Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 40 Records) |
Query Trace: Leidman E[original query] |
---|
Comparison of a non-invasive point-of-care measurement of anemia to conventionally used HemoCue devices in Gambella refugee camp, Ethiopia, 2022
Smith F , Woldeyohannes M , Lusigi M , Samson KLI , Mureverwi BT , Gazarwa D , Mohmand N , Theuri T , Leidman E . PLoS One 2025 20 (1) e0313319 Annual surveys of refugees in Gambella, Ethiopia suggest that anemia is a persistent public health problem among non-pregnant women of reproductive age (NP-WRA, 15-49 years). Measurement of anemia in most refugee camp settings is conducted using an invasive HemoCue 301. We assessed the accuracy and precision of a non-invasive, pulse CO-oximeter in measuring anemia among NP-WRA in four Gambella refugee camps. We conducted a population-representative household survey between November 7 and December 4, 2022. Hemoglobin (Hb) concentration was measured by HemoCue 301, using capillary blood, and Rad-67, a novel non-invasive device. We collected four measurements per participant: two per device. We calculated Rad-67 bias and precision of Hb measurements and sensitivity and specificity of detecting anemia. Of the 812 NP-WRAs selected, 807 (99%) participated in the study. Anemia was detected in 39% of NP-WRA as classified by the Rad-67 compared with 47% of NP-WRA as classified by the HemoCue 301. Average bias of Rad-67 measurements was 1.1 ± 1.0 SD g/dL, using HemoCue 301 as a comparator. Absolute mean difference between the first and second measurements was 0.9 g/dL (95% CI 0.8, 0.9) using the Rad-67, compared with 0.6 g/dL (95% CI 0.5, 0.6) using the HemoCue 301. The Rad-67 had 49% sensitivity and 70% specificity for detecting anemia, compared with the HemoCue 301. The Rad-67 can be a useful tool for anemia screening; however, lower accuracy and precision, and poor sensitivity suggest it cannot immediately replace the HemoCue 301 in the study area. |
Seasonal influenza vaccination programs in the Americas: A platform for sustainable life-course immunization and its role for pandemic preparedness and response
Nogareda F , Ghiselli M , Velandia-González M , de Mucio B , Jara J , Couto P , Rodriguez A , Rondy M , Vicari A , Ozturk MH , Goldin S , Vilajeliu A , Leidman E , Patel J , Carlton J , Fowlkes AL , Azziz-Baumgartner E , Salas Peraza D , Ropero AM . Vaccines 2024 12 (12) Background: Vaccination is one of the most effective measures to prevent influenza illness and its complications. Since the 1980s, countries and territories in the Americas have progressively implemented influenza vaccination operations in high-risk priority groups—such as older adults, pregnant persons, persons with comorbidities and health workers. Methods: In this review, we present the history and progress of the seasonal influenza program in the Americas, how the program contributed to the efficient and timely roll-out of the COVID-19 vaccines during the pandemic, and how the program can be used to promote immunization operations across the life span for existing and future vaccines. Results: The influenza A(H1N1)pdm09 pandemic in 2009 and the COVID-19 pandemic in 2020–2023 underscored the importance of having a robust seasonal influenza vaccination program for pandemic preparedness and response. Overall, countries with existing seasonal influenza vaccination programs were better prepared and rolled out the delivery of COVID-19 vaccines more quickly and effectively compared to other countries where the influenza vaccination platform was weak or non-existent. Conclusions: Traditionally, national immunization programs of developing countries have been predominately focused on newborns, children younger than five years and school-aged children while often limiting their investment in effective adult vaccination programs; these programs are typically isolated to high-income countries. Countries in Latin America have been the exception, with strong influenza vaccination programs for adults regardless of national income level. The presence of functional and effective adult influenza vaccination programs can also facilitate the acceptance and uptake of other adult vaccines targeting priority groups at higher risk for severe illness or complications. © 2024 by the authors. |
Caregiver use of MUAC tapes in South Sudan: a three-group prospective comparison
Doocy S , Ismail S , Lyles E , Altare C , Bauler S , Obali F , Atem D , Leidman E . Front Nutr 2024 11 1324063 INTRODUCTION: Nutrition program modifications occurred globally in response to the COVID-19 pandemic. Within community management of acute malnutrition (CMAM), community screenings for acute malnutrition were replaced by caregivers monitoring child mid-upper arm circumference (MUAC), but questions remain about different MUAC tapes' performance and acceptability for caregiver use. METHODS: The study was conducted in Central Equatoria and Warrap States, South Sudan, between March 2022 and January 2023. A three-group prospective non-randomized design was used to compare the performance of three MUAC tapes (UNICEF 2009, UNICEF 2020, and GOAL MAMI) used by caregivers. The primary outcome was the false negative rate (i.e., the proportion of children not identified as wasted by the caregiver but classified as wasted by enumerators). Caregivers with children aged 5-53 months were assigned to and trained on the use of 1 of the 3 tapes and followed for 8 months, including three monitoring visits and baseline/endline surveys. RESULTS: Of the 2,893 enrolled children, 2,401 (83.0%) completed baseline, endline, and two or more monitoring visits. Only 3.7% of children were identified as wasted by caregivers and 3.8% by study team measurement. Cumulative measurement agreement between caregivers and enumerators was similar by tape. False negative and false positive rates were both <0.5% overall and similar among the tapes. There were differences in training needs and durability between the tapes, but all three were acceptable and performed equally well. DISCUSSION: Caregiver measurement of child MUAC is feasible in South Sudan. The three MUAC tapes were acceptable, and caregivers could measure accurately with minimal support. All tapes performed similarly and are appropriate for use in Family MUAC programs in South Sudan. There were indications that the UNICEF 2020 tape may be less durable; the GOAL MAMI tape has the added benefit of being suitable for assessments of infants <6 months of age. |
Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study
Lyles E , Ismail S , Ramaswamy M , Drame A , Leidman E , Doocy S . J Health Popul Nutr 2024 43 (1) 21 BACKGROUND: As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes. METHODS: A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols. RESULTS: Very few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI - 30.2, - 26.5) and 5.1 days (CI - 6.2, - 4.0); the full adapted protocol had a decrease of 3.0 (CI - 5.1, - 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18-3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45-2.19); and fully adapted protocol AOR = 2.41 (CI 1.69-3.45). CONCLUSIONS: This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing. |
A prospective comparison of standard and modified acute malnutrition treatment protocols during COVID-19 in South Sudan
Doocy S , King S , Ismail S , Leidman E , Stobaugh H . Nutrients 2023 15 (23) A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan's standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6-59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP -10.0; TSFP -7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored. |
Infant and young child feeding practices in refugee settings across 203 population-based surveys from 2013-2019
Kianian B , Leidman E , Bilukha O . Matern Child Nutr 2023 20 (1) e13568 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. |
Enhanced Contact Investigations for Nine Early Travel-Related Cases of SARS-CoV-2 in the United States (preprint)
Burke RM , Balter S , Barnes E , Barry V , Bartlett K , Beer KD , Benowitz I , Biggs HM , Bruce H , Bryant-Genevier J , Cates J , Chatham-Stephens K , Chea N , Chiou H , Christiansen D , Chu VT , Clark S , Cody SH , Cohen M , Conners EE , Dasari V , Dawson P , DeSalvo T , Donahue M , Dratch A , Duca L , Duchin J , Dyal JW , Feldstein LR , Fenstersheib M , Fischer M , Fisher R , Foo C , Freeman-Ponder B , Fry AM , Gant J , Gautom R , Ghinai I , Gounder P , Grigg CT , Gunzenhauser J , Hall AJ , Han GS , Haupt T , Holshue M , Hunter J , Ibrahim MB , Jacobs MW , Jarashow MC , Joshi K , Kamali T , Kawakami V , Kim M , Kirking HL , Kita-Yarbro A , Klos R , Kobayashi M , Kocharian A , Lang M , Layden J , Leidman E , Lindquist S , Lindstrom S , Link-Gelles R , Marlow M , Mattison CP , McClung N , McPherson TD , Mello L , Midgley CM , Novosad S , Patel MT , Pettrone K , Pillai SK , Pray IW , Reese HE , Rhodes H , Robinson S , Rolfes M , Routh J , Rubin R , Rudman SL , Russell D , Scott S , Shetty V , Smith-Jeffcoat SE , Soda EA , Spitters C , Stierman B , Sunenshine R , Terashita D , Traub E , Vahey GM , Verani JR , Wallace M , Westercamp M , Wortham J , Xie A , Yousaf A , Zahn M . medRxiv 2020 2020.04.27.20081901 Background Coronavirus disease 2019 (COVID-19), the respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. As part of initial response activities in the United States, enhanced contact investigations were conducted to enable early identification and isolation of additional cases and to learn more about risk factors for transmission.Methods Close contacts of nine early travel-related cases in the United States were identified. Close contacts meeting criteria for active monitoring were followed, and selected individuals were targeted for collection of additional exposure details and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) at the Centers for Disease Control and Prevention.Results There were 404 close contacts who underwent active monitoring in the response jurisdictions; 338 had at least basic exposure data, of whom 159 had ≥1 set of respiratory samples collected and tested. Across all known close contacts under monitoring, two additional cases were identified; both secondary cases were in spouses of travel-associated case patients. The secondary attack rate among household members, all of whom had ≥1 respiratory sample tested, was 13% (95% CI: 4 – 38%).Conclusions The enhanced contact tracing investigations undertaken around nine early travel-related cases of COVID-19 in the United States identified two cases of secondary transmission, both spouses. Rapid detection and isolation of the travel-associated case patients, enabled by public awareness of COVID-19 among travelers from China, may have mitigated transmission risk among close contacts of these cases.Competing Interest StatementThe authors have declared no competing interest.Funding StatementNo external funding was sought or received.Author DeclarationsAll relevant ethical guidelines have been followed; any necessary IRB and/or ethics committee approvals have been obtained and details of the IRB/oversight body are included in the manuscript.YesAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesData may be available upon reasonable request. |
Injury-related deaths before and during the Islamic State insurgency - Baghdad, Iraq, 2010-2015
Goers M , Leidman E , Sultan AS , Hassan A , Bilukha O . Confl Health 2020 14 8 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. |
Acute malnutrition recovery rates improve with COVID-19 adapted nutrition treatment protocols in South Sudan: a mixed methods study
Lyles E , Banks S , Ramaswamy M , Ismail S , Leidman E , Doocy S . BMC Nutr 2023 9 (1) 46 BACKGROUND: Globally, emergency nutrition program adaptations were implemented as part of COVID-19 mitigation strategies, but the implications of the adoption of all protocol changes at scale in the context of deteriorating food security are not yet well characterized. With ongoing conflict, widespread floods, and declining food security, the secondary impacts of COVID-19 on child survival in South Sudan is of great concern. In light of this, the present study aimed to characterize the impact of COVID-19 on nutrition programming in South Sudan. METHODS: A mixed methods approach including a desk review and secondary analysis of facility-level program data was used to analyze trends in program indicators over time and compare two 15-month periods prior to the onset of COVID-19 (January 2019 - March 2020; "pre-COVID period") and after the start of the pandemic (April 2020 - June 2021; "COVID" period) in South Sudan. RESULTS: The median number of reporting Community Management of Acute Malnutrition sites increased from 1167 pre-COVID to 1189 during COVID. Admission trends followed historic seasonal patterns in South Sudan; however, compared to pre-COVID, declines were seen during COVID in total admissions (- 8.2%) and median monthly admissions (- 21.8%) for severe acute malnutrition. For moderate acute malnutrition, total admissions increased slightly during COVID (1.1%) while median monthly admissions declined (- 6.7%). Median monthly recovery rates improved for severe (92.0% pre-COVID to 95.7% during COVID) and moderate acute malnutrition (91.5 to 94.3%) with improvements also seen in all states. At the national level, rates also decreased for default (- 2.4% for severe, - 1.7% for moderate acute malnutrition) and non-recovery (- 0.9% for severe, - 1.1% for moderate acute malnutrition), with mortality rates remaining constant at 0.05-0.15%. CONCLUSIONS: Within the context of the ongoing COVID-19 pandemic in South Sudan, improved recovery, default, and non-responder rates were observed following adoption of changes to nutrition protocols. Policymakers in South Sudan and other resource-constrained settings should consider if simplified nutrition treatment protocols adopted during COVID-19 improved performance and should be maintained in lieu of reverting to standard treatment protocols. |
Outcomes after acute malnutrition program adaptations to COVID-19, Uganda, Ethiopia, and Somalia
Shragai T , Talley L , Summers A , Behringer H , Wrabel M , Stobaugh H , Leidman E . Emerg Infect Dis 2022 28 (13) S288-s298 At the onset of the COVID-19 pandemic, protocols for community-based management of acute malnutrition (CMAM) were implemented to support continuity of essential feeding services while mitigating COVID-19 transmission. To assess correlations between adaptation timing and CMAM program indicators, we evaluated routine program data in Uganda, Ethiopia, and Somalia for children 6-59 months of age. We specifically analyzed facility-level changes in total admissions, average length of stay (ALOS), total children screened for admission, and recovery rates before and after adaptations. We found no statistically significant changes in program indicators after adaptations. For Somalia, we also analyzed child-level changes in ALOS and in weight and mid-upper arm circumference at admission and discharge. ALOS significantly increased immediately after adaptations and then decreased to preadaptation levels. We found no meaningful changes in either weight or mid-upper arm circumference at admission or discharge. These findings indicate that adapted CMAM programs can remain effective. |
Clinical progression and outcomes of patients hospitalized with COVID-19 in humanitarian settings: a prospective cohort study in South Sudan and Eastern Democratic Republic of the Congo
Doocy S , Bollemeijer I , Leidman E , Sebushishe A , Mbong EN , Page K . PLoS Glob Public Health 2022 2 (10) e0000924 Little information is available on COVID-19 in Africa and virtually none is from humanitarian and more resource-constrained settings. This study characterizes hospitalized patients in the African humanitarian contexts of Juba, South Sudan and North and South Kivu in Eastern Democratic Republic of the Congo. This observational cohort was conducted between December 2020 and June 2021. Patients presenting for care at five facilities or referred from home-based care by mobile medical teams were eligible for enrollment and followed until death or recovery. Disease progression was characterized for hospitalized patients using survival analysis and mixed effects regression model to estimate survival odds for patient characteristics and treatments received. 144 COVID-19 cases enrolled as hospitalized patients were followed to recovery/death. The observed mortality proportion among hospitalized patients was 16.7% (CI: 11.2-23.3%); mortality was three times higher in South Sudan, where patients presented later after symptom onset and in worse conditions. Age and diabetes history were the only patient characteristics associated with decreased survival; clinical status indicators associated with decreased survival included fever, low oxygen level, elevated respiratory and pulse rates. The only therapy associated with survival was non-invasive oxygen; invasive oxygen therapies and other specialized treatments were rarely received. Improving availability of oxygen monitoring and proven COVID-19 therapies in humanitarian and resource-poor settings is critical for health equity. Customizing training to reflect availability of specific medications, therapies and operational constraints is particularly important given the range of challenges faced by providers in these settings. |
Risk factors for hospitalisation and death from COVID-19: a prospective cohort study in South Sudan and Eastern Democratic Republic of the Congo.
Leidman E , Doocy S , Heymsfield G , Sebushishe A , Mbong EN , Majer J , Bollemeijer I . BMJ Open 2022 12 (5) e060639 OBJECTIVES: Our study described demographic characteristics, exposures and symptoms, and comorbidities to evaluate risk factors of hospitalisation and mortality among cases in Juba, South Sudan (SSD) and North and South Kivu in eastern Democratic Republic of the Congo (DRC). DESIGN: Prospective observational cohort of COVID-19 cases. METHODS: Individuals presenting for care at one of five study facilities in SSD (n=1) or DRC (n=4) or referred from home-based care by mobile medical teams between December 2020 and June 2021 were eligible for enrolment. Demographic characteristics, COVID-19 exposures, symptoms at presentation, as well as acute and chronic comorbidities, were evaluated using a standard questionnaire at enrolment. Disease progression was characterised by location of care using mixed-effects regression models. RESULTS: 751 individuals were eligible for enrolment. Among cases followed to discharge or death (n=519), 375 were enrolled outpatients (75.7%). A similar number of cases were enrolled in DRC (n=262) and SSD (n=257). Overall mortality was 4.8% (95% CI: 3.2% to 6.9%); there were no outpatient deaths. Patients presenting with any symptoms had higher odds of hospitalisation (adjusted OR (AOR) 2.78, 95% CI 1.47 to 5.27) and all deaths occurred among symptomatic individuals. Odds of both hospitalisation and mortality were greatest among cases with respiratory symptoms; presence of low oxygen levels on enrolment was strongly associated with both hospitalisation (AOR 7.77, 95% CI 4.22 to 14.29) and mortality (AOR 25.29, 95% CI 6.42 to 99.54). Presence of more than one chronic comorbidity was associated with 4.96 (95% CI 1.51 to 16.31) times greater odds of death; neither infectious comorbidities evaluated, nor malnutrition, were significantly associated with increased mortality. CONCLUSIONS: Consistent with prior literature, older age, low oxygen level, other respiratory symptoms and chronic comorbidities were all risk factors for mortality. Patients presenting with these characteristics were more likely to be hospitalised, providing evidence of effective triage and referral. TRIAL REGISTRATION NUMBER: NCT04568499. |
Child nutritional status as screening tool for identifying undernourished mothers: an observational study of mother-child dyads in Mogadishu, Somalia, from November 2019 to March 2020
Zacks R , Ververs M , Hwang C , Mahdi A , Leidman E . BMJ Nutr Prev Health 2021 4 (2) 501-509 BACKGROUND: Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible to undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves. METHODS: The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6-59 months, parity and gestational status for women aged 19-50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <-2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m(2) for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status. RESULTS: A total of 93.6% (2142/2288) of enrolled dyads met inclusion criteria. Wasting was observed among 57.5% of children; 20.2% of pregnant mothers, 20.0% of lactating mothers and 7.95% of non-PLMs were undernourished. Models suggest significant, positive associations between child and maternal anthropometrics; a one-unit increase in WHZ and a 1 cm increase in child MUAC were associated with 0.22 kg/m(2) (95% CI 0.22 to 0.24) and 0.19 kg/m(2) (95% CI 0.16 to 0.21) increases in maternal BMI, respectively, and 0.20 cm (95% CI 0.18 to 0.22) and 0.24 cm (95% CI 0.23 to 0.25) increases in maternal MUAC, respectively. Adjusted R(2) values were low (range 0.06-0.10). CONCLUSIONS: Undernutrition among non-PLMs illustrates the importance of expanding screening. However, while significant, the strength of association between mother and child anthropometrics does not support child nutritional status as a screening tool for identifying at-risk mothers. |
Anemia design effects in cluster surveys of women and young children in refugee settings
Hulland EN , Leidman E , Wilkinson C , Tondeur M , Bilukha O . PLoS One 2021 16 (7) e0254031 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. |
COVID-19 Trends Among Persons Aged 0-24 Years - United States, March 1-December 12, 2020.
Leidman E , Duca LM , Omura JD , Proia K , Stephens JW , Sauber-Schatz EK . MMWR Morb Mortal Wkly Rep 2021 70 (3) 88-94 Coronavirus disease 2019 (COVID-19) case and electronic laboratory data reported to CDC were analyzed to describe demographic characteristics, underlying health conditions, and clinical outcomes, as well as trends in laboratory-confirmed COVID-19 incidence and testing volume among U.S. children, adolescents, and young adults (persons aged 0-24 years). This analysis provides a critical update and expansion of previously published data, to include trends after fall school reopenings, and adds preschool-aged children (0-4 years) and college-aged young adults (18-24 years) (1). Among children, adolescents, and young adults, weekly incidence (cases per 100,000 persons) increased with age and was highest during the final week of the review period (the week of December 6) among all age groups. Time trends in weekly reported incidence for children and adolescents aged 0-17 years tracked consistently with trends observed among adults since June, with both incidence and positive test results tending to increase since September after summer declines. Reported incidence and positive test results among children aged 0-10 years were consistently lower than those in older age groups. To reduce community transmission, which will support schools in operating more safely for in-person learning, communities and schools should fully implement and strictly adhere to recommended mitigation strategies, especially universal and proper masking, to reduce COVID-19 incidence. |
Comparison of anthropometric data quality in children aged 6-23 and 24-59 months: lessons from population-representative surveys from humanitarian settings
Bilukha O , Couture A , McCain K , Leidman E . BMC Nutr 2020 6 (1) 60 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. |
Adoption of Strategies to Mitigate Transmission of COVID-19 During a Statewide Primary Election - Delaware, September 2020.
Leidman E , Hall NB , Kirby AE , Garcia-Williams AG , Aponte J , Yoder JS , Hong R , Albence A , Coronado F , Massetti GM . MMWR Morb Mortal Wkly Rep 2020 69 (43) 1571-1575 Elections occurring during the coronavirus disease 2019 (COVID-19) pandemic have been affected by notable changes in the methods of voting, the number and type of polling locations, and in-person voting procedures (1). To mitigate transmission of COVID-19 at polling locations, jurisdictions have adopted changes to protocols and procedures, informed by CDC's interim guidance, developed in collaboration with the Election Assistance Commission (2). The driving principle for this guidance is that voting practices with lower infection risk will be those which reduce the number of voters who congregate indoors in polling locations by offering a variety of methods for voting and longer voting periods. The guidance for in-person voting includes considerations for election officials, poll workers, and voters to maintain healthy environments and operations. To assess knowledge and adoption of mitigation strategies, CDC collaborated with the Delaware Department of Health and Social Services and the Delaware State Election Commission on a survey of poll workers who served during the statewide primary election on September 15, 2020. Among 522 eligible poll workers, 93% correctly answered all three survey questions about COVID-19 transmission. Respondents noted that most voters and poll workers wore masks. However, masks were not always worn correctly (i.e., covering both the nose and mouth). Responses suggest that mitigation measures recommended for both poll workers and voters were widely adopted and feasible, but also highlighted gaps in infection prevention control efforts. Strengthening of measures intended to minimize the risk of poll workers acquiring COVID-19 from ill voters, such as additional training and necessary personal protective equipment (PPE), as well as support for alternative voting options for ill voters, are needed. Adherence to mitigation measures is important not only to protect voters but also to protect poll workers, many of whom are older adults, and thus at higher risk for severe COVID-19-associated illness. Enhanced attention to reducing congregation in polling locations, correct mask use, and providing safe voting options for ill voters are critical considerations to minimize risk to voters and poll workers. Evidence from the Delaware election supports the feasibility and acceptability of implementing current CDC guidance for election officials, poll workers, and voters for mitigating COVID-19 transmission at polling locations (2). |
Enhanced contact investigations for nine early travel-related cases of SARS-CoV-2 in the United States.
Burke RM , Balter S , Barnes E , Barry V , Bartlett K , Beer KD , Benowitz I , Biggs HM , Bruce H , Bryant-Genevier J , Cates J , Chatham-Stephens K , Chea N , Chiou H , Christiansen D , Chu VT , Clark S , Cody SH , Cohen M , Conners EE , Dasari V , Dawson P , DeSalvo T , Donahue M , Dratch A , Duca L , Duchin J , Dyal JW , Feldstein LR , Fenstersheib M , Fischer M , Fisher R , Foo C , Freeman-Ponder B , Fry AM , Gant J , Gautom R , Ghinai I , Gounder P , Grigg CT , Gunzenhauser J , Hall AJ , Han GS , Haupt T , Holshue M , Hunter J , Ibrahim MB , Jacobs MW , Jarashow MC , Joshi K , Kamali T , Kawakami V , Kim M , Kirking HL , Kita-Yarbro A , Klos R , Kobayashi M , Kocharian A , Lang M , Layden J , Leidman E , Lindquist S , Lindstrom S , Link-Gelles R , Marlow M , Mattison CP , McClung N , McPherson TD , Mello L , Midgley CM , Novosad S , Patel MT , Pettrone K , Pillai SK , Pray IW , Reese HE , Rhodes H , Robinson S , Rolfes M , Routh J , Rubin R , Rudman SL , Russell D , Scott S , Shetty V , Smith-Jeffcoat SE , Soda EA , Spitters C , Stierman B , Sunenshine R , Terashita D , Traub E , Vahey GM , Verani JR , Wallace M , Westercamp M , Wortham J , Xie A , Yousaf A , Zahn M . PLoS One 2020 15 (9) e0238342 Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19. |
Notes from the Field: Public Health Efforts to Mitigate COVID-19 Transmission During the April 7, 2020, Election - City of Milwaukee, Wisconsin, March 13-May 5, 2020.
Paradis H , Katrichis J , Stevenson M , Tomaro N , Mukai R , Torres G , Bhattacharyya S , Kowalik J , Schlanger K , Leidman E . MMWR Morb Mortal Wkly Rep 2020 69 (30) 1002-1003 Wisconsin was the first state to hold an election with in-person voting after stay-at-home orders were issued to limit transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). The statewide primary election, held on April 7, 2020, occurred fewer than 2 weeks after the statewide “Safer at Home” order* became effective on March 25. | | On March 3, 2020, CDC published interim guidance to prevent spread of SARS-CoV-2 at polling locations (1). Mitigation measures in line with the CDC guidance and additional measures were implemented in the city of Milwaukee (in Milwaukee County) to prevent the transmission of SARS-CoV-2 at in-person polling venues (Supplementary Table, https://stacks.cdc.gov/view/cdc/90768). In addition to the nearly 500 poll workers, election inspectors, and chief inspectors, Milwaukee city health department personnel and the Wisconsin National Guard were assigned to support mitigation efforts at each of five Milwaukee polling sites and the central count location. Mitigation measures implemented at the direction of the city health department complemented public messaging campaigns to encourage absentee voting. According to the Milwaukee Election Commission, comparing the number of persons voting in the spring of 2016 with those voting in the spring of 2020, the percentage of persons who voted by absentee mail-in ballots increased approximately fifteenfold, from 4.1% (6,874) to 68.0% (64,750) of voters; those who voted early (either in person or curbside [i.e., voting while remaining in their vehicle or at the voting place entrance]) increased by 160%, from 4.7% (7,949) to 12.2% (11,612). Although the proportion of those who voted in person on election day decreased 78%, from 91.2% (153,458) to 19.8% (18,806),† local news media reported long waiting times at Milwaukee voting locations on election day.§ Overall, the number of persons who voted decreased 43%, from 168,281 to 95,168, and the number of polling sites decreased from 181 to five. |
Assessment of immunity to polio among Rohingya children in Cox's Bazar, Bangladesh, 2018: A cross-sectional survey
Estivariz CF , Bennett SD , Lickness JS , Feldstein LR , Weldon WC , Leidman E , Ehlman DC , Khan MFH , Adhikari JM , Hasan M , Billah MM , Oberste MS , Alamgir ASM , Flora MD . PLoS Med 2020 17 (3) e1003070 BACKGROUND: We performed a cross-sectional survey in April-May 2018 among Rohingya in Cox's Bazar, Bangladesh, to assess polio immunity and inform vaccination strategies. METHODS AND FINDINGS: Rohingya children aged 1-6 years (younger group) and 7-14 years (older group) were selected using multi-stage cluster sampling in makeshift settlements and simple random sampling in Nayapara registered camp. Surveyors asked parents/caregivers if the child received any oral poliovirus vaccine (OPV) in Myanmar and, for younger children, if the child received vaccine in any of the 5 campaigns delivering bivalent OPV (serotypes 1 and 3) conducted during September 2017-April 2018 in Cox's Bazar. Dried blood spot (DBS) specimens were tested for neutralizing antibodies to poliovirus types 1, 2, and 3 in 580 younger and 297 older children. Titers >/= 1:8 were considered protective. Among 632 children (335 aged 1-6 years, 297 aged 7-14 years) enrolled in the study in makeshift settlements, 51% were male and 89% had arrived after August 9, 2017. Among 245 children (all aged 1-6 years) enrolled in the study in Nayapara, 54% were male and 10% had arrived after August 9, 2017. Among younger children, 74% in makeshift settlements and 92% in Nayapara received >3 bivalent OPV doses in campaigns. Type 1 seroprevalence was 85% (95% CI 80%-89%) among younger children and 91% (95% CI 86%-95%) among older children in makeshift settlements, and 92% (88%-95%) among younger children in Nayapara. Type 2 seroprevalence was lower among younger children than older children in makeshift settlements (74% [95% CI 68%-79%] versus 97% [95% CI 94%-99%], p < 0.001), and was 69% (95% CI 63%-74%) among younger children in Nayapara. Type 3 seroprevalence was below 75% for both age groups and areas. The limitations of this study are unknown routine immunization history and poor retention of vaccination cards. CONCLUSIONS: Younger Rohingya children had immunity gaps to all 3 polio serotypes and should be targeted by future campaigns and catch-up routine immunization. DBS collection can enhance the reliability of assessments of outbreak risk and vaccination strategy impact in emergency settings. |
Vaccination coverage survey and seroprevalence among forcibly displaced Rohingya children, Cox's Bazar, Bangladesh, 2018: A cross-sectional study
Feldstein LR , Bennett SD , Estivariz CF , Cooley GM , Weil L , Billah MM , Uzzaman MS , Bohara R , Vandenent M , Adhikari JM , Leidman E , Hasan M , Akhtar S , Hasman A , Conklin L , Ehlman D , Alamgir A , Flora MS . PLoS Med 2020 17 (3) e1003071 BACKGROUND: During August 2017-January 2018, more than 700,000 forcibly displaced Rohingyas crossed into Cox's Bazar, Bangladesh. In response to measles and diphtheria cases, first documented in September and November 2017, respectively, vaccination campaigns targeting children <15 years old were mobilized during September 2017-March 2018. However, in a rapidly evolving emergency situation, poor sanitation, malnutrition, overcrowding, and lack of access to safe water and healthcare can increase susceptibility to infectious diseases, particularly among children. We aimed to estimate population immunity to vaccine-preventable diseases (VPDs) after vaccination activities in the camps to identify any remaining immunity gaps among Rohingya children. METHODS AND FINDINGS: We conducted a cross-sectional serologic and vaccination coverage survey in Nayapara Registered Refugee Camp ("Nayapara") and makeshift settlements (MSs) April 28, 2018 to May 31, 2018, among 930 children aged 6 months to 14 years. MSs are informal, self-settled areas with a population of more than 850,000, the majority of whom arrived after August 2017, whereas Nayapara is a registered camp and has better infrastructure than MSs, including provision of routine immunization services. Households were identified using simple random sampling (SRS) in Nayapara and multistage cluster sampling in MSs (because household lists were unavailable). Dried blood spots (DBSs) were collected to estimate seroprotection against measles, rubella, diphtheria, and tetanus, using Luminex multiplex bead assay (MBA). Caregiver interviews assessed vaccination campaign participation using vaccination card or recall. In Nayapara, 273 children aged 1 to 6 years participated; 46% were female and 88% were registered refugees. In MSs, 358 children aged 1 to 6 years and 299 children aged 7 to 14 years participated; 48% of all children in MSs were female, and none were registered refugees. In Nayapara, estimated seroprotection among 1- to 6-year-olds was high for measles, rubella, diphtheria, and tetanus (91%-98%; 95% confidence interval [CI] 87%-99%); children >6 years were not assessed. In MSs, measles seroprotection was similarly high among 1- to 6-year-olds and 7- to 14-year-olds (91% [95% CI 86%-94%] and 99% [95% CI 96%-100%], respectively, p < 0.001). Rubella and diphtheria seroprotection in MSs were significantly lower among 1- to 6-year-olds (84% [95% CI 79%-88%] and 63% [95% CI 56%-70%]) compared to 7- to 14-year-olds (96% [95% CI 90%-98%] and 77% [95% CI 69%-84%]) (p < 0.001). Tetanus seroprevalence was similar among 1- to 6-year-olds and 7- to 14-year-olds (76% [95% CI 69%-81%] and 84% [95% CI 77%-89%], respectively; p = 0.07). Vaccination campaign coverage was consistent with seroprotection in both camps. However, nonresponse, the main limitation of the study, may have biased the seroprotection and campaign coverage results. CONCLUSIONS: In this study, we observed that despite multiple vaccination campaigns, immunity gaps exist among children in MSs, particularly for diphtheria, which requires serial vaccinations to achieve maximum protection. Therefore, an additional tetanus-diphtheria campaign may be warranted in MSs to address these remaining immunity gaps. Rapid scale-up and strengthening of routine immunization services to reach children and to deliver missed doses to older children is also critically needed to close immunity gaps and prevent future outbreaks. |
Comparing hemoglobin distributions between population-based surveys matched by country and time
Hruschka DJ , Williams AM , Mei Z , Leidman E , Suchdev PS , Young MF , Namaste S . BMC Public Health 2020 20 (1) 422 BACKGROUND: Valid measurement of hemoglobin is important for tracking and targeting interventions. This study compares hemoglobin distributions between surveys matched by country and time from The Demographic and Health Survey (DHS) Program and the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. METHODS: Four pairs of nationally representative surveys measuring hemoglobin using HemoCue(R) with capillary (DHS) or venous (BRINDA) blood were matched by country and time. Data included 17,719 children (6-59 months) and 21,594 non-pregnant women (15-49 y). Across paired surveys, we compared distributional statistics and anemia prevalence. RESULTS: Surveys from three of the four countries showed substantial differences in anemia estimates (9 to 31 percentage point differences) which were consistently lower in BRINDA compared to DHS (2 to 31 points for children, 1 to 16 points for women). CONCLUSION: We identify substantial differences in anemia estimates from surveys of similar populations. Further work is needed to identify the cause of these differences to improve the robustness of anemia estimates for comparing populations and tracking improvements over time. |
Malnutrition trends in Rohingya children aged 6-59 months residing in informal settlements in Cox's Bazar District, Bangladesh: An analysis of cross-sectional, population-representative surveys
Leidman E , Miah ML , Humphreys A , Toroitich-van Mil L , Wilkinson C , Chelang'at Koech M , Sebuliba H , Abu Bakr Siddique M , Bilukha O . PLoS Med 2020 17 (3) e1003060 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. |
Concordance between estimates of acute malnutrition measured by weight-for-height and by mid-upper arm circumference after age adjustment: population-representative surveys from humanitarian settings
Leidman E , Couture A , Hulland E , Bilukha O . BMC Nutr 2019 5 39 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. |
The burden of anaemia among displaced women and children in refugee settings worldwide, 2013-2016
Kay A , Leidman E , Lopez V , Wilkinson C , Tondeur M , Bilukha O . BMJ Glob Health 2019 4 (6) e001837 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. |
Serious psychological distress and disability among older persons living in conflict affected areas in eastern Ukraine: a cluster-randomized cross-sectional household survey
Summers A , Leidman E , Pereira Figueira Periquito IM , Bilukha OO . Confl Health 2019 13 10 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. |
Concordance between the estimates of wasting measured by weight-for-height and by mid-upper arm circumference for classification of severity of nutrition crisis: analysis of population-representative surveys from humanitarian settings
Bilukha O , Leidman E . BMC Nutr 2018 4 24 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. |
Assessment of anthropometric data following investments to ensure quality: Kenya Demographic Health Surveys Case Study, 2008 to 2009 and 2014
Leidman E , Mwirigi LM , Maina-Gathigi L , Wamae A , Imbwaga AA , Bilukha OO . Food Nutr Bull 2018 39 (3) 379572118783181 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. |
Notes from the Field: Diarrhea and acute respiratory infection, oral cholera vaccination coverage, and care-seeking behaviors of Rohingya refugees - Cox's Bazar, Bangladesh, October-November 2017
Summers A , Humphreys A , Leidman E , Van Mil LT , Wilkinson C , Narayan A , Miah ML , Cramer BG , Bilukha O . MMWR Morb Mortal Wkly Rep 2018 67 (18) 533-535 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). |
Acute malnutrition and anemia among Rohingya children in Kutupalong Camp, Bangladesh
Leidman E , Humphreys A , Greene Cramer B , Toroitich-Van Mil L , Wilkinson C , Narayan A , Bilukha O . JAMA 2018 319 (14) 1505-1506 This survey study assesses the health and nutritional status of Rohingya children aged 6 to 59 months in the Kutupalong refugee camp in Bangladesh. |
- Page last reviewed:Feb 1, 2024
- Page last updated:Jan 27, 2025
- Content source:
- Powered by CDC PHGKB Infrastructure