The occurrence of and factors associated with mental ill-health amongst humanitarian aid workers: A systematic review and meta-analysis

BACKGROUND

Humanitarian crises and disasters affect millions of people worldwide. Humanitarian aid workers are civilians or professionals who respond to disasters and provide humanitarian assistance. In doing so, they face several stressors and traumatic exposures. Humanitarian aid workers also face unique challenges associated with working in unfamiliar settings.

OBJECTIVE

To determine the occurrence of and factors associated with mental ill-health among humanitarian aid workers.

SEARCH STRATEGY

CINAHL plus, Cochrane library, Global Health, Medline, PubMed, Web of Science were searched from 2005-2020. Grey literature was searched on Google Scholar.

SELECTION CRITERIA

PRISMA guidelines were followed and after double screening, studies reporting occurrence of mental ill-health were included. Individual narratives and case studies were excluded, as were studies that reported outcomes in non-humanitarian aid workers.

DATA ANALYSIS

Data on occurrence of mental ill-health and associated factors were independently extracted and combined in a narrative summary. A random effects logistic regression model was used for the meta-analysis.

MAIN RESULTS

Nine studies were included with a total of 3619 participants, reporting on five types of mental ill-health (% occurrence) including psychological distress (6.5%-52.8%); burnout (8.5%-32%); anxiety (3.8%-38.5%); depression (10.4%-39.0%) and post-traumatic stress disorder (0% to 25%). Hazardous drinking of alcohol ranged from 16.2%-50.0%. Meta-analysis reporting OR (95% CI) among humanitarian aid workers, for psychological distress was 0.45 (0.12-1.64); burnout 0.34 (0.27-0.44); anxiety 0.22 (0.10-0.51); depression 0.32 (0.18-0.57) and PTSD 0.11 (0.03-0.39). Associated factors included young age, being female and pre-existing mental ill-health.

CONCLUSIONS

Mental ill-health is common among humanitarian aid workers, has a negative impact on personal well-being, and on a larger scale reduces the efficacy of humanitarian organisations with delivery of aid and retention of staff. It is imperative that mental ill-health is screened for, detected and treated in humanitarian aid workers, before, during and after their placements. It is essential to implement psychologically protective measures for individuals working in stressful and traumatic crises.

African polyvalent antivenom can maintain pharmacological stability and ability to neutralise murine venom lethality for decades post-expiry: evidence for increasing antivenom shelf life to aid in alleviating chronic shortages

INTRODUCTION

Antivenom is a lifesaving medicine for treating snakebite envenoming, yet there has been a crisis in antivenom supply for many decades. Despite this, substantial quantities of antivenom stocks expire before use. This study has investigated whether expired antivenoms retain preclinical quality and efficacy, with the rationale that they could be used in emergency situations when in-date antivenom is unavailable.

METHODS

Using WHO guidelines and industry test requirements, we examined the in vitro stability and murine in vivo efficacy of eight batches of the sub-Saharan African antivenom, South African Institute for Medical Research polyvalent, that had expired at various times over a period of 30 years.

RESULTS

We demonstrate modest declines in immunochemical stability, with antivenoms older than 25 years having high levels of turbidity. In vitro preclinical analysis demonstrated all expired antivenoms retained immunological recognition of venom antigens and the ability to inhibit key toxin families. All expired antivenoms retained comparable in vivo preclinical efficacy in preventing the lethal effects of envenoming in mice versus three regionally and medically important venoms.

CONCLUSIONS

This study provides strong rationale for stakeholders, including manufacturers, regulators and health authorities, to explore the use of expired antivenom more broadly, to aid in alleviating critical shortages in antivenom supply in the short term and the extension of antivenom shelf life in the longer term.

"It's complicated…": Exploring second stage caesarean sections and reasons for non-performance of assisted vaginal births in Kenya: A mixed methods study

Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues.

Assessing the use of minimally invasive self-sampling at home for long-term monitoring of the microbiota within UK families

Monitoring the presence of commensal and pathogenic respiratory microorganisms is of critical global importance. However, community-based surveillance is difficult because nasopharyngeal swabs are uncomfortable and painful for a wide age range of participants. We designed a methodology for minimally invasive self-sampling at home and assessed its use for longitudinal monitoring of the oral, nasal and hand microbiota of adults and children within families. Healthy families with two adults and up to three children, living in and near Liverpool, United Kingdom, self-collected saliva, nasal lining fluid using synthetic absorptive matrices and hand swabs at home every two weeks for six months. Questionnaires were used to collect demographic and epidemiological data and assess feasibility and acceptability. Participants were invited to take part in an exit interview. Thirty-three families completed the study. Sampling using our approach was acceptable to 25/33 (76%) families, as sampling was fast (76%), easy (76%) and painless (60%). Saliva and hand sampling was acceptable to all participants of any age, whereas nasal sampling was accepted mostly by adults and children older than 5 years. Multi-niche self-sampling at home can be used by adults and children for longitudinal surveillance of respiratory microorganisms, providing key data for design of future studies.

Exploring the influence of postnatal depression on neonatal care practices among mothers in Western Kenya: A qualitative study

BACKGROUND

Postnatal depression (PND) is associated with adverse infant neurodevelopmental outcomes. Evidence is limited on how PND influences neonatal (<28 days old) outcomes in low- and middle-income countries, such as Kenya, which bear the global burden of neonatal morbidity and mortality.

OBJECTIVES

To explore how PND influences neonatal feeding and care practices among women in the early postnatal period in rural Western Kenya.

DESIGN

A cross-sectional study.

METHODS

Semi-structured interviews were conducted at 2-weeks postpartum among mothers of newborn infants identified <72 h old from the postnatal wards and clinics across five health facilities in Kisumu County of Western Kenya. They were all screened for features suggestive of postnatal depression using the Edinburgh Postnatal Depression Scale.

RESULTS

Twenty-four mothers were interviewed, 13 of whom had features suggestive of PND. All mothers experienced health or socio-economic adversities in the perinatal period, including traumatic deliveries, financial constraints, and challenging relationships with partners/other family members. Feeding difficulties due to perceived insufficient breastmilk were a particular challenge for mothers with features of PND, who were more likely to introduce complementary feeds. Maternal health-seeking decisions were influenced by high financial cost, long waiting times and poor interactions with health care providers that induced stress and fear among mothers. Maternal caregiving capacity was influenced by her ability to juggle other household duties, which was difficult for mothers with features suggestive of PND. Support from friends and relatives positively impacted maternal mood and caregiving ability.

CONCLUSION

Mothers experienced many stress-inducing events in the perinatal period which potentially exacerbated features of PND in the immediate postnatal period. Women with features of PND were particularly vulnerable to these stressors that influenced infant caregiving practices. Addressing the socio-economic challenges and health system gaps that include scale up of compassionate and respectful care for women during pregnancy and childbirth, as well as early screening and intervention of PND, through enhanced referral pathways between health facilities and community support structures, could mitigate against the impact of PND on neonatal caregiving.

Transcriptomic and small RNA response to Mayaro virus infection in Anopheles stephensi mosquitoes

Mayaro virus (MAYV) is an arboviral pathogen in the genus Alphavirus that is circulating in South America with potential to spread to naïve regions. MAYV is also one of the few viruses with the ability to be transmitted by mosquitoes in the genus Anopheles, as well as the typical arboviral transmitting mosquitoes in the genus Aedes. Few studies have investigated the infection response of Anopheles mosquitoes. In this study we detail the transcriptomic and small RNA responses of An. stephensi to infection with MAYV via infectious bloodmeal at 2, 7, and 14 days post infection (dpi). 487 unique transcripts were significantly regulated, 78 putative novel miRNAs were identified, and an siRNA response is observed targeting the MAYV genome. Gene ontology analysis of transcripts regulated at each timepoint shows a number of proteases regulated at 2 and 7 dpi, potentially representative of Toll or melanization pathway activation, and repression of pathways related to autophagy and apoptosis at 14 dpi. These findings provide a basic understanding of the infection response of An. stephensi to MAYV and help to identify host factors which might be useful to target to inhibit viral replication in Anopheles mosquitoes.

Mayaro virus (MAYV) is a mosquito-borne Alphavirus responsible for outbreaks in South America and the Caribbean. In this study we infected Anopheles stephensi with MAYV and sequenced mRNA and small RNA to understand how MAYV infection impacts gene transcription and the expression of small RNAs in the mosquito vector. Genes involved with innate immunity and signaling pathways related to cell death are regulated in response to MAYV infection of An. stephensi, we also discovered novel miRNAs and describe the expression patterns of miRNAs, siRNAs, and piRNAs following bloodmeal ingestion. These results suggest that MAYV does induce a molecular response to infection in its mosquito vector species.

A gene expression panel for estimating age in males and females of the sleeping sickness vector Glossina morsitans

Many vector-borne diseases are controlled by methods that kill the insect vectors responsible for disease transmission. Recording the age structure of vector populations provides information on mortality rates and vectorial capacity, and should form part of the detailed monitoring that occurs in the wake of control programmes, yet tools for obtaining estimates of individual age remain limited. We investigate the potential of using markers of gene expression to predict age in tsetse flies, which are the vectors of deadly and economically damaging African trypanosomiases. We use RNAseq to identify candidate expression markers, and test these markers using qPCR in laboratory-reared Glossina morsitans morsitans of known age. Measuring the expression of six genes was sufficient to obtain a prediction of age with root mean squared error of less than 8 days, while just two genes were sufficient to classify flies into age categories of ≤15 and >15 days old. Further testing of these markers in field-caught samples and in other species will determine the accuracy of these markers in the field.

Negative density-dependent dispersal in tsetse (Glossina spp): An artefact of inappropriate analysis

Published analysis of genetic material from field-collected tsetse (Glossina spp, primarily from the Palpalis group) has been used to predict that the distance (δ) dispersed per generation increases as effective population densities (D_e) decrease, displaying negative density-dependent dispersal (NDDD). Using the published data we show this result is an artefact arising primarily from errors in estimates of S, the area occupied by a subpopulation, and thereby in D_e. The errors arise from the assumption that S can be estimated as the area (S^) regarded as being covered by traps. We use modelling to show that such errors result in anomalously high correlations between δ^ and S^ and the appearance of NDDD, with a slope of -0.5 for the regressions of log(δ^) on log(D^e), even in simulations where we specifically assume density-independent dispersal (DID). A complementary mathematical analysis confirms our findings. Modelling of field results shows, similarly, that the false signal of NDDD can be produced by varying trap deployment patterns. Errors in the estimates of δ in the published analysis were magnified because variation in estimates of S were greater than for all other variables measured, and accounted for the greatest proportion of variation in δ^. Errors in census population estimates result from an erroneous understanding of the relationship between trap placement and expected tsetse catch, exacerbated through failure to adjust for variations in trapping intensity, trap performance, and in capture probabilities between geographical situations and between tsetse species. Claims of support in the literature for NDDD are spurious. There is no suggested explanation for how NDDD might have evolved. We reject the NDDD hypothesis and caution that the idea should not be allowed to influence policy on tsetse and trypanosomiasis control.

Published analysis of genetic material from field-sampled tsetse (Glossina spp) has been used to suggest that, as tsetse population densities decrease, rates of dispersal increase–displaying negative density-dependent dispersal (NDDD), perhaps in all tsetse species. It is further suggested that tsetse control operations might, as a consequence of NDDD, unleash enhanced invasion of areas cleared of tsetse, prejudicing the long-term success of control campaigns. We demonstrate that NDDD in tsetse is an artefact consequent on multiple errors of analysis and interpretation. The most serious of these errors stems from a misunderstanding of the way in which traps sample tsetse, resulting in large errors in estimates of the areas covered by the traps, and occupied by the subpopulations being sampled. Our modelling studies show that these errors can produce the false signal of NDDD, even in situations where DID is assumed. Errors in census population estimates are made worse through failure to adjust for variations in trapping intensity, trap performance, and in capture probabilities between geographical situations, and between tsetse species. We reject the NDDD hypothesis and caution that the idea should not be allowed to influence policy on tsetse and trypanosomiasis control.

Methods of Inactivation of SARS-CoV-2 for Downstream Biological Assays

The scientific community has responded to the coronavirus disease 2019 (COVID-19) pandemic by rapidly undertaking research to find effective strategies to reduce the burden of this disease. Encouragingly, researchers from a diverse array of fields are collectively working towards this goal. Research with infectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is undertaken in high-containment laboratories; however, it is often desirable to work with samples at lower-containment levels. To facilitate the transfer of infectious samples from high-containment laboratories, we have tested methods commonly used to inactivate virus and prepare the sample for additional experiments. Incubation at 80°C, a range of detergents, Trizol reagents, and UV energies were successful at inactivating a high titer of SARS-CoV-2. Methanol and paraformaldehyde incubation of infected cells also inactivated the virus. These protocols can provide a framework for in-house inactivation of SARS-CoV-2 in other laboratories, ensuring the safe use of samples in lower-containment levels.

Isolation and transcriptomic analysis of Anopheles gambiae oenocytes enables the delineation of hydrocarbon biosynthesis

The surface of insects is coated in cuticular hydrocarbons (CHCs); variations in the composition of this layer affect a range of traits including adaptation to arid environments and defence against pathogens and toxins. In the African malaria vector, Anopheles gambiae quantitative and qualitative variance in CHC composition have been associated with speciation, ecological habitat and insecticide resistance. Understanding how these modifications arise will inform us of how mosquitoes are responding to climate change and vector control interventions. CHCs are synthesised in sub-epidermal cells called oenocytes that are very difficult to isolate from surrounding tissues. Here we utilise a transgenic line with fluorescent oenocytes to purify these cells for the first time. Comparative transcriptomics revealed the enrichment of biological processes related to long chain fatty acyl-CoA biosynthesis and elongation of mono-, poly-unsaturated and saturated fatty acids and enabled us to delineate, and partially validate, the hydrocarbon biosynthetic pathway in An. gambiae.

The assessment of gestational age: a comparison of different methods from a malaria pregnancy cohort in sub-Saharan Africa

BACKGROUND

Determining gestational age in resource-poor settings is challenging because of limited availability of ultrasound technology and late first presentation to antenatal clinic. Last menstrual period (LMP), symphysio-pubis fundal height (SFH) and Ballard Score (BS) at delivery are therefore often used. We assessed the accuracy of LMP, SFH, and BS to estimate gestational age at delivery and preterm birth compared to ultrasound (US) using a large dataset derived from a randomized controlled trial in pregnant malaria patients in four African countries.

METHODS

Mean and median gestational age for US, LMP, SFH and BS were calculated for the entire study population and stratified by country. Correlation coefficients were calculated using Pearson's rho, and Bland Altman plots were used to calculate mean differences in findings with 95% limit of agreements. Sensitivity, specificity, positive predictive value and negative predictive value were calculated considering US as reference method to identify term and preterm babies.

RESULTS

A total of 1630 women with P. falciparum infection and a gestational age > 24 weeks determined by ultrasound at enrolment were included in the analysis. The mean gestational age at delivery using US was 38.7 weeks (95%CI: 38.6-38.8), by LMP, 38.4 weeks (95%CI: 38.0-38.9), by SFH, 38.3 weeks (95%CI: 38.2-38.5), and by BS 38.0 weeks (95%CI: 37.9-38.1) (p < 0.001). Correlation between US and any of the other three methods was poor to moderate. Sensitivity and specificity to determine prematurity were 0.63 (95%CI 0.50-0.75) and 0.72 (95%CI, 0.66-0.76) for LMP, 0.80 (95%CI 0.74-0.85) and 0.74 (95%CI 0.72-0.76) for SFH and 0.42 (95%CI 0.35-0.49) and 0.77 (95%CI 0.74-0.79) for BS.

CONCLUSIONS

In settings with limited access to ultrasound, and in women who had been treated with P. falciparum malaria, SFH may be the most useful antenatal tool to date a pregnancy when women present first in second and third trimester. The Ballard postnatal maturation assessment has a limited role and lacks precision. Improving ultrasound facilities and skills, and early attendance, together with the development of new technologies such as automated image analysis and new postnatal methods to assess gestational age, are essential for the study and management of preterm birth in low-income settings.

Programmatic Use of Molecular Xenomonitoring at the Level of Evaluation Units to Assess Persistence of Lymphatic Filariasis in Sri Lanka

BACKGROUND

Sri Lanka's Anti Filariasis Campaign distributed 5 rounds of mass drug administration (MDA with DEC plus albendazole) to all endemic regions in the country from 2002-2006. Post-MDA surveillance results have generally been encouraging. However, recent studies have documented low level persistence of Wuchereria bancrofti in Galle district based on comprehensive surveys that include molecular xenomonitoring (MX, detection of filarial DNA in mosquitoes) results. The purposes of this study were to demonstrate the use of MX in large evaluation units (EUs) and to field test different mosquito sampling schemes.

METHODOLOGY/PRINCIPAL FINDINGS

Galle district (population 1.1 million) was divided into two EUs. These included a coastal EU with known persistent LF and an inland EU with little persistent LF. Mosquitoes were systematically sampled from ~300 trap locations in 30 randomly selected clusters (health administrative units) per EU. Approximately 28,000 Culex quinquefasciatus were collected with gravid traps and tested for filarial DNA by qPCR. 92/625 pools (14.7%) from the coastal EU and 8/583 pools (1.4%) from the inland EU were positive for filarial DNA. Maximum likelihood estimates (MLE) for filarial DNA rates were essentially the same when the same number of mosquito pools were collected and tested from 75, 150, or 300 trap sites (range 0.61-0.78% for the coastal EU and 0.04-0.07% for the inland EU). The ability to use a smaller number of trap sites reduces the cost and time required for mosquito sampling.

CONCLUSIONS/SIGNIFICANCE

These results suggest there is widespread persistence of W. bancrofti infection in the coastal Galle EU 8 years after the last round of MDA in 2006, and this is consistent with other data from the district. This study has shown that MX can be used by national programs to assess and map the persistence of W. bancrofti at the level of large EUs in areas with Culex transmission.