Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar.

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here

What questions we should be asking about COVID-19 in humanitarian settings: perspectives from the Social Sciences Analysis Cell in the Democratic Republic of the Congo.

COVID-19 is but one of many public health crises facing the people of the Democratic Republic of the Congo (DRC). On 25 June 2020, the DRC government announced the end of the country's largest Ebola outbreak on record and the second largest Ebola outbreak worldwide, a mere few weeks after a new outbreak (11th) started on 1 June 2020, in Mbandaka, Equateur Province.1 In 2019, measles claimed the lives of over 6000 people including 4500 children under the age of 5, malaria killed 17000 individuals, and cholera outbreaks affected 20 of 26 provinces, resulting in 31000 cases

How to improve outbreak response: a case study of integrated outbreak analytics from Ebola in Eastern Democratic Republic of the Congo.

The emerging field of outbreak analytics calls attention to the need for data from multiple sources to inform evidence-based decision making in managing infectious diseases outbreaks. To date, these approaches have not systematically integrated evidence from social and behavioural sciences. During the 2018-2020 Ebola outbreak in Eastern Democratic Republic of the Congo, an innovative solution to systematic and timely generation of integrated and actionable social science evidence emerged in the form of the Cellulle d'Analyse en Sciences Sociales (Social Sciences Analytics Cell) (CASS), a social science analytical cell. CASS worked closely with data scientists and epidemiologists operating under the Epidemiological Cell to produce integrated outbreak analytics (IOA), where quantitative epidemiological analyses were complemented by behavioural field studies and social science analyses to help better explain and understand drivers and barriers to outbreak dynamics. The primary activity of the CASS was to conduct operational social science analyses that were useful to decision makers. This included ensuring that research questions were relevant, driven by epidemiological data from the field, that research could be conducted rapidly (ie, often within days), that findings were regularly and systematically presented to partners and that recommendations were co-developed with response actors. The implementation of the recommendations based on CASS analytics was also monitored over time, to measure their impact on response operations. This practice paper presents the CASS logic model, developed through a field-based externally led consultation, and documents key factors contributing to the usefulness and adaption of CASS and IOA to guide replication for future outbreaks

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Diagnosis and short term prognosis of malnutrition in adults in complex emergencies

The aim of this thesis is to identify the characteristics of malnourished adults at risk of imminent death during complex humanitarian emergencies (i.e. in need of intensive medical and nutritional treatment). I studied the anthropometric and clinical presentation of 2409 out-patients from Supplementary Feeding Centres (SFC) and 2500 in-patients from Therapeutic Feeding Centres (TFC) in Burundi and Congo. SFC patients were admitted with BMI below 17 kg/m2 and only received weekly food distribution.  Those in TFC were admitted with BMI below 16 kg/m2 and received intensive medical and nutritional treatment. Overall, 9.7% of patients observed in SFC did not recover.  Among those in SFC with BMI below 16 kg/m2, 570 (76.7%) recovered, including some with BMI below 13 kg/m2.  BMI on admission is associated with outcome of treatment, but its ability to predict outcome is insufficient (positive predictive value 23.3%).  MUAC is associated with outcome as well, but has a lower predictive ability than BMI.  Symptoms of weakness (e.g. muscle hypotony), associated infection (e.g. fever and cough of more than one month) and malnutrition (typical skin lesions, sunken eyes), identified patients with a negative outcome of treatment.  Logistic regression modelling showed the need to consider separately three groups of patients i) patients with malnutrition secondary to disease (suspicion of tuberculosis) ii) patients with stable weight, and iii) patients with active weight loss.  Only the latter are equated to “Acute Malnutrition”.  Among them, BMI and muscular hypotony identified patients in need of intensive treatment (“Sever Acute Malnutrition”).  Low BMI or MUAC with stable weight are not absolute markers of risk of death in the short term.  Patients with stable weight are equated to “Chronic Malnutrition”. In TFC, BMI and MUAC are good prognostic indicators, with the second identifying better patients with associated infectious disease.  The clinical characteristics and the survival experience of patients in Congo approaches that expected in a population of patients with Acute Malnutrition, but not in Burundi.  This suggests the presence in Burundi TFCs of important number of patients with Chronic Malnutrition or Moderate Acute Malnutrition, rather than Severe Acute Magnetron, and confirms findings in SFC.  More than half of the deaths in TFC happened in patients with associated disease or malnutrition secondary to chronic disease, during the Rehabilitation phase of treatment.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Malnutrition infantile aiguë et mortalité hospitalière, revue de la littérature sur la physiopathologie et la prise en charge (étude descriptive des causes de mortalité dans un Centre Nutritionnel en Somalie)

PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar.

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here

Nutrition indicators as potential predictors of AIDS-defining illnesses among ARV-naïve HIV-positive adults in Kapiri Mposhi, Zambia 2008-2009.

Early changes in nutritional status may be predictive of subsequent HIV disease progression in people living with HIV (PLHIV). In addition to conventional anthropometric assessment using body mass index (BMI) and mid-upper arm circumferences (MUAC), measures of strength and fatigability may detect earlier changes in nutrition status which predict HIV disease progression. This study aims to examine the association between various nutritional metrics relevant in resource-scarce setting and HIV disease progression. The HIV disease progression outcome was defined as any occurrence of an incident AIDS-defining illnesses (ADI) among antiretroviral treatment (ART)-naïve PLHIV. From 2008-2009, HIV+ Zambian adult men and non-pregnant women were followed for 9 months at a Doctors without Borders (Medecins Sans Frontiers, MSF) HIV clinic in Kapiri Mposhi, Zambia. Since the study was conducted in the time period when former WHO recommendations on ART (i.e., ≤200 CD4 cell count as opposed to treating all individuals regardless of CD4 cell count or disease stage) were followed, caution should be applied when considering the implications from this study's results to improve HIV case management under current clinical guidelines, or when comparing findings from this study with studies conducted in recent years. Bivariable and multivariable logistic regression was used to assess the associations between baseline nutritional measurements and the outcome of incident ADI. Self-reported loss of appetite study (AOR 1.90, 95% CI 1.04, 3.45, P = 0.036) and moderate wasting based on MUAC classification (AOR 2.40, 95% CI 1.13, 5.10, P = 0.022) were independently associated with increased odds of developing incident ADI within 9 months, while continuous increments (in psi) of median handgrip strength (AOR 0.74, 95%CI 0.60, 0.91, P = 0.004) was independently associated with decreased odds of incident ADI only among women. The association between low BMI and the short-term outcome of ADI was attenuated after controlling for these nutritional indicators. These findings warrant further research to validate the consistency of these observed associations among larger ART-naïve HIV-infected populations, as well as to develop nutritional assessment tools for identifying disease progression risk among ART-naïve PLHIV

Centers for Disease Control and Prevention Public Health Response to Humanitarian Emergencies, 2007–2016

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

Establishment of CDC Global Rapid Response Team to Ensure Global Health Security

The 2014–2016 Ebola virus disease epidemic in West Africa highlighted challenges faced by the global response to a large public health emergency. Consequently, the US Centers for Disease Control and Prevention established the Global Rapid Response Team (GRRT) to strengthen emergency response capacity to global health threats, thereby ensuring global health security. Dedicated GRRT staff can be rapidly mobilized for extended missions, improving partner coordination and the continuity of response operations. A large, agencywide roster of surge staff enables rapid mobilization of qualified responders with wide-ranging experience and expertise. Team members are offered emergency response training, technical training, foreign language training, and responder readiness support. Recent response missions illustrate the breadth of support the team provides. GRRT serves as a model for other countries and is committed to strengthening emergency response capacity to respond to outbreaks and emergencies worldwide, thereby enhancing global health security