SARS-CoV-2 infections in infants in Haiti 2020–2021; evidence from a seroepidemiological cohort

Few data are available on frequency of SARS-CoV-2 infection among very young children in low- to middle-income countries (LMIC), with the studies that are available biased towards higher income countries with low reported infection and seroconversion rates. Between February 2019 and March 2021, 388 dried blood spot (DBS) samples were obtained from 257 children less than 30 months of age as part of a prospective observational cohort study of pregnant women and their infants in Haiti; longitudinal samples were available for 107 children. In a subsequent retrospective analysis, DBS samples were tested by ELISA for antibody targeting the receptor binding domain of the SARS-CoV-2 S1 protein. Over the course of the study, 16·7% of the infants became seropositive. All seropositive samples were collected after March 19, 2020 (the date of the first reported COVID-19 case in Haiti) with the highest hazards measured in August 2020. Sampling date was the only covariate associated with the hazard of seroconversion. Our data provide an estimate of SARS-CoV-2 infection rates among very young children without prior SARS-CoV-2 exposure during the initial pandemic waves in Haiti, and demonstrate that these children mount a detectable serological response which is independent of patient age.

The epidemiology of diphtheria in Haiti, December 2014–June 2021: A spatial modeling analysis

Background

Haiti has been experiencing a resurgence of diphtheria since December 2014. Little is known about the factors contributing to the spread and persistence of the disease in the country. Geographic information systems (GIS) and spatial analysis were used to characterize the epidemiology of diphtheria in Haiti between December 2014 and June 2021.

Methods

Data for the study were collected from official and open-source databases. Choropleth maps were developed to understand spatial trends of diphtheria incidence in Haiti at the commune level, the third administrative division of the country. Spatial autocorrelation was assessed using the global Moran’s I. Local indicators of spatial association (LISA) were employed to detect areas with spatial dependence. Ordinary least squares (OLS) and geographically weighted regression (GWR) models were built to identify factors associated with diphtheria incidence. The performance and fit of the models were compared using the adjusted r-squared (R²) and the corrected Akaike information criterion (AIC_c).

Results

From December 2014 to June 2021, the average annual incidence of confirmed diphtheria was 0.39 cases per 100,000 (range of annual incidence = 0.04–0.74 per 100,000). During the study period, diphtheria incidence presented weak but significant spatial autocorrelation (I = 0.18, p<0.001). Although diphtheria cases occurred throughout Haiti, nine communes were classified as disease hotspots. In the regression analyses, diphtheria incidence was positively associated with health facility density (number of facilities per 100,000 population) and degree of urbanization (proportion of urban population). Incidence was negatively associated with female literacy. The GWR model considerably improved model performance and fit compared to the OLS model, as indicated by the higher adjusted R² value (0.28 v 0.15) and lower AIC_c score (261.97 v 267.13).

Conclusion

This study demonstrates that GIS and spatial analysis can support the investigation of epidemiological patterns. Furthermore, it shows that diphtheria incidence exhibited spatial variability in Haiti. The disease hotspots and potential risk factors identified in this analysis could provide a basis for future public health interventions aimed at preventing and controlling diphtheria transmission.

Hoping for a Better Future during COVID-19: How Migration Plans Are Protective of Depressive Symptoms for Haitian Migrants Living in Chile

This paper explores the migration experiences, perceived COVID-19 impacts, and depression symptoms among Haitian migrants living in Santiago, Chile. Ninety-five participants from eight neighborhoods with a high density of Haitian migrants were recruited. Descriptive statistics, univariate analysis, and logistic regression analysis were conducted. Chi-squared tests were used to confirm univariate results. We found that 22% of participants had major depressive symptoms based on the CESD-R-20 scale, 87% reported major life changes due to COVID-19, and 78% said their migration plans had changed due to the pandemic. Factors associated with more depressive symptoms were being in debt (OR = 3.43) and experiencing discrimination (ORs: 0.60 to 6.19). Factors associated with less odds of depressive symptoms were social support (ORs: 0.06 to 0.25), change in migration plans due to COVID-19 (OR = 0.30), and planning to leave Chile (OR = 0.20). After accounting for relevant factors, planning to leave Chile is significantly predictive of fewer symptoms of depression. Haitian migrants living in Chile had a high prevalence of depression. Planning to leave Chile was a significant protector against depressive symptoms. Future studies should explore how nuanced experiences of uncertainty play out in migrants' lives, mental well-being, and planning for their future.

Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018

In low-resource settings, detection of healthcare-acquired outbreaks in neonatal units relies on astute clinical staff to observe unusual morbidity or mortality from sepsis as microbiological diagnostics are often absent. We aimed to generate reliable (and automated) early warnings for potential clusters of neonatal late onset sepsis using retrospective data that could signal the start of an outbreak in an NCU in Port au Prince, Haiti, using routinely collected data on neonatal admissions. We constructed smoothed time series for late onset sepsis cases, late onset sepsis rates, neonatal care unit (NCU) mortality, maternal admissions, neonatal admissions and neonatal antibiotic consumption. An outbreak was defined as a statistical increase in any of these time series indicators. We created three outbreak alarm classes: 1) thresholds: weeks in which the late onset sepsis cases exceeded four, the late onset sepsis rates exceeded 10% of total NCU admissions and the NCU mortality exceeded 15%; 2) differential: late onset sepsis rates and NCU mortality were double the previous week; and 3) aberration: using the improved Farrington model for late onset sepsis rates and NCU mortality. We validated pairs of alarms by calculating the sensitivity and specificity of the weeks in which each alarm was launched and comparing each alarm to the weeks in which a single GNB positive blood culture was reported from a neonate. The threshold and aberration alarms were the strongest predictors for current and future NCU mortality and current LOS rates (p<0.0002). The aberration alarms were also those with the highest sensitivity, specificity, negative predictive value, and positive predictive value. Without microbiological diagnostics in NCUs in low-resource settings, applying these simple algorithms to routinely collected data show great potential to facilitate early warning for possible healthcare-acquired outbreaks of LOS in neonates. The methods used in this study require validation across other low-resource settings.

Rapid Emergence and Spread of Severe Acute Respiratory Syndrome Coronavirus 2 Gamma (P.1) Variant in Haiti

After an initial wave of coronavirus disease 2019 (COVID-19) in Haiti in summer 2020 (primarily lineage B.1), seropositivity for anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) was ~40%. Variant P.1 (gamma) was introduced in February 2021, with an initially limited introduction followed by exponential local dissemination within this unvaccinated population with prior exposure to earlier SARS-CoV-2 lineages.

Prevalence and factors related to dating violence victimization and perpetration among a representative sample of adolescents and young adults in Haiti

BACKGROUND

Studies examining both victimization and perpetration of dating violence among both women and men are virtually non-existent in Haiti. This study aimed to document the prevalence and factors associated with victimization and perpetration of dating violence (DV) among adolescents and young adults aged 15-24 years in Haiti.

PARTICIPANTS AND SETTING

A total of 3586 participants (47.6% women; mean age = 19.37; SD = 2.71) were sampled in the 10 geographical departments according to residence areas (urban/rural), age group (15-19/20-24 years old), and gender (men/women).

METHOD

Participants completed questionnaires assessing DV victimization and perpetration, witnessing interparental violence, parental violence, violence acceptance, social desirability, and self-esteem.

RESULTS

Overall, 1538 participants (56% women) were in a romantic relationship in the past year. Results showed that men were more likely to experience both psychological (49.4% of women and 57% of men, X² = 8.17, p = .004), and physical violence (11.1% of women and 18.8% of men, X² = 8.13, p = .004). There were marginally significant differences for sexual violence between gender for adolescents aged 15 to 19 (26.5% of girls and 20.5% of boys, X² = 3.25, p = .07), and not for young adults (21.8% of women and 24.0% of men, X² = 0.49, p = .48). No significant difference was observed for any forms of DV perpetration. DV perpetration was positively associated with victimization (b = 0.5, p = .002), however victimization was not associated with perpetration. Results also showed different associations between violence perpetration and victimization, gender, social desirability, acceptance of violence, parental violence, and witnessing interparental violence.

CONCLUSIONS

This study highlights avenues for prevention and intervention that must begin at an early age, engage teachers, train peer-educators, promote healthy, non-violent and egalitarian romantic relationships.

Cholera in the Time of MINUSTAH: Experiences of Community Members Affected by Cholera in Haiti

In 2010, Haiti experienced one of the deadliest cholera outbreaks of the 21st century. United Nations (UN) peacekeepers are widely believed to have introduced cholera, and the UN has formally apologized to Haitians and accepted responsibility. The current analysis examines how Haitian community members experienced the epidemic and documents their attitudes around accountability. Using SenseMaker, Haitian research assistants collected micronarratives surrounding 10 UN bases in Haiti. Seventy-seven cholera-focused micronarratives were selected for a qualitative thematic analysis. The five following major themes were identified: (1) Cholera cases and deaths; (2) Accessing care and services; (3) Protests and riots against the UN; (4) Compensation; and (5) Anti-colonialism. Findings highlight fear, frustration, anger, and the devastating impact that cholera had on families and communities, which was sometimes compounded by an inability to access life-saving medical care. Most participants believed that the UN should compensate cholera victims through direct financial assistance but there was significant misinformation about the UN’s response. In conclusion, Haiti’s cholera victims and their families deserve transparent communication and appropriate remedies from the UN. To rebuild trust in the UN and foreign aid, adequate remedies must be provided in consultation with victims.

Comparing six cardiovascular risk prediction models in Haiti: implications for identifying high-risk individuals for primary prevention

BACKGROUND

Cardiovascular diseases (CVD) are rapidly increasing in low-middle income countries (LMICs). Accurate risk assessment is essential to reduce premature CVD by targeting primary prevention and risk factor treatment among high-risk groups. Available CVD risk prediction models are built on predominantly Caucasian risk profiles from high-income country populations, and have not been evaluated in LMIC populations. We aimed to compare six existing models for predicted 10-year risk of CVD and identify high-risk groups for targeted prevention and treatment in Haiti.

METHODS

We used cross-sectional data within the Haiti CVD Cohort Study, including 1345 adults ≥ 40 years without known history of CVD and with complete data. Six CVD risk prediction models were compared: pooled cohort equations (PCE), adjusted PCE with updated cohorts, Framingham CVD Lipids, Framingham CVD Body Mass Index (BMI), WHO Lipids, and WHO BMI. Risk factors were measured during clinical exams. Primary outcome was continuous and categorical predicted 10-year CVD risk. Secondary outcome was statin eligibility.

RESULTS

Sixty percent were female, 66.8% lived on a daily income of ≤ 1 USD, 52.9% had hypertension, 14.9% had hypercholesterolemia, 7.8% had diabetes mellitus, 4.0% were current smokers, and 2.5% had HIV. Predicted 10-year CVD risk ranged from 3.6% in adjusted PCE (IQR 1.7-8.2) to 9.6% in Framingham-BMI (IQR 4.9-18.0), and Spearman rank correlation coefficients ranged from 0.86 to 0.98. The percent of the cohort categorized as high risk using model specific thresholds ranged from 1.8% using the WHO-BMI model to 41.4% in the PCE model (χ2 = 1416, p value < 0.001). Statin eligibility also varied widely.

CONCLUSIONS

In the Haiti CVD Cohort, there was substantial variation in the proportion identified as high-risk and statin eligible using existing models, leading to very different treatment recommendations and public health implications depending on which prediction model is chosen. There is a need to design and validate CVD risk prediction tools for low-middle income countries that include locally relevant risk factors.

TRIAL REGISTRATION

clinicaltrials.gov NCT03892265 .

Hypertension continuum of care: Blood pressure screening, diagnosis, treatment, and control in a population-based cohort in Haiti

Cardiovascular disease (CVD) is the number one cause of death in low-income countries including Haiti, with hypertension (HTN) being the leading risk factor. This study aims to identify gaps in the HTN continuum of screening, diagnosis, treatment, and blood pressure (BP) control. Sociodemographic and clinical data were collected from a population-based sample of adults ≥18 years in Port-au-Prince (PAP) from March 2019 to April 2021. HTN was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or use of antihypertensive medication. Screening was defined as ever having had a BP measurement; diagnosis as previously being informed of a HTN diagnosis; treatment as having taken antihypertensives in the past 2 weeks; and controlled as taking antihypertensives and having BP < 140/90 mmHg. Factors associated with attaining each step in the continuum were assessed using Poisson multivariable regressions. Among 2737 participants, 810 (29% age-standardized) had HTN, of whom 97% had been screened, 72% diagnosed, 45% treated, and 13% controlled. There were no significant differences across age groups or sex. Obesity (BMI ≥ 30) was a significant factor associated with receiving treatment compared to normal weight (BMI < 25), with a prevalence ratio (PR) of 1.5 (95% CI 1.1-2.0). Having secondary or higher education was associated with higher likelihood of controlled BP (PR 1.9 [95% CI 1.1-3.3]). In this urban Haitian population, the greatest gaps in HTN care are treatment and control. Targeted interventions are needed to improve these steps, including broader access to affordable treatment, timely distribution of medications, and patient adherence to HTN medication.

Factors associated with physical violence against children in Haiti: a national population-based cross-sectional survey

Considering the recent sociopolitical and environmental stress in Haiti, from the COVID pandemic to repeated natural disasters, we aimed to identify risk and protective factors associated with childhood physical violence (CPV) after the 2010 earthquake. A population-based national survey was administered to 13-24-year-old Haitians in 2012. A three-stage clustered sample design was utilized. Adjusted prevalence ratios (aPR) and risk ratios (aRR). 64% of survey respondents experienced CPV were estimated. Respondents who reported emotional and/or sexual abuse prior to age 12 were twice as likely to be victims of physical violence later during childhood (emotional aRR 1.9, 95% CI 1.3-2.7; sexual aRR 2.1, 95% CI 1.4-3.1). Feeling close or very close to one's mother was protective (aPR 0.66, 95% CI 0.47-0.92). This study is the first to describe risk and protective factors and also delineate temporality of exposures associated with CPV.Supplemental data for this article is available online at https://doi.org/10.1080/17457300.2021.1996398.

Estimated blood pressure trajectories and hypertension patterns among pregnant women living with HIV, Haiti, 2007-2017

Hypertension in pregnancy is a key driver of mortality and morbidity among Haitian women. HIV infection and treatment may worsen hypertension and increase cardiovascular disease risk. The authors examined blood pressure and hypertension patterns among 1965 women (2306 pregnancies ending in live births) in a prevention of maternal-to-child transmission (PMTCT) program in Port-au-Prince, Haiti, between 2007 and 2017. Hypertension was defined as blood pressure ≥140/90 mm Hg on two consecutive visits. Latent class analysis assessed trajectories of mean arterial pressure (MAP) and multinomial ordinal logistic regression examined factors associated with higher trajectories. Between 2007-2009 and 2013-2016, hypertension at PMTCT entry increased from 1.3% to 3.8% (p = .005), while incidence at any time during PMTCT follow-up increased from 5.0 to 16.1 per 100 person-years (p < .001). Hypertension detected ≤20 weeks and > 20 weeks of gestation (possible gestational hypertension) increased from 1.1% to 3.5% (p = .003) and from 2.3% to 6.9% (p < .001), respectively. Five MAP trajectories ranged from low-stable to high-increasing. In multivariable analysis controlling for history of antiretroviral therapy, age, parity, and weight, program entry in more recent years was associated with greater odds of higher MAP trajectory (adjusted odds ratio for 2013-2016 vs. 2007-2009 = 3.1, 95% confidence interval: 1.7-5.6). The increasing prevalence and incidence of hypertension highlight a need for screening and management prior to PMTCT entry and during follow-up. In a population with limited access to chronic disease care, and where many deliveries occur outside of a clinical setting, the period of PMTCT follow-up represents an opportunity to diagnose and initiate management of preexisting and pregnancy-related hypertension.

Diabetes Epidemiology Among Adults in Port-au-Prince, Haiti: A Cross-Sectional Study

Introduction

Diabetes mellitus is a chronic noncommunicable disease associated with death and major disability, with increasing prevalence in low- and middle-income countries. There is limited population-based data about diabetes in Haiti. The objective of this study was to assess the prevalence of diabetes and associated factors among adults in Port-au-Prince, Haiti using a population-based cohort.

Methods

This study analyzes cross-sectional enrollment data from the population-based Haiti Cardiovascular Disease Cohort Study, conducted using multistage sampling with global positioning system waypoints in census blocks in the metropolitan area of Port-au-Prince, Haiti. A total of 3,005 adults ≥18 years old were enrolled from March 2019 to August 2021. We collected socio-demographic data, health-related behaviors, and clinical data using standardized questionnaires. Diabetes was defined as any of the following criteria: enrollment fasting glucose value ≥ 126 mg/dL or non-fasting glucose ≥ 200 mg/dL, patient self-report of taking diabetes medications, or study physician diagnosis of diabetes based on clinical evaluation.

Results

Among 2985 (99.3%) with complete diabetes data, median age was 40 years, 58.1% were female, and 17.2% were obese. The prevalence of diabetes was 5.4% crude, and 5.2% age standardized. In unadjusted analysis, older age, higher body mass index (BMI), low physical activity, low education were associated with a higher odds of diabetes. After multivariable logistic regression, older age [60+ vs 18-29, Odds Ratio (OR)17.7, 95% CI 6.6 to 47.9] and higher BMI (obese vs normal/underweight, OR 2.7, 95% CI 1.7 to 4.4) remained statistically significantly associated with higher odds of diabetes.

Conclusion

The prevalence of diabetes was relatively low among adults in Port-au-Prince, but much higher among certain groups (participants who were older and obese). The Haitian health system should be strengthened to prevent, diagnose, and treat diabetes among high-risk groups.

Dietary Risk Factors for Cardiovascular Disease among Low-Income Haitian Adults: Findings from a Population-Based Cohort

Poor diets are responsible for a large burden of noncommunicable disease (NCD). The prevalence of modifiable dietary risk factors is rising in lower-income countries such as Haiti, along with increasing urbanization and shifts to diets high in sugar, salt, and fat. We describe self-reported dietary patterns (intake of fruits, vegetables, fried food, sugar-sweetened beverages, and added salt and oil) among a population-based cohort of low-income adults in Port-au-Prince and assess for associated sociodemographic factors (age, sex, income, education, body mass index). Among 2989 participants, the median age was 40 years, and 58.0% were women. Less than 1% met the World Health Organization recommendation of at least five servings/day of fruits and vegetables. Participants consumed fried food on average 1.6 days/week and sugar-sweetened beverages on average 4.7 days/week; young males of low socioeconomic status were the most likely to consume these dietary risk factors. The vast majority of participants reported usually or often consuming salt (87.1%) and oil (86.5%) added to their meals eaten at home. Our findings underscore the need for public health campaigns, particularly those targeting young males and household cooks preparing family meals at home, to improve dietary patterns in Haiti in order to address the growing NCD burden.

Simulating the effect of evaluation unit size on eligibility to stop mass drug administration for lymphatic filariasis in Haiti

Background

The Transmission Assessment Survey (TAS) is a decision-making tool to determine when transmission of lymphatic filariasis is presumed to have reached a level low enough that it cannot be sustained even in the absence of mass drug administration. The survey is applied over geographic areas, called evaluation units (EUs); existing World Health Organization guidelines limit EU size to a population of no more than 2 million people.

Methodology/Principal findings

In 2015, TASs were conducted in 14 small EUs in Haiti. Simulations, using the observed TAS results, were performed to understand the potential programmatic impact had Haiti chosen to form larger EUs. Nine “combination-EUs” were formed by grouping adjacent EUs, and bootstrapping was used to simulate the expected TAS results.

When the combination-EUs were comprised of at least one “passing” and one “failing” EU, the majority of these combination-EU would pass the TAS 79% - 100% of the time. Even in the case when both component EUs had failed, the combination-EU was expected to “pass” 11% of the time.

Simulations of mini-TAS, a strategy with smaller power and hence smaller sample size than TAS, resulted in more conservative “passing” and “failing” when implemented in original EUs.

Conclusions/Significance

Our results demonstrate the high potential for misclassification when the average prevalence of lymphatic filariasis in the combined areas differs with regards to the TAS threshold. Of particular concern is the risk of “passing” larger EUs that include focal areas where prevalence is high enough to be potentially self-sustaining. Our results reaffirm the approach that Haiti took in forming smaller EUs. Where baseline or monitoring data show a high or heterogeneous prevalence, programs should leverage alternative strategies like mini-TAS in smaller EUs, or consider gathering additional data through spot check sites to advise EU formation.

Lymphatic filariasis is a disease caused by roundworms that may lead to disability, psychological problems, stigma, and lowered quality of life. One of the key strategies to control and eliminate lymphatic filariasis is mass drug administration (MDA), or repeated treatment of all at-risk people living in affected areas with an annual dose of medicine. To determine whether MDA can be stopped in a particular area, a transmission assessment survey (TAS) is conducted whereby a sample of children are tested for filarial antigen and proportion with a positive result is compared against a target threshold. Existing guidelines for delimiting the geographic areas to conduct TAS permit large evaluation units. In 2015, TASs were conducted in Haiti using more stringent criteria for forming evaluation units, resulting in much smaller geographic areas for evaluation. Using simulations, the authors found that, had Haiti followed the existing guidelines and assessed larger geographic areas, many of the areas might have been misclassified and MDA stopped prematurely in some settings. This research suggests that caution is needed when forming evaluation units for TAS, especially if the prevalence of lymphatic filariasis is not uniform.

Case-area targeted preventive interventions to interrupt cholera transmission: Current implementation practices and lessons learned

BACKGROUND

Cholera is a major cause of mortality and morbidity in low-resource and humanitarian settings. It is transmitted by fecal-oral route, and the infection risk is higher to those living in and near cholera cases. Rapid identification of cholera cases and implementation of measures to prevent subsequent transmission around cases may be an efficient strategy to reduce the size and scale of cholera outbreaks.

METHODOLOGY/PRINCIPLE FINDINGS

We investigated implementation of cholera case-area targeted interventions (CATIs) using systematic reviews and case studies. We identified 11 peer-reviewed and eight grey literature articles documenting CATIs and completed 30 key informant interviews in case studies in Democratic Republic of Congo, Haiti, Yemen, and Zimbabwe. We documented 15 outbreaks in 12 countries where CATIs were used. The team composition and the interventions varied, with water, sanitation, and hygiene interventions implemented more commonly than those of health. Alert systems triggering interventions were diverse ranging from suspected cholera cases to culture confirmed cases. Selection of high-risk households around the case household was inconsistent and ranged from only one case to approximately 100 surrounding households with different methods of selecting them. Coordination among actors and integration between sectors were consistently reported as challenging. Delays in sharing case information impeded rapid implementation of this approach, while evaluation of the effectiveness of interventions varied.

CONCLUSIONS/SIGNIFICANCE

CATIs appear effective in reducing cholera outbreaks, but there is limited and context specific evidence of their effectiveness in reducing the incidence of cholera cases and lack of guidance for their consistent implementation. We propose to 1) use uniform cholera case definitions considering a local capacity to trigger alert; 2) evaluate the effectiveness of individual or sets of interventions to interrupt cholera, and establish a set of evidence-based interventions; 3) establish criteria to select high-risk households; and 4) improve coordination and data sharing amongst actors and facilitate integration among sectors to strengthen CATI approaches in cholera outbreaks.

Prevalence and Factors Associated With Intimate Partner Violence Among Women in Haiti: Understanding Household, Individual, Partner, and Relationship Characteristics

Intimate partner violence (IPV) is a significant public health issue with detrimental consequences for women's reproductive, mental, and physical health. In Haiti, IPV is a major obstacle to women's development. Yet, the determinants of IPV victimization are still not well understood. In this study, we utilized the 2016-2017 Haiti Demographic and Health Survey to determine the prevalence of IPV victimization and its subtypes (emotional, physical, and sexual abuse) among married or cohabiting women (N = 3,805) of reproductive age (15-49) by their current husband/partner. Logistic regression was conducted to explore the association between IPV and household, individual, husband/partner, and relationship characteristics. The prevalence of IPV victimization was 32.5% with the majority reporting emotional (24.7%) followed by physical (16.8%) and sexual (10.5%) violence. Increased odds of IPV victimization were found among women with children in the household (adjusted odds ratio [AOR] = 1.45, 95% confidence interval [CI] = [1.03, 2.02]), with attitudinal acceptance of wife-beating (AOR = 1.45, 95% CI = [1.05, 2.02]), and those who witnessed their father beating their mother (AOR = 1.49, 95% CI = [1.18, 2.67]). Higher odds of reporting IPV victimization were also found among women whose partner drank alcohol (AOR = 2.89, 95% CI = [2.29, 3.65]), who were in a polygynous relationship (AOR = 1.76, 95% CI = [1.23, 2.40]), and displayed one or more controlling behaviors (AOR = 1.92, 95% CI = [1.42, 2.59]). Women who reported being afraid of their partner had greater odds of IPV victimization (AOR = 16.22, 95% CI = [8.38, 31.39]). Decreased odds of reporting IPV were associated with women living in rural areas (AOR = 0.73, 95% CI = [0.53, 1.00]) and those unmarried, but living with their partner (AOR = 0.62, 95% CI = [0.43, 0.90]). Our findings identify subgroups of women in Haiti that may be vulnerable to IPV victimization. Thus, we recommend a differentiated approach to IPV prevention strategies and interventions that consider women's family structure in the household as well as individual, partner, and relationship characteristics.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials

BACKGROUND

Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design.

OBJECTIVES

We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes.

METHODS

We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.

RESULTS

SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation.

CONCLUSIONS

The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Factors associated with antiretroviral therapy adherence among people living with HIV in Haiti: a cross-sectional study

BACKGROUND

Socioeconomic, demographic and clinical factors can affect adherence to treatment among people living with HIV (PLH) and potentially have an impact on their prognosis and survival. The main objective of this study was to assess these factors as potential barriers to adherence among patients receiving care in central Haiti.

METHODS

A cross-sectional study was conducted among PLH receiving antiretroviral therapy (ART) at the TB/HIV clinic at St. Therese Hospital in Hinche, Haiti. A total of 426 potential participants were approached during their follow-up visits from June to August 2019, of whom 411 participated in the study. After giving informed consent, study participants completed a structured interview that included the Self-Report Item Scale (SRIS), a standard measure, to assess adherence. Socio-demographic, economic and clinical factors were assessed for their association with adherence.

RESULTS

The 411 participating patients represented 39% of the patient population at the TB/HIV clinic during the timeframe of the study. The mean age was 43.7 years (range: 19-80), 65.5% were female and 78.1% had only achieved a primary level of schooling. Nearly 78% had received ART for less than 10 years, 3.41% reported having poor adherence and 28% less than excellent adherence. Factors related to poor adherence in bivariate analysis were age less than 40 years (OR: 6.32, 95% CI 2.04-10.58, p < 0.01) and inability to meet basic needs (OR: 2.70, 95% CI 1.04-7.0, p = 0.03).

CONCLUSIONS

To improve medication adherence, the hospital should strengthen patient counselling of younger recipients of ART and provide financial assistance and other social service interventions. Studies should be implemented in other HIV management centers in Haiti and similar contexts to examine barriers to ART adherence with the goal of improving prognosis and survival in the long-term among PLH in resource-limited setting.

Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers

BACKGROUND

Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development.

OBJECTIVES

We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects.

METHODS

We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024).

RESULTS

In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11).

CONCLUSIONS

Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Factors associated with diarrheal disease among children aged 1-5 years in a cholera epidemic in rural Haiti

Diarrheal illness is a major cause of morbidity and mortality among children in Haiti, and the impact of diarrheal illness was compounded by a cholera outbreak between 2010 and 2019. Our understanding of risk factors for diarrhea among children during this outbreak is limited. We conducted a secondary analysis of data collected as part of a cholera vaccine effectiveness study to identify factors associated with medically attended diarrhea among children in central Haiti from October of 2012 through November of 2016. We identified 47 children aged one to five years old who presented to medical clinics with acute, watery diarrhea, and 166 matched controls who did not have diarrhea, and we performed conditional logistic regression to identify factors associated with diarrhea. Discontinuing exclusive breastfeeding within one month of birth was associated with increased risk of diarrhea (RR 6.9, 95% CI 1.46–32.64), and diarrhea was inversely associated with reported history of supplementation with vitamin A (RR 0.05, 95% CI 0.004–0.56) and zinc (reported among 0% of cases vs. 17% of controls). Because of the concordance in supplementation patterns, it was not possible to attribute the association to vitamin A or zinc independently. While having a respondent who correctly identified ≥3 means of avoiding cholera was associated with reduced risk of diarrhea (RR 0.43, 95% CI 0.19–1.01), reported household sanitation practices and knowledge of cholera were not consistently associated with risk of diarrhea. These findings support ongoing efforts to reduce barriers to breastfeeding and promote pediatric supplementation with vitamin A and zinc in Haiti. Given the reduced efficacy of current oral cholera vaccines (OCV) among children, the results reinforce the importance of breastfeeding and micronutrient supplementation in preventing all-cause pediatric diarrheal illness generally and during cholera outbreaks.

Diarrheal diseases are leading causes of illness and death among children throughout the world, and children in Haiti were particularly impacted by diarrhea during the cholera outbreak that started in 2010. Between 2012 and 2016, data were collected as part of a case-control study of oral cholera vaccine (OCV) effectiveness in Haiti. We analyzed data from that study to identify factors associated with diarrheal illness, including cholera and non-cholera diarrhea, among children ages one through five years old. We found a direct association between longer duration of exclusive breastfeeding and supplementation with vitamin A and zinc and a reduced risk of diarrhea. These findings shed light on potentially important components of efforts to reduce pediatric diarrheal illness in Haiti generally, and to reduce pediatric diarrhea in the context of cholera outbreaks in Haiti and elsewhere.

Toward Cholera Elimination, Haiti

This study describes the apparent discontinuation of cholera transmission in Haiti since February 2019. Because vulnerabilities persist and vaccination remains limited, our findings suggest that case-area targeted interventions conducted by rapid response teams played a key role. We question the presence of environmental reservoirs in Haiti and discuss progress toward elimination.

Analysis of community-level factors contributing to cholera infection and water testing access in the Northern Corridor of Haiti

Vibrio cholera, the bacteria that cause cholera, is endemic in Haiti with a presence in both cities and remote areas. Improved access to drinking water testing and treatment in remote areas may reduce the impact of the disease. This case study uses correlation and regression analysis to identify the main factors that hinder access to water testing and that lead to high cholera infection rates among communities in the Northern Corridor of Haiti. Poor road conditions, mountainous terrain, and limited transportation options lead to high travel times up to 5.7 min/km between remote communities and drinking water testing facilities. The presence of springs in a community has a significant positive correlation with cholera infection rates in the Northern Corridor. However, socioeconomic factors had no significant correlation with cholera infection rate. The results of this study will be used to plan the implementation of a new drinking water testing laboratory near the city of Cap-Haitian and other programs for vulnerable remote areas. PRACTITIONER POINTS: Topography and road conditions may be more important than distance in determining the accessibility of water testing facilities for rural communities. A lack of access to private vehicles is a substantial challenge for many rural communities in accessing water testing. The presence of springs in a community had a significant positive correlation with cholera infection rate.