar to their NBW for weight, length and fine motor skills. LBW babies are delayed in gross motor, cognitive and communication skills development. Further research on the clinical significance of these findings and long term implications of this neurodevelopmental delay is needed.

Evaluation of community based surveillance in the Rohingya refugee camps in Cox's Bazar, Bangladesh, 2019

BACKGROUND

Following an influx of an estimated 742,000 Rohingya refugees in Bangladesh, Médecins sans Frontières (MSF) established an active indicator-based Community Based Surveillance (CBS) in 13 sub-camps in Cox's Bazar in August 2017. Its objective was to detect epidemic prone diseases early for rapid response. We describe the surveillance, alert and response in place from epidemiological week 20 (12 May 2019) until 44 (2 November 2019).

METHODS

Suspected cases were identified through passive health facility surveillance and active indicator-based CBS. CBS-teams conducted active case finding for suspected cases of acute watery diarrhea (AWD), acute jaundice syndrome (AJS), acute flaccid paralysis (AFP), dengue, diphtheria, measles and meningitis. We evaluate the following surveillance system attributes: usefulness, Positive Predictive Value (PPV), timeliness, simplicity, flexibility, acceptability, representativeness and stability.

RESULTS

Between epidemiological weeks 20 and 44, an average of 97,340 households were included in the CBS per surveillance cycle. Household coverage reached over 85%. Twenty-one RDT positive cholera cases and two clusters of AWD were identified by the CBS and health facility surveillance that triggered the response mechanism within 12 hours. The PPV of the CBS varied per disease between 41.7%-100%. The CBS required 354 full-time staff in 10 different roles. The CBS was sufficiently flexible to integrate dengue surveillance. The CBS was representative of the population in the catchment area due to its exhaustive character and high household coverage. All households consented to CBS participation, showing acceptability.

DISCUSSION

The CBS allowed for timely response but was resource intensive. Disease trends identified by the health facility surveillance and suspected diseases trends identified by CBS were similar, which might indicate limited additional value of the CBS in a dense and stable setting such as Cox's Bazar. Instead, a passive community-event-based surveillance mechanism combined with health facility-based surveillance could be more appropriate.

Bridging research integrity and global health epidemiology (BRIDGE) guidelines: explanation and elaboration

Over the past decade, two movements have profoundly changed the environment in which global health epidemiologists work: research integrity and research fairness. Both ought to be equally nurtured by global health epidemiologists who aim to produce high quality impactful research. Yet bridging between these two aspirations can lead to practical and ethical dilemmas. In the light of these reflections we have proposed the BRIDGE guidelines for the conduct of fair global health epidemiology, targeted at stakeholders involved in the commissioning, conduct, appraisal and publication of global health research. The guidelines follow the conduct of a study chronologically from the early stages of study preparation until the dissemination and communication of findings. They can be used as a checklist by research teams, funders and other stakeholders to ensure that a study is conducted in line with both research integrity and research fairness principles. In this paper we offer a detailed explanation for each item of the BRIDGE guidelines. We have focused on practical implementation issues, making this document most of interest to those who are actually conducting the epidemiological work.

Bridging research integrity and global health epidemiology (BRIDGE) statement: guidelines for good epidemiological practice

BACKGROUND

Research integrity and research fairness have gained considerable momentum in the past decade and have direct implications for global health epidemiology. Research integrity and research fairness principles should be equally nurtured to produce high-quality impactful research-but bridging the two can lead to practical and ethical dilemmas. In order to provide practical guidance to researchers and epidemiologist, we set out to develop good epidemiological practice guidelines specifically for global health epidemiology, targeted at stakeholders involved in the commissioning, conduct, appraisal and publication of global health research.

METHODS

We developed preliminary guidelines based on targeted online searches on existing best practices for epidemiological studies and sought to align these with key elements of global health research and research fairness. We validated these guidelines through a Delphi consultation study, to reach a consensus among a wide representation of stakeholders.

RESULTS

A total of 45 experts provided input on the first round of e-Delphi consultation and 40 in the second. Respondents covered a range of organisations (including for example academia, ministries, NGOs, research funders, technical agencies) involved in epidemiological studies from countries around the world (Europe: 19; Africa: 10; North America: 7; Asia: 5; South-America: 3 Australia: 1). A selection of eight experts were invited for a face-to-face meeting. The final guidelines consist of a set of 6 standards and 42 accompanying criteria including study preparation, protocol development, data collection, data management, data analysis, dissemination and communication.

CONCLUSION

While guidelines will not by themselves guard global health from questionable and unfair research practices, they are certainly part of a concerted effort to ensure not only mutual accountability between individual researchers, their institutions and their funders but most importantly their joint accountability towards the communities they study and society at large.

Rectal screening displays high negative predictive value for bloodstream infection with (ESBL-producing) Gram-negative bacteria in neonates with suspected sepsis in a low-resource setting neonatal care unit

OBJECTIVES

We analysed the concordance of rectal swab isolates and blood culture for Gram-negative bacteria (GNB) isolates in neonates with a suspicion of neonatal sepsis admitted to a neonatal care unit in Haiti.

METHODS

We matched pairs of blood and rectal samples taken on the date of suspected sepsis onset in the same neonate. We calculated the proportion of rectal isolates in concordance with the blood isolates by species and genus. We calculated the negative predictive value (NPV) for GNB and extended-spectrum β-lactamase (ESBL)-producing GNB for all rectal and blood isolate pairs in neonates with suspected sepsis.

RESULTS

We identified 238 blood and rectal samples pairs, with 238 blood isolate results and 309 rectal isolate results. The overall concordance in genus and species between blood and rectal isolates was 22.3% [95% confidence interval (CI) 17.4-28.0%] and 20.6% (95% CI 16.0-26.2%), respectively. The highest concordance between blood and rectal isolates was observed for samples with no bacterial growth (65%), followed byKlebsiella pneumoniae (18%) and Klebsiella oxytoca (12%). The NPV of detecting GNB bacterial isolates in rectal samples compared with those in blood samples was 81.6% and the NPV for ESBL-positive GNB was 92.6%.

CONCLUSIONS

The NPV of rectal swab GNB isolates was high in all patient groups and was even higher for ESBL-positive GNB. Clinicians can use the results from rectal swabs when taken simultaneously with blood samples during outbreaks to inform the (de-)escalation of antibiotic therapy in those neonates that have an ongoing sepsis profile.

Translating drug resistant tuberculosis treatment guidelines to reality in war-torn Kandahar, Afghanistan: A retrospective cohort study

INTRODUCTION

Afghanistan is affected by one of the world's longest protracted armed conflicts, frequent natural disasters, disease outbreaks and large population movements and it suffers from a high burden of tuberculosis (TB), including rifampicin-resistant TB (RR-TB). The study shows Médecins Sans Frontières' experiences with care for patients with RR-TB in Kandahar Province. We describe the uptake of RR-TB treatment, how World Health Organisation criteria for the choice between the short and an individualized regimen were implemented, and treatment outcomes.

METHODS

This is a retrospective cohort analysis of routinely collected data from RR-TB patients enrolled in care from 2016 until 2019. Descriptive analysis was performed to present characteristics of patients and treatment outcomes. Multivariable Cox analysis was performed to identify risk factors for having an unfavourable treatment outcome.

RESULTS

Out of 146 enrolled RR-TB patients, 112 (76.7%) started treatment: 41 (36.6%) and 71 (63.4%) with the short and individualized treatment regimen, respectively. Of 82 with results for fluoroquinolone susceptibility, 39 (47.6%) had fluoroquinolone-resistant TB. Seven patients with initially fluoroquinolone-resistant TB and three pregnant women started the short regimen and 18 patients eligible for the short regimen started the injectable-free individualized regimen. Overall, six-month smear and culture conversion were 98.7% and 97.1%, respectively; treatment success was 70.1%. Known initial fluoroquinolone resistance (aHR 3.77, 95%CI:1.53-9.27) but not choice of regimen predicted having an unfavourable outcome.

CONCLUSION

Even though criteria for the choice of treatment regimen were not applied strictly, we have achieved acceptable outcomes in this cohort. To expand RR-TB care, treatment regimens should fit provision at primary health care level and take patient preferences into account.

Does community-wide water chlorination reduce hepatitis E virus infections during an outbreak? A geospatial analysis of data from an outbreak in Am Timan, Chad (2016-2017)

Hepatitis E Virus (HEV) genotype 1 and 2 infect an estimated 20 million people each year, via the faecal-oral transmission route. An urban outbreak of HEV occurred in Am Timan, Chad, between September 2016 and April 2017. As part of the outbreak response, Médecins Sans Frontières and the Ministry of Health implemented water and hygiene interventions, including the chlorination of town water sources. We aimed to understand whether these water treatment activities had any impact on the number of HEV infections, using geospatial analysis of epidemiological and water treatment monitoring data. By conducting cluster analysis we investigated whether there were areas of particularly high and low infection risk during the outbreak and explored the reasons for this. We observed two high-risk spatial clusters of suspected cases and one high-risk cluster of confirmed cases. Our main finding was that confirmed HEV cases had a higher median number of days of exposure to unsafe water compared to suspected and non-confirmed cases (Kruskal-Wallis Chi Square: 15.5; p < 0.001). Our study confirms the mixed, but shifting, transmission routes during this outbreak. It also highlights the spatial and temporal analytical methods, which can be employed in future outbreaks to improve understanding of HEV transmission.

'I treat it but I don't know what this disease is': a qualitative study on noma (cancrum oris) and traditional healing in northwest Nigeria

Background

Noma, a neglected disease mostly affecting children, with a 90% mortality rate if untreated, is an orofacial gangrene that disintegrates the tissues of the face in <1 wk. Noma can become inactive with early stage antibiotic treatment. Traditional healers, known as mai maganin gargajiya in Hausa, play an important role in the health system and provide care to noma patients.

Methods

We conducted 12 in-depth interviews with caretakers who were looking after noma patients admitted at the Noma Children's Hospital and 15 traditional healers in their home villages in Sokoto state, northwest Nigeria. We explored perceptions of noma, relationship dynamics, healthcare practices and intervention opportunities. Interviews were audiorecorded, transcribed and translated. Manual coding and thematic analysis were utilised.

Results

Traditional healers offered specialised forms of care for specific conditions and referral guidance. They viewed the stages of noma as different conditions with individualised remedies and were willing to refer noma patients. Caretakers trusted traditional healers.

Conclusions

Traditional healers could play a crucial role in the early detection of noma and the health-seeking decision-making process of patients. Intervention programmes should include traditional healers through training and referral partnerships. This collaboration could save lives and reduce the severity of noma complications.

The prevalence of noma in northwest Nigeria

Background

Noma, a rapidly progressing infection of the oral cavity, mainly affects children. The true burden is unknown. This study reports estimated noma prevalence in children in northwest Nigeria.

Methods

Oral screening was performed on all ≤15 year olds, with caretaker consent, in selected households during this cross-sectional survey. Noma stages were classified using WHO criteria and caretakers answered survey questions. The prevalence of noma was estimated stratified by age group (0–5 and 6–15 years). Factors associated with noma were estimated using logistic regression.

Results

A total of 177 clusters, 3499 households and 7122 children were included. In this sample, 4239 (59.8%) were 0–5 years and 3692 (52.1%) were female. Simple gingivitis was identified in 3.1% (n=181; 95% CI 2.6 to 3.8), acute necrotising gingivitis in 0.1% (n=10; CI 0.1 to 0.3) and oedema in 0.05% (n=3; CI 0.02 to 0.2). No cases of late-stage noma were detected. Multivariable analysis in the group aged 0–5 years showed having a well as the drinking water source (adjusted odds ratio (aOR) 2.1; CI 1.2 to 3.6) and being aged 3–5 years (aOR 3.9; CI 2.1 to 7.8) was associated with being a noma case. In 6–15 year olds, being male (aOR 1.5; CI 1.0 to 2.2) was associated with being a noma case and preparing pap once or more per week (aOR 0.4; CI 0.2 to 0.8) was associated with not having noma. We estimated that 129120 (CI 105294 to 1 52 947) individuals <15 years of age would have any stage of noma at the time of the survey within the two states. Most of these cases (93%; n=120 082) would be children with simple gingivitis.

Conclusions

Our study identified a high prevalence of children at risk of developing advanced noma. This disease is important but neglected and therefore merits inclusion in the WHO neglected tropical diseases list.

Language and beliefs in relation to noma: a qualitative study, northwest Nigeria

Background

Noma is an orofacial gangrene that rapidly disintegrates the tissues of the face. Little is known about noma, as most patients live in underserved and inaccessible regions. We aimed to assess the descriptive language used and beliefs around noma, at the Noma Children’s Hospital in Sokoto, Nigeria. Findings will be used to inform prevention programs.

Methods

Five focus group discussions (FGD) were held with caretakers of patients with noma who were admitted to the hospital at the time of interview, and 12 in-depth interviews (IDI) were held with staff at the hospital. Topic guides used for interviews were adapted to encourage the natural flow of conversation. Emergent codes, patterns and themes were deciphered from the data derived from IDI’s and FGDs.

Results

Our study uncovered two main themes: names, descriptions and explanations for the disease, and risks and consequences of noma. Naming of the disease differed between caretakers and heath care workers. The general names used for noma illustrate the beliefs and social system used to explain the disease. Beliefs were varied; participant responses demonstrate a wide range of understanding of the disease and its causes. Difficulty in accessing care for patients with noma was evident and the findings suggest a variety of actions taking place before reaching a health center or health worker. Patient caretakers mentioned that barriers to care included a lack of knowledge regarding this medical condition, as well as a lack of trust in seeking medical care. Participants in our study spoke of the mental health strain the disease placed on them, particularly due to the stigma that is associated with noma.

Conclusions

Caretaker and practitioner perspectives enhance our understanding of the disease in this context and can be used to improve treatment and prevention programs, and to better understand barriers to accessing health care. Differences in disease naming illustrate the difference in beliefs about the disease. This has an impact on health seeking behaviours, which for noma cases has important ramifications on outcomes, due to the rapid progression of the disease.

Noma (cancrum oris) is an orofacial gangrene that rapidly disintegrates the hard and soft tissues of the face. Little is known about noma as most cases live in underserved and inaccessible regions. We aimed to assess the language used and beliefs around noma, in northwest Nigeria. Findings will be used to inform prevention programs. Five focus group discussions were held with caretakers of patients with noma admitted to the hospital at the time of interview, and 12 in-depth interviews were held with staff at the hospital. Our study uncovered two main themes: names; descriptions and explanations for the disease, and risks and consequences of noma. Naming of the disease differed between caretakers and heath care workers. Difficulty in accessing care for patients with noma was evident. Barriers to care and lack of knowledge and trust were evident. The impact of noma was not limited to physical presentation; stigmatisation was mentioned as a key difficulty. Differences in disease naming illustrate the difference in beliefs and has an impact on health seeking behaviour, which for noma cases, has severe ramifications due to the rapid progression of the disease.

Trauma in the Kashmir Valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety

BACKGROUND

The negative psychological impact of living in a setting of protracted conflict has been well studied, however there is a recognized need to understand the role that non-conflict related factors have on mediating exposure to trauma and signs of psychological distress.

METHODS

We used data from the 2015 Kashmir Mental Health Survey and conducted mediation analysis to assess the extent to which daily stressors mediated the effect of traumatic experiences on poor mental health outcomes. Outcomes of interest were probable diagnosis of anxiety, depression, or PTSD; measured using the pre-validated Hopkins Symptoms Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ).

RESULTS

Total effect mediated were statistically significant but the proportions of effect mediated were found to be small in practical terms. Financial stress mediated 6.8% [95% Confidence Interval (CI) 6∙0-8∙4], 6.7% [CI 6.2-7∙7] and 3.6% [CI 3∙4-4∙0] of the effect of experiencing multiple traumaticogenic events on symptoms of anxiety, depression and PTSD, respectively. Family stress mediated 11.3% [CI 10.3-13.8], 10.3% [CI 9.5-11.9] and 6.1% [CI 5.7-6.7] of the effect of experiencing multiple traumatogenic events on symptoms of anxiety, depression and PTSD, respectively. Poor physical health mediated 10.0% [CI 9.1-12∙0], 7.2% [CI 6.6-8.2] and 4.0% [CI 3.8,4.4] of the effect of experiencing more than seven traumatic events on symptoms of anxiety, depression and PTSD, respectively.

CONCLUSION

Our findings highlight that not only do we need to move beyond a trauma-focussed approach to addressing psychological distress in populations affected by protracted conflict but we must also move beyond focussing on daily stressors as explanatory mediators.

Dua Ti Dawa Ti: understanding psychological distress in the ten districts of the Kashmir Valley and community mental health service needs

Background

An extensive body of research exists looking at the level of psychological distress in populations affected by political conflict. Recommended response to psychological distress in humanitarian crises is still based on frameworks for interventions developed in western/European contexts including psychological first aid, counselling and group therapy. While there is growing, but limited, evidence that culturally modified interventions can lead to reduction in symptoms of psychological distress in conflict affected populations, there is a need to understand mental health help-seeking behaviour and mental health service needs from the perspective of affected communities.

Methods

This study employed a qualitative exploratory research design based on principles of grounded theory. A combination of convenience and snowball sampling was used to recruit 186 adults from the general population to 20 focus group discussions; 95 men, median age 40 years, interquartile range (IQR): 27–48 years and 91 women, median age 40 years IQR: 32–50 years. Trained Kashmiri facilitators used a semi-structured interview guide to ascertain community perceptions on mental illness, help-seeking and service needs from the perspective of communities in the Kashmir Valley. Content analysis of transcripts resulted in the identification of seven overarching themes.

Results

Common locally recognized symptoms of psychological distress were synonymous with symptoms listed in the Hopkins Symptoms Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). Protracted political insecurity was highlighted as a major perceived cause of psychological distress in communities. Mental health help-seeking included traditional/spiritual healers in combination with practitioners of western medicine, with access highlighted as the main barrier. Divergent views were expressed on the effectiveness of treatment received. Participants’ expressed the need for investment in mental health literacy to improve the community’s capacity to recognize and support those suffering from psychological distress.

Conclusions

Our findings demonstrate the universality of symptoms of psychological distress whilst simultaneously highlighting the importance of recognizing the cultural, spiritual and contextual framework within which psychological distress is understood and manifest. Co-constructed models of community based mental health services are needed.

Événements indésirables au cours de transfert interhospitalier de patients présentant un syndrome coronaire aigu non ST+

Introduction : Cette étude a pour objectif de connaître l’incidence et la nature des événements indésirables (EI) se produisant lors des transports interhospitaliers (TIH) des patients souffrant d’un syndrome coronarien aigu sans sus-décalage du segment ST (SCA non ST+). L’objectif secondaire est d’étudier les performances pronostiques des différentes évaluations de risque existantes de ces malades (score de GRACE, score de TIMI, grille de Fiancette et niveau de risque de la Société européenne de cardiologie [ESC]) dans la prédiction de ces EI.

Méthode : Il s’agit d’une étude de cohorte multicentrique rétrospective. Du 1er novembre 2016 au 31 octobre 2017, les patients SCA non ST+ et bénéficiant d’un transport secondaire ont été inclus à partir des fiches de régulation de trois Samu du sud-ouest de la France. Les types d’EI ont été recueillis. Les différents scores ont été calculés pour chaque patient ainsi que leur performance pronostique (sensibilité, spécificité, valeurs prédictives positives [VPP] et négatives [VPN]).

Résultats : Sur un an, 315 patients ont été inclus, et neuf patients (3 % ; IC 95 % : 1,3–5,3) ont présenté un EI. Soixante-dix-huit pour cent des événements recueillis n’ont pas engagé le pronostic vital des patients, et 40 % n’ont pas nécessité d’intervention thérapeutique nécessitant la présence physique d’un médecin. Aucun score n’est retrouvé statistiquement significatif dans la prédiction des EI. Toutefois, la stratification du risque de la ESC semble être la plus simple d’utilisation tout en assurant une valeur prédictive négative de 98 % (IC 95 % : 94–99).

Conclusion : Il y a peu d’EI lors du transport des SCA non ST+. L’utilisation en régulation de l’évaluation du risque ischémique de la ESC pourrait réduire la surmédicalisation de ces malades au bénéfice des TIH.

Risks and seasonal pattern for mortality among hospitalized infants in a conflict-affected area of Pakistan, 2013-2016. A retrospective chart review

Background: In recent years, Médecins Sans Frontières has observed high mortality rates among hospitalized infants in Pakistan. We describe the clinical characteristics of the infants admitted between 2013 and 2016 in order to acquire a better understanding on the risk factors for mortality. 

Methods: We analyzed routinely collected medical data from infants (<7 months) admitted in Chaman and Dera Murad Jamali (DMJ) hospitals. The association between clinical characteristics and mortality was estimated using Poisson regression.

Results: Between 2013 and 2016, 5,214 children were admitted (male/female ratio: 1.60) and 1,178 (23%) died. Days since admission was associated with a higher risk of mortality and decreased with each extra day of admission after seven days. The first 48 hours of admission was strongly associated with a higher risk of mortality. A primary diagnosis of tetanus, necrotizing enterocolitis, prematurity, sepsis and hypoxic-ischemic encephalopathy were strongly associated with higher rates of mortality. We observed an annual peak in the mortality rate in September.

Conclusions: The first days of admission are critical for infant survival. Furthermore, the found male/female ratio was exceedingly higher than the national ratio of Pakistan. The observed seasonality in mortality rate by week has not been previously reported. It is fully recommended to do further in-depth research on male/female ratio differences and the reasons behind the annual peaks in mortality rate by week.

Inclusion of Real-Time Hand Hygiene Observation and Feedback in a Multimodal Hand Hygiene Improvement Strategy in Low-Resource Settings

Importance

Hand hygiene adherence monitoring and feedback can reduce health care-acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings.

Objective

To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers' hand hygiene adherence data.

Design, Setting, and Participants

This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children's Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018.

Exposures

Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time.

Main Outcomes and Measures

Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene.

Results

A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children's Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children's Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children's Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient's surroundings (47.1% [124 of 263 moments]).

Conclusions and Relevance

This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.

High levels of mortality, exposure to violence and psychological distress experienced by the internally displaced population of Ein Issa camp prior to and during their displacement in Northeast Syria, November 2017

Background

War in Syria has lasted for more than eight years, causing population displacement, collapse of medical and public health services, extensive violence and countless deaths. Since November 2016, military operations in Northeast Syria intensified. In October 2017 a large influx of internally displaced persons (IDPs) arrived to Ein Issa camp, Raqqa governate. Médecins Sans Frontières (MSF) assessed the health status of recently arrived IDPs in Ein Issa camp.

Methods

MSF carried out a cross-sectional survey using simple random sampling between 8 and 18 November 2017, enrolling households who had arrived to Ein Issa camp since 1 October 2017. A questionnaire collected data on demographics, history of displacement, retrospective one-year mortality, two-week morbidities, non-communicable diseases, exposure to violence in the last year and two-week psychological distress symptoms among all household members as well as vaccination status in children aged 6 to 59 months. The latter were also screened for malnutrition. Prevalence estimates and mortality rates were calculated with their 95% confidence interval. Mortality rates were calculated as the number of deaths/10,000 persons/day using the individual person-day contribution of all household members.

Results

MSF surveyed 257 households (1482 participants). They reported 31 deaths in the previous year, resulting in a crude mortality rate of 0.56 deaths/10,000 persons/day (95%CI: 0.39–0.80). Conflict-related violence was the most frequently reported cause of death (64.5%). In the previous year, 31.7% (95%CI: 29.4–34.2) of the participants experienced at least one violent episode. The most frequent type of violence reported was witnessing atrocities (floggings, executions or public body displays); 18.9% (95%CI: 17.0–21.0) of the population and 9.8% (95%CI: 7.9–12.0) of the children under 15 years had witnessed such atrocities. In men over 14 years, 15.8% (95%CI: 11.9–20.8) were detained/kidnapped and 11.3% (95%CI: 8.0–15.8) tortured/beaten/attacked. In the two weeks prior to interview, 14.4% (95%CI: 10.6–19.3) of the respondents felt so hopeless that they did not want to carry on living most of the time.

Conclusions

High levels of mortality, exposure to violence and psychological distress were reported. These survey results increase understanding of the impact of the conflict on the IDP population in Northeast Syria.

Outcomes of an individual counselling programme in Grozny, Chechnya: a randomised controlled study

OBJECTIVES

To evaluate the effectiveness of individual counselling on functioning of clients participating in a mental health intervention in a humanitarian setting.

DESIGN

Randomised controlled trial.

SETTING

Mental health programme implemented by Médecins Sans Frontières in Grozny, Republic of Chechnya.

PARTICIPANTS

168 eligible clients were randomly assigned to the intervention and waitlisted (2 months) arms between November 2014 and February 2015.

INTERVENTION

Individual counselling sessions.

MAIN OUTCOME MEASURES

Change in functioning was measured using the Short Form 6 (SF6) and gender-specific locally adapted Chechen functioning instruments in the intervention group at the end of counselling and the waitlisted group after their waitlisted period. Unadjusted differences in gain scores (DGSs) between intervention and waitlisted groups were calculated with effect size (Cohen's d) for both tools. Linear regression compared the mean DGS in both groups.

RESULTS

The intervention group (n=78) improved compared with waitlisted controls (n=80) on the SF6 measures with moderate to large effect sizes: general health (DGS 12.14, d=0.52), body pain (DGS 10.26, d=0.35), social support (DGS 16.07, d=0.69) and emotional functioning (DGS 16.87, d=0.91). Similar improvement was seen using the Chechen functioning instrument score (female DGS -0.33, d=0.55; male DGS -0.40, d=0.99). Adjusted analysis showed significant improvement (p<0.05) in the intervention group for all SF6 measures and for the Chechen functioning instrument score in women but not men (p=0.07).

CONCLUSIONS

Individual counselling significantly improved participants' ability to function in the intervention group compared with the waitlisted group. Further research is needed to determine whether similar positive results can be shown in other settings and further exploring the impact in male clients' population.

TRIAL REGISTRATION NUMBER

NTR4689.

Risk factors for diagnosed noma in northwest Nigeria: A case-control study, 2017

Background

Noma (cancrum oris), a neglected tropical disease, rapidly disintegrates the hard and soft tissue of the face and leads to severe disfiguration and high mortality. The disease is poorly understood. We aimed to estimate risk factors for diagnosed noma to better guide existing prevention and treatment strategies using a case-control study design.

Methods

Cases were patients admitted between May 2015 and June 2016, who were under 15 years of age at reported onset of the disease. Controls were individuals matched to cases by village, age and sex. Caretakers answered the questionnaires. Risk factors for diagnosed noma were estimated by calculating unadjusted and adjusted odds ratios (ORs) and respective 95% confidence intervals (CI) using conditional logistic regression.

Findings

We included 74 cases and 222 controls (both median age 5 (IQR 3, 15)). Five cases (6.5%) and 36 (16.2%) controls had a vaccination card (p = 0.03). Vaccination coverage for polio and measles was below 7% in both groups. The two main reported water sources were a bore hole in the village (cases n = 27, 35.1%; controls n = 63, 28.4%; p = 0.08), and a well in the compound (cases n = 24, 31.2%; controls n = 102, 45.9%; p = 0.08). The adjusted analysis identified potential risk and protective factors for diagnosed noma which need further exploration. These include the potential risk factor of the child being fed pap every day (OR 9.8; CI 1.5, 62.7); and potential protective factors including the mother being the primary caretaker (OR 0.08; CI 0.01, 0.5); the caretaker being married (OR 0.006; CI 0.0006, 0.5) and colostrum being given to the baby (OR 0.4; CI 0.09, 2.09).

Interpretation

This study suggests that social conditions and infant feeding practices are potentially associated with being a diagnosed noma case in northwest Nigeria; these findings warrant further investigation into these factors.

Noma or cancrum oris is an orofacial gangrene that rapidly disintegrates the hard and soft tissue of the face. Little is known about noma as most cases live in underserved, difficult to reach locations. There is a dearth of literature on the risk factors for the development of noma. Médecins Sans Frontières (MSF) in collaboration with the Nigerian Ministry of Health runs projects at the Noma Children’s Hospital in Sokoto. A case control study was conducted in northwest Nigeria to explore exposures associated with diagnosed noma using unadjusted and adjusted conditional logistic regression models. Potential risk and protective factors for diagnosed noma were identified and these findings need further exploration. The study identified that feeding pap to the child every day was a potential risk factor for diagnosed noma (possibly a proxy for poor variety in the diet). The following potential protective factors for diagnosed noma were identified: the mother being the primary caretaker, the caretaker being married, and colostrum being given to the baby. Noma is a neglected disease, and current risk factors suggest that intervention efforts could be more effective by focussing on access to health care, the benefits of breastfeeding and a varied diet. However, more research is needed in order to better understand the pathogenesis of this disease in order to improve prevention, early detection and treatment.

Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan

Background

Tackling the high non-communicable disease (NCD) burden among Syrian refugees poses a challenge to humanitarian actors and host countries. Current response priorities are the identification and integration of key interventions for NCD care into humanitarian programs as well as sustainable financing. To provide evidence for effective NCD intervention planning, we conducted a cross-sectional survey among non-camp Syrian refugees in northern Jordan to investigate the burden and determinants for high NCDs prevalence and NCD multi-morbidities and assess the access to NCD care.

Methods

We used a two-stage cluster design with 329 randomly selected clusters and eight households identified through snowball sampling. Consenting households were interviewed about self-reported NCDs, NCD service utilization, and barriers to care.

We estimated the adult prevalence of hypertension, diabetes type I/II, cardiovascular- and chronic respiratory conditions, thyroid disease and cancer and analysed the pattern of NCD multi-morbidities. We used the Cox proportional hazard model to calculate the prevalence ratios (PR) to analyse determinants for NCD prevalence and logistic regression to determine risk factors for NCD multi-morbidities by calculating odds ratios (ORs).

Results

Among 8041 adults, 21.8%, (95% CI: 20.9–22.8) suffered from at least one NCD; hypertension (14.0, 95% CI: 13.2–14.8) and diabetes (9.2, 95% CI: 8.5–9.9) were the most prevalent NCDs. NCD multi-morbidities were reported by 44.7% (95% CI: 42.4–47.0) of patients. Higher age was associated with higher NCD prevalence and the risk for NCD-multi-morbidities; education was inversely associated.

Of those patients who needed NCD care, 23.0% (95% CI: 20.5–25.6) did not seek it; 61.5% (95% CI: 54.7–67.9) cited provider cost as the main barrier. An NCD medication interruption was reported by 23.1% (95% CI: 20–4-26.1) of patients with regular medication needs; predominant reason was unaffordability (63.4, 95% CI: 56.7–69.6).

Conclusion

The burden of NCDs and multi-morbidities is high among Syrian refugees in northern Jordan. Elderly and those with a lower education are key target groups for NCD prevention and care, which informs NCD service planning and developing patient-centred approaches.

Important unmet needs for NCD care exist; removing the main barriers to care could include cost-reduction for medications through humanitarian pricing models. Nevertheless, it is still essential that international donors agencies and countries fulfill their commitment to support the Syrian-crisis response.

Electronic supplementary material

The online version of this article (10.1186/s13031-018-0168-7) contains supplementary material, which is available to authorized users.

Seroprevalence and risk factors of recent infection with hepatitis E virus during an acute outbreak in an urban setting in Chad, 2017

BACKGROUND

From September 2016-April 2017, Am Timan, Chad, experienced a large HEV outbreak in an urban setting with a limited impact in terms of morbidity and mortality. To better understand HEV epidemiology in this context, we estimated the seroprevalence of anti-HEV antibodies (IgM and IgG) and assessed the risk factors for recent HEV infections (positive anti-HEV IgM) during this outbreak.

METHODS

A serological survey using simple random sampling was implemented in Am Timan at the tail-end of the outbreak (sample size aim = 384 household). Household members provided us with blood samples and household heads answered questions around water, sanitation and hygiene practices and animal ownership. Blood samples were tested for HEV IgG and IgM antibodies using Enzyme-Immune-Assay (EIA). We calculated weighted prevalence estimates and prevalence ratios (PRs) for possible risk factors for recent infection using multivariate Cox regression.

RESULTS

We included 241 households (1529 participants). IgM prevalence decreased with age: 12.6% (< 5 years) to 4.3% (> 15 years). IgG prevalence increased with age: 23.5% (< 5 years) to 75.9% (> 15 years). Risk factors for recent HEV infections included: sharing the sanitation facility with other HHs (PR 1.72; 95%CI: 1.08-2.73), not systematically using soap for HW (PR 1.85; 95%CI: 1.30-2.63) and having animals sleeping inside the compound (PR 1.69; 95%CI: 1.15-2.50).

CONCLUSIONS

Evidence suggests that Am Timan was already highly endemic for HEV before the outbreak, potentially explaining the limited extent of the outbreak. Recent infection with HEV was linked to household level exposures. Future HEV outbreak response must include ensuring access to safe water, and reducing household level transmission through active hygiene and sanitation promotion activities.

Validation of mental health screening instruments in the Kashmir Valley, India

The present study aimed to culturally adapt, translate, and validate the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire-Posttraumatic Stress Symptoms Checklist (HTQ-16) prior to use in a cross-sectional mental health population survey in the Kashmir Valley. Cultural adaptation and translation of the HSCL-25 and the HTQ-16 employed multiple forms of transcultural validity check. The HSCL-25 and HTQ-16 were compared against a "gold standard" structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Interviews were conducted with 290 respondents recruited using consecutive sampling from general medical outpatient departments in five districts of the Kashmir Valley. Receiver operating characteristics (ROC) analysis was used to estimate the cut point with optimal discriminatory power based on sensitivity and specificity. Internal reliability of the HSCL-25 was high, Cronbach's alpha (α) = .92, intraclass correlation coefficient (ICC) = 0.75, with an estimated optimal cut point of 1.50, lower than the conventional cut point of 1.75. Separation of the instruments into subscales demonstrated a difference in the estimated cut point for the anxiety subscale and the depression subscale, 1.75 and 1.57, respectively. Too few respondents were diagnosed with posttraumatic stress disorder (PTSD) during structured psychiatric interview, and therefore the HTQ-16 could not be validated despite the fact that high internal reliability was demonstrated (α = .90). This study verified the importance of culturally adapting and validating screening instruments in particular contexts. The use of the conventional cut point of 1.75 would likely have misclassified depression in our survey, leading to an underestimate of this condition.

Learning from water treatment and hygiene interventions in response to a hepatitis E outbreak in an open setting in Chad

In September 2016, Médecins Sans Frontières responded to a hepatitis E (HEV) outbreak in Chad by implementing water treatment and hygiene interventions. To evaluate the coverage and use of these interventions, we conducted a cross-sectional study in the community. Our results showed that 99% of households interviewed had received a hygiene kit from us, aimed at improving water handling practice and personal hygiene and almost all respondents had heard messages about preventing jaundice and handwashing. Acceptance of chlorination of drinking water was also very high, although at the time of interview, we were only able to measure a safe free residual chlorine level (free chlorine residual (FRC) ≥0.2 mg/L) in 43% of households. Households which had refilled water containers within the last 18 hours, had sourced water from private wells or had poured water into a previously empty container, were all more likely to have a safe FRC level. In this open setting, we were able to achieve high coverage for chlorination, hygiene messaging and hygiene kit ownership; however, a review of our technical practice is needed in order to maintain safe FRC levels in drinking water in households, particularly when water is collected from multiple sources, stored and mixed with older water.

A Nosocomial Outbreak of Clinical Sepsis in a Neonatal Care Unit (NCU) in Port-Au-Prince Haiti, July 2014 - September 2015

Introduction

Between July 2014 and September 2015, a neonatal care unit (NCU) in Port Au Prince, Haiti, experienced an outbreak of sepsis, most probably due to nosocomial transmission of Extended Beta Lactamase (ESBL) producing gram negative bacteria, included Klebsiella pneumoniae.

Methods

We describe the epidemiological and microbiological activities performed as part of the outbreak investigation and the control measures implemented throughout this period.

Results

During the study period 257 cases of sepsis were reported, of which 191 died. The case fatality decreased from 100% in July 2014 to 24% in September 2015 and could be attributed to an improvement in clinical management and strengthened infection prevention and control measures. Risk factors identified to be associated with having late onset sepsis (sepsis onset >48 hours after birth)(n=205/257, 79. included: all categories of birthweight lower than <2500g (p=<0.0001) and all categories of gestational age younger than 36 weeks (p=0.0002). Microbiological investigations confirmed that out of 32 isolates (N=55; 58%) that were positive for gram negative bacteria, 27 (89%) were due to K. pneumoniae and most of these were from single MLST type (ST37).

Discussion 

This outbreak highlighted the importance of epidemiological and microbiological surveillance during an outbreak of sepsis in a NCU in a low resource setting, including regular point prevalence surveys.

Infectious Disease Risk and Vaccination in Northern Syria after 5 Years of Civil War: The MSF Experience

Introduction:

In 2015, following an influx of population into Kobanê in northern Syria, Médecins Sans Frontières (MSF) in collaboration with the Kobanê Health Administration (KHA) initiated primary healthcare activities. A vaccination coverage survey and vaccine-preventable disease (VPD) risk analysis were undertaken to clarify the VPD risk and vaccination needs. This was followed by a measles Supplementary Immunization Activity (SIA). We describe the methods and results used for this prioritisation activity around vaccination in Kobanê in 2015.

Methods:

We implemented a pre-SIA survey in 135 randomly-selected households in Kobanê using a vaccination history questionnaire for all children <5 years. We conducted a VPD Risk Analysis using MSF ‘Preventive Vaccination in Humanitarian Emergencies’ guidance to prioritize antigens with the highest public health threat for mass vaccination activities. A Measles SIA was then implemented and followed by vaccine coverage survey in 282 randomly-selected households targeting children <5 years.

Results:

The pre-SIA survey showed that 168/212 children (79.3%; 95%CI=72.7-84.6%) had received one vaccine or more in their lifetime. Forty-three children (20.3%; 95%CI: 15.1-26.6%) had received all vaccines due by their age; only one was <12 months old and this child had received all vaccinations outside of Syria. The VPD Risk Analysis prioritised measles, Haemophilus Influenza type B (Hib) and Pneumococcus vaccinations. In the measles SIA, 3410 children aged 6-59 months were vaccinated. The use of multiple small vaccination sites to reduce risks associated with crowds in this active conflict setting was noted as a lesson learnt. The post-SIA survey estimated 82% (95%CI: 76.9-85.9%; n=229/280) measles vaccination coverage in children 6-59 months.

Discussion:

As a result of the conflict in Syria, the progressive collapse of the health care system in Kobanê has resulted in low vaccine coverage rates, particularly in younger age groups. The repeated displacements of the population, attacks on health institutions and exodus of healthcare workers, challenge the resumption of routine immunization in this conflict setting and limit the use of SIAs to ensure sustainable immunity to VPDs. We have shown that the risk for several VPDs in Kobanê remains high.

Conclusion:

We call on all health actors and the international community to work towards re-establishment of routine immunisation activities as a priority to ensure that children who have had no access to vaccination in the last five years are adequately protected for VPDs as soon as possible.

Impact of war on child health in northern Syria: the experience of Médecins Sans Frontières

Few data are available to evaluate the impact of Syrian war on civilian population; to describe this impact on child health, this article uses data from Médecins Sans Frontières-Operational Centre Amsterdam's activities in Tal-Abyad and Kobane cities, northern Syria (2013-2016). Data were obtained from routine medical datasets and narrative reports, for out-patient clinics, immunisation, nutritional monitoring and assessments, and in-patient care, and were analysed quantitatively and qualitatively. Infections were the largest contributor to morbidity. The proportion of < 5 year out-patient consultations of infectious diseases that are listed for outbreak monitoring in emergencies was 15% in 2013, 51% in 2014, 75% in 2015 and 70% in 2016. Thalassemia was recorded in 0.5% of 2014 < 5 year out-patient consultations and 3.4% of 2013-2014 < 18-year in-patient admissions. Measles immunisation activities and routine Extended Programme for Immunisation were re-activated across northern Syria; however, immunisation coverage could not be calculated. Results from our routine data must be compared cautiously, due to differences in settings and disease categories.

CONCLUSION

With such scattered interventions, routine data are limited in providing a quantified evidence of emergency's health impact; however, they help in drawing a picture of children's health status and highlighting difficulties in providing curative and preventive services, in order to reflect part of population's plight. What is Known • Few data exist to evaluate the impact of the Syrian war on the health of children; • Médecins Sans Frontières (MSF-OCA) has worked in northern Syria during different times since 2013. What is New • Quantitative and qualitative analysis of MSF's routine medical data and situtation reports show that one fifth of all consultations in children < 5 years in MSF health facilities in northern Syria 2013-2016 were due to communicable diseases; • The analysis also highlights the burden of chronic conditions that were prevalent in Syria before the war, e.g. thalassemia.

A large outbreak of Hepatitis E virus genotype 1 infection in an urban setting in Chad likely linked to household level transmission factors, 2016-2017

Background

In September 2016, three acutely jaundiced (AJS) pregnant women were admitted to Am Timan Hospital, eastern Chad. We described the outbreak and conducted a case test-negative study to identify risk factors for this genotype of HEV in an acute outbreak setting.

Methods

Active case finding using a community based surveillance network identified suspected AJS cases. Pregnant or visibly ill AJS cases presenting at hospital were tested with Assure^® IgM HEV rapid diagnostic tests (RDTs) and some with Polymerase Chain Reaction (PCR) in Amsterdam; confirmed cases were RDT-positive and controls were RDT-negative. All answered questions around: demographics, household makeup, area of residence, handwashing practices, water collection behaviour and clinical presentation. We calculated unadjusted odds ratios (ORs) and 95% confidence intervals (95% CI).

Results

Between September and April 2017, 1443 AJS cases (1293 confirmed) were detected in the town(attack rate: 2%; estimated 65,000 population). PCR testing confirmed HEV genotype 1e.

HEV RDTs were used for 250 AJS cases; 100 (40%) were confirmed. Risk factors for HEV infection, included: having at least two children under the age of 5 years (OR 2.1, 95%CI 1.1–4.3), having another household member with jaundice (OR 2.4, 95%CI 0.90–6.3) and, with borderline significance, living in the neighbourhoods of Riad (OR 3.8, 95%CI 1.0–1.8) or Ridina (OR 3.3, 95%CI 1.0–12.6). Cases were more likely to present with vomiting (OR 3.2, 9%CI 1.4–7.9) than controls; possibly due to selection bias. Cases were non-significantly less likely to report always washing hands before meals compared with controls (OR 0.33, 95%CI 0.1–1.1).

Discussion

Our study suggests household factors and area of residence (possibly linked to access to water and sanitation) play a role in HEV transmission; which could inform future outbreak responses. Ongoing sero-prevalence studies will elucidate more aspects of transmission dynamics of this virus with genotype 1e.

Prevalence of anxiety, depression and post-traumatic stress disorder in the Kashmir Valley

BACKGROUND

Following the partition of India in 1947, the Kashmir Valley has been subject to continual political insecurity and ongoing conflict, the region remains highly militarised. We conducted a representative cross-sectional population-based survey of adults to estimate the prevalence and predictors of anxiety, depression and post-traumatic stress disorder (PTSD) in the 10 districts of the Kashmir Valley.

METHODS

Between October and December 2015, we interviewed 5519 out of 5600 invited participants, ≥18 years of age, randomly sampled using a probability proportional to size cluster sampling design. We estimated the prevalence of a probable psychological disorder using the Hopkins Symptom Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ-16). Both screening instruments had been culturally adapted and translated. Data were weighted to account for the sampling design and multivariate logistic regression analysis was conducted to identify risk factors for developing symptoms of psychological distress.

FINDINGS

The estimated prevalence of mental distress in adults in the Kashmir Valley was 45% (95% CI 42.6 to 47.0). We identified 41% (95% CI 39.2 to 43.4) of adults with probable depression, 26% (95% CI 23.8 to 27.5) with probable anxiety and 19% (95% CI 17.5 to 21.2) with probable PTSD. The three disorders were associated with the following characteristics: being female, over 55 years of age, having had no formal education, living in a rural area and being widowed/divorced or separated. A dose-response association was found between the number of traumatic events experienced or witnessed and all three mental disorders.

INTERPRETATION

The implementation of mental health awareness programmes, interventions aimed at high risk groups and addressing trauma-related symptoms from all causes are needed in the Kashmir Valley.

Using lot quality assurance sampling to assess access to water, sanitation and hygiene services in a refugee camp setting in South Sudan: a feasibility study

Background

Humanitarian agencies working in refugee camp settings require rapid assessment methods to measure the needs of the populations they serve. Due to the high level of dependency of refugees, agencies need to carry out these assessments. Lot Quality Assurance Sampling (LQAS) is a method commonly used in development settings to assess populations living in a project catchment area to identify their greatest needs. LQAS could be well suited to serve the needs of refugee populations, but it has rarely been used in humanitarian settings. We adapted and implemented an LQAS survey design in Batil refugee camp, South Sudan in May 2013 to measure the added value of using it for sub-camp level assessment.

Methods

Using pre-existing divisions within the camp, we divided the Batil catchment area into six contiguous segments, called ‘supervision areas’ (SA). Six teams of two data collectors randomly selected 19 respondents in each SA, who they interviewed to collect information on water, sanitation, hygiene, and diarrhoea prevalence. These findings were aggregated into a stratified random sample of 114 respondents, and the results were analysed to produce a coverage estimate with 95% confidence interval for the camp and to prioritize SAs within the camp.

Results

The survey provided coverage estimates on WASH indicators as well as evidence that areas of the camp closer to the main road, to clinics and to the market were better served than areas at the periphery of the camp. This assumption did not hold for all services, however, as sanitation services were uniformly high regardless of location. While it was necessary to adapt the standard LQAS protocol used in low-resource communities, the LQAS model proved to be feasible in a refugee camp setting, and program managers found the results useful at both the catchment area and SA level.

Conclusions

This study, one of the few adaptations of LQAS for a camp setting, shows that it is a feasible method for regular monitoring, with the added value of enabling camp managers to identify and advocate for the least served areas within the camp. Feedback on the results from stakeholders was overwhelmingly positive.

Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011-2014

We assessed risk factors for fetal death during cholera infection and effect of treatment changes on these deaths. Third trimester gestation, younger maternal age, severe dehydration, and vomiting were risk factors. Changes in treatment had limited effects on fetal death, highlighting the need for prevention and evidence-based treatment.

Mental health problems among conflict-affected adults in Grozny, Chechnya: a qualitative study

Background

A decade of conflict in Chechnya destroyed infrastructure and resulted in widespread exposure to violence. Amidst substantial reconstruction, periodic violence has contributed to an ongoing atmosphere of insecurity. We conducted a qualitative study to understand the mental health and psychosocial problems affecting adult Chechens in this context to inform development of assessment tools for an evaluation study related to individual counseling.

Methods

Data were collected in July 2014. A convenience sample of 59 Chechen adults was asked to Free List all problems affecting people in the area. Four problems were explored further in 19 Key Interviewee (KI) interviews, with respondents identified using snowball sampling. Data analysis was conducted in Russian by the Chechen interviewers.

Results

Multiple mental health and psychosocial problems emerged, including ‘bad psychological health’, ‘depression’, ‘stress and nervous people’, and ‘problems in the family’. Aggression, ‘emotional blowing’, and ‘not adequate’ behavior were frequently reported indicators of these problems, with negative effects on the whole family. Chechens reported seeking help through informal social networks, psychiatric and psychological services, and Islamic Centers.

Conclusion

Chechens reported mental health and psychosocial problems similar to those experienced in other post-conflict settings. The description of ‘emotional blowing’ mirrored prior findings in Chechen asylum seekers and fits within a cluster of cultural concepts of distress featuring anger that has been identified in other conflict-affected populations. Further exploration of the nature and prevalence of this construct, as well as evaluations of interventions aimed at reducing these symptoms, is warranted.

Perioperative mortality: Analysis of 3 years of operative data across 7 general surgical projects of Médecins Sans Frontières in Democratic Republic of Congo, Central African Republic, and South Sudan

BACKGROUND

The African continent has the greatest burden of surgical disability-adjusted life years, yet the least is known about operative care here. This analysis describes the surgical patients admitted to 7 hospitals supported by the Médécins Sans Frontières (MSF) over 3 years in 3 conflict-affected countries-Eastern Democratic Republic of Congo, Central African Republic, and South Sudan.

METHODS

A standardized operative data collection tool was used for routine collection of operative inpatient data between 2011 and 2013 at 7 MSF surgical facilities. Surgical records of 14,482 patients were analyzed to describe surgical epidemiology, major procedures, and perioperative mortality. The perioperative mortality rate (POMR) was calculated within 2 days of admission (POMR2) and within 30 days from admission (POMR30). The POMR is used as a marker of quality of operative care.

RESULTS

Caesarean delivery was the most common major procedure performed and had a POMR30 of 5.28 per 1,000 admissions. The overall inpatient mortality was 19.67 per 1,000 admissions. Children had greater POMR than adults for the same procedure types (47.97 vs 15.89 deaths per 1,000 admissions, P < .001); 85.1% of all major procedures were emergency procedures and between 3 and 30% of admissions were related to violence. After adjustment, perioperative death was associated with emergency surgery, violence, and age younger than 15 years.

CONCLUSION

POMRs varied by age group and type of major procedure performed. Collecting surgical data is achievable and can inform future planning and support for national surgical programs. More information is needed on operative outcomes in adults and children in low-resource settings to improve quality and access to care.