Infant and young child feeding practices (IYCF) are crucial for children's growth and development but often deteriorate during periods of instability. A cross-sectional survey conducted in three oblasts of Ukraine-Kyiv City and Kyiv, Lviv, and Odesa-enroled 724 children 0-23 months of age from 699 households. Using global WHO IYCF Guidelines, 12 indicators of optimal IYCF practices were evaluated. The study found IYCF practices to be relatively stable since 2015, despite the continued escalation of conflict, with an improvement in exclusive breastfeeding (EBF). EBF was reported by 51% of mothers, while breastfeeding was initiated early in 65% of children. Complementary feeding practices were optimal for most children, with 79% having a minimum acceptable diet. Infant formula assistance was independently associated with suboptimal breastfeeding practices in multi-variable models. Children from households that received formula assistance had 67% (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.14-0.73) lower odds of being exclusively breastfed, 65% (aOR 0.35, 95% CI 0.20-0.61) lower odds of continued breastfeeding at 12 months, and 3.3 times (95% CI 2.31-4.78) higher odds of being bottlefed. Baby food assistance did not independently predict a minimum acceptable diet. High levels of optimal complementary feeding sustained since 2015 suggest protective factors for child nutrition in Ukraine, such as domestic agriculture and social safety nets. Additionally, maternal education was consistently linked to better IYCF outcomes, highlighting the need for targeted support for less-educated mothers. The negative association of formula assistance with EBF warrants further research alongside reinforcement of guidelines to prevent inappropriate formula targeting.

INTRODUCTION: During emergencies, breastfeeding protects infants by providing essential nutrients, food security, comfort, and protection and is a priority lifesaving intervention. On February 24, 2022, the war in Ukraine escalated, creating a humanitarian catastrophe. The war has resulted in death, injuries, and mass internal displacement of over 5 million people. A further 8.2 million people have taken refuge in neighboring countries, including Poland. Among those impacted are infants and young children and their mothers. We conducted a study to explore the infant feeding challenges and needs of Ukrainian women affected by the war. METHODS: We conducted a qualitative descriptive study involving in-depth interviews (IDIs) with 75 war-affected Ukrainian mothers who had at least one infant aged less than 12 months at the time of the interview. Eligible mothers were either (1) living as Ukrainian refugees in Poland, having crossed the border from Ukraine on or after February 24, 2022, when the war started (n = 30) or (2) living in Ukraine as internally displaced persons or as residents in the community (n = 45). All interviews were audio-recorded (either transcribed or had responses summarized as expanded notes) and analyzed using qualitative thematic analysis using a two-step rapid analysis process. RESULTS: Participants in Ukraine who wanted to initiate breastfeeding right after birth faced opposition from healthcare workers at maternity hospitals. Ukrainian refugees who gave birth in Poland faced language barriers when seeking breastfeeding support. Half of the participants in Ukraine received commercial milk formula (CMF) donations even if they said they did not need them. Most respondents stated that breastfeeding information and support were urgently needed. CONCLUSION: Our data suggests that healthcare workers in Ukrainian maternity hospitals require additional training and motivation on delivering breastfeeding support. In addition, lactation consultants in maternity ward are needed in Ukraine, and interpretation support is needed for refugees to overcome language barriers. There is a need to control the indiscriminate donations of commercial milk formula and to ensure that complementary foods and commercial milk formula are available to those that need it. This study confirms the need for actions to ensure infant and young child feeding (IYCF) support is provided during emergencies.

BACKGROUND: Currently, there is a lack of clear guidance on hemoglobin (Hb) data quality parameters and plausible flagging ranges for population-representative surveys. There is a need to determine which properties of Hb data indicate lower data quality and increased measurement error and which represent intrinsic statistical properties of Hb distributions rather than quality problems. METHODS: We explored statistical characteristics of Hb distributions and plausible exclusion ranges in population-representative surveys of non-pregnant women of reproductive age (WRA) (15-49 years, n = 401 surveys) and children (6-59 months, n = 461 surveys) conducted in refugee settings by the United Nations High Commissioner for Refugees (UNHCR). Hb distribution characteristics [standard deviation (SD), skewness and kurtosis] were compared to those from Demographic and Health Surveys (DHS). RESULTS: Overall, 0.08% of child and 0.14% of WRA Hb values were outside of the previously proposed 4.0-18.0 g/dL plausible range. Surveys conducted in Uganda tended to have unusually high SD compared with surveys from other settings, possibly an indication of problematic measurement quality. We therefore used summary results on SD, skewness and kurtosis excluding surveys from Uganda when comparing with DHS results or proposing plausible ranges. Both WRA and child Hb distributions tended to be left-skewed and had excess positive kurtosis. Mean survey-level SD was greater, mean skewness more negative, and mean kurtosis more positive in WRA surveys compared to child surveys. All these findings were broadly similar to those from DHS surveys. Mean SD in DHS surveys was higher than that in our data for both children (1.48 vs. 1.34) and WRA (1.58 vs. 1.43). CONCLUSIONS: We observed several statistical characteristics of Hb distributions that may not necessarily be indicative of data quality problems and bear strong similarities with the characteristics found in DHS surveys. Hb distributions tended to be negatively skewed and positively kurtotic, and SD in many surveys exceeded 1.5 (previously proposed upper plausible range). Based on our empirical evidence, surveys with skewness above + 0.2 and kurtosis below -0.5 or Hb SD outside the range of 1.1-1.55 g/dL for children (6-59 mo) or 1.1-1.65 g/dL for non-pregnant WRA (15-49 y) may require further quality investigation.

Infant and young child feeding (IYCF) plays a crucial role in early childhood growth and development. This study summarizes recent IYCF practices in multiple refugee settings and compares them to those in the host countries. We analyzed 203 surveys conducted among refugees residing in 15 countries and 120 unique sites and assessed eight IYCF indicators available from those surveys. A total of 146 surveys were conducted in Eastern and Southern Africa (ESA) and 50 in Western and Central Africa (WCA) regions. The median prevalence across surveys of all four indicators describing intake of breast milk was relatively high: 96.6% for ever breastfed, 81.2% for initiation of breastfeeding within 1 h of birth, 76.9% for exclusive breastfeeding 0-5 months, and 75.0% for continued breastfeeding 12-23 months. The median prevalence of early initiation and exclusive breastfeeding was markedly higher in ESA than in WCA (85.0% vs. 37.5% and 83.5% vs. 56.1%, respectively). Conversely, the overall median prevalence of timely introduction of solid and semisolid foods and flesh food consumption was low: 51.8% and 16.1%, respectively. Flesh food consumption was higher in WCA than in ESA (27.4% vs. 11.6%). The median prevalence of mixed milk feeding at 0-5 months and bottle feeding was very low: 2.4% and 3.8%, respectively. Indicators describing breast milk intake were generally either similar or higher in refugees than in the host country populations, whereas the other indicators were generally higher in the host populations than in refugees. The low prevalence of timely introduction of solids and of flesh food consumption in refugees is concerning and requires substantial improvement.

BACKGROUND: Following a period of low intensity conflict during 2009-2012, the emergence of the Islamic State of Iraq and Levant (or Islamic State) in 2013 was associated with a resurgence of violence in Baghdad, Iraq's capital and largest city. We evaluated trends in injury-related deaths in Baghdad before and during the Islamic State insurgency. METHODS: Iraqi National Injury Mortality Surveillance System prospectively collects information on fatal injuries from governorate coroner offices using standardized reporting forms. Trained coroner clerks collect information on victim demographics, intention of injury and mechanism of injury during medical examinations using reports from police and families. We analyzed data on all deaths reported by the Baghdad Forensic Institute from January 1, 2010 to December 31, 2015. RESULTS: There were 17,555 injury-related deaths with documented intent and mechanism (range 2385-3347 per year): 6241 from gunfire (36%), 1381 explosions (8%), 1348 non-gunfire assaults (8%), 3435 traffic accidents (20%), and 5150 other unintentional injuries (29%). Rates of gunfire (23.45 per 100,000) and explosion (5.90 per 100,000) deaths were significantly higher in 2014 than in all other years during the review period (p < 0.001 and p = 0.03, respectively). During the same period from 2010 to 2015, traffic accident deaths declined significantly from 13.29 to 6.35 (p = 0.002), with declines observed primarily among pedestrians. Trends in the rate of non-gunfire-assault and unintentional deaths, comparing 2010 and 2015, were not significant (p = 0.12 and p = 0.63, respectively). Unintentional deaths were mostly attributed to burns (46%) and electricity-related injuries (31%). The proportion of both females and children was highest in unintentional injury deaths. CONCLUSIONS: During the study period, deaths from both gunfire and explosions in Baghdad peaked in 2014, corresponding with emergence of the Islamic State. Trends suggest a potential impact of insurgency-related activity on other injuries as evidenced by a decrease in the death rate from traffic accidents. The decreased traffic-related death rate could be from decreased vehicle and pedestrian activity during times of violence. Monitoring trends in injury mortality during conflict allows Iraq to identify priority injury causes to inform public health interventions.

Despite frequent use of mid-upper arm circumference (MUAC) to assess populations in humanitarian settings, no guidance exists about the ranges for excluding implausible extreme outliers (flags) from MUAC data and about the quality assessment of collected MUAC data. We analysed 701 population-representative anthropometric surveys in children aged 6-59 months from 40 countries conducted between 2011 and 2019. We explored characteristics of flags as well as changes in survey-level MUAC-for-age z-score (MUACZ) and MUAC means, SD and percentage of flags based on three flagging approaches: ±3 and ±4 MUACZ z-scores from observed MUACZ survey mean and a fixed interval 100-200 mm of MUAC. Both ±4 and 100-200 flagging approaches identified as flags approximately 0.15% of records; about 60% of all surveys had no flags and less than 1% of surveys had >2% of flags. The ±3 approach flagged 0.6% records in the data set and 3% of surveys had >2% of flags. Plausible ranges (defined as 2.5th and 97.5th percentiles) for SD of MUACZ and MUAC were 0.8-1.2 and 10.5-14.4 mm, respectively. Survey-level SDs of MUAC and MUACZ were highly correlated (r = 0.68). The average SD of MUACZ was 0.96 using the ±4 flagging approach and 0.94 with ±3 approach. Defining outliers in MUAC data based on the MUACZ approach is feasible and adjusts for different probability of extreme values based on age and nutrition status of surveyed population. In assessments where age is not recorded and therefore MUACZ cannot be generated, using 100-200 mm range for flag exclusion could be a feasible solution.

BACKGROUND: Nutrition surveys in many refugee settings routinely estimate anemia prevalence in high-risk population groups. Given the lack of information on anemia design effects (DEFF) observed in surveys in these settings, the goal of this paper is to better understand the magnitude and distribution of DEFFs and intracluster correlation coefficients (ICCs) in order to inform future survey design. METHODS: Two-stage cluster surveys conducted during 2013-2016 were included if they measured hemoglobin in refugee children aged 6-59 months and/or non-pregnant women aged 15-49 years. Prevalence of anemia, anemia DEFFs and ICCs, mean cluster size, number of clusters, and total sample size were calculated per-survey for non-pregnant women and children. Non-parametric tests were used to assess differences and correlations of ICC and DEFF between women and children and inter-regional differences. RESULTS: Eighty-seven unique cluster surveys from nine countries were included in this analysis. More than 90% of all surveys had ICC values for anemia below 0.10. Median ICC for children was 0.032 (IQR: 0.015-0.048), not significantly different from that observed for non-pregnant women for whom the median was 0.024 (IQR: -0.002-0.055). DEFFs were significantly higher for children [1.54 (IQR: 1.21-1.82)] versus women [1.20 (IQR: 0.99-1.46)]. Regional differences in DEFFs and ICCs were observed. CONCLUSIONS: Both ICCs and DEFF were relatively small for both non-pregnant women and preschool children and fall in a narrow range. Differences in ICCs between women and children were non-significant, suggesting similar inter-cluster distributions of anemia; significant differences in DEFF were likely attributable to differing cluster sizes. Given regional differences in both ICCs and DEFFs, location-specific values are preferred. However, in the absence of other context-specific information, we suggest using DEFFs of 1.4-1.8 if mean cluster size is around 20, and DEFFs of 1.2-1.4 if mean cluster size is around 10.

BACKGROUND: One newly proposed approach to determining eligibility of children aged 6-59 months for therapeutic feeding programs (TFPs) is to use mid-upper arm circumference (MUAC) < 115 mm, bilateral oedema or Weight-for-Age Z-score (WAZ) < - 3 as admission criteria (MUAC+SWAZ). We explored potential consequences of this approach on the eligibility for treatment, as compared with the existing WHO normative guidance. We also compared sensitivity and specificity parameters of this approach for detecting wasted children to the previously described "Expanded MUAC" approach. METHODS: We analyzed data from 558 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and those who are both wasted and stunted (WA + ST), and calculated proportions of previously eligible children who would now be excluded from treatment, as well as proportions of non-malnourished children among those who would become eligible. We also analyzed the expected changes in the number and demographics (sex, age) of the selected populations of children according to the different admission approaches. RESULTS: Both MUAC+SWAZ and Expanded MUAC case detection approaches substantially increase the sensitivity in detecting SAM, as compared to an approach which restricts detection of SAM cases to MUAC< 115 mm and oedema. Improved sensitivity however is attained at the expense of specificity and would require a very large increase of the size of TFPs, while still missing a non-negligible proportion (20-25%) of the SAM caseload. While our results confirm the sensitivity of the MUAC+SWAZ case detection approach in detecting WA + ST (over 80%), they show, on the other hand, that about half of the additional target detected by using SWAZ criterion will be neither SAM nor WA + ST. CONCLUSIONS: These results suggest that recently promoted approaches to case detection inflate TFPs' targets through the allocation of treatment to large numbers of children who have not been shown to require this type of support, including a significant proportion of non-acutely malnourished children in the MUAC+SWAZ approach. Considering the scarcity of resources for the implementation of TFPs, the rationale of abandoning the use of WHZ and of these alternative case detection strategies need to be critically reviewed.

Background: Ensuring the quality of anthropometry data is paramount for getting accurate estimates of malnutrition prevalence among children aged 6–59 months in humanitarian and refugee settings. Previous reports based on data from Demographic and Health Surveys suggested systematic differences in anthropometric data quality between the younger and older groups of preschool children. Methods: We analyzed 712 anthropometric population-representative field surveys from humanitarian and refugee settings conducted during 2011–2018. We examined and compared the quality of five anthropometric indicators in children aged 6–23 months and children aged 24–59 months: weight for height, weight for age, height for age, body mass index for age and mid-upper arm circumference (MUAC) for age. Using the z-score distribution of each indicator, we calculated the following parameters: standard deviation (SD), percentage of outliers, and measures of distribution normality. We also examined and compared the quality of height, weight, MUAC and age measurements using missing data and rounding criteria. Results: Both SD and percentage of flags were significantly smaller on average in older than in younger age group for all five anthropometric indicators. Differences in SD between age groups did not change meaningfully depending on overall survey quality or on the quality of age ascertainment. Over 50% of surveys overall did not deviate significantly from normality. The percentage of non-normal surveys was higher in older than in the younger age groups. Digit preference score for weight, height and MUAC was slightly higher in younger age group, and for age slightly higher in the older age group. Children with reported exact date of birth (DOB) had much lower digit preference for age than those without exact DOB. SD, percentage flags and digit preference scores were positively correlated between the two age groups at the survey level, such as those surveys showing higher anthropometry data quality in younger age group also tended to show higher quality in older age group. Conclusions: There should be an emphasis on increased rigor of training survey measurers in taking anthropometric measurements in the youngest children. Standardization test, a mandatory component of the pre-survey measurer training and evaluation, of 10 children should include at least 4–5 children below 2 years of age.

BACKGROUND: There is limited research on noncommunicable diseases (NCDs) in humanitarian settings despite the overall global burden and disproportionate growth in many conflicts and disaster-prone settings. This study aimed to determine the prevalence of NCDs and assess the perceived effect of conflict on NCD severity and access to treatment among conflict-affected adults (>/= 30 years) in Ukraine. METHODS AND FINDINGS: We conducted two population-representative, stratified, cross-sectional household surveys: one among adult internally displaced people (IDPs) throughout Ukraine and one among adults living in Donbas in eastern Ukraine. One randomly selected adult per household answered questions about their demographics, height and weight, diagnosed NCDs, access to medications and healthcare since the conflict began, as well as questions assessing psychological distress, trauma exposure, and posttraumatic stress disorder. More than half of participants reported having at least one NCD (55.7% Donbas; 59.8% IDPs) A higher proportion of IDPs compared to adults in Donbas experienced serious psychological distress (29.9% vs. 18.7%), interruptions in care (9.7-14.3% vs. 23.1-51.3%), and interruptions in medication than adults in Donbas (14.9-45.6% vs. 30.2-77.5%). Factors associated with perceived worsening of disease included psychological distress (p: 0.002-0.043), displacement status (IDP vs. Donbas) (p: <0.001-0.011), interruptions in medication (p: 0.002-0.004), and inability to see a doctor at some point since the start of the conflict (p: <0.001-0.008). CONCLUSIONS: Our study found a high burden of NCDs among two conflict-affected populations in Ukraine and identified obstacles to accessing care and medication. Psychological distress, interruptions to care, and interruptions in medication were all reported by a higher proportion of IDPs than adults in Donbas. There is a need for targeted policies and programs to support the unique needs of displaced conflict-affected individuals in Ukraine that address the economic and perceived barriers to NCD treatment and care.

BACKGROUND: More than 700,000 ethnic Rohingya have crossed the border from Rakhine State, Myanmar to Cox's Bazar District, Bangladesh, following escalated violence by Myanmar security forces. The majority of these displaced Rohingya settled in informal sites on previously forested land, in areas without basic infrastructure or access to services. METHODS AND FINDINGS: Three cross-sectional population-representative cluster surveys were conducted, including all informal settlements of Rohingya refugees in the Ukhia and Teknaf Upazilas of Cox's Bazar District. The first survey was conducted during the acute phase of the humanitarian response (October-November 2017), and the second and third surveys were conducted 6 (April-May 2018) and 12 (October-November 2018) months later. Anthropometric indices (weight, height, mid-upper arm circumference [MUAC], oedema) and haemoglobin (Hb) were measured in children aged 6-59 months following standard procedures. Final samples for survey rounds 1, 2, and 3 (R1, R2, and R3) included 1,113, 628, and 683 children, respectively, of which approximately half were male (50.7%-53.5% per round) and a third were 6-23 months of age (32.4%-33.3% per round). Prevalence of global acute malnutrition (GAM) as assessed by weight for height in R2 (12.1%, 95% CI: 9.6-15.1) and R3 (11.0%, 95% CI: 8.4-14.2) represent a significant decline from the observed prevalence in R1 (19.4%, 95% CI: 16.8-22.3) (p < 0.001 for both comparisons). Overall, the prevalence of anaemia significantly declined (p < 0.001) between the first 2 rounds (47.9%, 95% CI: 44.1-51.7 and 32.3%, 95% CI: 27.8-37.1, respectively); prevalence increased significantly (p = 0.04) to 39.8% (95% CI, 34.1-45.4) during R3 but remained below R1 levels. Reported receipt of both fortified blended foods (12.8%) and micronutrient powders (10.3%) were low during R1 but increased significantly (p < 0.001 for both) within the first 6 months to 49.8% and 29.9%, respectively. Although findings demonstrate improvement in anthropometric indicators during a period in which nutrition programme coverage increased, causation cannot be determined from the cross-sectional design. CONCLUSIONS: These data document significant improvements in both acute and micronutrient malnutrition among Rohingya children in makeshift settlements. These declines coincide with a scaleup of services aimed at prevention and treatment of malnutrition. Ongoing activities to improve access to nutritional services may facilitate further reductions in malnutrition levels to sustained below-crisis levels.

BACKGROUND: The United States has admitted over 80,000 Special Immigrant Visa holders (SIVH), which include children. Despite the increase in the proportion of SIVH admissions to the US over recent years, little is known about health conditions in SIV children. We report the frequency of selected diseases identified overseas and assess differences in selected conditions between SIV children from Iraq and Afghanistan. METHODS AND FINDINGS: We analyzed 15,729 overseas medical exam data in Centers for Disease Control and Prevention's Electronic Disease Notification system (EDN) for children less than 18 years of age from Iraq (29.1%) and Afghanistan (70.9%) who were admitted to the US from April 2009 through December 2017 in a cross-sectional analysis. Variables included age, sex, native language, measured height and weight, and results of the overseas medical examination. From our analysis, less than 1% of SIV children (Iraqi: 0.1%; Afghan: 0.12%) were reported to have abnormal tuberculosis test findings, less than 1% (Iraqi: 0.3%; Afghan: 0.7%) had hearing abnormalities, and about 4% (Iraqi: 6.0% Afghan: 2.9%) had vision abnormalities, with a greater prevalence of vision abnormalities noted in Iraqis (OR: 1.9, 95% CI 1.6-2.2, p <0.001). Seizure disorders were noted in 46 (0.3%) children, with Iraqis more likely to have a seizure disorder (OR: 7.6, 95% CI 3.8-15.0, p < 0.001). On average, children from Afghanistan had a lower mean height-for-age z-score (Iraqi: -0.28; Afghan: -0.68). Only the data quality assessment for height for age for children >/=5 years fell within WHO recommendations. Limitations included the inability to obtain all SIVH records and self-reported medical history of noncommunicable diseases. CONCLUSION: In this investigation, we found that less than 1% of SIV children were reported to have abnormal tuberculosis test findings and 4% of SIV children had reported vision abnormalities. Domestic providers caring for SIVH should follow the US Centers for Disease Control and Prevention (CDC) Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees, including an evaluation for malnutrition. Measurement techniques and anthropometric equipment used in panel site clinics should be assessed, and additional training in measurement techniques should be considered. Future analyses could further explore the health of SIV children after resettlement in the US.

Background: Some of the recently piloted innovative approaches for the management of acute malnutrition in children use the "expanded MUAC-only" approach, with Mid Upper Arm Circumference (MUAC) < 125 mm as the sole anthropometric criterion for screening and admission, classification of cases as severe using the 115 mm cut-off, and use Ready-to-Use-Therapeutic-Food (RUTF) for the management of both moderate (MAM) and severe (SAM) cases of acute malnutrition. Our study aimed at exploring the potential consequences of this "expanded MUAC-only" program scenario on the eligibility for treatment and RUTF allocation, as compared with the existing WHO normative guidance. Methods: We analyzed data from 550 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as SAM and MAM according to currently used case definitions, and calculated the proportions of SAM children who would be excluded from treatment, misclassified as MAM, or whose specific risks (because of having both MUAC and weight-for height deficits) would be ignored. We also analyzed the expected changes in the number and demographics (sex, age) of children meant to receive RUTF according to the new approach. Results: We found that approximately one quarter of SAM children would not be detected and eligible for treatment under the "expanded MUAC-only" scenario, and another 20% would be classified as MAM. A further 17% of the total SAM children would be admitted and followed only according to their MUAC or oedema status, while they also present with a severe weight-for height deficit on admission. Considering MAM targeting, about half of the MAM children would be left undetected. This scenario also shows a 2.5 time increase in the number of children targeted with RUTF, with approximately 70% of MAM and 30% of SAM cases among this new RUTF target. Conclusions: This empirical evidence suggests that adoption of "expanded MUAC-only" programs would likely lead to a priori exclusion from treatment or misclassifying as MAM a large proportion of SAM cases, while redirecting programmatic costs in favor of those less in need. It underscores the need to explore other options for improving the impact of programs addressing the needs of acutely malnourished children.

Background: Mid-upper arm circumference (MUAC) and weight-for-height (WHZ) are commonly used indicators to identify acute malnutrition. However, MUAC and WHZ diagnose different children, and produce prevalence estimates that are meaningfully different. Previous research in Somalia has suggested improved concordance using MUAC-for-age (MUACZ) rather than MUAC. We further evaluate the relationship between MUACZ, MUAC, and WHZ using surveys conducted globally. Methods: We analyzed 882 population representative surveys from 41 countries. Children ages 6-59 months were classified as acutely malnourished using three independent criteria: WHZ < - 2 (WHZ2), MUAC< 125 mm (MUAC125), MUACZ < - 2 (MUACZ2). Population prevalence using each of the three criteria are presented by country and region. Correlations of survey prevalence for each indicator pair were assessed. Multivariable regression models of MUACZ and MUAC125 adjusted for WHZ2, stunting prevalence, age, and sex. To evaluate individual level diagnostic concordance, we compared the proportion of children identified by each of the three criteria. Results: Median prevalence of acute malnutrition overall was highest for MUACZ2 (14.0%) followed by WHZ2 (10.6%), and lowest for MUAC125 (7.3%). The absolute difference in prevalence between MUACZ2 and WHZ2 was smaller than the difference between MUAC125 and WHZ2 for 51.3% of surveys. The correlations of WHZ2 with both MUACZ2 as well as with MUAC125 were weak, positive associations (Pearson's r = 0.5757 and 0.4943, respectively), but MUAC125 and MUACZ2 had a strong, linear relationship (Pearson's r = 0.9265). The adjusted regression model for MUACZ2 had greater fit (R(2) = 0.50) relative to the adjusted model for MUAC125 (R(2) = 0.43). The proportion of children identified by both MUAC125 and WHZ2 was 25.5%, smaller than the proportion identified by both MUACZ2 and WHZ2 (30.6%). Conclusions: MUACZ identified more children as malnourished than MUAC, resulting in a higher prevalence of acute malnutrition in nearly all settings. Prevalence by MUACZ was not consistently more similar to WHZ than that estimated by MUAC, and correlations with WHZ were only slightly improved relative to MUAC. Consequently, programmatic use of MUACZ cannot be justified based on improved concordance with WHZ. Further research on morbidity and mortality of children with low MUACZ only are needed before recommending MUACZ for wider use.

Introduction Displaced persons have a unique risk for developing anaemia due to often limited diets, overcrowding, new infections and inadequate sanitation and hygiene. The lack of anaemia prevalence estimates among the displaced inhibit global planning for anaemia reduction. Methods We analysed population representative, cross-sectional nutrition surveys from 2013 to 2016 conducted by the United Nations High Commissioner for Refugees and partner agencies. Included surveys measured haemoglobin concentration among children 6-59 months, non-pregnant women 15-49 years, or both groups. For each survey, we calculated mean haemoglobin and prevalence of total anaemia (<110 g/L in children, <120 g/L in women), and classified public health severity following WHO guidelines. Pearson correlations between indicators from women and children surveys were calculated where both subpopulations were measured. Results Analysis included 196 surveys among children and 184 surveys among women from 121 unique refugee settings in 24 countries. The median prevalence of total anaemia in children and women was 44% and 28%, respectively. Sixty-one per cent of child surveys indicated a problem of severe public health importance compared with 25% of surveys in women. The prevalence of total anaemia in children and women was strongly correlated (ρ=0.80). Median prevalence of total anaemia was approximately 55% greater and mean haemoglobin was 6 g/L lower among children age 6-23 months compared with children 24-59 months. West and Central Africa region had the highest median prevalence of anaemia both in women and children. Conclusion While the burden of anaemia is high among the displaced, it mirrors that of the general population. Haemoglobin should continue to be measured in nutrition surveys in refugee settings. Sustained, multisectoral efforts to reduce anaemia are needed, with specific focus on children under 2 years of age and refugee settings in the West and Central Africa region.

Background: Older persons are often unable to leave conflict areas; however, little is known about the mental and physical health among this population. Our objective was to determine the prevalence of and whether there was an association between psychological distress and disability among older persons affected by conflict in eastern Ukraine. Methods: We conducted a cluster-randomized cross-sectional household survey of persons aged >/=60 years in government and non-government controlled areas (GCA and NGCA) of Donetsk and Luhansk regions in January-March 2016. Psychological distress and dependency (degree of disability) were measured using the Kessler K6 Psychological Distress Scale and Katz Index of Independence in Activities of Daily Living, respectively. Association between psychological distress and dependency was assessed using logistic regression adjusting for demographic and socioeconomic characteristics. Results: Final sample included 758 and 418 persons in GCA and NGCA, respectively. Prevalence of serious psychological distress was 33.6% (95% Confidence Interval (CI), 28.0-39.7%) in GCA and 42.5% (95%CI, 36.1-49.2%) in NGCA. Overall, 32.2% (95%CI, 27.9-36.7%) of independent persons and 74.0% (95%CI, 65.2-81.2%) of moderately/severely dependent persons reported serious psychological distress (P < .0001). Being dependent, a woman, and having a chronic disease were all significantly associated with psychological distress in a logistic regression model. Conclusions: Prevalence of serious psychological distress was very high compared with rates reported from developed countries and was highly associated with disability. Health services for the disabled, including psychological as well as physical support, could help in reducing the proportion of people needing mental health services not normally identified.

BACKGROUND: Despite frequent use of mid-upper arm circumference (MUAC) to assess populations at risk of nutrition emergencies, as well as evidence that measurement of children based on MUAC identifies different children than weight-for-height (WHZ) as wasted, no crisis classification thresholds based on prevalence of wasting by MUAC currently exist. METHODS: We analyzed 733 population-representative anthropometric surveys from 41 countries conducted by Action Contre la Faim (ACF) and the United Nations High Commissioner for Refugees (UNHCR) between 2001 and 2016. Children aged 6-59 months were classified as wasted if they had a WHZ < - 2 and/or a MUAC < 125 mm. Prevalence of wasting as assessed by WHZ and by MUAC were compared using correlations and linear regression models adjusting for stunting prevalence, sex and age distribution of the sample. Median prevalence of wasting by MUAC corresponding to each of the WHZ-based crisis thresholds was examined. RESULTS: Median prevalence of wasting by WHZ was 10.47% (IQR: 6.34-17.55%) and by MUAC was 6.66% (IQR:4.12-10.88%). Prevalence of wasting by WHZ exceeded prevalence by MUAC in 543 (74.1%) surveys and median prevalence by WHZ was greater in 30 (73.17%) countries. Prevalence of wasting by WHZ is poorly correlated with prevalence of wasting by MUAC (ρ = 0.55). R(2) was 0.36 for unadjusted and 0.45 for adjusted linear regression model. The difference between the prevalence by WHZ and by MUAC increased as the overall prevalence by WHZ increased (ρ = 0.69). Surveys with prevalence of wasting by WHZ approximately equal to thresholds for "poor" (5% ± 2.5%), "serious" (10% ± 2.5%), "emergency" (15% ± 2.5%), and "famine" (30% ± 2.5%) were observed to have median prevalence of wasting by MUAC of 4.51% (IQR: 2.73-6.81%), 6.67% (IQR: 4.27-10.03%), 8.15% (IQR: 5.11-11.86%), and 15.71% (IQR: 10.28-17.50%), respectively. There was a very substantial overlap of MUAC values across the threshold categories. CONCLUSIONS: Given a poor correlation between population prevalence of wasting by WHZ and by MUAC, classification of surveys based on prevalence of wasting by MUAC will result in poor concordance with current WHZ-based crisis thresholds, even if regional differences are considered, regardless of the cutoffs used.

BACKGROUND: Evidence-based nutrition programs depend on accurate estimates of malnutrition derived from data collected in population representative surveys. The feasibility of obtaining accurate anthropometric data as part of national, multisectoral surveys has been a debated issue. OBJECTIVES: The study aimed to evaluate changes in anthropometric data quality corresponding to investments by the Kenya Ministry of Health and nutrition sector partners for the 2014 Kenya Demographic Health Survey. METHODS: Anthropometric data collected during the 2008 to 2009 and 2014 Kenya surveys were reanalyzed to assess standard parameters of quality: standard deviation, skewness, and kurtosis of z-score values for 3 anthropometric indicators (weight for height, height for age, and weight for age), percentage of children with missing measurements and outlier values, digit preference, and heaping of age. RESULTS: A total of 9936 households were selected in 2008 to 2009, and 39 679 households were selected in 2014. Standard deviation of z-scores for all 3 indicators was smaller in 2014 than in 2008 to 2009. Applying original Demographic and Health Survey exclusion criteria, weight for height z-scores were 1.16 in 2014, 10.1% narrower than 2008 to 2009. The percentage of outlying values declined significantly from 2008 to 2009 to 2014 for both height for age and weight for height ( P < .001). Digit preference scores in 2014 improved for both weight ( P = .011) and height ( P < .001) suggesting less rounding of terminal digits. CONCLUSIONS: All tests of data quality suggest an improvement in 2014 relative to 2008 to 2009, despite the complexity implied by the larger sample. This improvement corresponds with efforts to enhance training and supervision of anthropometry, suggesting a positive effect of these enhancements.

Violence in the Rakhine State of Myanmar, which began on August 25, 2017, prompted mass displacement of Rohingya to the bordering district of Cox’s Bazar, Bangladesh. Joining the nearly 213,000 Rohingya already in the region, an estimated 45,000 persons settled in two preexisting refugee camps, Nayapara and Kutupalong, and nearly 550,000 into new makeshift settlements (1). Mass violence and displacement, accompanied by malnutrition, overcrowding, poor hygiene, and lack of access to safe water and health care increase the vulnerability of children to infectious diseases, including pneumonia and diarrhea (2).

This survey study assesses the health and nutritional status of Rohingya children aged 6 to 59 months in the Kutupalong refugee camp in Bangladesh.

Background: Following decades of armed conflict, Colombia remains highly affected by explosive device (ED) contamination, especially in rural areas. Many victims are injured by EDs despite knowing their dangers. Determining risk factors for unsafe behaviors toward EDs, including grenades, is critical for preventing injuries. Methods: In 2012, CDC assisted Colombian partners in conducting a multi-stage knowledge, attitudes, and practices survey in rural ED-affected areas. Within each of 40 clusters, 28 households were selected, and participants aged 10 years or older were asked about behaviors toward EDs. Participants reported actual behaviors toward past EDs encountered and theoretical behaviors toward EDs not encountered. Behaviors were a priori classified as unsafe or safe. This analysis focuses on behaviors toward the most commonly encountered device, grenades. Results: Of 928 adult and 562 child participants, 488 (52.5%) adults and 249 (43.9%) children encountered ED, while 121 (13.7%) adults and 148 (26.9%) children received mine risk education (MRE). Among the 430 (46.7%) adults who encountered grenades, 113 (25.7%) reported unsafe behaviors; multivariable analysis showed that unsafe behavior was associated with working outdoors (adjusted odds ratio [aOR]: 1.7, 95% confidence interval [CI]: 1.1-2.7). Among the 429 (46.5%) adults who did not encounter ED, 61 (14.6%) described unsafe theoretical behaviors toward grenades; multivariable analysis showed that unsafe behavior was associated with older age (aOR: 1.02, 95% confidence limit [CL]: 1.00-1.05) and black or Afro-Colombian identity (aOR: 2.5, 95% CI 1.3-5.1). Among the 181 (32.0%) children who encountered grenades, 41 (23.8%) reported unsafe behaviors, while among the 311 (55.9%) children who did not encounter ED, 30 (10.2%) reported unsafe behavior. In both groups of children, multivariable analysis showed that unsafe behavior was associated with lower mean score on knowledge of ED, with aOR: 0.7, 95% CL: 0.6-0.9, and aOR: 0.8, 95% CL: 0.6-0.98, respectively. Conclusions: Participants reported frequent ED exposure but low receipt of MRE. Our findings should guide MRE improvement in ED-affected areas by strengthening the connection between ED knowledge and avoiding unsafe behavior, with a particular focus on people working outdoors. MRE should promote knowledge of ED risks but should also recognize socioeconomic factors that lead to engaging in unsafe behaviors.

Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB's responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB's multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.

OBJECTIVE: To determine current status, areas for improvement and effect of conflict on infant and young child feeding (IYCF) practices among internally displaced persons (IDP) in eastern Ukraine. DESIGN: Cross-sectional household survey, June 2015. SETTING: Kharkiv, Dnipropetrovsk and Zaporizhia oblasts (Ukrainian administrative divisions) bordering conflict area in Ukraine. SUBJECTS: Randomly selected IDP households with children aged <2 years registered with local non-governmental organizations. Questions based on the WHO IYCF assessment questionnaire were asked for 477 children. Mid-upper arm circumference was measured in 411 children aged 6-23 months. RESULTS: Exclusive breast-feeding prevalence for infants aged <6 months was 25.8 (95 % CI 15.8, 38.0) %. Percentage of mothers continuing breast-feeding when their child was aged 1 and 2 years was 53.5 (95 % CI 43.2, 63.6) % and 20.6 (95 % CI 11.5, 32.7) %, respectively. Bottle-feeding was common for children aged <2 years (68.1 %; 95 % CI 63.7, 72.3 %). Almost all infants aged 6-8 months received solid foods (98.6 %; 95 % CI 88.5, 99.9 %). Mothers who discontinued breast-feeding before their infant was 6 months old more often listed stress related to conflict as their primary reason for discontinuation (45.7 %) compared with mothers who discontinued breast-feeding when their child was aged 6-23 months (14.3 %; P<0.0001). CONCLUSIONS: To mitigate the effects of conflict and improve child health, humanitarian action is needed focused on helping mothers cope with stress related to conflict and displacement while supporting women to adhere to recommended IYCF practices if possible and providing appropriate support to women when adherence is not feasible.

BACKGROUND: In Iraq, where Islamic State of Iraq and Syria (ISIS) and other groups have contributed to escalating violence in recent years, understanding the epidemiology of intentional firearm-related fatalities is essential for public health action. METHODS: The Iraqi Ministry of Health (MoH; Baghdad, Iraq) compiles surveillance of fatal injuries in eight of Iraq's 18 governorates (Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya). Information is collected from coroner's reports and interviews with family members. Analysis was performed on intentional firearm-related injuries, excluding injuries from intentional self-harm or negligent discharges, that occurred during 2010-2013, a subset of all fatal injuries, and compared to previously published explosive-related fatalities. RESULTS: Overall, the dataset included 7,985 firearm-related fatalities. Yearly fatalities were: 2010=1,706; 2011=1,642; 2012=1,662; and 2013=2,975. Among fatalities, 86.0% were men and 13.7% women; 83.4% were adults and 6.2% children <18 years of age. Where age and sex were both known, men aged 20-39 years accounted for 56.3% of fatalities. Three "high-burden" governorates had the highest fatality rate per 100,000 population-Baghdad (12.9), Ninevah (17.0), and Al-Anbar (14.6)-accounting for 85.9% of fatalities recorded in the eight governorates. Most fatalities occurred in the street (56.3%), followed by workplace (12.2%), home (11.3%), and farm/countryside (8.4%). Comparing the ratio of firearm-related fatalities to explosives-related fatalities revealed an overall ratio of 2.8:1. The ratio in Baghdad more than doubled from 2.9 in 2010 to 6.1 in 2013; the highest ratios were seen outside the high-burden governorates. CONCLUSIONS: Firearm-related fatalities remained relatively stable throughout 2010-2012, and almost doubled in 2013, correlating with increased ISIS activity. Three governorates contributed the majority of fatalities and experienced the highest fatality rates; these saw high levels of conflict. Firearm-related fatalities disproportionately affected younger men, who historically are over-represented as victims and perpetrators of violence. More than one-half of fatalities occurred in the street, indicating this as a common environment for conflict involving firearms. Firearms appear to account for more fatalities in Iraq than explosives and largely accounted for escalating violence in Baghdad during the study period. The high ratio observed outside the high-burden governorates is reflective of very low numbers of explosives-related fatalities; thus, violence in these governorates is likely non-conflict-related. These observations provide valuable public health information for targeted intervention to prevent violence. Nerlander MP , Leidman E , Hassan A , Sultan ASS , Hussain SJ , Browne LB , Bilukha OO . Fatalities from firearm-related injuries in selected governorates of Iraq, 2010-2013. Prehosp Disaster Med. 2017;32(5):1-8.

BACKGROUND: Cluster surveys provide rapid but representative estimates of key nutrition indicators in humanitarian crises. For these surveys, an accurate estimate of the design effect is critical to calculate a sample size that achieves adequate precision with the minimum number of sampling units. This paper describes the variability in design effect for three key nutrition indicators measured in small-scale surveys and models the association of design effect with parameters hypothesized to explain this variability. METHODS: 380 small-scale surveys from 28 countries conducted between 2006 and 2013 were analyzed. We calculated prevalence and design effect of wasting, underweight, and stunting for each survey as well as standard deviations of the underlying continuous Z-score distribution. Mean cluster size, survey location and year were recorded. To describe design effects, median and interquartile ranges were examined. Generalized linear regression models were run to identify potential predictors of design effect. RESULTS: Median design effect was under 2.00 for all three indicators; for wasting, the median was 1.35, the lowest among the indicators. Multivariable linear regression models suggest significant, positive associations of design effect and mean cluster size for all three indicators, and with prevalence of wasting and underweight, but not stunting. Standard deviation was positively associated with design effect for wasting but negatively associated for stunting. Survey region was significant in all three models. CONCLUSIONS: This study supports the current field survey guidance recommending the use of 1.5 as a benchmark for design effect of wasting, but suggests this value may not be large enough for surveys with a primary objective of measuring stunting or underweight. The strong relationship between design effect and region in the models underscores the continued need to consider country- and locality-specific estimates when designing surveys. These models also provide empirical evidence of a positive relationship between design effect and both mean cluster size and prevalence, and introduces standard deviation of the underlying continuous variable (Z-scores) as a previously unexplored factor significantly associated with design effect. The magnitude and directionality of this association differed by indicator, underscoring the need for further investigation into the relationship between standard deviation and design effect.

BACKGROUND: Ongoing armed conflict in Syria has caused large scale displacement. Approximately half of the population of Syria have been displaced including the millions living as refugees in neighboring countries. We sought to assess the health and nutrition of Syrian refugees affected by the conflict. METHODS: Representative cross-sectional surveys of Syrian refugees were conducted between October 2 and November 30, 2013 in Lebanon, April 12 and May 1, 2014 in Jordan, and May 20 and 31, 2013 in Iraq. Surveys in Lebanon were organized in four geographical regions (North, South, Beirut/Mount Lebanon and Bekaa). In Jordan, independent surveys assessed refugees residing in Za'atri refugee camp and refugees residing among host community nationwide. In Iraq, refugees residing in Domiz refugee camp in the Kurdistan region were assessed. Data collected on children aged 6 to 59 months included anthropometric indicators, morbidity and feeding practices. In Jordan and Lebanon, data collection also included hemoglobin concentration for children and non-pregnant women aged 15 to 49 years, anthropometric indicators for both pregnant and non-pregnant women, and household level indicators such as access to safe water and sanitation. RESULTS: The prevalence of global acute malnutrition among children 6 to 59 months of age was less than 5 % in all samples (range 0.3-4.4 %). Prevalence of acute malnutrition among women 15 to 49 years of age, defined as mid-upper arm circumference less than 23.0 cm, was also relatively low in all surveys (range 3.5-6.5 %). For both children and non-pregnant women, anemia prevalence was highest in Za'atri camp in Jordan (48.4 % and 44.8 %, respectively). Most anemia was mild or moderate; prevalence of severe anemia was less than or equal to 1.1 % in all samples of children and women. CONCLUSIONS: Despite the ongoing conflict, results from all surveys indicate that global acute malnutrition is relatively low in the assessed Syrian refugee populations. However, prevalence of anemia suggests a serious public health problem among women and children, especially in Za'atri camp. Based on these findings, nutrition partners in the region have reprioritized response interventions, focusing on activities to address micronutrient deficiencies such as food fortification.

OBJECTIVE: After several years of relative stability in Iraq, the emergence of the Islamic State militant group has spurred a resurgence of violence. This study explores the impact of the conflict on the overall injury profile to estimate the proportion of injury fatalities related to conflict and better understand how violence has affected nonconflict-related injuries. DESIGN: Routine prospective injury surveillance operated by the Iraqi Ministry of Health. SETTING: Surveillance data were collected from coroner offices in eight pilot governorates: Al-Anbar, Baghdad, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. PARTICIPANTS: We analyzed all fatalities from external injury causes recorded between January 1, 2010 and December 31, 2013. Analysis included 32,664 fatal injuries. RESULTS: Of all injury fatalities reported, 27.1 percent were conflict-related fatalities, approximately the same proportion as road traffic-related fatalities (24.4 percent) and other unintentional injuries (27.5 percent). The proportion of fatalities from conflict was approximately three times higher among males than females (33.0 percent and 10.3 percent, respectively) and four times higher among adults than children (29.8 percent and 7.3 percent, respectively). The total number of injury fatalities remained stable between 2010 and 2012; an increase in injury fatalities in 2013 was driven primarily by increases in fatalities from both interpersonal violence and conflict. CONCLUSIONS: From 2010 to 2013, nearly one in four injury fatalities in Iraq was attributable to conflict, a notably higher proportion than other conflict-affected countries in the region. The overall profile of nonconflict injuries in Iraq is also distinct from other countries of similar socioeconomic level that have not experienced violence.

BACKGROUND: The insurgency tactics that characterize modern warfare, such as suicide car bombs and roadside bombs, have the potential to significantly impact road traffic injuries in conflict affected-countries. As road traffic incidents are one of the top ten causes of death in Iraq, changes in incidence have important implications for the health system. We aimed to describe patterns of road traffic fatalities for all demographic groups and types of road users in Iraq during a period characterized by a resurgence in insurgency activity. METHODS: Iraqi Ministry of Health routine prospective injury surveillance collects information on all fatal injuries in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. From all injury fatalities documented at the coroner office, we analyzed only those attributed to road traffic that occurred between 1 January 2010 and 31 December 2013. Coroners ascertain information from physical examinations, police reports and family members. RESULTS: Analysis included 7,976 road traffic fatalities. Overall, 6,238 (78.2 %) fatalities were male and 2,272 (28.5 %) were children under 18 years of age. The highest numbers of road traffic fatalities were among males 15 to 34 years of age and children of both sexes under 5 years of age. 49.2 % of fatalities occurred among pedestrians. Among children and females, the majority of road traffic fatalities were pedestrians, 69.0 % and 56.6 %, respectively. Fatalities among motorcyclists (3.7 %) and bicyclists (0.4 %) were least common. Rates of road traffic fatalities ranged from 8.6 to 10.7 per 100,000 population. CONCLUSIONS: The injury surveillance system provides the first data from a conflict-affected country on road traffic fatalities disaggregated by type of road user. The highest numbers of fatalities were among children and young men. Nearly half of fatalities were pedestrians, a proportion nearly double that of any neighboring country. As insurgency activity increased in 2013, the number of road traffic fatalities declined.

Reliable data are critical to assess the severity of a crisis and respond appropriately. In crises affecting the food security of a population, nutrition indicators inform decisions on types of interventions, geographic prioritisation, and levels of funding.1 Unfortunately, recent experiences have demonstrated that rigorous and representative nutrition data and robust nutrition surveillance systems are often lacking in humanitarian crises with few exceptions, e.g. nutrition surveillance implemented by the Food Security and Nutrition Analysis Unit (FSNAU) in Somalia.2,3 This is particularly true in the most severe crises when overwhelming needs restrict available resources and limited access constrains the ability to collect data. This challenging paradox—the need for data when they are least available—is common in sudden onset disasters, as well as during severe deterioration of a protracted crisis. | | Continuous monitoring of nutrition status over time, often required in a crisis, poses even greater challenges compared to individual assessments. This type of analysis requires ongoing, systematic collection of data, i.e. surveillance.5 Practitioners use many methods of data collection to help monitor changes in the nutritional status of a population and, where possible, respond in a timely manner. There are at least five recognized approaches to nutrition surveillance.6 Nearly all of these methods, however, have key limitations. For instance, health facility-based surveillance systems only include individuals who visit health centres; they are often not representative, potentially over-sampling younger children (who come for immunisations) and those who are sick. Mass screenings include all children, however do not produce ongoing data, and the quality of anthropometry data obtained from mass screenings can be difficult to control. Interpreting data from therapeutic feeding programmes can be challenging, as changes in nutritional status may be attributed to many factors including stock-outs of commodities or changes in access.7,8 In emergency contexts, using these methods can be even more challenging and costly than in non-emergency settings given access constraints and other factors that may disrupt existing systems.

INTRODUCTION: The aim of this study was to describe the most recent trends and epidemiologic patterns of fatal injuries resulting from explosions in Iraq, one of the countries most affected by violence from explosive devices. METHODS: Iraqi Ministry of Health (MoH) routine prospective injury surveillance collects information on all fatal injuries recorded by coroners from physical examinations, police reports, and family members in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. This study analyzed explosive-related fatal injuries that occurred from January 1, 2010 through December 31, 2013. RESULTS: Analysis included 2,803 fatal injuries. The number of fatal injuries declined from 2010 through 2012, followed by an increase in 2013. One-thousand one-hundred and one explosion-related fatalities were documented in 2013, more than twice as many as in 2012 or in 2011. Most fatalities were among men aged 20-39 years. Of all causalities, 194 (6.9%) were among females and 302 (10.8%) were among children aged less than 18 years. The majority of fatalities were caused by improvised explosive devices (IEDs): car bombs (15.3%), suicide bombs (4.0%), and other IEDs (29.6%). The highest number of fatalities occurred in streets and roads. Of all deaths, 95.6% occurred in three governorates: Baghdad, Ninevah, and Al-Anbar. CONCLUSIONS: Explosives continue to result in a high number of fatal injuries in Iraq. Following a period of declining violence from explosives, in 2013, fatalities increased. Most explosion-related injuries resulted from IEDs; males aged 20-39 years were at greatest risk.