Showing papers in "Conflict and Health in 2011"

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

Abstract: Background: Substance 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. Methods: Studies 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 interventionoriented 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. Results: Widespread 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. Conclusions: The 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.

Experiences of female survivors of sexual violence in eastern Democratic Republic of the Congo: a mixed-methods study

Abstract: The conflict in eastern Democratic Republic of the Congo (DRC) is the deadliest since World War II. Over a decade of fighting amongst an array of armed groups has resulted in extensive human rights abuses, particularly the widespread use of sexual violence against women. Using a mixed-methods approach, we surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). We then conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively. Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape. Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as "contaminated" with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors' feelings of shame and social isolation. Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

Providing surgical care in Somalia: A model of task shifting

Abstract: Background: Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the “remote” model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context. Methods: In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and nonviolent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff. Results: Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) of interventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot wounds accounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists. Conclusions: The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improves in Somalia, on-site training by expatriate surgeons and anesthesiologists will be re-established. Until then, the best way MSF has found to support surgical care in Somalia is continue to support in a “remote” manner.

Resilience of refugees displaced in the developing world: a qualitative analysis of strengths and struggles of urban refugees in Nepal

Abstract: Background: Mental health and psychosocial wellbeing are key concerns in displaced populations. Despite urban refugees constituting more than half of the world’s refugees, minimal attention has been paid to their psychosocial wellbeing. The purpose of this study was to assess coping behaviour and aspects of resilience amongst refugees in Kathmandu, Nepal. Methods: This study examined the experiences of 16 Pakistani and 8 Somali urban refugees in Kathmandu, Nepal through in-depth individual interviews, focus groups, and Photovoice methodology. Such qualitative approaches enabled us to broadly discuss themes such as personal experiences of being a refugee in Kathmandu, perceived causes of psychosocial distress, and strategies and resources for coping. Thematic network analysis was used in this study to systematically interpret and code the data. Results: Our findings highlight that urban refugees’ active coping efforts, notwithstanding significant adversity and resulting distress, are most frequently through primary relationships. Informed by Axel Honneth’s theory on the struggle for recognition, findings suggest that coping is a function beyond the individual and involves the ability to negotiate recognition. This negotiation involves not only primary relationships, but also the legal order and other social networks such as family and friends. Honneth’s work was used because of its emphasis on the importance of legal recognition and larger structural factors in facilitating daily coping. Conclusions: Understanding how urban refugees cope by negotiating access to various forms of recognition in the absence of legal-recognition will enable organisations working with them to leverage such strengths and develop relevant programmes. In particular, building on these existing resources will lead to culturally compelling and sustainable care for these populations.

PTSD, depression and anxiety among former abductees in Northern Uganda

Abstract: Background: The population in Northern Uganda has been exposed to extreme levels of traumatic stress and thousands abducted forcibly became rebel combatants. Methods: Using structured interviews, the prevalence and severity of posttraumatic stress disorder (PTSD), depression and anxiety was assessed in 72 former abducted adults, 62 of them being former child soldiers. Results: As retrospective reports of exposure to traumatic stress increased, anxiety and PTSD occurrence increased (r = .45). 49% of respondents were diagnosed with PTSD, 70% presented with symptoms of depression, and 59% with those of anxiety. In a multiple linear regression analysis four factors could best explain the development of PTSD symptoms: male respondents (sex) living in an IDP-Camp (location) with a kinship murdered in the war (family members killed in the war) and having experienced a high number of traumatic events (number of traumatic events) were more likely to develop symptoms of PTSD than others. In disagreement to a simple doseresponse-effect though, we also observed a negative correlation between the time spent with the rebels and the PTSD symptom level. Conclusions: Former abductees continue to suffer from severe mental ill-health. Adaptation to the living condition of rebels, however, may lower trauma-related mental suffering.

Family planning in conflict: results of cross-sectional baseline surveys in three African countries.

Abstract: Despite the serious consequences of conflict for reproductive health, populations affected by conflict and its aftermath face tremendous barriers to accessing reproductive health services, due to insecurity, inadequate numbers of trained personnel and lack of supplies. Family planning is often particularly neglected. In six conflict-affected areas in Sudan, northern Uganda and the Democratic Republic of Congo, household surveys of married or in-union women of reproductive age were conducted to determine baseline measures of family planning knowledge, attitudes and behaviors regarding contraception. Health facility assessments were carried out to assess baseline measures of family planning services availability. Data were double-entered into CSPro 3.2 and exported to SAS 9.2, which was used to calculate descriptive statistics. The studies' purposes were to guide program activities and to serve as a baseline against which program accomplishments could be measured. Knowledge of modern contraceptive methods was low relative to other sub-Saharan African countries, and use of modern methods was under 4% in four sites; in two sites with prior family planning services it was 12% and 16.2%. From 30% to 40% of women reported they did not want a child within two years, however, and an additional 12% to 35% wanted no additional children, suggesting a clear need for family planning services. The health facilities assessment showed that at most only one-third of the facilities mandated to provide family planning had the necessary staff, equipment and supplies to do so adequately; in some areas, none of the facilities were prepared to offer such services. Family planning services are desired by women living in crisis situations when offered in a manner appropriate to their needs, yet services are rarely adequate to meet these needs. Refugee and internally displaced women must be included in national and donors' plans to improve family planning in Africa.

Uranium and other contaminants in hair from the parents of children with congenital anomalies in Fallujah, Iraq

Abstract: Recent reports have drawn attention to increases in congenital birth anomalies and cancer in Fallujah Iraq blamed on teratogenic, genetic and genomic stress thought to result from depleted Uranium contamination following the battles in the town in 2004. Contamination of the parents of the children and of the environment by Uranium and other elements was investigated using Inductively Coupled Plasma Mass Spectrometry. Hair samples from 25 fathers and mothers of children diagnosed with congenital anomalies were analysed for Uranium and 51 other elements. Mean ages of the parents was: fathers 29.6 (SD 6.2); mothers: 27.3 (SD 6.8). For a sub-group of 6 women, long locks of hair were analysed for Uranium along the length of the hair to obtain information about historic exposures. Samples of soil and water were also analysed and Uranium isotope ratios determined. Levels of Ca, Mg, Co, Fe, Mn, V, Zn, Sr, Al, Ba, Bi, Ga, Pb, Hg, Pd and U (for mothers only) were significantly higher than published mean levels in an uncontaminated population in Sweden. In high excess were Ca, Mg, Sr, Al, Bi and Hg. Of these only Hg can be considered as a possible cause of congenital anomaly. Mean levels for Uranium were 0.16 ppm (SD: 0.11) range 0.02 to 0.4, higher in mothers (0.18 ppm SD 0.09) than fathers (0.11 ppm; SD 0.13). The highly unusual non-normal Fallujah distribution mean was significantly higher than literature results for a control population Southern Israel (0.062 ppm) and a non-parametric test (Mann Whitney-Wilcoxon) gave p = 0.016 for this comparison of the distribution. Mean levels in Fallujah were also much higher than the mean of measurements reported from Japan, Brazil, Sweden and Slovenia (0.04 ppm SD 0.02). Soil samples show low concentrations with a mean of 0.76 ppm (SD 0.42) and range 0.1-1.5 ppm; (N = 18). However it may be consistent with levels in drinking water (2.28 μgL-1) which had similar levels to water from wells (2.72 μgL-1) and the river Euphrates (2.24 μgL-1). In a separate study of a sub group of mothers with long hair to investigate historic Uranium excretion the results suggested that levels were much higher in the past. Uranium traces detected in the soil samples and the hair showed slightly enriched isotopic signatures for hair U238/U235 = (135.16 SD 1.45) compared with the natural ratio of 137.88. Soil sample Uranium isotope ratios were determined after extraction and concentration of the Uranium by ion exchange. Results showed statistically significant presence of enriched Uranium with a mean of 129 with SD5.9 (for this determination, the natural Uranium 95% CI was 132.1 < Ratio < 144.1). Whilst caution must be exercised about ruling out other possibilities, because none of the elements found in excess are reported to cause congenital diseases and cancer except Uranium, these findings suggest the enriched Uranium exposure is either a primary cause or related to the cause of the congenital anomaly and cancer increases. Questions are thus raised about the characteristics and composition of weapons now being deployed in modern battlefields

Incidence and risk factors for malaria, pneumonia and diarrhea in children under 5 in UNHCR refugee camps: A retrospective study

Abstract: United Nations High Commissioner for Refugees (UNHCR) refugee camps are located predominantly in rural areas of Africa and Asia in protracted or post-emergency contexts. Recognizing the importance of malaria, pneumonia and diarrheal diseases as major causes of child morbidity and mortality in refugee camps, we analyzed data from the UNHCR Health Information System (HIS) to estimate incidence and risk factors for these diseases in refugee children younger than five years of age. Data from 90 UNHCR camps in 16 countries, including morbidity, mortality, health services and refugee health status, were obtained from the UNHCR HIS for the period January 2006 to February 2010. Monthly camp-level data were aggregated to yearly estimates for analysis and stratified by location in Africa (including Yemen) or Asia. Poisson regression models with random effects were constructed to identify factors associated with malaria, pneumonia and diarrheal diseases. Spatial patterns in the incidence of malaria, pneumonia and diarrheal diseases were mapped to identify regional heterogeneities. Malaria and pneumonia were the two most common causes of mortality, with confirmed malaria and pneumonia each accounting for 20% of child deaths. Suspected and confirmed malaria accounted for 23% of child morbidity and pneumonia accounted for 17% of child morbidity. Diarrheal diseases were the cause of 7% of deaths and 10% of morbidity in children under five. Mean under-five incidence rates across all refugee camps by region were: malaria [Africa 84.7 cases/1000 U5 population/month (95% CI 67.5-102.0), Asia 2.2/1000/month (95% CI 1.4-3.0)]; pneumonia [Africa 59.2/1000/month (95% CI 49.8-68.7), Asia 254.5/1000/month (95% CI 207.1-301.8)]; and diarrheal disease [Africa 35.5/1000/month (95% CI 28.7-42.4), Asia 69.2/1000/month (95% CI 61.0-77.5)]. Measles was infrequent and accounted for a small proportion of child morbidity (503 cases, < 1%) and mortality (6 deaths, < 1%). As in stable settings, pneumonia and diarrhea are important causes of mortality among refugee children. Malaria remains a significant cause of child mortality in refugee camps in Africa and will need to be addressed as part of regional malaria control and elimination efforts. Little is known of neonatal morbidity and mortality in refugee settings, and neonatal deaths are likely to be under-reported. Global measles control efforts have reduced the incidence of measles among refugee children.

Family planning among people living with HIV in post-conflict Northern Uganda: A mixed methods study

Abstract: Background: Northern Uganda experienced severe civil conflict for over 20 years and is also a region of high HIV prevalence. This study examined knowledge of, access to, and factors associated with use of family planning services among people living with HIV (PLHIV) in this region. Methods: Between February and May 2009, a total of 476 HIV clinic attendees from three health facilities in Gulu, Northern Uganda, were interviewed using a structured questionnaire. Semi-structured interviews were conducted with another 26 participants. Factors associated with use of family planning methods were examined using logistic regression methods, while qualitative data was analyzed within a social-ecological framework using thematic analysis. Results: There was a high level of knowledge about family planning methods among the PLHIV surveyed (96%). However, there were a significantly higher proportion of males (52%) than females (25%) who reported using contraception. Factors significantly associated with the use of contraception were having ever gone to school [adjusted odds ratio (AOR) = 4.32, 95% confidence interval (CI): 1.33-14.07; p = .015], discussion of family planning with a health worker (AOR = 2.08, 95% CI: 1.01-4.27; p = .046), or with one’s spouse (AOR = 5.13, 95% CI: 2.35-11.16; p = .000), not attending the Catholic-run clinic (AOR = 3.67, 95% CI: 1.79-7.54; p = .000), and spouses’ non-desire for children (AOR = 2.19, 95% CI: 1.10-4.36; p = .025). Qualitative data revealed six major factors influencing contraception use among PLHIV in Gulu including personal and structural barriers to contraceptive use, perceptions of family planning, decision making, covert use of family planning methods and targeting of women for family planning services. Conclusions: Multilevel, context-specific health interventions including an integration of family planning services into HIV clinics could help overcome some of the individual and structural barriers to accessing family planning services among PLHIV in Gulu. The integration also has the potential to reduce HIV incidence in this post-conflict region.

Vulnerability to high risk sexual behaviour (HRSB) following exposure to war trauma as seen in post-conflict communities in eastern uganda: a qualitative study

Abstract: Background Much of the literature on the relationship between conflict-related trauma and high risk sexual behaviour (HRSB) often focuses on refugees and not mass in-country displaced people due to armed conflicts. There is paucity of research about contexts underlying HRSB and HIV/AIDS in conflict and post-conflict communities in Uganda. Understanding factors that underpin vulnerability to HRSB in post-conflict communities is vital in designing HIV/AIDS prevention interventions. We explored the socio-cultural factors, social interactions, socio-cultural practices, social norms and social network structures that underlie war trauma and vulnerability to HRSB in a post-conflict population.

Challenges of controlling sleeping sickness in areas of violent conflict: experience in the Democratic Republic of Congo

Abstract: Human African trypanosomiasis (HAT), or sleeping sickness, is a fatal neglected tropical disease if left untreated. HAT primarily affects people living in rural sub-Saharan Africa, often in regions afflicted by violent conflict. Screening and treatment of HAT is complex and resource-intensive, and especially difficult in insecure, resource-constrained settings. The country with the highest endemicity of HAT is the Democratic Republic of Congo (DRC), which has a number of foci of high disease prevalence. We present here the challenges of carrying out HAT control programmes in general and in a conflict-affected region of DRC. We discuss the difficulties of measuring disease burden, medical care complexities, waning international support, and research and development barriers for HAT. In 2007, Medecins Sans Frontieres (MSF) began screening for HAT in the Haut-Uele and Bas-Uele districts of Orientale Province in northeastern DRC, an area of high prevalence affected by armed conflict. Through early 2009, HAT prevalence rate of 3.4% was found, reaching 10% in some villages. More than 46,000 patients were screened and 1,570 treated for HAT during this time. In March 2009, two treatment centres were forced to close due to insecurity, disrupting patient treatment, follow-up, and transmission-control efforts. One project was reopened in December 2009 when the security situation improved, and another in late 2010 based on concerns that population displacement might reactivate historic foci. In all of 2010, 770 patients were treated at these sites, despite a limited geographical range of action for the mobile teams. In conflict settings where HAT is prevalent, targeted medical interventions are needed to provide care to the patients caught in these areas. Strategies of integrating care into existing health systems may be unfeasible since such infrastructure is often absent in resource-poor contexts. HAT care in conflict areas must balance logistical and medical capacity with security considerations, and community networks and international-response coordination should be maintained. Research and development for less complicated, field-adapted tools for diagnosis and treatment, and international support for funding and program implementation, are urgently needed to facilitate HAT control in these remote and insecure areas.

Detection of infectious disease outbreaks in twenty-two fragile states, 2000-2010: a systematic review.

Abstract: Fragile states are home to a sixth of the world's population, and their populations are particularly vulnerable to infectious disease outbreaks. Timely surveillance and control are essential to minimise the impact of these outbreaks, but little evidence is published about the effectiveness of existing surveillance systems. We did a systematic review of the circumstances (mode) of detection of outbreaks occurring in 22 fragile states in the decade 2000-2010 (i.e. all states consistently meeting fragility criteria during the timeframe of the review), as well as time lags from onset to detection of these outbreaks, and from detection to further events in their timeline. The aim of this review was to enhance the evidence base for implementing infectious disease surveillance in these complex, resource-constrained settings, and to assess the relative importance of different routes whereby outbreak detection occurs. We identified 61 reports concerning 38 outbreaks. Twenty of these were detected by existing surveillance systems, but 10 detections occurred following formal notifications by participating health facilities rather than data analysis. A further 15 outbreaks were detected by informal notifications, including rumours. There were long delays from onset to detection (median 29 days) and from detection to further events (investigation, confirmation, declaration, control). Existing surveillance systems yielded the shortest detection delays when linked to reduced barriers to health care and frequent analysis and reporting of incidence data. Epidemic surveillance and control appear to be insufficiently timely in fragile states, and need to be strengthened. Greater reliance on formal and informal notifications is warranted. Outbreak reports should be more standardised and enable monitoring of surveillance systems' effectiveness.

Public health equity in refugee situations.

Abstract: Addressing increasing concerns about public health equity in the context of violent conflict and the consequent forced displacement of populations is complex. Important operational questions now faced by humanitarian agencies can to some extent be clarified by reference to relevant ethical theory. Priorities of service delivery, the allocation choices, and the processes by which they are arrived at are now coming under renewed scrutiny in the light of the estimated two million refugees who fled from Iraq since 2003. Operational questions that need to be addressed include health as a relative priority, allocations between and within different populations, and transition and exit strategies. Public health equity issues faced by the humanitarian community can be framed as issues of resource allocation and issues of decision-making. The ethical approach to resource allocation in health requires taking adequate steps to reduce suffering and promote wellbeing, with the upper bound being to avoid harming those at the lower end of the welfare continuum. Deliberations in the realm of international justice have not provided a legal or implementation platform for reducing health disparities across the world, although norms and expectations, including within the humanitarian community, may be moving in that direction. Despite the limitations of applying ethical theory in the fluid, complex and highly political environment of refugee settings, this article explores how this theory could be used in these contexts and provides practical examples. The intent is to encourage professionals in the field, such as aid workers, health care providers, policy makers, and academics, to consider these ethical principles when making decisions.

The burden of malaria in post-emergency refugee sites: A retrospective study

Abstract: Almost two-thirds of refugees, internally displaced persons, returnees and other persons affected by humanitarian emergencies live in malaria endemic regions. Malaria remains a significant threat to the health of these populations. Data on malaria incidence and mortality were analyzed from January 2006 to December 2009 from the United Nations High Commissioner for Refugees Health Information System database collected at sites in Burundi, Chad, Cameroon, Ethiopia, Kenya, Sudan, Tanzania, Thailand, and Uganda. Data from three countries during 2006 and 2007, and all nine countries from 2008 to 2009, were used to describe trends in malaria incidence and mortality. Monthly counts of malaria morbidity and mortality were aggregated into an annual country rate averaged over the study period. An average of 1.18 million refugees resided in 60 refugee sites within nine countries with at least 50 cases of malaria per 1000 refugees during the study period 2008-2009. The highest incidence of malaria was in refugee sites in Tanzania, where the annual incidence of malaria was 399 confirmed cases per 1,000 refugees and 728 confirmed cases per 1,000 refugee children younger than five years. Malaria incidence in children younger than five years of age, based on the sum of confirmed and suspected cases, declined substantially at sites in two countries between 2006 and 2009, but a slight increase was reported at sites within four of seven countries between 2008 and 2009. Annual malaria mortality rates were highest in sites in Sudan (0.9 deaths per 1,000 refugees), Uganda and Tanzania (0.7 deaths per 1000 refugees each). Malaria was the cause of 16% of deaths in refugee children younger than five years of age in all study sites. These findings represent one of the most extensive reports on malaria among refugees in post-emergency sites. Despite declines in malaria incidence among refugees in several countries, malaria remains a significant cause of mortality among children younger than five years of age. Further progress in malaria control, both within and outside of post-emergency sites, is necessary to further reduce malaria incidence and mortality among refugees and achieve global goals in malaria control and elimination.

Measles vaccination in humanitarian emergencies: a review of recent practice

Abstract: The health needs of children and adolescents in humanitarian emergencies are critical to the success of relief efforts and reduction in mortality. Measles has been one of the major causes of child deaths in humanitarian emergencies and further contributes to mortality by exacerbating malnutrition and vitamin A deficiency. Here, we review measles vaccination activities in humanitarian emergencies as documented in published literature. Our main interest was to review the available evidence focusing on the target age range for mass vaccination campaigns either in response to a humanitarian emergency or in response to an outbreak of measles in a humanitarian context to determine whether the current guidance required revision based on recent experience. We searched the published literature for articles published from January 1, 1998 to January 1, 2010 reporting on measles in emergencies. As definitions and concepts of emergencies vary and have changed over time, we chose to consider any context where an application for either a Consolidated Appeals Process or a Flash Appeal to the UN Central Emergency Revolving Fund (CERF) occurred during the period examined. We included publications from countries irrespective of their progress in measles control as humanitarian emergencies may occur in any of these contexts and as such, guidance applies irrespective of measles control goals. Of the few well-documented epidemic descriptions in humanitarian emergencies, the age range of cases is not limited to under 5 year olds. Combining all data, both from preventive and outbreak response interventions, about 59% of cases in reports with sufficient data reviewed here remain in children under 5, 18% in 5-15 and 2% above 15 years. In instances where interventions targeted a reduced age range, several reports concluded that the age range should have been extended to 15 years, given that a significant proportion of cases occurred beyond 5 years of age. Measles outbreaks continue to occur in humanitarian emergencies due to low levels of pre-existing population immunity. According to available published information, cases continue to occur in children over age 5. Preventing cases in older age groups may prevent younger children from becoming infected and reduce mortality in both younger and older age groups.

Are there any changes in burden and management of communicable diseases in areas affected by Cyclone Nargis

Abstract: Background This study aims to assess the situation of communicable diseases under national surveillance in the Cyclone Nargis-affected areas in Myanmar (Burma) before and after the incident.

Utilization of outpatient services in refugee settlement health facilities: A comparison by age, gender, and refugee versus host national status

Abstract: Comparisons between refugees receiving health care in settlement-based facilities and persons living in host communities have found that refugees have better health outcomes. However, data that compares utilization of health services between refugees and the host population, and across refugee settlements, countries and regions is limited. The paper will address this information gap. The analysis in this paper uses data from the United Nations High Commissioner of Refugees (UNHCR) Health Information System (HIS). Data about settlement populations and the use of outpatient health services were exported from the UNHCR health information system database. Tableau Desktop was used to explore the data. STATA was used for data cleaning and statistical analysis. Differences in various indicators of the use of health services by region, gender, age groups, and status (host national vs. refugee population) were analyzed for statistical significance using generalized estimating equation models that adjusted for correlated data within refugee settlements over time. Eighty-one refugee settlements were included in this study and an average population of 1.53 million refugees was receiving outpatient health services between 2008 and 2009. The crude utilization rate among refugees is 2.2 visits per person per year across all settlements. The refugee utilization rate in Asia (3.5) was higher than in Africa on average (1.8). Among refugees, females have a statistically significant higher utilization rate than males (2.4 visits per person per year vs. 2.1). The proportion of new outpatient attributable to refugees is higher than that attributable to host nationals. In the Asian settlements, only 2% outpatient visits, on average, were attributable to host community members. By contrast, in Africa, the proportion of new outpatient (OPD) visits by host nationals was 21% on average; in many Ugandan settlements, the proportion of outpatient visits attributable to host community members was higher than that for refugees. There was no statistically significant difference between the size of the male and female populations across refugee settlements. Across all settlements reporting to the UNHCR database, the percent of the refugee population that was less than five years of age is 16% on average. The availability of a centralized database of health information across UNHCR-supported refugee settlements is a rich resource. The SPHERE standard for emergencies of 1-4 visits per person per year appears to be relevant for Asia in the post-emergency phase, but not for Africa. In Africa, a post-emergency standard of 1-2 visits per person per year should be considered. Although it is often assumed that the size of the female population in refugee settlements is higher than males, we found no statistically significant difference between the size of the male and female populations in refugee settlements overall. Another assumption---that the under-fives make up 20% of the settlement population during the emergency phase---does not appear to hold for the post-emergency phase; under-fives made up about 16% of refugee settlement populations.

Measuring human rights violations in a conflict- affected country: results from a nationwide cluster survey in Central African Republic

Abstract: Background: Measuring human rights violations is particularly challenging during or after armed conflict. A recent nationwide survey in the Central African Republic produced estimates of rates of grave violations against children and adults affected by armed conflict, using an approach known as the “Neighborhood Method”. Methods: In June and July, 2009, a random household survey was conducted based on population estimates from the 2003 national census. Clusters were assigned systematically proportional to population size. Respondents in randomly selected households were interviewed regarding incidents of killing, intentional injury, recruitment into armed groups, abduction, sexual abuse and rape between January 1, 2008 and the date of interview, occurring in their homes’ and those of their three closest neighbors. Results: Sixty of the selected 69 clusters were surveyed. In total, 599 women were interviewed about events in 2,370 households representing 13,669 persons. Estimates of annual rates of each violation occurring per 1000 people in each of two strata are provided for children between the ages of five and 17, adults 18 years of age and older and the entire population five years and older, along with a combined and weighted national rate. The national rates for children age five to 17 were estimated to be 0.98/1000/year (95% CI: 0.18 - 1.78) for recruitment, 2.56/1000/year (95% CI: 1.50 - 3.62) for abduction, 1.13/1000/year (95% CI: 0.33 - 1.93) for intentional injury, 10.72/ 1000 girls/year (95% CI: 7.40 - 14.04) for rape, and 4.80/1000 girls/year (95% CI: 2.61 - 6.00) for sexual abuse. No reports of any violation against a person under the age of five were recorded and there were no reports of rape or sexual abuse of males. No children were reported to have been killed during the recall period. Rape and abduction were the most frequently reported events. Conclusions: The population-based figures greatly augment existing information on human rights violations in CAR, and represent a step forward in quantifying the protection needs of Central Africans. Government, donors, and international organizations should make use of this data to better inform advocacy, prevention, and response programs, to assist in fundraising, and to develop surveillance activities to monitor child protection concerns.

Reproductive health for refugees by refugees in Guinea III: maternal health.

Abstract: Maternal mortality can be particularly high in conflict and chronic emergency settings, partly due to inaccessible maternal care. This paper examines associations of refugee-led health education, formal education, age, and parity on maternal knowledge, attitudes, and practices among reproductive-age women in refugee camps in Guinea. Data comes from a 1999 cross-sectional survey of 444 female refugees in 23 camps. Associations of reported maternal health outcomes with exposure to health education (exposed versus unexposed), formal education (none versus some), age (adolescent versus adult), or parity (nulliparous, parous, grand multiparous), were analysed using logistic regression. No significant differences were found in maternal knowledge or attitudes. Virtually all respondents said pregnant women should attend antenatal care and knew the importance of tetanus vaccination. Most recognised abdominal pain (75%) and headaches (24%) as maternal danger signs and recommended facility attendance for danger signs. Most had last delivered at a facility (67%), mainly for safety reasons (99%). Higher odds of facility delivery were found for those exposed to RHG health education (adjusted odds ratio 2.03, 95%CI 1.23-3.01), formally educated (adjusted OR 1.93, 95%CI 1.05-3.92), or grand multipara (adjusted OR 2.13, 95%CI 1.21-3.75). Main reasons for delivering at home were distance to a facility (94%) and privacy (55%). Refugee-led maternal health education appeared to increase facility delivery for these refugee women. Improved knowledge of danger signs and the importance of skilled birth attendance, while vital, may be less important in chronic emergency settings than improving facility access where quality of care is acceptable.

Performance of UNHCR nutrition programs in post-emergency refugee camps

Abstract: Background The United Nations High Commissioner for Refugees (UNHCR) launched a health information system (HIS) in 2005 to enhance quality and consistency of routine health information available in post-emergency refugee camps. This paper reviews nutrition indicators and examines their application for monitoring and evaluating the performance of UNHCR nutrition programs in more than 90 refugee camps in 18 countries.

Facing medical care problems of victims of sexual violence in Goma/Eastern Democratic Republic of the Congo

Abstract: Background Since 1998, the Eastern Democratic Republic of the Congo has been torn by a military conflict. A particular atrocity of the war is widespread sexual violence.

Reproductive health for refugees by refugees in Guinea IV: Peer education and HIV knowledge, attitudes, and reported practices

Abstract: Both conflict and HIV affect sub-Saharan Africa, and supportive approaches for HIV prevention among refugees are crucial. Peer education has been associated with improved HIV outcomes, though relatively little research has been published on refugee settings. The primary objective of this study was to assess whether exposure to refugee peer education was associated with improved HIV knowledge, attitudes, or practice outcomes among refugees in Guinea. Secondary objectives were to assess whether gender, age, or formal education were more strongly associated than peer education with improved HIV outcomes. Data was collected by cross-sectional survey from 889 reproductive-age men and women in 23 camps in the Forest Region of Guinea. Selected exposures (i.e. peer education, gender, formal education, age) were analysed for associations with HIV outcomes using logistic regression odds ratios (OR). Most participants (88%) had heard of HIV, particularly those exposed to peer or formal education. Most correctly identified ways to protect themselves, while maintaining misconceptions about HIV transmission. Women and those exposed to either peer or formal education had significantly fewer misconceptions. Half of participants considered themselves at risk of HIV, women with 52% higher odds than men (adjusted OR 1.52, 95%CI 1.01-2.29). Participants exposed to peer education had more than twice the odds of reporting having made HIV-avoidant behavioural changes than unexposed participants (72% versus 58%; adjusted OR 2.49, 95%CI 1.52-4.08). While women had 57% lower odds than men of reporting HIV-avoidant behavioural changes (OR 0.43, 95%CI 0.31-0.60), women exposed to peer education had greater odds than exposed men of reporting HIV-avoidant changes (OR 2.70 versus OR 1.95). Staying faithful (66%) was the most frequent behavioural change reported. Peer education was most strongly associated with reported HIV-avoidant behaviour change. Gender was most associated with HIV knowledge and risk perception. Refugee women had fewer misconceptions than men had, but were more likely to report HIV risk and less likely to report making behavioural changes. Peer education appears promising for HIV interventions in chronic-emergency settings, if gender disparities and related barriers to condom usage are also addressed.

Integrating mental health into primary care for displaced populations: the experience of Mindanao, Philippines.

Abstract: For more than forty years, episodes of violence in the Mindanao conflict have recurrently led to civilian displacement. In 2008, Medecins Sans Frontieres set up a mental health program integrated into primary health care in Mindanao Region. In this article, we describe a model of mental health care and the characteristics and outcomes of patients attending mental health services. Psychologists working in mobile clinics assessed patients referred by trained clinicians located at primary level. They provided psychological first aid, brief psychotherapy and referral for severe patients. Patient characteristics and outcomes in terms of Self-Reporting Questionnaire (SRQ20) and Global Assessment of Functioning score (GAF) are described. Among the 463 adult patients diagnosed with a common mental disorder with at least two visits, median SRQ20 score diminished from 7 to 3 (p < 0.001) and median GAF score increased from 60 to 70 (p < 0.001). Baseline score and score at last assessment were different for both discharged patients and defaulters (p < 0.001). Brief psychotherapy sessions provided at primary level during emergencies can potentially improve patients' symptoms of distress.

High prevalence of syphilis among demobilized child soldiers in Eastern Congo: a cross-sectional study

Abstract: Background: Syphilis, a known major public health issue for soldiers during periods of conflict, is exacerbated in the Democratic Republic of Congo due to widespread sexual violence. However, there has been no previous study to determine the extent of this problem. Therefore, we determined the prevalence of syphilis among young demobilized soldiers. Methods: Screening of syphilis using the rapid plasma reagin test and the Treponema pallidum hemagglutination assay was conducted in three transit sites of soldier reintegration in 2005. The Fisher Exact probability test was used to compare results. Results: The prevalence of syphilis was found to be 3.4%, with almost equal distribution in respect to sex, location. Conclusion: Syphilis continues to be highly prevalent in demobilized child soldiers in Eastern Congo. Syphilis screening tests are recommended. Background Syphilis and to some extent other sexually transmitted infections (STIs) are a major public health issue for soldiers during periods of conflict. In the Democratic Republic of Congo (Congo), these have been exacerbated by widespread sexual violence. Child soldiers are particularly vulnerable due to several factors: incomplete maturation, low social conditions, use as sexual workers by superiors, and their promiscuous environment. During World Wars Ia nd II and subsequent armed conflicts throughout the world, syphilis has played an unprecedented role in soldier morbidity [1]. The Congo, with almost two decades of armed conflicts, is characterized by widespread sexual violence [2,3]. In the Congo and other African countries, recruitment of child soldiers has been largely practiced despite its war-crime characterization as defined by the Rome Statute of the International Criminal Court [4]. As a war nears its end, disarmament, demobilization, and reinsertion (DDR) of combatants is a compulsory post-conflict step. In the Congo, all child soldiers undergo this process, which allows soldiers who desire, or who are children, to return to civilian life. At the transit camp soldiers undergo compulsory syphilis testing. To prevent possible spread of the disease upon reintegration, those who test positive undergo treatment. Despite a number of studies dealing with syphilis prevalence in various contexts, to our knowledge, little is known about syphilis prevalence in demobilized soldiers, and particularly in child soldiers. Therefore, we determined the prevalence of syphilis among this group in the Congo.

Age-specific mortality patterns in Central Mozambique during and after the end of the Civil War.

Abstract: Background: In recent years, vigorous debate has developed concerning how conflicts contribute to the spread of infectious diseases, and in particular, the role of post-conflict situations in the epidemiology of HIV/AIDS. This study details the age-specific mortality patterns among the population in the central provincial capital of Beira, Mozambique, during and after the Mozambican civil war which ended in 1992. Methods: Data was collected from the death register at Beira’s Central Hospital between 1985 and 2003 and descriptively analyzed. Results: The data show two distinct periods: before and after the peace agreements in 1992. Before 1992 (during the civil war), the main impact of mortality was on children below 5 years of age, including still births, accounting for 58% of all deaths. After the war ended in 1992, the pattern shifted dramatically and rapidly to the 15-49 year old age group which accounted for 49% of all deaths by 2003. Conclusions: As under-5 mortality rates were decreasing at the end of the conflict, rates for 24-49 year old adults began to dramatically increase due to AIDS. This study demonstrates that strategies can be implemented during conflicts to decrease mortality rates in one vulnerable population but post-conflict dynamics can bring together other factors which contribute to the rapid spread of other infectious diseases in other vulnerable populations.