Contributors:Dema, T, Thinley, S, Lhazeen, K, Penjore, T, Tenzin, K, Subba, D, Rani, M, Tripathy, J, Dhendup, T, Gurung, M, Tshering, T, Laxmeshwar, C, MSF India
Suicide is one of the leading causes of death and Disability Adjusted Life Years (DALYs) worldwide. The economic, emotional and human cost of suicidal behaviour to individuals, families, communities and society makes it a serious public health issue. We aim to determine the prevalence and factors associated with self-reported suicidal behaviour (suicidal ideation and attempt) among school going adolescents (13–17 years).
Contributors:Wren, S, Wild, H, Gurney, J, Amirtharajah, M, Osmers, I, Pagano, H, Trelles, M, Brown, ZW, Burckle, FM
Importance: Armed conflict in the 21st century poses new challenges to a
humanitarian surgical response, including changing security requirements, access
to patients, and communities in need, limited deployable surgical assets,
resource constraints, and the requirement to address both traumatic injuries as
well as emergency surgical needs of the population. At the same time, recent
improvements in trauma care and systems have reduced injury-related mortality.
This combination of new challenges and medical capabilities warrants
reconsideration of long-standing humanitarian surgery protocols.
Objective: To describe a consensus framework for surgical care designed to
respond to this emerging need.
Design, Setting, and Participants: An international group of 35 representatives
from humanitarian agencies, US military, and academic trauma programs was invited
to the Stanford Humanitarian Surgical Response in Conflict Working Group to
engage in a structured process to review extant trauma protocols and make
recommendations for revision.
Main Outcomes and Measures: The working group's method adapted core elements of a
modified Delphi process combined with consensus development conference from
August 3 to August 5, 2018.
Results: Lessons from civilian and military trauma systems as well as recent
battlefield experiences in humanitarian settings were integrated into a tiered
continuum of response from point of injury through rehabilitation. The framework
addresses the security and medical requirements as well as ethical and legal
principles that guide humanitarian action. The consensus framework includes
trained, lay first responders; far-forward resuscitation/stabilization centers;
rapid damage control surgical access; and definitive care facilities. The system
also includes nontrauma surgical care, injury prevention, quality improvement,
data collection, and predeployment training requirements.
Conclusions and Relevance: Evidence suggests that modern trauma systems save
lives. However, the requirements of providing this standard of care in insecure
conflict settings places new burdens on humanitarian systems that must provide
both emergency and trauma surgical care. This consensus framework integrates
advances in trauma care and surgical systems in response to a changing security
environment. It is possible to reduce disparities and improve the standard of
care in these settings.
Contributors:Housen, T, Lenglet, A, Shah, S, Sha, H, Richardson, A, Pintaldi, G, Shabnum, A, MSF OCA and MSF India
The negative psychological impact of living in a setting of protracted conflict has been well studied, however there is a recognized need to understand the role that non-conflict related factors have on mediating exposure to trauma and signs of psychological distress.
We used data from the 2015 Kashmir Mental Health Survey and conducted mediation analysis to assess the extent to which daily stressors mediated the effect of traumatic experiences on poor mental health outcomes. Outcomes of interest were probable diagnosis of anxiety, depression, or PTSD; measured using the pre-validated Hopkins Symptoms Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ).
Total effect mediated were statistically significant but the proportions of effect mediated were found to be small in practical terms. Financial stress mediated 6.8% [95% Confidence Interval (CI) 6∙0–8∙4], 6.7% [CI 6.2–7∙7] and 3.6% [CI 3∙4–4∙0] of the effect of experiencing multiple traumaticogenic events on symptoms of anxiety, depression and PTSD, respectively. Family stress mediated 11.3% [CI 10.3–13.8], 10.3% [CI 9.5–11.9] and 6.1% [CI 5.7–6.7] of the effect of experiencing multiple traumatogenic events on symptoms of anxiety, depression and PTSD, respectively. Poor physical health mediated 10.0% [CI 9.1–12∙0], 7.2% [CI 6.6–8.2] and 4.0% [CI 3.8,4.4] of the effect of experiencing more than seven traumatic events on symptoms of anxiety, depression and PTSD, respectively.
Our findings highlight that not only do we need to move beyond a trauma-focussed approach to addressing psychological distress in populations affected by protracted conflict but we must also move beyond focussing on daily stressors as explanatory mediators.
Contributors:Gil Cuesta, J, Trelles, M, Naseer, A, Momin, A, Ngabo Mulamira, L, Caluwaerts, S, Guha-Sapir, D
Introduction: Conflicts frequently occur in countries with high maternal and neonatal mortality and can aggravate difficulties accessing emergency care. No literature is available on whether the presence of conflict influences the outcomes of mothers and neonates during Caesarean sections (C-sections) in high-mortality settings.
Objective: To determine whether the presence of conflict was associated with changes in maternal and neonatal mortality during C-sections.
Methods: We analysed routinely collected data on C-sections from 17 Médecins Sans Frontières (MSF)
health facilities in 12 countries. Exposure variables included presence and intensity of conflict, type of health facility and other types of access to emergency care.
Results: During 2008–2015, 30,921 C-sections were performed in MSF facilities; of which 55.4% were in areas
of conflict. No differences were observed in maternal mortality in conflict settings (0.1%) vs. non-conflict settings (0.1%) (P = 0.08), nor in neonatal mortality between conflict (12.2%) and non-conflict settings (11.5%)
(P = 0.1). Among the C-sections carried out in conflict settings, neonatal mortality was slightly higher in war
zones compared to areas of minor conflict (P = 0.02); there was no difference in maternal mortality (P = 0.38).
Conclusions: Maternal and neonatal mortality did not appear to be affected by the presence of conflict in a
large number of MSF facilities. This finding should encourage humanitarian organisations to support C-sections in conflict settings to ensure access to quality maternity care.
Contributors:Ferreras, E, Matapo, B, Chizema-Kawesha, E, Chewe, O, Mzyece, H, Blake, A, Moonde, L, Zulu, G, Poncin, M, Sinyange, N, Kasese-Chanda, N, Phiri, C, Malama, K, Mukonka, V, Cohuet, S, Uzzeni, F, Ciglenecki, I, Danovaro-Holliday, MC, Luquero, FJ, Pezzoli, L
In April 2016, an emergency vaccination campaign using one dose of Oral Cholera Vaccine (OCV) was organized in response to a cholera outbreak that started in Lusaka in February 2016. In December 2016, a second round of vaccination was conducted, with the objective of increasing the duration of protection, before the high-risk period for cholera transmission. We assessed vaccination coverage for the first and second rounds of the OCV campaign.
Vaccination coverage was estimated after each round from a sample selected from targeted-areas for vaccination using a cross-sectional survey in to establish the vaccination status of the individuals recruited. The study population included all individuals older than 12 months residing in the areas targeted for vaccination. We interviewed 505 randomly selected individuals after the first round and 442 after the second round. Vaccination status was ascertained either by vaccination card or verbal reporting. Households were selected using spatial random sampling.
The vaccination coverage with two doses was 58.1% (25/43; 95%CI: 42.1-72.9) in children 1-5 years old, 59.5% (69/116; 95%CI: 49.9-68.5) in children 5-15 years old and 19.9% (56/281; 95%CI: 15.4-25.1) in adults above 15 years old. The overall dropout rate was 10.9% (95%CI: 8.1-14.1). Overall, 69.9% (n = 309/442; 95%CI: 65.4-74.1) reported to have received at least one OCV dose.
The areas at highest risk of suffering cholera outbreaks were targeted for vaccination obtaining relatively high vaccine coverage after each round. However, the long delay between doses in areas subject to considerable population movement resulted in many individuals receiving only one OCV dose. Additional vaccination campaigns may be required to sustain protection over time in case of persistence of risk. Further evidence is needed to establish a maximum optimal interval time of a delayed second dose and variations in different settings.
Contributors:De Castaneda, RR, Durso, AM, Ray, N, Fernandez, JL, Williams, DJ, Alcoba, G, Chappuis, F, Salathe, M, Bolon, I
Contributors:Funk, S, Takahashi, S, Hellewell, J, Gadroen, K, Carrion-Martin, I, van Lenthe, M, Rivette, K, Dietrich, S, Edmunds, WJ, Siddiqui, MR, Rao, VB
The Katanga region in the Democratic Republic of Congo (DRC) has been struck by repeated epidemics of measles, with large outbreaks occurring in 2010–13 and 2015. In many of the affected health zones, reactive mass vaccination campaigns were conducted in response to the outbreaks. Here, we attempted to determine how effective the vaccination campaigns in 2015 were in curtailing the ongoing outbreak. We further sought to establish whether the risk of large measles outbreaks in different health zones could have been determined in advance to help prioritise areas for vaccination campaign and speed up the response. In doing so, we first attempted to identify factors that could have been used in 2015 to predict in which health zones the greatest outbreaks would occur. Administrative vaccination coverage was not a good predictor of the size of outbreaks in different health zones. Vaccination coverage derived from surveys, on the other hand, appeared to give more reliable estimates of health zones of low vaccination coverage and, consequently, large outbreaks. On a coarser geographical scale, the provinces most affected in 2015 could be predicted from the outbreak sizes in 2010–13. This, combined with the fact that the vast majority of reported cases were in under-5 year olds, would suggest that there are systematic issues of undervaccination. If this was to continue, outbreaks would be expected to continue to occur in the affected health zones at regular intervals, mostly concentrated in under-5 year olds. We further used a model of measles transmission to estimate the impact of the vaccination campaigns, by first fitting a model to the data including the campaigns and then re-running this without vaccination. We estimated the reactive campaigns to have reduced the size of the overall outbreak by approximately 21,000 (IQR: 16,000–27,000; 95% CI: 8300–38,000) cases. There was considerable heterogeneity in the impact of campaigns, with campaigns started earlier after the start of an outbreak being more impactful. Taken together, these findings suggest that while a strong routine vaccination regime remains the most effective means of measles control, it might be possible to improve the effectiveness of reactive campaigns by considering predictive factors to trigger a more targeted vaccination response.
Contributors:Kerkhoff, AD, Sossen, B, Schutz, C, Reipold, EI, Trollip, A, Moreau, E, Schumacher, SG, Burton, R, Ward, A, Nicol, MP, Meinties, G, Denkinger, CM, Broger, T
Contributors:Bottineau, MC, Kouevi, KA, Chauvet, E, Garcia, DM, Galetto-Lacour, A, Wagner, N
Introduction: Tuberculosis is a common illness for vulnerable populations in resource-limited settings. Lymph nodes in tuberculosis represent the most frequent extra-pulmonary form of tuberculosis in children, but lymph nodes are rarely generalized and large. We report an atypical pediatric case of tuberculosis with lymphadenopathy. Patient concerns and findings: A two-year-old child with severe acute malnutrition presented with painless, generalized, and excessively large nodes which were not compressive and were without fistula. Main diagnoses, interventions, outcomes: Fine needle aspiration was performed and led to the detection of lymph node granulomatous lymphadenitis suggestive of tuberculosis. Conclusion: The child was immediately initiated on anti-tuberculosis therapy with a very successful outcome. Clinicians should be aware of atypical manifestations such as the one we describe in the interest of swift diagnosis and initiation of treatment.