Cancer in Syrian refugees in Jordan and Lebanon between 2015 and 2017

Protracted conflicts in the Middle East have led to successive waves of refugees crossing borders. Chronic, non-communicable diseases are now recognised as diseases that need to be addressed in such crises. Cancer, in particular, with its costly, multidisciplinary care, poses considerable financial and ethical challenges for policy makers. In 2014 and with funding from the United Nations High Commissioner for Refugees, we reported on cancer cases among Iraqi refugees in Jordan (2010-12) and Syria (2009-11). In this Policy Review, we provide data on 733 refugees referred to the United Nations High Commissioner for Refugees in Lebanon (2015-17) and Jordan (2016-17), analysed by cancer type, demographic risk factors, treatment coverage status, and cost. Results show the need for increased funding and evidence-based standard operating procedures across countries to ensure that patients have equitable access to care. We recommend a holistic response to humanitarian crises that includes education, screening, treatment, and palliative care for refugees and nationals and prioritises breast cancer and childhood cancers.

Investigating the delivery of health and nutrition interventions for women and children in conflict settings: a collection of case studies from the BRANCH Consortium

Globally, the number of people affected by conflict is the highest in history, and continues to steadily increase. There is currently a pressing need to better understand how to deliver critical health interventions to women and children affected by conflict. The compendium of articles presented in this Conflict and Health Collection brings together a range of case studies recently undertaken by the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women and Children). These case studies describe how humanitarian actors navigate and negotiate the multiple obstacles and forces that challenge the delivery of health and nutrition interventions for women, children and adolescents in conflict-affected settings, and to ultimately provide some insight into how service delivery can be improved.

Interpretation of vulnerability and cumulative disadvantage among unaccompanied adolescent migrants in Greece: A qualitative study

BACKGROUND

In settings of mass displacement, unaccompanied minors (UAMs) are recognized as a vulnerable group and consequently prioritized by relief efforts. This study examines how the interpretation of vulnerability by the national shelter system for male UAMs in Greece shapes their trajectories into adulthood.

METHODS AND FINDINGS

Between August 2018 and April 2019, key informant interviews were carried out with child protection staff from Greek non-governmental organizations that refer UAMs to specialized children's shelters in Athens to understand how child protection workers interpret vulnerability. In-depth interviews and life history calendars were collected from 44 male migrant youths from Afghanistan, Pakistan, Bangladesh, and Iran who arrived in Greece as UAMs but had since transitioned into adulthood. Analysis of in-depth interviews and life history calendars examined how cumulative disadvantage and engagement with the shelter system altered youths' trajectories into adulthood. Younger adolescents were perceived as more vulnerable and prioritized for shelters over those who were "almost 18" years old. However, a subset of youths who requested shelter at the age of 17 years had experienced prolonged journeys where they spent months or years living on their own in socially isolated environments that excluded them from experiences conducive to adolescent development. The shelter system for UAMs in Greece enabled youths to develop new skills and networks that facilitated integration into society, and transferred them into adult housing when they turned 18 years old so that they could continue developing new skills. Those who were not in shelters by age 18 years could not access adult housing and lost this opportunity. Limitations included possible underrepresentation of homeless youth as well as the inability to capture all nationalities of UAMs in Greece, though the 2 most common nationalities, Afghan and Pakistani, were included.

CONCLUSIONS

Due to the way vulnerability was interpreted by the shelter system for UAMs, youths who had the greatest need to learn new skills to facilitate their integration often had the least opportunity to do so. To avoid creating long-lasting disparities between UAMs who are placed in shelters and those who are not, pathways should be developed to allow young adult males to enter accommodation facilities and build skills and networks that facilitate integration. Furthermore, cumulative disadvantages should be taken into account while assessing UAMs' vulnerability. Following UAMs' trajectories into early adulthood was critical for capturing this long-term consequence of the shelter system's interpretation of vulnerability.

Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway

BACKGROUND

Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016-July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts.

METHODOLOGY

A qualitative study design was used to examine the Mosul civilian trauma response. From August-December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified.

RESULTS

The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system.

CONCLUSIONS

The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.

The humanitarian system is not just broke, but broken: recommendations for future humanitarian action

An unprecedented number of humanitarian emergencies of large magnitude and duration is causing the largest number of people in a generation to be forcibly displaced. Yet the existing humanitarian system was created for a different time and is no longer fit for purpose. On the basis of lessons learned from recent crises, particularly the Syrian conflict and the Ebola epidemic, I recommend four sets of actions that would make the humanitarian system relevant for future public health responses: (1) operationalise the concept of centrality of protection; (2) integrate affected persons into national health systems by addressing the humanitarian-development nexus; (3) remake, do not simply revise, leadership and coordination; and (4) make interventions efficient, effective, and sustainable. For these recommendations to be implemented, governments, UN agencies, multilateral organisations, and international non-governmental organisations will need to put aside differences and relinquish authority, influence, and funding.

HIV behavioural surveillance among refugees and surrounding host communities in Uganda, 2006

We used a standardised behavioural surveillance survey (BSS), modified to be directly relevant to populations in conflict and post-conflict settings as well as to their surrounding host populations, to survey the populations of a refugee settlement in south-western Uganda and its surrounding area. Two-stage probability sampling was used to conduct 800 interviews in each population. The BSS questionnaire adapted for displaced populations was administered to adults aged 15-59 years. It collected information on HIV knowledge, attitudes and practices; issues before, during and after displacement; level of interaction and sexual exploitation among the refugees and host communities (i.e., nationals). Population parameters were compared and 95% confidence intervals were calculated for core HIV indicators. The demographic characteristics were similar (except for educational achievement), and HIV awareness was very high (>95%) in both populations. The refugees reported more-accepting attitudes towards persons with HIV than did nationals (19% versus 13%; p < 0.01). More refugees than nationals reported ever having had transactional sex (10% versus 6%; p < 0.01), which mostly occurred post-displacement. Five percent of females among both the refugees and nationals reported experiencing forced sex, which mostly occurred post-displacement and after the arrival of refugees, respectively. Nationals reported more frequent travel to refugee settlements than reported by refugees to national villages (22% versus 11%; p < 0.01). The high mobility and frequent interactions of these two populations suggest that integrated HIV programmes should be developed and would be an efficient use of resources. Evidence suggesting that female refugees may be at elevated risk for HIV infection, due to forced sex, transactional sex and other vulnerabilities, warrants further examination through qualitative research. The findings indicate a need for additional, focused HIV-prevention programmes, such as youth education, for both refugees and Ugandan nationals.

Changes in HIV-related behaviours, knowledge and testing among refugees and surrounding national populations: a multicountry study

To our knowledge, there is currently no published data on the prevalence of risky sex over time as displaced populations settle into long-term post-emergency refugee camps. To measure trends in HIV-related behaviours, we conducted a series of cross-sectional HIV behavioural surveillance surveys among refugees and surrounding community residents living in Kenya, Tanzania and Uganda, at baseline in 2004/2005 and at follow-up in 2010/2011. We selected participants using two-stage cluster sampling, except in the Tanzanian refugee camp where systematic random sampling was employed. Participants had to reside in a selected household for more than weeks and aged between 15 and 49 years. We interviewed 11,582 participants (6448 at baseline and 5134 at follow-up) in three camps and their surrounding communities. The prevalence of multiple sexual partnerships ranged between 10.1 and 32.6% at baseline and 4.2 and 20.1% at follow-up, casual partnerships ranged between 8.0 and 33.2% at baseline and 3.5 and 17.4% at follow-up, and transactional partnerships between 1.1 and 14.0% at baseline and 0.8 and 12.0% at follow-up. The prevalence of multiple partnerships and casual sex in the Kenyan and Ugandan camps was not higher than among nationals. To our knowledge these data are the first to describe and compare trends in the prevalence of risky sex among conflict-affected populations and nationals living nearby. The large reductions in risky sexual partnerships are promising and possibly indicative of the success of HIV prevention programs. However, evaluation of specific prevention programmes remains necessary to assess which, and to what extent, specific activities contributed to behavioural change. Notably, refugees had lower levels of multiple and casual sexual partnerships than nationals in Kenya and Uganda and thus should not automatically be assumed to have higher levels of risky sexual behaviours than neighbouring nationals elsewhere.

Relationship of the availability of micronutrient powder with iron status and hemoglobin among women and children in the Kakuma Refugee Camp, Kenya

BACKGROUND

Micronutrient powder is a potential strategy to improve iron status and reduce anemia in refugee populations.

OBJECTIVE

To evaluate the effect of the availability of home fortification with a micronutrient powder containing 2.5 mg of sodium iron ethylenediaminetetraacetate (NaFeEDTA) on iron status and hemoglobin in women and children in the Kakuma Refugee Camp in northwest Kenya.

METHODS

Hemoglobin and soluble transferrin receptor were measured in 410 children 6 to 59 months of age and 458 women of childbearing age at baseline (just before micronutrient powder was distributed, along with the regular food ration) and at midline (6 months) and endline (13 months)follow-up visits.

RESULTS

At the baseline, midline, and endline visits, respectively, the mean (+/- SE) hemoglobin concentration in women was 121.4 +/- 0.8, 120.8 +/- 0.9, and 120.6 +/- 1.0 g/L (p = .42); the prevalence of anemia (hemoglobin < 120 g/L) was 42.6%, 41.3%, and 41.7% (p = .92); and the mean soluble transferrin receptor concentration was 24.1 +/- 0.5, 20.7 +/- 0.7, and 20.8 +/- 0.7 nmol/L (p = .0006). In children, the mean hemoglobin concentration was 105.7 +/- 0.6, 109.0 30322 1.5, and 105.5 +/- 0.3 g/L (p = .95), respectively; the prevalence of anemia (hemoglobin < 110 g/L) was 55.5%, 52.3%, and 59.8% (p = .26); and the mean soluble transferrin receptor concentration was 36.1 +/- 0.7, 29.5 +/- 1.9, and 28.4 +/- 3.2 nmol/L (p = .02), in models that were adjusted for age using least squares means regression.

CONCLUSIONS

In children and in women of childbearing age, the availability of micronutrient powder was associated with a small improvement in iron status but no significant change in hemoglobin in this refugee camp setting.

Conflict-affected displaced persons need to benefit more from HIV and malaria national strategic plans and Global Fund grants

BACKGROUND

Access to HIV and malaria control programmes for refugees and internally displaced persons (IDPs) is not only a human rights issue but a public health priority for affected populations and host populations. The primary source of funding for malaria and HIV programmes for many countries is the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). This article analyses the current HIV and malaria National Strategic Plans (NSPs) and Global Fund approved proposals from rounds 1-8 for countries in Africa hosting populations with refugees and/or IDPs to document their inclusion.

METHODS

The review was limited to countries in Africa as they constitute the highest caseload of refugees and IDPs affected by HIV and malaria. Only countries with a refugee and/or IDP population of > or = 10,000 persons were included. NSPs were retrieved from primary and secondary sources while approved Global Fund proposals were obtained from the organisation's website. Refugee figures were obtained from the United Nations High Commissioner for Refugees' database and IDP figures from the Internal Displacement Monitoring Centre. The inclusion of refugees and IDPs was classified into three categories: 1) no reference; 2) referenced; and 3) referenced with specific activities.

FINDINGS

A majority of countries did not mention IDPs (57%) compared with 48% for refugees in their HIV NSPs. For malaria, refugees were not included in 47% of NSPs compared with 44% for IDPs. A minority (21-29%) of HIV and malaria NSPs referenced and included activities for refugees and IDPs. There were more approved Global Fund proposals for HIV than malaria for countries with both refugees and IDPs, respectively. The majority of countries with > or =10,000 refugees and IDPs did not include these groups in their approved proposals (61%-83%) with malaria having a higher rate of exclusion than HIV.

INTERPRETATION

Countries that have signed the 1951 refugee convention have an obligation to care for refugees and this includes provision of health care. IDPs are citizens of their own country but like refugees may also not be a priority for Governments' NSPs and funding proposals. Besides legal obligations, Governments have a public health imperative to include these groups in NSPs and funding proposals. Governments may wish to add a component for refugees that is additional to the needs for their own citizens. The inclusion of forcibly displaced persons in funding proposals may have positive direct effects for host populations as international and United Nations agencies often have strong logistical capabilities that could benefit both populations. For NSPs, strong and concerted advocacy at global, regional and country levels needs to occur to successfully ensure that affected populations are included in their plans. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals.

Funding for reproductive health in conflict and post-conflict countries: a familiar story of inequity and insufficient data

Paul Spiegel and colleagues discuss a new study that examines funding for sexual and reproductive health programs in conflict-affected low-income countries.

Differences in HIV-related behaviors at Lugufu refugee camp and surrounding host villages, Tanzania

Background

An HIV behavioral surveillance survey was undertaken in November 2005 at Lugufu refugee camp and surrounding host villages, located near western Tanzania's border with the Democratic Republic of Congo (DRC).

Methods

The sample size was 1,743 persons based on cluster survey methodology. All members of selected households between 15–49 years old were eligible respondents. Questions included HIV-related behaviors, population displacement, mobility, networking and forced sex. Data was analyzed using Stata to measure differences in proportions (chi-square) and differences in means (t-test) between gender, age groups, and settlement location for variables of interest.

Results

Study results reflect the complexity of factors that may promote or inhibit HIV transmission in conflict-affected and displaced populations. Within this setting, factors that may increase the risk of HIV infections among refugees compared to the population in surrounding villages include young age of sexual initiation among males (15.9 years vs. 19.8 years, p = .000), high-risk sex partners in the 15–24 year age group (40% vs. 21%, χ² 33.83, p = .000), limited access to income (16% vs. 51% χ² 222.94, p = .000), and the vulnerability of refugee women, especially widowed, divorced and never-married women, to transactional sex (married vs. never married, divorced, widowed: for 15–24 age group, 4% and 18% respectively, χ² 8.07, p = .004; for 25–49 age group, 4% and 23% respectively, χ² 21.46, p = .000). A majority of both refugee and host village respondents who experienced forced sex in the past 12 months identified their partner as perpetrator (64% camp and 87% in villages). Although restrictions on movements in and out of the camp exist, there was regular interaction between communities. Condom use was found to be below 50%, and expanded population networks may also increase opportunities for HIV transmission. Availability of refugee health services may be a protective factor. Most respondents knew where to go for HIV testing (84% of refugee respondents and 78% of respondents in surrounding villages), while more refugees than respondents from villages had ever been tested (42% vs. 22%, χ² 63.69, p = .000).

Conclusion

This research has important programmatic implications. Regardless of differences between camp and village populations, study results point to the need for targeted activities within each population. Services should include youth education and life skills programs emphasizing the benefits of delayed sexual initiation and the risks involved in transactional sex, especially in the camp where greater proportions of youth are affected by these issues relative to the surrounding host villages. As well, programs should stress the importance of correct and consistent condom use to increase usage in both populations. Further investigation into forced sex within regular partnerships, and programs that encourage male involvement in addressing this issue are needed. Program managers should verify that current commodity distribution systems ensure vulnerable women's access to resources, and consider additional program responses.

Estimates of HIV burden in emergencies

Objective:

To quantify the proportion of people living with HIV who are being affected by emergencies.

Methods:

Emergencies were defined as conflict, natural disaster and/or displacement. Country-specific estimates of populations affected by emergencies were developed based on eight publicly available databases and sources. These estimates were calculated as proportions and then combined with updated country-level HIV estimates for the years 2003, 2005 and 2006 to obtain estimates of the number of men, women and children living with HIV who were also affected by emergencies.

Results:

In 2006, 1.8 (range 1.3–2.5) million people living with HIV (PLHIV) were also affected by conflict, disaster or displacement, representing 5.4% (range 4.0–7.6%) of the global number of PLHIV. In the same year, an estimated 930 000 (range 660 000–1.3 million) women and 150 000 (range 110 000–230 000) children under 15 years living with HIV were affected by emergencies. In emergency settings, the estimated numbers of PLHIV in 2003 and 2005 were 2.6 million (range 2.0–3.4 million) and 1.7 million (range 1.4–2.1 million), respectively, representing 7.9% and 5.1% of the global number of PLHIV).

Conclusions:

These estimates provide a rationale to ensure that HIV interventions are integrated into rapid assessment of all emergency and preparedness and response plans to prevent HIV infections and address excess suffering, morbidity and mortality among these often overlooked vulnerable groups.

Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what?

BACKGROUND

Sub-Saharan Africa (SSA) is severely affected by HIV/AIDS and conflict. Sexual violence as a weapon of war has been associated with concerns about heightened HIV incidence among women. Widespread rape by combatants has been documented in Burundi, Sierra Leone, Rwanda, Democratic Republic of Congo, Liberia, Sudan and Uganda. To examine the assertion that widespread rape may not directly increase HIV prevalence at the population level, we built a model to determine the potential impact of varying scenarios of widespread rape on HIV prevalence in the above seven African countries.

DISCUSSION

Our findings show that even in the most extreme situations, where 15% of the female population was raped, where HIV prevalence among assailants was 8 times the country population prevalence, and where the HIV transmission rate was highest at 4 times the average high rate, widespread rape increased the absolute HIV prevalence of these countries by only 0.023%. These projections support the finding that widespread rape in conflict-affected countries in SSA has not incurred a major direct population-level change in HIV prevalence. However, this must not be interpreted to say that widespread rape does not pose serious problems to women's acquisition of HIV on an individual basis or in specific settings. Furthermore, direct and indirect consequences of sexual violence, such as physical and psychosocial trauma, unwanted pregnancies, and stigma and discrimination cannot be understated.

SUMMARY

The conclusions of this article do not significantly change current practices in the field from an operational perspective. Proper care and treatment must be provided to every survivor of rape regardless of the epidemiological effects of HIV transmission at the population level. Sexual violence must be treated as a protection issue and not solely a reproductive health and psychosocial issue. It is worth publishing data and conclusions that could be misconstrued and may not make much of a programmatic difference in the field. Data, if collected, analysed and interpreted carefully, help to improve our understanding of complicated and nuanced situations. Ultimately, our understanding of what the outcomes of such interventions can achieve will be more realistic. It also helps decision-makers prioritise their funding and interventions.

Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review

BACKGROUND

Violence and rape are believed to fuel the HIV epidemic in countries affected by conflict. We compared HIV prevalence in populations directly affected by conflict with that in those not directly affected and in refugees versus the nearest surrounding host communities in sub-Saharan African countries.

METHODS

Seven countries affected by conflict (Democratic Republic of Congo, southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia, and Burundi) were chosen since HIV prevalence surveys within the past 5 years had been done and data, including original antenatal-care sentinel surveillance data, were available. We did a systematic and comprehensive literature search using Medline and Embase. Only articles and reports that contained original data for prevalence of HIV infection were included. All survey reports were independently evaluated by two epidemiologists to assess internationally accepted guidelines for HIV sentinel surveillance and population-based surveys. Whenever possible, data from the nearest antenatal care and host country sentinel site of the neighbouring countries were presented. 95% CIs were provided when available.

FINDINGS

Of the 295 articles that met our search criteria, 88 had original prevalence data and 65 had data from the seven selected countries. Data from these countries did not show an increase in prevalence of HIV infection during periods of conflict, irrespective of prevalence when conflict began. Prevalence in urban areas affected by conflict decreased in Burundi, Rwanda, and Uganda at similar rates to urban areas unaffected by conflict in their respective countries. Prevalence in conflict-affected rural areas remained low and fairly stable in these countries. Of the 12 sets of refugee camps, nine had a lower prevalence of HIV infection, two a similar prevalence, and one a higher prevalence than their respective host communities. Despite wide-scale rape in many countries, there are no data to show that rape increased prevalence of HIV infection at the population level.

INTERPRETATION

We have shown that there is a need for mechanisms to provide time-sensitive information on the effect of conflict on incidence of HIV infection, since we found insufficient data to support the assertions that conflict, forced displacement, and wide-scale rape increase prevalence or that refugees spread HIV infection in host communities.

Who should be undertaking population-based surveys in humanitarian emergencies?

BACKGROUND

Timely and accurate data are necessary to prioritise and effectively respond to humanitarian emergencies. 30-by-30 cluster surveys are commonly used in humanitarian emergencies because of their purported simplicity and reasonable validity and precision. Agencies have increasingly used 30-by-30 cluster surveys to undertake measurements beyond immunisation coverage and nutritional status. Methodological errors in cluster surveys have likely occurred for decades in humanitarian emergencies, often with unknown or unevaluated consequences.

DISCUSSION

Most surveys in humanitarian emergencies are done by non-governmental organisations (NGOs). Some undertake good quality surveys while others have an already overburdened staff with limited epidemiological skills. Manuals explaining cluster survey methodology are available and in use. However, it is debatable as to whether using standardised, 'cookbook' survey methodologies are appropriate. Coordination of surveys is often lacking. If a coordinating body is established, as recommended, it is questionable whether it should have sole authority to release surveys due to insufficient independence. Donors should provide sufficient funding for personnel, training, and survey implementation, and not solely for direct programme implementation.

SUMMARY

A dedicated corps of trained epidemiologists needs to be identified and made available to undertake surveys in humanitarian emergencies. NGOs in the field may need to form an alliance with certain specialised agencies or pool technically capable personnel. If NGOs continue to do surveys by themselves, a simple training manual with sample survey questionnaires, methodology, standardised files for data entry and analysis, and manual for interpretation should be developed and modified locally for each situation. At the beginning of an emergency, a central coordinating body should be established that has sufficient authority to set survey standards, coordinate when and where surveys should be undertaken and act as a survey repository. Technical expertise is expensive and donors must pay for it. As donors increasingly demand evidence-based programming, they have an obligation to ensure that sufficient funds are provided so organisations have adequate technical staff.

A review of methodology and analysis of nutrition and mortality surveys conducted in humanitarian emergencies from October 1993 to April 2004

BACKGROUND

Malnutrition prevalence and mortality rates are increasingly used as essential indicators to assess the severity of a crisis, to follow trends, and to guide decision-making, including allocation of funds. Although consensus has slowly developed on the methodology to accurately measure these indicators, errors in the application of the survey methodology and analysis have persisted. The aim of this study was to identify common methodological weaknesses in nutrition and mortality surveys and to provide practical recommendations for improvement.

METHODS

Nutrition (N = 368) and crude mortality rate (CMR; N = 158) surveys conducted by 33 non-governmental organisations and United Nations agencies in 17 countries from October 1993 to April 2004 were analysed for sampling validity, precision, quality of measurement and calculation according to several criteria.

RESULTS

One hundred and thirty (35.3%) nutrition surveys and 5 (3.2%) CMR surveys met the criteria for quality. Quality of surveys varied significantly depending on the agency. The proportion of nutrition surveys that met criteria for quality rose significantly from 1993 to 2004; there was no improvement for mortality surveys during this period.

CONCLUSION

Significant errors and imprecision in the methodology and reporting of nutrition and mortality surveys were identified. While there was an improvement in the quality of nutrition surveys over the years, the quality of mortality surveys remained poor. Recent initiatives aimed at standardising nutrition and mortality survey quality should be strengthened. There are still a number of methodological issues in nutrition and mortality surveys in humanitarian emergencies that need further study.

Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995-2004)

Background

The fields of expertise of natural disasters and complex emergencies (CEs) are quite distinct, with different tools for mitigation and response as well as different types of competent organizations and qualified professionals who respond. However, natural disasters and CEs can occur concurrently in the same geographic location, and epidemics can occur during or following either event. The occurrence and overlap of these three types of events have not been well studied.

Methods

All natural disasters, CEs and epidemics occurring within the past decade (1995–2004) that met the inclusion criteria were included. The largest 30 events in each category were based on the total number of deaths recorded. The main databases used were the Emergency Events Database for natural disasters, the Uppsala Conflict Database Program for CEs and the World Health Organization outbreaks archive for epidemics.

Analysis

During the past decade, 63% of the largest CEs had ≥1 epidemic compared with 23% of the largest natural disasters. Twenty-seven percent of the largest natural disasters occurred in areas with ≥1 ongoing CE while 87% of the largest CEs had ≥1 natural disaster.

Conclusion

Epidemics commonly occur during CEs. The data presented in this article do not support the often-repeated assertion that epidemics, especially large-scale epidemics, commonly occur following large-scale natural disasters. This observation has important policy and programmatic implications when preparing and responding to epidemics. There is an important and previously unrecognized overlap between natural disasters and CEs. Training and tools are needed to help bridge the gap between the different type of organizations and professionals who respond to natural disasters and CEs to ensure an integrated and coordinated response.

Using design effects from previous cluster surveys to guide sample size calculation in emergency settings

A good estimate of the design effect is critical for calculating the most efficient sample size for cluster surveys. We reviewed the design effects for seven nutrition and health outcomes from nine population-based cluster surveys conducted in emergency settings. Most of the design effects for outcomes in children, and one-half of the design effects for crude mortality, were below two. A reassessment of mortality data from Kosovo and Badghis, Afghanistan revealed that, given the same number of clusters, changing sample size had a relatively small impact on the precision of the estimate of mortality. We concluded that, in most surveys, assuming a design effect of 1.5 for acute malnutrition in children and two or less for crude mortality would produce a more efficient sample size. In addition, enhancing the sample size in cluster surveys without increasing the number of clusters may not result in substantial improvements in precision.

HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action

Conflict, displacement, food insecurity and poverty make affected populations more vulnerable to HIV transmission. However, the common assumption that this vulnerability necessarily translates into more HIV infections and consequently fuels the HIV/AIDS epidemic is not supported by data. Whether or not conflict and displacement affect HIV transmission depends upon numerous competing and interacting factors. This paper explores and explains the epidemiology of HIV/AIDS in conflict and addresses the unique characteristics that must be addressed when planning and implementing HIV/AIDS interventions among populations affected by conflict as compared with those in resource-poor settings. These include targeting at-risk groups, protection, programming strategies, coordination and integration and monitoring and evaluation. Areas for future HIV/AIDS operational research in conflict are discussed.

Quality of malnutrition assessment surveys conducted during famine in Ethiopia

CONTEXT

During 1999 and 2000, approximately 10 million people were affected by famine in Ethiopia. Results of nutrition assessments and surveys conducted by humanitarian organizations were used by donors and government agencies to determine needs for food aid and to make other decisions on geographic allocation of limited resources; however, accurate results might have been hampered by methodological errors.

OBJECTIVES

To identify common methodological errors in nutrition assessments and surveys and to provide practical recommendations for improvement.

DESIGN AND SETTING

Nutrition assessments and surveys (n = 125) conducted by 14 nongovernmental organizations (NGOs) in 54 woredas (districts) in Ethiopia from May 1, 1999, through July 31, 2000. Surveys were ranked as valid and precise according to 5 criteria: use of population proportional to size sampling, sample size, number of clusters, number of children per cluster, and use of weight-for-height index.

MAIN OUTCOME MEASURES

Number and proportion of surveys that used standard, internationally accepted methods and reported valid and precise results.

RESULTS

Fifty-eight of the 125 surveys (46%) were not intended to be standard 30 x 30 cluster surveys. Of the remaining 67 surveys, 6 (9%) met predetermined criteria for validity and precision. All 67 used the anthropometric index of weight-for-height, with 58 (87%) reporting z scores. Fifty-four (81%) used nonrandom sampling without consideration of population size and 6 (9%) had sample sizes of fewer than 500 persons.

CONCLUSIONS

Major methodological errors were identified among 30 x 30 cluster surveys designed to measure acute malnutrition prevalence in Ethiopia during the famine of 1999-2000. Donor agencies and NGOs should be educated about the need for improved quality of nutrition assessments and their essential role in directing allocation of scarce food resources.