Armed conflict and public health: into the 21st century.

BACKGROUND: Many people worldwide are affected by conflict, and countries affected are less likely to meet the UN Sustainable Development Goals. This review outlines the effects of conflict on health and focuses on areas requiring more attention. METHODS: We completed a search of the literature using Medline, Embase and Global Health. RESULTS: Health effects of conflict include trauma; mental health; non-communicable diseases (NCDs); child health; sexual, reproductive and maternal health; and infectious diseases. Conflict damages health directly through fighting, and indirectly through wider socioeconomic effects. Health outcomes are influenced by pre-existing population health and demographics, and access to appropriate healthcare. Vulnerable populations (the elderly, children, neonates and women) are especially at risk. CONCLUSION: Several areas pose key challenges including: tactics of war as a public health problem; a lack of focus on neonatal care and NCDs; the long-term consequences of conflict across a life-course and into future generations; and the need to focus on wellbeing beyond standard health parameters. Clear decisions about prioritisation need to be made. The effects on civilians must be documented and recorded. Further research is required to understand chronic health needs and effects on future generations, to support fair and equitable resource prioritisation to best meet the needs of conflict-affected populations.

Characteristics of human encounters and social mixing patterns relevant to infectious diseases spread by close contact: a survey in Southwest Uganda.

BACKGROUND: Quantification of human interactions relevant to infectious disease transmission through social contact is central to predict disease dynamics, yet data from low-resource settings remain scarce. METHODS: We undertook a social contact survey in rural Uganda, whereby participants were asked to recall details about the frequency, type, and socio-demographic characteristics of any conversational encounter that lasted for ≥5 min (henceforth defined as 'contacts') during the previous day. An estimate of the number of 'casual contacts' (i.e. < 5 min) was also obtained. RESULTS: In total, 566 individuals were included in the study. On average participants reported having routine contact with 7.2 individuals (range 1-25). Children aged 5-14 years had the highest frequency of contacts and the elderly (≥65 years) the fewest (P < 0.001). A strong age-assortative pattern was seen, particularly outside the household and increasingly so for contacts occurring further away from home. Adults aged 25-64 years tended to travel more often and further than others, and males travelled more frequently than females. CONCLUSION: Our study provides detailed information on contact patterns and their spatial characteristics in an African setting. It therefore fills an important knowledge gap that will help more accurately predict transmission dynamics and the impact of control strategies in such areas.

Risk in the "Red Zone": Outcomes for Children Admitted to Ebola Holding Units in Sierra Leone Without Ebola Virus Disease.

We collected data on 1054 children admitted to Ebola Holding Units in Sierra Leone and describe outcomes of 697/1054 children testing negative for Ebola virus disease (EVD) and accompanying caregivers. Case-fatality was 9%; 3/630 (0.5%) children discharged testing negative were readmitted EVD-positive. Nosocomial EVD transmission risk may be lower than feared.

Strengthening the evidence base for health programming in humanitarian crises.

Given the growing scale and complexity of responses to humanitarian crises, it is important to develop a stronger evidence base for health interventions in such contexts. Humanitarian crises present unique challenges to rigorous and effective research, but there are substantial opportunities for scientific advance. Studies need to focus where the translation of evidence from noncrisis scenarios is not viable and on ethical ways of determining what happens in the absence of an intervention. Robust methodologies suited to crisis settings have to be developed and used to assess interventions with potential for delivery at scale. Strengthening research capacity in the low- to middle-income countries that are vulnerable to crises is also crucial.

Patterns of funding allocation for tuberculosis control in fragile states.

OBJECTIVE: To assess recent (2006-2010) tuberculosis (TB) funding patterns in conflict and non-conflict-affected fragile states to inform global policy. METHODS: The Creditor Reporting System was analysed for official development assistance funding disbursements towards TB control in 11 conflict-affected states, 17 non-conflict-affected fragile states and 38 comparable non-fragile states. The amounts of funding, funding relative to burden, funding relative to malaria and human immunodeficiency virus (HIV) control, disbursements relative to commitments, sources of funding as well as funding activities were extracted and analysed. RESULTS: Fragile states received on average more per capita for TB control relative to non-fragile states (US0.159 vs. US0.079). However conflict-affected fragile states received on average less per capita than non-conflict-affected states (US0.144 vs. US0.203), despite worse development indicators. Conflict-affected fragile states also received on average only 70% of TB funds already committed. Analysis by burden revealed the least disparity in funding in highest prevalence settings. Analysis of funding activities suggests increasing importance of TB-HIV integration, multidrug-resistant TB and research in both fragile and non-fragile states. Relative to non-conflict-affected fragile states, conflict-affected fragile states received approximately two thirds the per capita funding for TB. CONCLUSIONS: This study revealed disparities in TB control funding between fragile and non-fragile as well as between conflict and non-conflict-affected fragile states. Findings suggest possible avenues for improving the allocation of global TB funding.

Efficacy of amodiaquine for uncomplicated Plasmodium falciparum malaria in Harper, Liberia.

In the face of spreading chloroquine and sulfadoxine-pyrimethamine (SP) resistance, amodiaquine remains a cheap and efficacious alternative for treating uncomplicated Plasmodium falciparum malaria in many settings. In Harper, south-eastern Liberia, a previous study we conducted showed very high levels of resistance to both chloroquine and SP. In 2001, in an effort to look for possible alternatives, we measured in the same setting the efficacy of amodiaquine in a 28-d study in vivo, with results corrected by polymerase chain reaction genotyping to distinguish recrudescences from reinfections. In total, 107 children were included in the study and received a 3-d supervised course of 25 mg/kg amodiaquine. Of these, 81 were analysable at day 28. The overall failure rate was 19.8% (95% CI 11.7-30.1%) considering both parasitological and clinical outcomes. These results provide hitherto missing data on amodiaquine in Liberia, and confirm that the drug may still be efficacious in settings where chloroquine and SP are failing. We recommend the introduction of amodiaquine in association with artesunate as a first-line antimalarial in Harper.

High Plasmodium falciparum resistance to chloroquine and sulfadoxine-pyrimethamine in Harper, Liberia: results in vivo and analysis of point mutations.

In Liberia, little information is available on the efficacy of antimalarials against Plasmodium falciparum malaria. We measured parasitological resistance to chloroquine and sulfadoxine-pyrimethamine (SP) in Harper, south-west Liberia in a 28-d study in vivo. A total of 50 patients completed follow-up in the chloroquine group, and 66 in the SP group. The chloroquine failure rate was 74.0% (95% confidence interval [95% CI] 59.7-85.4%) after 14 d of follow-up and 84.0% (95% CI 70.9-92.8%) after 28 d (no polymerase chain reaction [PCR] analysis was performed to detect reinfections in this group). In the SP group, the failure rate was 48.5% (95% CI 36.2-61.0%) after 14 d and 69.7% (95% CI 57.1-80.4%) after 28 d, readjusted to 51.5% (95% CI 38.9-64.0%) after taking into account reinfections detected by PCR. Genomic analysis of parasite isolates was also performed to look for point mutations associated with resistance. Genotyping of parasite isolates revealed that all carried chloroquine-resistant K-76T mutations at gene pfcrt, whereas the triple mutation (S108N, N511, C59R) at dhfr and the A437G mutation at dhps, both associated with resistance to SP, were present in 84% and 79% of pretreatment isolates respectively. These results seriously question the continued use of chloroquine and SP in Harper and highlight the urgency of making alternative antimalarial therapies available. Our study confirms that resistance to chloroquine may be high in Liberia and yields hitherto missing information on SP.