Publications

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.

Background: Since March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country.

Methods: We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services.

Results: The time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services.

Background

Cash-based assistance in humanitarian contexts has grown substantially in recent years, yet little is empirically known about differential impacts of cash for diverse beneficiaries, which could better inform assistance targeting. In the context of increasing food insecurity and extreme levels of famine in South Sudan despite significant scale-up of humanitarian assistance, this analysis examined food security and household economy outcomes to better understand the impact of cash assistance and characteristics associated with worsened household food security and coping strategies.

Methods

In 2019–2021, a prospective cohort study was conducted leveraging a program providing cash for work in community gardens. 1213 households receiving cash prior to the start of the study (Cohort A/B), 582 non-intervention households (Control), and 300 households that received cash after the start of the study (Cohort C) completed 2 interviews spaced one year apart to measure household food insecurity and coping mechanism adoption.

Results

There were no significant differences in change over time in household hunger score (p = 0.074), livelihoods coping strategy index score (p = 0.104), or meal frequency (p = 0.113) between program participants and the comparison group. The comparison group had a significantly larger increase in dietary diversity over time (0.6 vs. 0.2 in Cohort A/B, p = 0.005); however, at endline there were no significant differences in dietary diversity between program participants and the non-intervention group (4.3 in both groups). There were few factors associated with increased likelihood of worsened food security and coping outcomes, the most noticeable being recent investment livestock, which was associated with 1.5 times greater odds of worsened hunger and 1.63 times greater odds of worsened coping strategy adoption.

Objective

This study aims to investigate maternal, fetal, and perinatal outcomes during the 2018–2020 Ebola outbreak in Democratic Republic of Congo (DRC).

Methods

Mortality between pregnant and non-pregnant women of reproductive age admitted to DRC’s Mangina Ebola treatment center (ETC) were compared using propensity score matching. Propensity scores were calculated using age, initial Ebola viral load, Ebola vaccination status, and investigational therapeutic. Additionally, fetal and perinatal outcomes of pregnancies were also described.

Results

Twenty-seven pregnant women were admitted to the Mangina ETC during December 2018—January 2020 among 162 women of childbearing age. We found no evidence of increase mortality among pregnant women compared to non-pregnant women (relative risk:1.0, 95%CI: 0.58–1.72). Among surviving mothers, pregnancy outcomes were poor with at least 58% (11/19) experiencing loss of pregnancy while 16% (3/19) were discharged with viable pregnancy. Two mothers with viable pregnancies were vaccinated, and all received investigational therapeutics. Two live births occurred, with one infant surviving after the infant and mother received an investigational post-exposure prophylaxis and Ebola therapeutic respectively.

Establishing a practical anthropometric measurement, with an appropriate cut-off threshold, to identify pregnant women as undernourished in humanitarian settings can assist in the implementation of necessary interventions to avoid unfavourable maternal and birth outcomes. A key gap in maternal nutrition is that there is currently no agreed-upon standard set in the Sphere Handbook that defines maternal acute undernutrition through an optimal, context-specific MUAC cut-off point (Sphere Association, 2018).

In 2013, Médecins Sans Frontières Switzerland undertook an extensive literature review (Ververs et al, 2013) of articles published between January 1995 and September 2012 exploring anthropometric indicators that are able to identify pregnant women as acutely undernourished and at risk for adverse outcomes – including maternal mortality, low birth weight (LBW), intra-uterine growth restriction (IUGR), pre-term birth (PTB), small-for-gestational-age (SGA), and stunting at birth.

The review concluded that maternal MUAC can be used as a reliable indicator of risk of LBW. Maternal MUAC was identified as the preferential indicator, as opposed to body mass index, maternal weight for gestational age, maternal weight gain, or maternal stature. Maternal MUAC has a strong association with birth weight, is a simple measurement to take, particularly in humanitarian contexts, and is independent from gestational age. The proposed conservative cut-off value to enrol pregnant women in nutritional programmes, most frequently supplementary feeding programmes, was a MUAC of <23 cm.

This scoping review aims to analyse studies published after September 2012, specifically focusing on determining the specific MUAC cut-off threshold used to identify adverse birth and maternal outcomes to understand if a MUAC of <23cm should be used rather than a MUAC of <21cm as is used in some humanitarian nutrition programmes.

Objectives 

To provide a thorough mapping of the current quality and depth of evidence examining the effectiveness of health interventions in humanitarian settings in low and middle-income countries published in peer-reviewed journals since 2013.

Methods 

We searched MEDLINE, Embase and Global Health for English language peer-reviewed literature published from May 2013 through April 2021 to analyse the strength of evidence on health interventions’ effectiveness in humanitarian settings in low and middle-income countries across nine thematic areas. Quality was assessed using standardised criteria and critical appraisal tools based on study design.

Results 

A total of 269 publications were included in this review. The volume of publications increased since the first Elrha Humanitarian Health Evidence Review in 2013, but non-communicable diseases and water, sanitation and hygiene remain the areas with the most limited evidence base on intervention effectiveness in addition to injury and rehabilitation. Economic evaluations continued to constitute a small proportion (5%) of studies. Half of studies had unclear risk of bias, while 28% had low, 11% moderate and 11% high risk of bias. Despite increased diversity in studied interventions, variations across and within topics do not necessarily reflect the health issues of greatest concern or barriers to quality service delivery in humanitarian settings.

Background

The Taliban takeover in August 2021 brought global economic sanctions, economic collapse, and draconian restrictions on women’s freedom of movement, work, political participation, and education. This study examined Afghan health workers’ experiences and perceptions of availability and quality of maternal and child health care since then.

Methods

We conducted a survey, using a convenience sample, of health workers from urban, semi-rural, and rural public and private clinics and hospitals across the 34 provinces, covering changes in working conditions, safety, health care access and quality, maternal and infant mortality as well as perceptions about the future of maternal and child health and health care. Interviews were conducted with a subsample of health workers to further explore their perceptions of changes in working conditions, quality of care, and health outcomes since the Taliban takeover.

Background

Venezuela has experienced substantial human displacement since 2015. To inform HIV programmes and treatment distribution, we aimed to estimate HIV prevalence and associated indicators among migrants and refugees from Venezuela residing in Colombia, the largest receiving country.

Methods

We conducted a biobehavioural, cross-sectional survey using respondent-driven sampling among Venezuelan people aged 18 years or older who had arrived in Colombia since 2015 and resided in four cities (ie, Bogotá, Soacha, Soledad, and Barranquilla). Participants completed sociobehavioural questionnaires and rapid HIV and syphilis screening with laboratory-based confirmatory testing, CD4 cell counts, and viral load quantification. Policies related to migration status affect access to insurance and HIV services in Colombia, as in many receiving countries, so we provided legal assistance and navigation support to participants with HIV for sustained access to treatment. Population-based estimates were weighted for the complex sampling design. Penalised multivariable logistic regression analysis was used to identify correlates of viral suppression (HIV-1 RNA <1000 copies per mL).

Background

Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas.

Methods

We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017–February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant.

Results

Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic.

On the morning of May 26, a Russian missile destroyed Dnipropetrovsk City Hospital No 14 in Dnipro, Ukraine, killing at least two people and injuring more than 30. Later that same day, the BBC reported that attacks on medical facilities and staff in Sudan might constitute war crimes. As described in a World Report, such attacks continue in Sudan, including most recently the looting and occupation of centres run by Médecins Sans Frontières, denying Sudanese civilians much needed medical care. From the deliberate targeting of hospitals in Syria and the destruction of the health system in Yemen, to the arrest and abduction of doctors in Myanmar and the persecution of health workers and violations of medical neutrality in Iran, the sanctity of the Red Cross and Red Crescent appears to be at a new low. The uncomfortable truth is that attacks against health facilities and staff in conflicts can be committed largely with legal impunity.

Background

Despite increasing evidence on COVID-19, few studies have been conducted in humanitarian settings and none have investigated the direct and indirect effects of the pandemic in the Central African Republic. We studied the COVID-19 epidemiology, health service utilization, and health care seeking behavior in the first year of the pandemic in Bangui and surrounding areas.

Methods

This mixed-methods study encompasses four components: descriptive epidemiological analysis of reported COVID-19 cases data; interrupted time series analysis of health service utilization using routine health service data; qualitative analysis of health care workers’ perceptions of how health services were affected; and health care seeking behavior of community members with a household survey and focus group discussions.

Background

Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services.

Methods

A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country’s 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis was conducted using SPSS v28.

Results

All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines, and supplies necessary for quality antenatal, intrapartum, and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, ho

Until recently, little attention from humanitarian agencies has been given to management of noncommunicable diseases in emergencies. Chronic kidney disease (CKD) is a common non-communicable disease, and despite its increasing prevalence, management of CKD, including kidney failure (KF) and kidney transplantation, receives little support in health emergencies. Management of patients with end-stage kidney failure on maintenance dialysis requires a complex infrastructure consisting of a built environment, electricity, water delivery, dialysis equipment, secure dialysis supplies chain, skilled medical staff, and leadership, which may not be available in many situations. Where these requirements do exist, they are easily disrupted in humanitarian emergencies. Protracted conflicts, such as those in the Democratic Republic of the Congo, Iraq, Libya, Syria, Somalia, Yemen, and Ukraine, have produced a new urgency for the planning and management of persons with KF and other non-communicable diseases.

Cholera outbreaks primarily occur in areas lacking adequate water, sanitation, and hygiene (WASH), and infection can cause severe dehydration and death. As individuals living near cholera cases are more likely to contract cholera, case-area targeted interventions (CATI), where a response team visits case and neighbor households and conducts WASH and/or epidemiological interventions, are increasingly implemented to interrupt cholera transmission. As part of a multi-pronged evaluation on whether CATIs reduce cholera transmission, we compared two organizations' standard operating procedures (SOPs) with information from key informant interviews with 26 staff at national/headquarters and field levels who implemented CATIs in Nigeria in 2021. While organizations generally adhered to SOPs during implementation, deviations related to accessing case household and neighbor household selection were made due to incomplete line lists, high population density, and insufficient staffing and materials. We recommend reducing the CATI radius, providing more explicit context-specific guidance in SOPs, adopting more measures to ensure sufficient staffing and supplies, improving surveillance and data management, and strengthening risk communication and community engagement. The qualitative results herein will inform future quantitative analysis to provide recommendations for overall CATI implementation in future cholera responses in fragile contexts.