Nadine Ezard

Six rapid assessments of alcohol and other substance use in populations displaced by conflict

BackgroundSubstance use among populations displaced by conflict is a neglected area of public health. Alcohol, khat, benzodiazepine, opiate, and other substance use have been documented among a range of displaced populations, with wide-reaching health and social impacts. Changing agendas in humanitarian response-including increased prominence of mental health and chronic illness-have so far failed to be translated into meaningful interventions for substance use.MethodsStudies were conducted from 2006 to 2008 in six different settings of protracted displacement, three in Africa (Kenya, Liberia, northern Uganda) and three in Asia (Iran, Pakistan, and Thailand). We used intervention-oriented qualitative Rapid Assessment and Response methods, adapted from two decades of experience among non-displaced populations. The main sources of data were individual and group interviews conducted with a culturally representative (non-probabilistic) sample of community members and service providers.ResultsWidespread use of alcohol, particularly artisanally-produced alcohol, in Kenya, Liberia, Uganda, and Thailand, and opiates in Iran and Pakistan was believed by participants to be linked to a range of health, social and protection problems, including illness, injury (intentional and unintentional), gender-based violence, risky behaviour for HIV and other sexually transmitted infection and blood-borne virus transmission, as well as detrimental effects to household economy. Displacement experiences, including dispossession, livelihood restriction, hopelessness and uncertain future may make communities particularly vulnerable to substance use and its impact, and changing social norms and networks (including the surrounding population) may result in changed - and potentially more harmful-patterns of use. Limited access to services, including health services, and exclusion from relevant host population programmes, may exacerbate the harmful consequences.ConclusionsThe six studies show the feasibility and value of conducting rapid assessments in displaced populations. One outcome of these studies is the development of a UNHCR/WHO field guide on rapid assessment of alcohol and other substance use among conflict-affected populations. More work is required on gathering population-based epidemiological data, and much more experience is required on delivering effective interventions. Presentation of these findings should contribute to increased awareness, improved response, and more vigorous debate around this important but neglected area.

Substance use among populations displaced by conflict: a literature review

This paper reviews the literature on substance use among populations displaced by conflict. Of the 17 publications presenting primary data retained for review, all consider populations in or recovering from protracted conflict, the majority (10) in non-camp settings. Most studies (10) offer prevalence estimates, suggesting that substance use (such as of alcohol, opiates, or minor tranquilizers) is common in some displaced settings. Five describe harmful consequences of substance use among displaced populations (such as HIV transmission, tuberculosis treatment failure, gender-based violence, and economic problems). Three studies suggest risk factors for substance use problems (such as gender, trauma-related conditions, pre-displacement substance use, and socio-economic factors); two examine qualitatively the gendered nature of alcohol-related harm and its links with gender-based violence. One study examines an intervention. The evidence base is weak. Findings are used to develop a conceptual framework emphasizing the risk environment to inform further research, to encourage debate among researchers and practitioners, and to enable the development of interventions.

Public health, human rights and the harm reduction paradigm: from risk reduction to vulnerability reduction

This paper explores the utility of expanding the harm reduction paradigm to incorporate vulnerability reduction. The thrust of harm reduction interventions to date, particularly in injection drug use, has been risk reduction. Many interventions have been designed to reduce drug-related harm by altering high-risk behaviours. Vulnerability looks behind risk. The notion of vulnerability incorporates the complex of underlying factors that promotes harmful outcomes as a result of drug use, and limits attempts to modify drug use to make harmful outcomes less likely. A conceptual framework will be introduced that looks at harm, risk and vulnerability at the three levels of individual, community and society. This paper uses illicit injection drug use as an example. This conceptual framework will be used to position human rights more centrally in the harm reduction debate. Human rights violations and infringements can contribute to drug-related harm by first creating the preconditions for risky drug use; and second, by limiting access to prevention and care. A human rights framework allows us to better understand vulnerability to drug-related harm, and provides an important advocacy tool for improved interventions. This expanded harm reduction paradigm that incorporates vulnerability and human rights allows for better development of a public health approach in harm reduction, exposes gaps in research, and allows for better development of more effective interventions.

Evaluation of the Xpert HCV Viral Load point-of-care assay from venepuncture-collected and finger-stick capillary whole-blood samples: a cohort study

BACKGROUND Point-of-care hepatitis C virus (HCV) RNA testing offers an advantage over antibody testing (which only indicates previous exposure), enabling diagnosis of active infection in a single visit. In this study, we evaluated the performance of the Xpert HCV Viral Load assay with venepuncture and finger-stick capillary whole-blood samples. METHODS Plasma and finger-stick capillary whole-blood samples were collected from participants in an observational cohort enrolled at five sites in Australia (three drug and alcohol clinics, one homelessness service, and one needle and syringe programme). We compared the sensitivity and specificity of the Xpert HCV Viral Load test for HCV RNA detection by venepuncture and finger-stick collection with the Abbott RealTime HCV Viral Load assay (gold standard). FINDINGS Of 210 participants enrolled between Feb 8, 2016, and July 27, 2016, 150 participants had viral load testing results for the three assays tested. HCV RNA was detected in 45 (30% [95% CI 23-38]) of 150 participants based on Abbott RealTime. Sensitivity of the Xpert HCV Viral Load assay for HCV RNA detection in plasma collected by venepuncture was 100·0% (95% CI 92·0-100·0) and specificity was 99·1% (95% CI 94·9-100·0). Sensitivity of the Xpert HCV Viral Load assay for HCV RNA detection in samples collected by finger-stick was 95·5% (95% CI 84·5-99·4) and specificity was 98·1% (95% CI 93·4-99·8). No adverse events caused by the index test or the reference standard were observed. IMPLICATIONS The Xpert HCV Viral Load test can detect active infection from a finger-stick sample, which represents an advance over antibody-based tests that only indicate past or previous exposure. FUNDING National Health and Medical Research Council (Australia), Cepheid, South Eastern Sydney Local Health District (Australia), and Merck Sharp & Dohme (Australia).

An evaluation of community methadone services in Victoria, Australia: results of a client survey

One hundred and ninety-five metropolitan clients enrolled in the community-based methadone programme in Victoria, Australia were surveyed in order to evaluate client perspectives of methadone treatment delivered from primary health care settings. Results indicated that the average daily methadone dose was 41 mg, ranging from 7 mg to 140 mg. The majority of clients were satisfied with the programme and the services delivered by dispensing pharmacies and prescribing doctors. Most clients were found to have reduced their heroin use and criminal activity since commencing methadone. A number of concerns about the programme were identified, however, including the high proportion of weekly income spent on methadone-related activities and a high use of tranquillizers by clients on higher methadone doses. In general the community-based methadone programme was found to be an acceptable methadone of service delivery to metropolitan clients in Victoria, Australia. [Ezard N, Lintzeris N, Odgers P, Koutroulis G, Muhleisen P, Stowe A, Lanagan A. An evaluation of community methadone services in Victoria, Australia: results of a client survey. Drug Alcohol Rev 1999;18 :417 i423]

Screening and brief intervention for high-risk alcohol use in Mae La refugee camp, Thailand: a pilot project on the feasibility of training and implementation

Many populations that are displaced by conflict experience health and social problems connected to alcohol use. Screening for high-risk alcohol use and brief intervention is a core public health strategy for decreasing the harm related to alcohol use. Experience among populations displaced by conflict is, however, limited. The authors conducted a pilot project in a long standing Burmese refugee camp in Thailand, using the Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument. The intervention was piloted through the existing primary health care system. Screening and brief intervention for high-risk alcohol use was feasible in this refugee camp setting. More work is required to assess the effectiveness of this intervention in settings of forced displacement, as well as the feasibility of incorporating such interventions into community mobilisation strategies and measures, addressing the drinking environment more generally.

Risky alcohol use among reproductive-age men, not women, in Mae La refugee camp, Thailand, 2009

BackgroundGlobally, alcohol use contributes to close to 4% of all deaths and is a leading cause of ill health and premature death among men of reproductive age. Problem alcohol use is an unaddressed public health issue among populations displaced by conflict. Assessing the magnitude of the problem and identifying affected groups and risk behaviours is difficult in mobile and unstable populations.MethodsFrom 15–28 December 2009 we conducted a simple rapid screening test of risky alcohol use using the single item modified Short Assessment Screening Questionnaire (mSASQ) by all women currently enrolled in the antenatal care clinic in Mae La refugee camp, a long standing displaced setting on the Thai Burma border. Women self- reported and gave a secondary report of their male partners. Gender differences in alcohol use were further explored in semi-structured interviews with camp residents on attitudes, behaviours, and beliefs regarding alcohol and analysed thematically.ResultsOf 636 women screened in the antenatal clinic, almost none (0.2%, 95CI 0.0-0.9%) reported risky alcohol use prior to pregnancy, whereas around a quarter (24.4%, 95CI 21.2-27.9%) reported risky alcohol use by their male partners. Interviews with 97 camp residents described strong social controls against women’s alcohol use and men’s drinking to intoxication, despite a dominant perception that the social context of life in displacement promoted alcohol use and that controls are loosening.ConclusionsAs a stigmatised behaviour, alcohol use is difficult to assess, particularly in the context of highly mobile adult male populations: the simple assessment methods here show that it is feasible to obtain adequate data for the purposes of intervention design. The data suggest that risky drinking is common and normalised among men, but that the population may have been partially protected from rapid rises in problem alcohol use observed in nation-wide data from Thailand. The changing social context contains vulnerabilities that might promote problem alcohol use: further investigation, ongoing monitoring, and development of targeted interventions are warranted.

Why are we not doing more for alcohol use disorder among conflict‐affected populations?

Keywords: Alcohol; armed conflict; humanitarian; mental health; non-communicable diseases; refugees; substance abuse; war

It's not just the alcohol: Gender, alcohol use, and intimate partner violence in Mae La Refugee Camp, Thailand, 2009

Alcohol use is common in many conflict-displaced populations; population perspectives of alcohol use have not been well studied. Interviews were conducted with a convenience sample of 97 people (September–December 2009) in Mae La, a long-standing refugee camp on the Thai-Burma border, and analyzed thematically. Intimate partner violence (IPV) emerged as a prominent theme, with four subthemes: alcohol use is subject to strongly gendered social controls; alcohol use is changing under the pressures of displacement; IPV is an emergent alcohol-related harm; the relationship between IPV and alcohol is complex. The studys limitations are noted, and future practice and research directions are discussed.

Efficacy of chloroquine in the treatment of uncomplicated Plasmodium falciparum infection in East Timor, 2000.

Access to an efficacious antimalarial drug is one of the cornerstones of the Roll Back Malaria initiative to decrease malaria morbidity and mortality. This is particularly important in emergency and post-emergency settings where access to treatment in the event of therapeutic failure may be restricted. In the aftermath of violence securing the independence of East Timor (1999), chloroquine continued to be used as first line therapy for the treatment of malaria. However, reliable data on the efficacy of chloroquine was not available. This paper represents the first attempt to document treatment failure with chloroquine in East Timor. The study was conducted using modified WHO guidelines in a rural hospital outpatient department in an area where there is seasonal transmission of both Plasmodium vivax and Plasmodium falciparum. 48 subjects presenting with fever and microscopically confirmed P. falciparum monoinfection were given supervised oral treatment with quality controlled chloroquine (25 mg/kg over 3 days) and followed clinically and parasitologically for 28 days. 32 of the 48 subjects had recurrent parasitaemia, and PCR confirmed that 28 of these were likely to be due to recrudescent parasites. The corrected treatment failure was, therefore, 58.3% (28/48), with all but one (2.1%) defined as late treatment failures (7-28 days after treatment). Further research into appropriate chemotherapy, including sulphadoxine-pyrimethamine and combination therapy for example with artemesinin or its derivatives, should be undertaken to select the most appropriate first line therapy for the management of uncomplicated malaria in East Timor.