Publications

During the 2014-2016 Ebola virus epidemic, more than 500 health care workers (HCWs) died in spite of the use of personal protective equipment (PPE). The Johns Hopkins University Center for Bioengineering Innovation and Design (CBID) and Jhpiego, an international nongovernmental organization affiliate of Johns Hopkins, collaborated to create new PPE to improve the ease of the doffing process.

As Venezuela's economic and political crises continues to evolve, hyperinflation, declining food production and food shortages are contributing to the deterioration of the food and nutrition situation. While official data is largely unavailable, food security and nutrition data from a variety of sources suggest that nearly the entire population is food insecure and that prevalence of acute malnutrition among children is reaching crisis levels in vulnerable populations. In the most recent national survey, 80% of households were food insecure and most households receiving government food assistance reported only occasional receipt. Prevalence of acute malnutrition among children under five increased in vulnerable communities across many states, surpassing serious or critical thresholds in multiple states. Hospitals across the country are reporting increases in both the number and proportion of pediatric consultations and admissions with acute malnutrition, and malnutrition deaths are increasingly common. Declining food security, increases in prevalence of acute malnutrition among children in vulnerable communities, rising pediatric hospital admissions with acute malnutrition and clinician reports of child deaths due to acute malnutrition are indicative of a crisis. The response to the nutrition and food security crisis to date has been limited. There is an urgent need to begin taking steps to address widespread food insecurity and to support treatment for children with acute malnutrition.

The term asylum seeker might be expected to denote those who have not (or not yet) been given international protection. The term refugee should then cover all those who are seeking asylum, regardless of the recognition of their claim – an argument frequently made by organizations such as the Refugee Council. “Refugees” may refer to all those fleeing persecution or only to those with the legal right to remain in the country of refuge. However, the research described in this report (a) used the term “refugee” to denote “refugee” and “asylum seeker”, (b) used the terms “refugee” and “asylum seeker” interchangeably, or (c) conflated the two, since the line between refugee and migrant is “very fuzzy”.

High-consequence pathogens create a unique problem. To provide effective treatment for infected patients while providing safety for the community, a series of 10 high-level isolation units have been created across the country; they are known as Regional Ebola and Special Pathogen Treatment Centers (RESPTCs). The activation of a high-level isolation unit is a highly resource-intensive activity, with effects that ripple across the healthcare system. The incident command system (ICS), a standard tool for command, control, and coordination in domestic emergencies, is a command structure that may be useful in a biocontainment event. A version of this system, the hospital emergency incident command system, provides an adaptable all-hazards approach in healthcare delivery systems. Here we describe its utility in an operational response to safely care for a patient(s) infected with a high-consequence pathogen on a high-level isolation unit. The Johns Hopkins Hospital created a high-level isolation unit to manage the comprehensive and complex needs of patients with high-consequence infectious diseases, including Ebola virus disease. The unique challenges of and opportunities for providing care in this high-level isolation unit led the authors to modify the hospital incident command system model for use during activation. This system has been tested and refined during full-scale functional and tabletop exercises. Lessons learned from the after-action reviews of these exercises led to optimization of the structure and implementation of ICS on the biocontainment unit, including improved job action sheets, designation of physical location of roles, and communication approaches. Overall, the adaptation of ICS for use in the high-level isolation unit setting may be an effective approach to emergency management during an activation.

Yemen is currently experiencing, to our knowledge, the largest cholera epidemic in recent history. The first cases were declared in September 2016, and over 1.1 million cases and 2,300 deaths have since been reported1. Here we investigate the phylogenetic relationships, pathogenesis and determinants of antimicrobial resistance by sequencing the genomes of Vibrio cholerae isolates from the epidemic in Yemen and recent isolates from neighbouring regions. These 116 genomic sequences were placed within the phylogenetic context of a global collection of 1,087 isolates of the seventh pandemic V. cholerae serogroups O1 and O139 biotype El Tor2-4. We show that the isolates from Yemen that were collected during the two epidemiological waves of the epidemic1-the first between 28 September 2016 and 23 April 2017 (25,839 suspected cases) and the second beginning on 24 April 2017 (more than 1 million suspected cases)-are V. cholerae serotype Ogawa isolates from a single sublineage of the seventh pandemic V. cholerae O1 El Tor (7PET) lineage. Using genomic approaches, we link the epidemic in Yemen to global radiations of pandemic V. cholerae and show that this sublineage originated from South Asia and that it caused outbreaks in East Africa before appearing in Yemen. Furthermore, we show that the isolates from Yemen are susceptible to several antibiotics that are commonly used to treat cholera and to polymyxin B, resistance to which is used as a marker of the El Tor biotype.

Background: In Myanmar, HIV is concentrated among key populations, yet less than half of the estimated 250,000 men who have sex with men (MSM) and transgender women (TW) report recent HIV testing. As many as 50% of MSM and TW may conceal their same-sex preferences and behaviors, yet little is known about the barriers faced by those who are locally regarded as 'hidden' - that is, MSM who do not disclose same-sex preferences and/or identify as gay. This study explored specific barriers to accessing HIV testing and other prevention services among 'hidden' MSM to inform appropriate models of service delivery.

Methods: In-depth interviews with MSM (n = 12) and TW (n = 13) and focus group discussions (FGD) with MSM and TW community members, leaders and key informants (n = 35) were undertaken in Yangon during June - September 2015. Participants were recruited by word-of-mouth by trained peer data collectors. Responses to questions from semi-structured guides were transcribed and coded using Atlas Ti. Codes were based on key domains in the guides and applied to transcripts to identify and analyze emerging themes.

Results: Fear of stigma and discrimination and the need to meet gender expectations were key reasons for non-disclosure of same-sex preferences and behaviors; this typically manifested as avoidance of other MSM and settings in which sexual identity might be implicated. These concerns influenced preference and interaction with HIV services, with many avoiding MSM-specific services or eschewing HIV testing services entirely. The difficulties of engaging hidden MSM in HIV prevention was strongly corroborated by service providers.

Conclusion: Hidden MSM face multiple barriers to HIV testing and prevention. Strategies cognizant of concerns for anonymity and privacy, such as One-Stop Shop services and online-based health promotion, can discretely provide services appropriate for hidden MSM. Enhanced capacity of peer-service providers and mainstream health staff to identify and respond to the psychosocial challenges reported by hidden MSM in this study may further encourage service engagement. Overarching strategies to strengthen the enabling environment, such as legal reform and LGBTI community mobilisation, can lessen stigma and discrimination and increase hidden MSM's comfort and willingness to discuss same-sex behavior and access appropriate services.

The 2013-2016 epidemic of Ebola virus disease (EVD) that originated in West Africa underscored many of the challenges to conducting clinical research during an ongoing infectious disease epidemic, both in the most affected countries of Guinea, Liberia, and Sierra Leone, as well as in the United States and Europe, where a total of 27 patients with EVD received care in biocontainment units. The Special Pathogens Research Network (SPRN) was established in the United States in November 2016 to provide an organizational structure to leverage the expertise of the 10 Regional Ebola and Other Special Pathogen Treatment Centers (RESPTCs); it was intended to develop and support infrastructure to improve readiness to conduct clinical research in the United States. The network enables the rapid activation and coordination of clinical research in the event of an epidemic and facilitates opportunities for multicenter research when the RESPTCs are actively caring for patients requiring a biocontainment unit. Here we provide an overview of opportunities identified in the clinical research infrastructure during the West Africa EVD epidemic and the SPRN activities to meet the ongoing challenges in the context of Ebola virus and other special pathogens.

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.

Introduction/ProblemFor more than 60 years, Colombia experienced an armed conflict involving government forces, guerrillas, and other illegal armed groups. Violence, including torture and massacres, has caused displacement of entire rural communities to urban areas. Lack of information on the problems displaced communities face and on their perceptions on potential solutions to these problems may prevent programs from delivering appropriate services to these communities. This study explores the problems of Afro-Colombian survivors from two major cities in Colombia; the activities they do to take care of themselves, their families, and their community; and possible solutions to these problems.

Ability to function in tasks and activities is an important aspect of daily living. There are factors that increase the risk for impaired functioning, such as experiences of domestic violence (DV) and other trauma types, and factors that provide a buffer to existing risks and allow the individual to continue and build functioning, such as access to social resources. This cross-sectional study investigated the direct effects of DV and access to social resources (perceived social support, social integration, and frequency of social contact), as well as their potential interactive effects, on daily functioning among 894 male and female trauma survivors who attended primary care clinics in Kurdistan, Iraq in 2009 and 2010. Experiencing DV was not associated with functioning for males (p=.15) or females (p=.60), suggesting that in the context of a trauma-affected sample, the experience of DV may not significantly increase the risk for functional impairment. Greater amounts of social integration were associated with less functional impairment among males (p<.01) and females (p<.05); social integration was associated with less functional impairment among males only (p<.01); and frequency of social contact was associated with less functional impairment among females only (p<.05), indicating that the association between social resource type and functioning differed by gender. Standardized beta coefficients indicated that social resources had a stronger effect on functioning among men compared to women. Among males who experienced DV, social integration was the only social resource associated with less functional impairment (p<.01); among male trauma survivors who did not experience DV, social support was the only resource associated with less functional impairment (p<.01). Further investigation into the association of social resources with functioning and how these differ by gender and DV exposure is warranted to inform intervention strategies for survivors of DV and other traumas in post-conflict settings.

With one billion people on the move or having moved in 2018, migration is a global reality. International migration has increased to 258 million, and the numbers of refugees and people displaced by conflict, natural disasters, and climate change are at their highest levels: 22 and 40 million, respectively. Despite negative political narratives, migration is not overwhelming high-income countries—instead, it takes place mostly between low-income and middle-income countries and most people are migrating for work. By and large, migration is a positive and diverse experience. But migration has also become a political lightning rod. 

Exposure to violence has negative consequences on mental health. Armed-conflict in Colombia has widely affected Afro-descendants in the Pacific region. Evidence regarding effectiveness of mental health interventions is lacking in low-income settings, especially in areas with active conflict. The objective of this study is to evaluate an individualized Common Elements Treatment Approach (CETA), a transdiagnostic psychotherapy model based on Cognitive-Behavioral Therapy, for adult trauma survivors.

Lack of legal immigration status is associated with poor HIV-related outcomes for immigrant Latinx sexual and gender minorities (LSGM). LSGM often meet eligibility criteria for legal immigration relief. A Medical-Legal Partnership (MLP) may thus be strategic to improve their health. We know little about the challenges LSGM face during the immigration legal process. We conducted in-depth interviews with six key informants and sixteen LSGM who recently applied for immigration legal relief. We coded and analyzed the data for emergent themes. Challenges to instituting an MLP for LSGM included lack of specialized training on working with SGM for immigration attorneys, and for clients: knowledge about legal deadlines, lack of housing and family support, and re-traumatizing experiences. Clients' outcomes were positive when attorneys and mental health providers collaborated. For LSGM, the benefits of immigration relief included reduced HIV risk. An MLP that addresses the surmountable challenges could improve HIV-related outcomes among LSGM.

To evaluate effectiveness of point-of-use water treatment in improving treatment of children affected by severe acute malnutrition (SAM).

To examine the demographic characteristics and mental health of women in rural Zambia who experienced physical intimate partner violence (IPV) postpartum.

Obtaining accurate and valid measurements of disruptive behavior disorders remains a challenge in non-Western settings due to variability in societal norms for child behavior and a lack of tools developed outside of Western contexts. This paper assesses the reliability and construct validity of the Disruptive Behavior International Scale - Nepal version (DBIS-N)-a scale developed using ethnographic research in Nepal-and compares it with a widely used Western-derived scale in assessing locally defined child behavior problems.

Abstract

In our work as clinicians, researchers, and immigrant rights advocates, we have noted increased anxiety about the possibility of deportation and disruptions in care among immigrants with HIV. Before the 2016 US elections, patients rarely asked about HIV treatment in their home countries. However, since the increase in anti-immigrant rhetoric and arrests by US Immigration and Customs Enforcement, patients have voiced concerns about the availability of HIV treatment in their home countries much more frequently. Although antiretroviral therapy is available throughout Latin America, access depends on economic, social, and political circumstances. Maintaining uninterrupted continuity of care among immigrants held in detention or deported to their home countries is challenging. In this Viewpoint, we identify periods of particular vulnerability for immigrants during deportation proceedings, from initial detention to deposition in their country of origin. We discuss the effect of enhanced immigration enforcement on the health and wellbeing of HIV-infected immigrants, and on public health. Finally, we also discuss recommendations for clinicians, immigration authorities, and public health institutions in the USA and in receiving countries.

The use of oral cholera vaccine (OCV) has increased since 2011, when Shanchol, the first OCV suitable for large-scale use, became available. Médecins Sans Frontières considers OCVs an essential cholera outbreak control tool and has contributed to generating new evidence on OCV use in outbreaks. We showed that large-scale mass campaigns are feasible during outbreaks, documented high short-term effectiveness and showed that vaccines are likely safe in pregnancy. We found that a single-dose regimen has high short-term effectiveness, making rapid delivery of vaccine during outbreaks easier, especially given the on-going global vaccine shortage. Despite progress, OCV has still not been used widely in some of the largest recent outbreaks and thousands of cholera deaths are reported every year. While working towards improving our tools to protect those most at-risk of cholera, we must strive to use all available effective interventions in efficient ways, including OCV, to prevent avoidable deaths today.

Dureab and colleagues concur with our call for urgent measures to enhance cholera preparedness and response in Yemen to stop the outbreak that has persisted for more than 2 years. However, they challenge our finding that the large second epidemic wave was associated with the start of the rainy season from April to May, 2017. They suggest that rainfall is unlikely to be a major risk factor for cholera transmission in Yemen because cholera and rainfall are spatially and temporally variable within the country, and because our analyses used modelled and not measured estimates of precipitation.

Although the World Health Organization (WHO) has recommended guidelines for the treatment of opioid dependence, there are myriad challenges to successfully implementing such guidelines in resource constrained settings, such as in low and middle-income countries (LMICs). To highlight these challenges, this paper presents a clinical case study of an adolescent study participant in a randomized controlled trial comparing two counseling programs in Lusaka, Zambia.