Publications

In today's modern warfare, there is a growing risk of chemical and biological weapons use. Despite the widespread adoption of the United Nations Biological and Toxin Weapons Convention1 in 1975 and the Chemical Weapons Convention2 in 1997, we have seen notable examples of state-sponsored use of agents on vulnerable populations, as well as the use by individuals and nonstate actors.3-7 With the rise in acts of terrorism and conflict, there is an increased likelihood of exposure to chemical or biological agents by women and young children, who often represent the most vulnerable among the population. Children aged 0 to 5 years carry the most significant burden of conflict-related deaths of all age groups.8 Women of reproductive age who live in conflict zones have 3 times higher mortality than women who live in predominantly conflict-free settings.9

Despite the stark evidence of severe short- and long-term impacts of conflict on women and young children, this population has historically been overlooked when it comes to setting policy or providing holistic or human-centered guidance in conflict settings.10 There are abundant guidelines and research available on chemical and biological threats and how the general population could be impacted, as well as references to the treatment of breastfeeding women when discussing antidotes, vaccines, and drug treatments. However, there is very little guidance on whether women can safely continue to breastfeed after specific chemical and biological events and at what point breastfeeding can be safely resumed. Current information about breastfeeding safety in this scenario is disparate and hard to find.

Abstract

In today's modern warfare, there is a growing risk of chemical and biological weapons use. Despite the widespread adoption of the United Nations Biological and Toxin Weapons Convention in 1975 and the Chemical Weapons Convention in 1997, we have seen notable examples of state-sponsored use of agents on vulnerable populations, as well as the use by individuals and nonstate actors. With the rise in acts of terrorism and conflict, there is an increased likelihood of exposure to chemical or biological agents by women and young children, who often represent the most vulnerable among the population. Children aged 0 to 5 years carry the most significant burden of conflict-related deaths of all age groups. Women of reproductive age who live in conflict zones have 3 times higher mortality than women who live in predominantly conflict-free settings.

Despite the stark evidence of severe short- and long-term impacts of conflict on women and young children, this population has historically been overlooked when it comes to setting policy or providing holistic or human-centered guidance in conflict settings. There are abundant guidelines and research available on chemical and biological threats and how the general population could be impacted, as well as references to the treatment of breastfeeding women when discussing antidotes, vaccines, and drug treatments. However, there is very little guidance on whether women can safely continue to breastfeed after specific chemical and biological events and at what point breastfeeding can be safely resumed. Current information about breastfeeding safety in this scenario is disparate and hard to find.

Abstract

The humanitarian situation in the Gaza Strip is untenable. An estimated 1·7 million people—over 75% of the population—have been displaced across Gaza as of Jan 30, 2024, often multiple times. Families have been forced to move multiple times in search of safety. According to local authorities, as of Jan 7, 2024, at least 26 901 Palestinians have been killed, 65 949 have been injured, and 7780 are missing, mostly under the rubble. Access to life-saving health services has been severely affected. Electricity, fuel, water, and medicines are either in very short supply or non-existent.  

Throughout this war—and before it, amid years of blockade—the UN Relief and Works Agency (UNRWA) has been a lifeline for people in Gaza. As of Jan 31, 2024, nearly 1·7 million displaced people are now sheltering in emergency shelters (both UNRWA and public shelters), informal sites, or in close vicinity to UNRWA shelters and distribution sites within host communities.

As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes.

To respond to the COVID-19 pandemic, countries introduced public health and social measures that had indirect societal, economic consequences. Concerns during epidemics include continuity of routine health services. We investigate how healthcare utilisation and healthcare seeking behaviour changed during the first year of the COVID-19 pandemic among host communities in Cox’s Bazar, Bangladesh. This mixed-methods study combines quantitative analyses of routine health data and population-based findings about healthcare seeking behaviours. Trends in consultations changed according to facility level (higher-level facilities included Upazila Health Complexes and District Hospitals; lower-level facilities included Community Clinics and Union Health and Family Welfare Centers). At the pandemic’s beginning, drops were seen at higher-level health facilities for outpatient department (OPD) consultations, respiratory infections, and antenatal care. Minor reductions or increases were seen at lower-level facilities for the same services. Half of the subdistricts reported a cumulative increase in OPD and respiratory tract infection consultations. Most subdistricts reported a cumulative decrease in antenatal care. Child vaccinations dropped in all subdistricts, half of which did not catch-up, resulting in a cumulative decrease of delivered doses. Fear of contracting COVID-19 and financial constraints were the main reasons for decreased access. Drivers of healthcare seeking behaviours should be better understood to guide preparedness and service delivery modalities at primary and secondary levels.

Population-based estimates of syphilis prevalence are critical to informing public health response. We aimed to measure syphilis prevalence among Venezuelan refugees and migrants in Colombia to inform public health programming.

The ongoing war in Gaza has led to unprecedented death and destruction.  Hostilities continue to have a dire effect on the 2·2 million people living in Gaza, with particular and acute effects on the estimated 52 000 women who are currently pregnant.  At the time of writing, around 1·93 million people in Gaza (85% of the population) have been displaced and over 18 205 lives have been lost; of these lives lost, 5153 were women and 7729 were children, constituting 70% of the fatalities. Indirect causes of excess mortality, including from unmanaged obstetric complications, are expected to increasingly contribute to death.

In 2020, 149.2 million children worldwide under 5 years suffered from stunting, and 45.4 million experienced wasting. Many infants are born already stunted, while others are at high risk for growth faltering early after birth. Growth faltering is linked to transgenerational impacts of poverty and marginalization. Few interventions address growth faltering in infants under 6 months, despite a likely increasing prevalence due to the negative global economic impacts of the COVID-19 pandemic. Breastfeeding is a critical intervention to alleviate malnutrition and improve child health outcomes, but rarely receives adequate attention in growth faltering interventions. A systematic review and meta-analysis were undertaken to identify and evaluate interventions addressing growth faltering among infants under 6 months that employed supplemental milks. The review was carried out following guidelines from the USA National Academy of Medicine. A total of 10,405 references were identified, and after deduplication 7390 studies were screened for eligibility. Of these, 227 were assessed for full text eligibility and relevance. Two randomized controlled trials were ultimately included, which differed in inclusion criteria and methodology and had few shared outcomes. Both studies had small sample sizes, high attrition and high risk of bias. A Bangladeshi study (n = 153) found significantly higher rates of weight gain for F-100 and diluted F-100 (DF-100) compared with infant formula (IF), while a DRC trial (n = 146) did not find statistically significant differences in rate of weight gain for DF-100 compared with IF offered in the context of broader lactation and relactation support. The meta-analysis of rate of weight gain showed no statistical difference and some evidence of moderate heterogeneity. Few interventions address growth faltering among infants under 6 months. These studies have limited generalizability and have not comprehensively supported lactation. Greater investment is necessary to accelerate research that addresses growth faltering following a new research framework that calls for comprehensive lactation support.

We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan.

Mortality reporting is a crucial indicator of the severity of a conflict setting, but it can also be inflated or under-reported for political purposes. Amidst the ongoing conflict in Gaza, some political parties have indicated scepticism about the reporting of fatalities by the Gaza Ministry of Health (MoH). The Gaza MoH has historically reported accurate mortality data, with discrepancies between MoH reporting and independent United Nations analyses ranging from 1·5% to 3·8% in previous conflicts. A comparison between the Gaza MoH and Israeli Foreign Ministry mortality figures for the 2014 war yielded an 8·0% discrepancy.  Public scepticism of the current reports by the Gaza MoH might undermine the efforts to reduce civilian harm and provide life-saving assistance.

This case describes rare preterm newborn survival in the setting of an Ebola treatment unit in Eastern DRC. The neonate was born vaginally to an acutely ill 17‐year‐old mother who was vaccinated against Ebola virus after being identified as a contact of her father, who was a confirmed case and who did not survive his infection. This woman was admitted to an Ebola treatment unit at 32 weeks of gestation and given monoclonal antibody treatment. She gave birth vaginally, succumbing to postpartum hemorrhage 14 h after delivery. This child survived despite compounding vulnerabilities of preterm birth and maternal Ebola infection. Despite a negative test for EVD, the neonate was given a single dose of monoclonal antibody therapy in the first days of life. We believe maternal vaccination and neonatal monoclonal antibody treatment contributed to the child's survival. The circumstances surrounding neonatal survival in this extremely resource‐limited context must be analyzed and disseminated in order to increase rates of neonatal and maternal survival in future outbreaks. Maternal and neonatal health are critical aspects of outbreak response that have been understudied and underreported leaving clinicians severely underresourced to provide life‐saving care in outbreak settings. Pregnancy and childbirth do not stop in times of disease outbreak, adequate equipment and trained staff required for quality neonatal care must be considered in future outbreak responses.

A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan’s standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6–59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP −10.0; TSFP −7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored.

he armed conflict in Israel and Gaza has strained the medical systems of both places, particularly in Gaza where at least 40 health-care workers have been killed. The destruction of hospitals and clinics in Gaza, with more than 75 attacks between Oct 7 and Oct 24, 2023, is a tragic echo of both targeted and indiscriminate violence against health care across the globe. The Safeguarding Health in Conflict Coalition reported nearly 2000 incidents of attacks on health care in 2022 globally, and the 2023 trajectory is set to surpass this.

Using a model-based analysis, we calculated the total costs associated with the exclusive breast-feeding (EBF) and breast milk substitute (BMS) usage for one infant for six months within select humanitarian contexts to (a) determine if there is a notable difference in costs and (b) use these results to inform future creation of data-informed humanitarian response standard operating procedures.

Cash assistance has rapidly expanded in the Syrian refugee response in Jordan and global humanitarian programming, yet little is known about the effect of multipurpose cash transfers (MPC) on health in humanitarian contexts. A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the effectiveness of MPC in improving access to healthcare and health expenditures by Syrian refugees in Jordan. Households receiving MPCs (US$113–219 monthly) were compared to control households not receiving MPCs using difference-in-difference analyses. Overall health care-seeking was consistently high (>85%). Care-seeking for child illness improved among MPCs but declined among controls with a significant adjusted difference in change of 11.1% (P<0.05). In both groups, child outpatient visits significantly increased while emergency room visits decreased. Changes in care-seeking and medication access for adult acute illness were similar between groups; however, hospital admissions decreased among MPCs, yet increased among controls (-8.3% significant difference in change; P<0.05). There were no significant differences in change in chronic illness care utilization. Health expenditures were higher among MPCs at baseline and endline; the only significant difference in health expenditure measures’ changes between groups was in borrowing money to pay for health costs, which decreased among MPCs and increased among controls with an adjusted difference in change of -10.3% (P<0.05). The impacts of MPC on health were varied and significant differences were observed for few outcomes. MPC significantly improved care-seeking for child illness, reduced hospitalizations for adult acute illness, and lowered rates of borrowing to pay for health expenditures. No significant improvements in chronic health condition indicators or shifts in sector of care-seeking were associated with MPC. While MPC should not be considered as a stand-alone health intervention, findings may be positive for humanitarian response financing given the potential for investment in MPC to translate to health sector response savings.

Background 

Infection prevention and control (IPC) was a central component of the Democratic Republic of the Congo’s COVID-19 response in 2020, aiming to prevent infections and ensure safe health service provision.

Objectives 

We aimed to assess the evolution of IPC capacity in 65 health facilities supported by Action Contre la Faim in three health zones in Kinshasa (Binza Meteo (BM), Binza Ozone (BO), and Gombe), investigate how triage and alert validation were implemented, and estimate how health service utilisation changed in these facilities (April–December 2020).

Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them.

Background

Noncommunicable disease (NCD) prevention and control in humanitarian emergencies is a well-recognized need, but there is little evidence to guide responses, leading to varying care delivery. The Sana.NCD mobile health (mHealth) app, initially developed in Lebanon, is the only known mHealth tool for NCD management designed to increase care quality and coverage for providers in humanitarian settings.

Objective

We evaluated a specialized mHealth app consisting of an abbreviated medical record for patients with hypertension or diabetes, adapted for a Kenyan refugee camp setting.