Annick Lenglet

Mortality rates above emergency threshold in population affected by conflict in North Kivu, Democratic Republic of Congo, July 2012-April 2013

The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement. Médecins-Sans-Frontières (MSF) returned to provide primary healthcare in July 2012. To better understand the impact of the ongoing conflict and displacement on the population, a retrospective mortality survey was conducted in April 2013. A two-stage randomized cluster survey using 31 clusters of 21 households was conducted. Heads of households provided information on their household make-up, ownership of non-food items (NFIs), access to healthcare and information on deaths and occurrence of self-reported disease in the household during the recall period. The recall period was of 325 days (July 2012–April 2013). In total, 173 deaths were reported during the recall period. The crude mortality rate (CMR) was of 1.4/10,000 persons/day (CI95%: 1.2–1.7) and the under-five- mortality rate (U5MR) of 1.9/10,000 persons per day (CI95%: 1.3–2.5). The most frequently reported cause of death was fever/malaria 34.1% (CI95%: 25.4–42.9). Thirteen deaths were due to intentional violence. Over 70% of all households had been displaced at some time during the recall period. Out of households with someone sick in the last two weeks, 63.8% sought health care; the main reason not to seek health care was the lack of money (n = 134, 63.8%, CI95%: 52.2–75.4). Non Food Items (NFI) ownership was low: 69.0% (CI95%: 53.1–79.7) at least one 10 liter jerry can, 30.1% (CI95%: 24.3–36.5) of households with visible soap available and 1.6 bednets per household. The results from this survey in Walikale clearly illustrate the impact that ongoing conflict and displacement are having on the population in this part of DRC. The gravity of their health status was highlighted by a CMR that was well above the emergency threshold of 1 person/10,000/day and an U5MR that approaches the 2 children/10,000/day threshold for the recall period.

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.

Measles vaccination coverage survey in Moba, Katanga, Democratic Republic of Congo, 2013: need to adapt routine and mass vaccination campaigns to reach the unreached

The Democratic Republic of Congo (DRC) has committed to eliminate measles by 2020. In 2013, in response to a large outbreak, Médecins Sans Frontières conducted a mass vaccination campaign (MVC) in Moba, Katanga, DRC. We estimated the measles vaccination coverage for the MVC, the Expanded Programme on Immunization routine measles vaccination (EPI) and assessed reasons for non-vaccination. We conducted a household-based survey among caretakers of children aged 6 months-15 years in Moba from November to December 2013. We used a two-stage-cluster-sampling, where clusters were allocated proportionally to village size and households were randomly selected from each cluster. The questionnaire included demographic variables, vaccination status (card or oral history) during MVC and EPI and reasons for non-vaccination. We estimated the coverage by gender, age and the reasons for non-vaccination and calculated 95% confidence intervals (95% CI). We recruited 4,768 children living in 1,684 households. The MVC coverage by vaccination card and oral history was 87% (95% CI 84-90) and 66% (95% CI 61-70) if documented by card. The EPI coverage was 76% (95% CI 72-81) and 3% (95% CI 1-4) respectively. The MVC coverage was significantly higher among children previously vaccinated during EPI 91% (95% CI 88-93), compared to 74% (95% CI 66-80) among those not previously vaccinated. Six percent (n=317) of children were never vaccinated. The main reason for non-vaccination was family absence 68% (95% CI 58-78). The MVC and EPI measles coverage was insufficient to prevent the recurrence of outbreaks in Moba. Lack of EPI vaccination and lack of accessibility by road were associated with lower MVC coverage. We recommend intensified social mobilization and extended EPI and MVCs to increase the coverage of absent residents and unreached children. Routine and MVCs need to be adapted accordingly to improve coverage in hard-to-reach populations in DRC.

Uptake of household disinfection kits as an additional measure in response to a cholera outbreak in urban areas of Haiti.

Médecins Sans Frontières-Operational Centre Amsterdam piloted the distribution of household disinfection kits (HDKs) and health promotion sessions for cholera prevention in households of patients admitted to their cholera treatment centres in Carrefour, Port au Prince, Haiti, between December 2010 and February 2011. We conducted a follow-up survey with 208 recipient households to determine the uptake and use of the kits and understanding of the health promotion messages. In 61% of surveyed households, a caregiver had been the recipient of the HDK and 57.7% of households had received the HDKs after the discharge of the patient. Among surveyed households, 97.6% stated they had used the contents of the HDK after receiving it, with 75% of these reporting using five or more items, with the two most popular items being chlorine and soap. A significant (p < 0.05) increase in self-reported use items in the HDK was observed in households that received kits after 24 January 2011 when the education messages were strengthened. To our knowledge, this is the first time it has been demonstrated that during a large-scale cholera outbreak, the distribution of simple kits, with readily available cleaning products and materials, combined with health promotion is easy, feasible, and valued by the target population.

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.

Keeping it simple: a gender-specific sanitation tool for emergencies

Mainstreaming gender in an emergency water and sanitation (WatSan) response can be difficult as standard consultations and participation processes take too much time. To facilitate a rapid response that includes womens needs, a simple Gender and Sanitation Tool has been developed that can also be used by less experienced staff. The tool is a step-by-step guide on how to collect required data to define design parameters for sanitation facilities, based on ad hoc consultations with women who will be their users. In 2012 the tool was tested in South Sudan within the context of a Medecins Sans Frontieres (MSF) emergency intervention. Using the tool allowed for a quick and easy way to consult women about the design of facilities and consequently, after construction, an increased usage of facilities was observed in the intervention group compared with a control group where the tool was not used.

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.

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.

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.