Risk factors and risk factor cascades for communicable disease outbreaks in complex humanitarian emergencies: A qualitative systematic review

Background: Communicable diseases are a major concern during complex humanitarian emergencies. Descriptions of risk factors for infectious disease outbreaks are often non-specific and yet not easily generalizable to similar situations. This review attempts to capture relevant evidence and explore whether it is possible to better generalize the role of risk factors and the risk factor cascades these factors may form. Methods: A systematic search of the key databases and websites was conducted. Search terms included terms for complex humanitarian emergencies (per United Nations Office for the Coordination of Humanitarian Affairs definition) and terms for communicable diseases. Due to the types of evidence found, a thematic synthesis was conducted. Results: 26 articles met inclusion criteria. Key contextual risk factors include crowded conditions, forced displacement, poor quality shelter, poor water, sanitation and hygiene conditions, lack of health care facilities and lack of adequate surveillance. Most identified risk factors do not relate to specific diseases, or are specific to a group of diseases such as diarrheal diseases and not to a particular disease within that group. Risk factors are often listed in general terms but are poorly evidenced, not contextualized and not considered with respect to interaction effects in individual publications. The high level of the interrelatedness of risk factors became evident, demonstrating risk factor cascades that are triggered by individual risk factors or clusters of risk factors. Conclusions: Complex humanitarian emergencies pose a significant threat to public health. More rigorous research on the risk of communicable disease outbreaks in complex humanitarian emergencies is needed, both from a practitioner and from an academic point of view

Risk factors for communicable diseases in humanitarian emergencies and disasters: Results from a three-stage expert elicitation

Background: Humanitarian emergencies including disasters associated with natural hazards, conflict, complex emergencies and famines can pose significant risks to public health, especially when they lead to population displacement into inadequate conditions. In order to reduce the risk of communicable disease outbreaks in such situations it is necessary to know the key risk factors, their thresholds (quantitative risk factors only) and their relative importance in different types of emergencies. Methods: We conducted a three-stage structured expert consultation. Experts from the fields of health protection and humanitarian assistance were invited to complete three successive online questionnaires. Experts were asked to choose the 20 most critical risk factors and in subsequent rounds to determine thresholds for urgent (yellow threshold level) and critical action (red threshold level). Additionally, experts were asked to assign weights for the risk factors in different emergency types. Results: We identified 20 key risk factors, which include factors related to water, sanitation and hygiene, access to health care, vaccination, nutrition, political will and others. Nine out of the 20 risk factors were quantifiable, for those risk factors yellow and red thresholds are given. 11 risk factors were qualitative. All risk factors scored highly when weighted in different emergency types and differences between risk factor weights in different types of emergencies were limited. Conclusion: Communicable disease risks in humanitarian emergencies are a nexus of complex and often interrelated individual issues. Knowing key risk factors and their thresholds and weight in different types of emergencies can help guide emergency response and risk reduction efforts

Is water carriage associated with the water carrier’s health? A systematic review of quantitative and qualitative evidence

Introduction: The work of carrying water falls mainly on women and children, particularly in sub-Saharan Africa and rural areas. While concerns have been raised, how water carriage is associated with health of the water carrier is not clear. The aim of this review is to summarise evidence on whether, and how, water carriage is associated with the water carrier’s health. Methods: A systematic review of literature was conducted, searching Embase; Medline; Web of Science Social Sciences Citation Index; Web of Science Arts and Humanities Citation Index; International Initiative for Impact Evaluation website; WHO Virtual Health Sciences Library and WHO African index medicus, from inception to 8 November 2017. Results: Forty-two studies were included. Their ability to demonstrate cause and effect relationships was limited by study design and fair or poor methodological quality. Overall, the studies suggest that water carriage is associated with negative aspects of the water carriers’ health. There is moderate quantitative and strong qualitative evidence that water carriage is associated with pain, fatigue, perinatal health problems and violence against vulnerable people, and inconclusive evidence of an association with stress or self-reported mental health and general health status. Conclusion: In many circumstances, water carriage is a potential barrier to Sustainable Development Goal (SDG) 6 target ‘universal and equitable access to safe and affordable drinking water for all’ and SDG 3 ‘ensure healthy lives and promote well-being for all at all ages’. Efforts should focus on providing water on premises, and where this is not possible, providing water close to home and reducing risk of gender-based violence

Emergency infection prevention and control training in fragile, conflict-affected or vulnerable settings: A scoping review

Background: It is uncertain what could be the best training methods for infection prevention and control when an infectious disease threat is active or imminent in especially vulnerable or resource-scarce settings. Methods: A scoping review was undertaken to find and summarise relevant information about training modalities, replicability and effectiveness of IPC training programmes for clinical staff as reported in multiple study designs. Eligible settings were conflict-affected or in countries classified as low-income or lower-middle income (World Bank 2022 classifications). Search terms for LILACS and Scopus were developed with input of an expert working group. Initially found articles were dual-screened independently, data were extracted especially about infection threat, training outcomes, needs assessment and teaching modalities. Backwards and forwards citation searches were done to find additional studies. Narrative summary describes outcomes and aspects of the training programmes. A customised quality assessment tool was developed to describe whether each study could be informative for developing specific future training programmes in relevant vulnerable settings, based on six questions about replicability and eight questions about other biases. Findings: Included studies numbered 29, almost all (n=27) were pre-post design, two were trials. Information within the included studies to enable replicability was low (average score 3.7/6). Nearly all studies reported significant improvement in outcomes suggesting that the predominant study design (pre-post) is inadequate to assess improvement with low bias, that any and all such training is beneficial, or that publication bias prevented reporting of less successful interventions and thus a informative overview. Conclusion: It seems likely that many possible training formats and methods can lead to improved worker knowledge, skills and / or practice in infection prevention and control. Definitive evidence in favour of any specific training format or method is hard to demonstrate due to incomplete descriptions, lack of documentation about unsuccessful training, and few least-biased study designs (experimental trials). Our results suggest that there is a significant opportunity to design experiments that could give insights in favour of or against specific training methods. “Sleeping” protocols for randomised controlled trials could be developed and then applied quickly when relevant future events arise, with evaluation for outcomes such as knowledge, practices, skills, confidence, and awareness

Faster and safer:Research priorities in water and health

The United Nations’ Sustainable Development Goals initiated in 2016 reiterated the need for safe water and healthy lives across the globe. The tenth anniversary meeting of the International Water and Health Seminar in 2018 brought together experts, students, and practitioners, setting the stage for development of an inclusive and evidence-based research agenda on water and health. Data collection relied on a nominal group technique gathering perceived research priorities as well as underlying drivers and adaptation needs. Under a common driver of public health protection, primary research priorities included the socioeconomy of water, risk assessment and management, and improved monitoring methods and intelligence. Adaptations stemming from these drivers included translating existing knowledge to providing safe and timely services to support the diversity of human water needs. Our findings present a comprehensive agenda of topics at the forefront of water and health research. This information can frame and inform collective efforts of water and health researchers over the coming decades, contributing to improved water services, public health, and socioeconomic outcomes

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019 : a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66–2·79) in 2000 to 2·31 (2·17–2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5–137·8) in 2000 to a peak of 139·6 million (133·0–146·9) in 2016. Global livebirths then declined to 135·3 million (127·2–144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4–27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8–67·6) in 2000 to 73·5 years (72·8–74·3) in 2019. The total number of deaths increased from 50·7 million (49·5–51·9) in 2000 to 56·5 million (53·7–59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1–10·3) in 2000 to 5·0 million (4·3–6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0–6·3) in 2000 to 7·7 billion (7·5–8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1–60·8) in 2000 to 63·5 years (60·8–66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

(Re-) conceptualising vulnerability as a part of risk in global health emergency response: updating the pressure and release model for global health emergencies.

Vulnerability has become a key concept in emergency response research and is being critically discussed across several disciplines. While the concept has been adopted into global health, its conceptualisation and especially its role in the conceptualisation of risk and therefore in risk assessments is still lacking. This paper uses the risk concept pioneered in hazard research that assumes that risk is a function of the interaction between hazard and vulnerability rather than the neo-liberal conceptualisation of vulnerability and vulnerable groups and communities. By seeking to modify the original pressure and release model, the paper unpacks the representation or lack of representation of vulnerability in risk assessments in global health emergency response and discusses what benefits can be gained from making the underlying assumptions about vulnerability, which are present whether vulnerability is sufficiently conceptualised and consciously included or not, explicit. The paper argues that discussions about risk in global health emergencies should be better grounded in a theoretical understanding of the concept of vulnerability and that this theoretical understanding needs to inform risk assessments which implicitly used the concept of vulnerability. By using the hazard research approach to vulnerability, it offers an alternative narrative with new perspectives on the value and limits of vulnerability as a concept and a tool

Is water carriage associated with the water carrier's health? A systematic review of quantitative and qualitative evidence.

INTRODUCTION: The work of carrying water falls mainly on women and children, particularly in sub-Saharan Africa and rural areas. While concerns have been raised, how water carriage is associated with health of the water carrier is not clear. The aim of this review is to summarise evidence on whether, and how, water carriage is associated with the water carrier's health. METHODS: A systematic review of literature was conducted, searching Embase; Medline; Web of Science Social Sciences Citation Index; Web of Science Arts and Humanities Citation Index; International Initiative for Impact Evaluation website; WHO Virtual Health Sciences Library and WHO African index medicus, from inception to 8 November 2017. RESULTS: Forty-two studies were included. Their ability to demonstrate cause and effect relationships was limited by study design and fair or poor methodological quality. Overall, the studies suggest that water carriage is associated with negative aspects of the water carriers' health. There is moderate quantitative and strong qualitative evidence that water carriage is associated with pain, fatigue, perinatal health problems and violence against vulnerable people, and inconclusive evidence of an association with stress or self-reported mental health and general health status. CONCLUSION: In many circumstances, water carriage is a potential barrier to Sustainable Development Goal (SDG) 6 target 'universal and equitable access to safe and affordable drinking water for all' and SDG 3 'ensure healthy lives and promote well-being for all at all ages'. Efforts should focus on providing water on premises, and where this is not possible, providing water close to home and reducing risk of gender-based violence

Emergency infection prevention and control training in fragile, conflict-affected or vulnerable settings: a scoping review.

Acknowledgements: We thank members of the WHO Expert Working Group for comments and guidance.BACKGROUND: It is uncertain what could be the best training methods for infection prevention and control when an infectious disease threat is active or imminent in especially vulnerable or resource-scarce settings. METHODS: A scoping review was undertaken to find and summarise relevant information about training modalities, replicability and effectiveness of IPC training programmes for clinical staff as reported in multiple study designs. Eligible settings were conflict-affected or in countries classified as low-income or lower-middle income (World Bank 2022 classifications). Search terms for LILACS and Scopus were developed with input of an expert working group. Initially found articles were dual-screened independently, data were extracted especially about infection threat, training outcomes, needs assessment and teaching modalities. Backwards and forwards citation searches were done to find additional studies. Narrative summary describes outcomes and aspects of the training programmes. A customised quality assessment tool was developed to describe whether each study could be informative for developing specific future training programmes in relevant vulnerable settings, based on six questions about replicability and eight questions about other biases. FINDINGS: Included studies numbered 29, almost all (n = 27) were pre-post design, two were trials. Information within the included studies to enable replicability was low (average score 3.7/6). Nearly all studies reported significant improvement in outcomes suggesting that the predominant study design (pre-post) is inadequate to assess improvement with low bias, that any and all such training is beneficial, or that publication bias prevented reporting of less successful interventions and thus a informative overview. CONCLUSION: It seems likely that many possible training formats and methods can lead to improved worker knowledge, skills and / or practice in infection prevention and control. Definitive evidence in favour of any specific training format or method is hard to demonstrate due to incomplete descriptions, lack of documentation about unsuccessful training, and few least-biased study designs (experimental trials). Our results suggest that there is a significant opportunity to design experiments that could give insights in favour of or against specific training methods. "Sleeping" protocols for randomised controlled trials could be developed and then applied quickly when relevant future events arise, with evaluation for outcomes such as knowledge, practices, skills, confidence, and awareness