Predictors of exceeding emergency under-five mortality thresholds using small-scale survey data from humanitarian settings (1999 - 2020): considerations for measles vaccination, malnutrition, and displacement status.

BACKGROUND: Quantifying the effect of measles containing vaccine (MCV) coverage and the prevalence of global acute malnutrition (GAM) on mortality levels in populations of displaced and crisis-affected resident children is important for intervention programming in humanitarian emergencies. METHODS: A total of 1597 surveys containing data on under-five death rate, population status (internally displaced, refugee, or crisis-affected resident), measles containing vaccine coverage, and global acute malnutrition were extracted from the Complex Emergency Database (CE-DAT). Under-five mortality rates were dichotomized to those exceeding critical levels or otherwise. A Bayesian multivariable mixed-effect logistic regression model was used to assess the association between an under-five death rate (U5DR) exceeding this threshold and population status (i.e., internally displaced, refugees or residents), GAM prevalence (proxy for food security), and MCV coverage. RESULTS: The prevalence of GAM, MCV and U5DR were higher in internally displaced children (IDC) with values of 14.6%, 69.9% and 2.07 deaths per 10 000 per day, respectively. Refugee populations had lower average under-five mortality rate (0.89 deaths per 10 000 per day), GAM of 12.0% and the highest measles containing vaccine coverage (80.0%). In crisis-affected residents the prevalence of GAM, MCV and average U5DR are 11.1%, 65.5% and 1.20 deaths per 10 000 per day respectively. In mixed-effect logistic model taking 2 deaths per 10 000 children less than five years old per as emergency threshold (Model III); MCV (AOR = 0.66, 95% Highest Density Interval (HDI): 0.57, 0.78), GAM (AOR = 1.79, 95% HDI: 1.52, 2.12) were associated with a reduction of the odds of U5DR exceeding critical level accounting for country-specific levels of variability. The odds of U5DR exceeding critical level (2/10000/day) in crisis-affected resident children and refugees were 0.36 (95% HDI: 0.22, 0.58) and 0.25(95% HDI: 0.11, 0.55) less than amongst IDP children adjusting for GAM and MCV. In considering country specific yearly median U5DR (model IV) the odds of U5DR exceeding twice the median U5DR were associated with MCV (AOR = 0.72, 95% HDI: 0.64, 0.82), GAM (AOR = 1.53, 95%HDI: 1.34, 1.76). The odds of U5DR exceeding critical level in crisis-affected resident children was 0.30(95% HDI: 0.20, 0.45) less than IDP children, after adjusting for MCV and GAM. We found no difference between the odds of U5DR exceeding twice the country level median U5DR in the refugee population compared to the IDPs. CONCLUSIONS: In this study vaccination coverage and global acute malnutrition (proxy for food security) were associated with U5DR exceeding critical level. The emergency threshold for IDPs and affected residents is significantly different and consistent across the different outcomes, whereas the result is inconsistent for IDPs and refugees. Continued improvement in measles vaccination coverage and reduction of malnutrition in humanitarian emergencies have the potential to minimize the deterioration of mortality level amongst children in emergency settings. To generate a robust understanding of the critical level of child mortality in displaced and affected resident populations, studies accounting for the impact of the duration of displacement, contextual factors in humanitarian settings, and the level of humanitarian assistance provided are needed.

COVID-19 measures in Belgium: how perception and adherence of the general population differ between time periods.

BACKGROUND: Since the onset of the COVID-19 pandemic, Belgium has been hit by a series of surges in the number of COVID-19 cases. Each of these resulted in more stringent measures being taken to curb the pandemic. This study compared perception of and adherence to COVID-19 measures of the Belgian population at two time periods: September 2020 (survey 1) and April/May 2021 (survey 2). METHODS: Two samples of approximately 2000 participants, representative for the Belgian population in terms of gender, age, province and socio-economic status, participated in an online survey. The survey questionnaire measured the perceived infection risk and severity, and the perception of and adherence to protective measures. Answers were compared between the time periods and risk factors for lower adherence were identified using multivariate linear regression. RESULTS: In survey 2, at which time the measures were more stringent, respondents assessed the risk of infection for themselves as lower, and for parents and grandparents as higher than in survey 1. Scores for understanding and usefulness of the measures were higher in survey 2 compared to survey 1, while reported past and future adherence were lower. Risk factors for a lower adherence were being male, being young, speaking French vs. Dutch, and having undergone a symptomatic infection. CONCLUSIONS: It is important to consider the potential effect of fatigue among the population with regards to measures that are sustained for a long time, especially regarding measures related to social contacts. The identified risk factors for lower adherence offer insights to policy makers for future crisis communication regarding COVID-19.

The Relation between Perceived and Actual Understanding and Adherence: Results from a National Survey on COVID-19 Measures in Belgium.

To reduce the spread of COVID-19 among the population, Belgium has implemented various infection prevention and control measures over time. This study investigated the extent to which understanding of the COVID-19 measures contributed to adherence, and which personal characteristics were considered risk factors for lower adherence. It consisted of a large online survey among a sample of the population (n = 2008), representative of citizens of Belgium in terms of gender, age, province and socio-economic status. The survey was conducted in September 2020, and included questions on perceived and actual understanding of COVID-19 protective measures in place during that time, as well as past and future adherence to those measures. The results showed that both perceived and actual understanding contributed significantly to past as well as future adherence. Risk factors for perceived understanding included being male and belonging to a younger age group, while risk factors for actual understanding were speaking French (versus Dutch) and belonging to a lower socio-economic level. Communication about COVID-19 measures should put more focus on trying to improve the understanding of the measures, instead of only making them known, particularly for those who are less health literate and as such at risk of poor understanding.

Determinants of adherence to COVID-19 measures among the Belgian population: an application of the protection motivation theory.

BACKGROUND: Since the start of the COVID-19 outbreak, the Belgian government has implemented various infection prevention and control measures. This study assessed the extent to which the general population in Belgium adhered to these measures, and which determinants were associated with adherence. METHODS: We undertook an internet survey among a sample of the Belgian population, representative for sex, age, socio-economic status and province. The questionnaire included various demographic, socio-economic and health-related questions, and also drew upon the Protection Motivation Theory as a theoretical framework to measure levels of perceived severity, vulnerability, perceived usefulness of the measures (response efficacy), perceived personal capacity to adhere (self-efficacy), and past and future adherence. Data were collected in Dutch and French, the main languages of Belgium. RESULTS: Our study was carried out in September 2020, and the number of respondents was 2008. On average, respondents provided high scores for each of the measures in place in September in terms of response efficacy (range of 3.54-4.32 on 1 to 5 Likert-scale), self-efficacy (range of 3.00-4.00), past adherence (4.00-4.68) and future adherence (3.99-4.61). The measure that overall received the highest scores was wearing a face mask in public spaces, while 'the social bubble of 5' generally received the lowest scores. There was a statistically significant relationship between response efficacy and self-efficacy on the one hand and (past and future) adherence on the other hand, in a multivariate model corrected for confounders. Vulnerability and severity did not show statistical significance. CONCLUSION: Risk communication regarding COVID-19 should place a stronger emphasis on helping people understand why implemented measures are useful and how they can be put into practice, more than on increasing fear appeals.

Heatwave-protective knowledge and behaviour among urban populations: a multi-country study in Tunisia, Georgia and Israel.

BACKGROUND: There is an expected increase in heatwaves globally. As such, it is imperative to have sufficient levels of heatwave-protective knowledge and behaviour in areas regularly affected by heatwaves. Our study assessed this among urban populations in Tunisia, Georgia and Israel. METHODS: We undertook a cross-sectional population survey in the three countries. The questionnaire focused on obtaining information on respondents' knowledge level regarding 1) symptoms due to overheating, 2) risk groups for heatwaves, 3) actions to take when someone is overheated, and 4) heatwave-protective measures. Furthermore, we asked respondents about protective measures they applied during the last heatwave. We compared the results between the countries. RESULTS: Heatwave-protective knowledge was highest in Israel, and lowest in Georgia, for all indicators except for heatwave-protective measures, for which knowledge was highest in Tunisia. Most respondents who named certain protective measures had also applied these during the last heatwave: more than 90% for all measures except for one in Tunisia and Israel, and more than 80% for all measures in Georgia. CONCLUSION: There is a need to further improve heatwave-protective knowledge in Tunisia, Georgia and Israel. One potential solution to achieve this is by implementing a National Heat Health Action Plan. Improving knowledge is a vital step before adaptive behaviour can take place.

Hospital Resilience After the 2015 Earthquake in Nepal: Results From Semi-structured Interviews With Hospital Staff.

Background: Resilient hospitals are increasingly recognized as a cornerstone of disaster reduction in global policies such as the Sendai Framework for Action. However, current hospital resilience frameworks emerged from pre-disaster conceptualizations, and have not been verified in real-life disaster contexts nor in the frontlines. Our aim was to study a tertiary hospital's resilience after the 2015 earthquake in Nepal, as experienced by its staff. Methods: We undertook a qualitative study in the Tribhuvan University Teaching Hospital (TUTH), where we conducted 18 semi-structured interviews with hospital staff. We inductively created themes to describe the earthquake burden to the hospital, and to analyze individual resilience of hospital staff. In addition, we deductively documented the resilience of the hospital as a system, according to the system resilience dimensions: means of resilience (redundancy and resourcefulness), and ends of resilience (robustness and rapidity). Results: In terms of robustness, TUTH increased its capacity for earthquake victims as elective activities were temporarily interrupted and quality of care was not a priority. Three stages of rapidity were identified: critical rapidity to address immediate needs, stabilizing rapidity until the hospital re-started routine activities, and recovery rapidity. In addition to the disaster plan, emerging adaptations played a major role in redundancy and resourcefulness. We found that individual resilience depended on three determinants: safety, meaningfulness, and sense of belonging. Conclusions: Hospital resilience results from a complexity of emerging and planned adaptations, as well as from interdependencies with individual resilience. Frameworks and plans to improve hospital resilience must reflect flexibility of response, and a concern for well-being of hospital staff is central for sustainable disaster response and improved resilience.

Governing heatwaves in Europe: comparing health policy and practices to better understand roles, responsibilities and collaboration.

BACKGROUND: The expectation that climate change will further exacerbate extreme weather events such as heatwaves is of primary concern to policymakers and scientists. Effective governance is fundamental to preparedness for and response to such threats. This paper explores the governance structures of European heat health action plans and provides insights into key stakeholders, roles, responsibilities and collaboration. METHODS: This was a two-phase qualitative study, in which we complemented a desk review of 15 European national heat health action plans (NHHAPs) with, after obtaining informed consent, 68 interviews in nine countries with key informants involved in the development, implementation and/or evaluation of these NHHAPs. A thematic analysis was used to analyze the NHHAPs inductively. This analysis focused on three themes: identifying key stakeholders, defining and assigning roles and collaboration among stakeholders. The iteratively created codebook was then applied to the analysis of the key informant interviews. All analyses were done using NVivo 10 qualitative analysis software. RESULTS: The majority of the NHHAPs have governance as one of their main objectives, to support the coordination of actions and collaboration among involved stakeholders. There are, however, significant differences between plan and practice. On the basis of the available data, we have little insight into the process of stakeholder identification, but we do find that most countries involve the same types of stakeholders. Roles are mainly defined and assigned in relation to the alert levels of the warning system, causing other role aspects and other roles to be vague and ambiguous. Collaboration is key to many NHHAP elements and is mainly experienced positively, though improvements and new collaborations are considered. CONCLUSIONS: Our findings show a need for a more deliberate and structured approach to governance in the context of NHHAPs. A cross-sectoral approach to the identification of key stakeholders can facilitate a broader preparedness and response to heatwaves. Roles and responsibilities of stakeholders should be defined and assigned more clearly to avoid confusion and to improve effective implementation. To this extent, we identify and describe seven key roles and potential stakeholders to which these roles are usually assigned. Finally, also collaboration among stakeholders can benefit from a cross-sectoral approach, but also formal structures can be beneficial.

Street temperature and building characteristics as determinants of indoor heat exposure.

Higher temperatures are associated with morbidity and mortality. Most epidemiological studies use outdoor temperature data, however, people spend most of their time indoors. Indoor temperatures and determinants of indoor temperatures have rarely been studied on a large scale. We measured living room and bedroom temperature in 113 homes of elderly subjects, as well as outdoor temperatures, in two cities in the Netherlands. Linear regression was used to determine the influence of building characteristics on indoor living room and bedroom temperatures in the warm episode. During the warm episode, indoor temperatures were higher during the night and lower during the day than outdoor temperatures. Indoor temperatures on average exceeded outdoor temperatures. The weekly average indoor temperature in living rooms varied between 23.1 and 30.2 °C. Dwellings that warmed up easily, also cooled down more easily. Outdoor and indoor temperatures were moderately correlated (R2 = 0.36 and 0.34 for living rooms and bedrooms, respectively). Building year before 1930 and rooms being located on the top floor were associated with higher indoor temperatures. Green in the vicinity was associated with lower temperatures in bedrooms. This study shows that indoor temperatures vary widely between dwellings, and are determined by outdoor temperatures and building characteristics. As most people, especially the elderly, spend most of the time indoor, indoor temperature is a more exact predictor of heat exposure than outdoor temperature. The importance of mitigating high indoor temperatures will be more important in the future because of higher temperatures due to climate change.

Measuring mental health burden in humanitarian settings: a critical review of assessment tools.

BACKGROUND: The effects of disasters and conflicts are widespread and heavily studied. While attention to disasters' impacts on mental health is growing, mental health effects are not well understood due to inconsistencies in measurement. OBJECTIVE: The purpose of this study is to review mental health assessment tools and their use in populations affected by disasters and conflicts. METHOD: Tools that assess posttraumatic stress disorder, depression, substance use disorder, and general mental health were examined. This review began with a search for assessment tools in PubMed, PsycINFO, and Google Scholar. Next, validation studies for the tools were obtained through snowball sampling. A final search was conducted for scientific studies using the selected tools in humanitarian settings to collect the data for analysis. The benefits and limitations described for each tool were compiled into a complete table. RESULTS: Twelve assessment tools were included, with 88 studies using them. The primary findings indicate that half of the studies used the Impact of Events Scale-Revised. The most common limitation discussed is that self-report tools inaccurately estimate the prevalence of mental health problems. This inaccuracy is further exacerbated by a lack of cultural appropriateness of the tools, as many are developed for Western contexts. CONCLUSION: It is recommended that researchers and humanitarian workers reflect on the effectiveness of the mental health assessment tool they use to accurately represent the populations under study in emergency settings. In addition, mental health assessment should be coupled with action.

Impact of Recurrent Floods on the Utilization of Maternal and Newborn Healthcare in Bangladesh.

OBJECTIVE: Floods are one of the most common types of disasters in Bangladesh and lead to direct and indirect impacts on health. The aim of the study was to assess the impact of floods on Maternal and Newborn Healthcare (MNH) utilization in Bangladesh between the years 2011 and 2014. METHODS: We used variables from the Bangladesh Demographic and Health Survey 2014 data and georeferenced data of floods between 2011 and 2014 from the Emergency Events Database. Multivariate logistic regression was used to determine whether the flood-affected exposures were significant in predicting differences in MNH utilization. RESULTS: The odds for the received antenatal care by skilled providers, institutional deliveries, deliveries by c-section, and postnatal care of the babies were significantly lower (Unadjusted OR = 0.81, 0.88, 0.83, and 0.82 respectively; P < 0.05) in the flood-affected area than the non-affected area. Additionally, the odds of postnatal checkup of women was statistically significant (P < 0.001) and less likely to be received in flood-affected area (OR = 0.76). The odds of all indicators were significantly lower (OR < 1) for the women living in the twice and four times flooded areas compared to the once flooded areas. CONCLUSIONS FOR PRACTICE: The study shows that floods can have a negative impact on MNH utilization. In addition, repeated floods have a worse impact on MNH utilization than incidental floods. Extra effort should be put on ensuring access to MNH of women in flood-affected areas.

Changes in patient admissions after the 2015 Earthquake: a tertiary hospital-based study in Kathmandu, Nepal.

Literature on earthquake impact on hospital admissions is lacking, particularly in low-resource settings. Our aim was to study the pattern of admissions before and after the 2015 earthquake in a tertiary hospital in Nepal. We used routine hospital data from 9,596 admissions, and defined four periods: pre-earthquake (pre-EQ), acute (EQ1), post-acute (EQ2), and post-earthquake (post-EQ). We compared length of hospital stay (LOS) across the study periods using negative binomial regressions. We used logistic regressions to study changes in probability of admission for diagnostic categories, and Generalized Additive Models to model the difference in number of admissions compared to pre-EQ baseline. LOS was longer in EQ1 than during pre-EQ, in particular for injury-related admissions. In EQ1, the odds of injury admissions increased, while they decreased for the majority of other diagnoses, with the odds of pregnancy-related admissions remaining low until post-EQ. The number of admissions dropped in EQ1 and EQ2, and returned to pre-EQ trends in post-EQ, accumulating 381 admissions lost (CI: 206-556). Our findings suggest that hospital disaster plans must not only foresee injury management after earthquakes, but also ensure accessibility, in particular for pregnant women, and promote a quick return to normality to prevent additional negative health outcomes.

Impact of mass vaccination campaigns on measles transmission during an outbreak in Guinea, 2017.

OBJECTIVE: To estimate the time-dependent measles effective reproduction number (Rt) as an indicator of the impact of three outbreak response vaccination (ORV) campaigns on measles transmission during a nationwide outbreak in Guinea. METHODS: Rt represents the average number of secondary cases generated by a single primary case in a partially immune population during a given time period. Measles Rt was estimated using daily incidence data for 3952 outbreak-associated measles cases in Guinea in 2017 for the time periods prior to, between, and following each of three ORV campaigns using a simple and extensible mathematical model. RESULTS: Rt was estimated to be above the threshold value of 1 during the initial growth period of the outbreak until the first ORV campaign began on March 13 (Rt = 1.60, 95% CI: 1.55-1.67). It subsequently dropped below 1 and remained <1 through the end of the year (range: 0.71-0.91), although low levels of transmission persisted. CONCLUSIONS: Reduction in Rt coincided with implementation of the ORV campaigns, indicating success of the campaigns at maintaining measles transmission intensity below epidemic growth levels. However, persistent measles transmission remains an issue in Guinea due to insufficient levels of herd immunity. Estimation of Rt should be further leveraged to help decision makers and field staff understand outbreak progress and the timing and type of vaccination efforts needed to halt transmission.

Medical Consultations After Typhoon Haiyan in a Field Hospital in the Philippines.

INTRODUCTION AND OBJECTIVES: Typhoon Haiyan partially destroyed the Ormoc District Hospital in the Philippines. A field hospital was established to replace its outpatient department for 5 weeks. We investigated the reasons for medical consultation in the field hospital. METHODS: We described the consultations by sex, age, week, and diagnosis according to the Surveillance in Post-Extreme Emergencies and Disasters system. We compared the number and proportion of upper respiratory tract infections (URTIs) with a control season in 2014. RESULTS: We included 6785 consultations, 55.9% from women. The majority of consultations were communicable diseases (88.2%) followed by noncommunicable (7.1%) and injuries (5.6%). Males suffered more often from injuries than women (66.0% vs 34.0%). Consultations due to injuries decreased from 10.0% in the first to 2.9% in the last week. The most frequent diagnosis over the study period was acute respiratory infections (ARIs) (73.1%), of which 83.0% were children. The number of daily URTIs was higher than in a similar 2014 period. CONCLUSIONS: ARI was the most prevalent diagnosis. We recommend ARI treatments being fully accessible after such a disaster. During the first week, injury prevention should focus on adult men. Studies after natural disasters should include control periods to better understand disease distribution, ultimately improving the prioritization in disasters.

Clinical and demographic profile of admitted victims in a tertiary hospital after the 2015 earthquake in Nepal.

BACKGROUND: In 2015, an earthquake killing 9,000 and injuring 22,000 people hit Nepal. The Tribhuvan University Teaching Hospital (TUTH), a reference tertiary hospital, was operational immediately after the earthquake. We studied the profile of earthquake victims admitted in TUTH and assessed what factors could influence hospital length of stay. METHODS: An earthquake victim dataset was created based on patient records, with information on sex, age, date of admission and discharge, diagnosis, and surgical intervention. We performed an initial descriptive overview of the earthquake victims followed by a time-to-event analysis to compare length of hospital stay in different groups, using log rank test and cox regression to calculate Hazard Ratios. RESULTS: There were in total 501 admitted victims, with the peak of admissions occurring on the fifth day after the earthquake. About 89% had injury as main diagnosis, mostly in lower limbs, and 66% of all injuries were fractures. Nearly 69% of all patients underwent surgery. The median length of hospital stay was 10 days. Lower limb and trunk injuries had longer hospital stays than injuries in the head and neck (HR = 0.68, p = 0.009, and HR = 0.62 p = 0.005, respectively). Plastic surgeries had longer hospital stays than orthopaedic surgeries (HR = 0.57 p = 0.006). Having a crush injury and undergoing an amputation also increased time to discharge (HR = 0.57, p = 0.013, and HR = 0.65 p = 0.045 respectively). CONCLUSIONS: Hospital stay was particularly long in this sample in comparison to other studies on earthquake victims, indirectly indicating the high burden TUTH had to bear to treat these patients. To strengthen resilience, tertiary hospitals should have preparedness plans to cope with a large influx of injured patients after a large-scale disaster, in particular for the initial days when there is limited external aid.

Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings.

INTRODUCTION: Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings. METHODOLOGY: This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays. RESULTS: We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7). CONCLUSIONS: Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.

Heat and emergency room admissions in the Netherlands.

BACKGROUND: Due to a global warming-related increase in heatwaves, it is important to obtain detailed understanding of the relationship between heat and health. We assessed the relationship between heat and urgent emergency room admissions in the Netherlands. METHODS: We collected daily maximum temperature and relative humidity data over the period 2002-2007. Daily urgent emergency room admissions were divided by sex, age group and disease category. We used distributed lag non-linear Poisson models, estimating temperature-admission associations. We estimated the relative risk (RR) for urgent hospital admissions for a range of temperatures compared to a baseline temperature of 21 °C. In addition, we compared the impact of three different temperature scenarios on admissions using the RR. RESULTS: There is a positive relationship between increasing temperatures above 21 °C and the RR for urgent emergency room admissions for the disease categories 'Potential heat-related diseases' and 'Respiratory diseases'. This relationship is strongest in the 85+ group. The RRs are strongest for lag 0. For admissions for 'circulatory diseases', there is only a small significant increase of RRs within the 85+ age group for moderate heat, but not for extreme heat. The RRs for a one-day event with extreme heat are comparable to the RRs for multiple-day events with moderate heat. CONCLUSIONS: Hospitals should adjust the capacity of their emergency departments on warm days, and the days immediately thereafter. The elderly in particular should be targeted through prevention programmes to reduce harmful effects of heat. The fact that this increase in admissions already occurs in temperatures above 21 °C is different from previous findings in warmer countries. Given the similar impact of three consecutive days of moderate heat and one day of extreme heat on admissions, criteria for activation of national heatwave plans need adjustments based on different temperature scenarios.

The impact of Typhoon Haiyan on admissions in two hospitals in Eastern Visayas, Philippines.

OBJECTIVES: We investigated the short-term impact of Typhoon Haiyan, one of the strongest typhoons ever to make landfall, on the pattern of admissions in two hospitals in Eastern Visayas, the Philippines. METHODS: This study took place at Eastern Visayas Regional Medical Center (EVRMC) in Tacloban, and Ormoc District Hospital (ODH) in Ormoc. We determined whether there were differences in the pattern of admissions between the week before and the three weeks after Haiyan by using information on sex, age, diagnosis, ward and outcome at discharge from patient records. RESULTS: There was a drop in admissions in both hospitals after Haiyan as compared to before. Admissions climbed back to the baseline after ten days in EVRMC and after two weeks in ODH. When comparing the period after Haiyan to the period before, there was a relative increase in male versus female admissions in ODH (OR 2.8, 95%CI 1.7-4.3), but not in EVRMC. Patients aged ≥50 years and 0-14 years had the highest relative increase in admissions. There was a relative decrease in admissions for the ICD10 group 'Pregnancy, childbirth and the puerperium' (OR 0.4, 95%CI 0.3-0.6), and an increase in 'Certain infectious and parasitic diseases' (OR 2.1, 95%CI 1.2-3.5), mainly gastroenteritis, and 'Diseases of the respiratory system' (OR 1.8, 95%CI 1.0-3.0), mainly pneumonia, compared to all other diagnosis groups in ODH. Out of all reasons for admission within the study period, 66% belong to these three ICD-10 groups. Data on reasons for admission were not available for EVRMC. CONCLUSIONS: The observed reduction in patients after the Typhoon calls for ensuring that hospital accessibility should be protected and reinforced, especially for pregnant women, by trying to remove debris in the direct hospital vicinity. Hospitals in areas prone to tropical cyclones should be prepared to treat large numbers of patients with gastroenteritis and pneumonia, as part of their disaster plans.

General Population Knowledge about Extreme Heat: A Cross-Sectional Survey in Lisbon and Madrid.

Extreme heat is associated with an increased mortality and morbidity. National heat plans have been implemented to minimize the effect of extreme heat. The population's awareness and knowledge of national heat plans and extreme heat is essential to improve the community's behavior and adaptation. A general population survey was conducted in Lisbon and in Madrid to assess this knowledge. We used a questionnaire to interview passers-by. Results were compared between Lisbon and Madrid and between locals and foreigners, using Pearson Chi-square tests and Fisher's exact test. We conducted 260 interviews in six locations of different socio-economic backgrounds in each city. The most frequently mentioned extreme heat-related risk groups were the elderly (79.2%), children (49.6%) and babies (21.5%). The most frequently reported protective measures were increased fluid intake (73.1%) and avoiding exposure to the sun (50.8%). Knowledge about the heat plan was higher in Lisbon (37.2%) than in Madrid (25.2%) (p-value = 0.03). Foreigners had less knowledge of risk groups compared to locals. Heat plans were not widely known in Madrid and Lisbon. Nonetheless, knowledge of practical concepts to face extreme heat, such as certain risk groups and protective measures, was found. Our results were similar to comparable surveys where specific respondents' groups were identified as less knowledgeable. This highlighted the importance of addressing these groups when communicating public health messages on heat. Foreigners should be specifically targeted to increase their awareness.

Barriers to surgical care in Nepal.

BACKGROUND: Various barriers exist that preclude individuals from undergoing surgical care in low-income countries. Our study assessed the main barriers in Nepal, and identified individuals most at risk for not receiving required surgical care. METHODS: A countrywide survey, using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool, was carried out in 2014, surveying 2,695 individuals with a response rate of 97%. Our study used data from a subset, namely individuals who required surgical care in the last twelve months. Data were collected on individual characteristics, transport characteristics, and reasons why individuals did not undergo surgical care. RESULTS: Of the 2,695 individuals surveyed, 207 individuals needed surgical care at least once in the previous 12 months. The main reasons for not undergoing surgery were affordability (n = 42), accessibility (n = 42) and fear/no trust (n = 34). A factor significantly associated with affordability was having a low education (OR = 5.77 of having no education vs. having secondary education). Living in a rural area (OR = 2.59) and a long travel time to a secondary and tertiary health facility (OR = 1.17 and 1.09, respectively) were some of the factors significantly associated with accessibility. Being a woman was significantly associated with fear/no trust (OR = 3.54). CONCLUSIONS: More than half of the individuals who needed surgical care did not undergo surgery due to affordability, accessibility, or fear/no trust. Providing subsidised transport, introducing mobile surgical clinics or organising awareness raising campaigns are measures that could be implemented to overcome these barriers to surgical care.

How resilient is the general population to heatwaves? A knowledge survey from the ENHANCE project in Brussels and Amsterdam.

BACKGROUND: Studies have shown an increase in mortality and morbidity during heatwaves, especially among the elderly. We assessed the knowledge of the general population of Brussels and Amsterdam on groups at risk and protective measures for heat-related health effects. RESULTS: Six locations with mixed populations were selected in each city. Passer-by's in both cities were asked to participate in a short survey. Respondents in Brussels (n = 120) had significantly more knowledge on risk groups and protective measures than respondents in Amsterdam (n = 133). In both cities, individuals with higher education had better knowledge on risk groups and protective measures than individuals with lower education. CONCLUSIONS: Efforts at heat-awareness raising must be strengthened, especially in Amsterdam, and public health actions should effectively target vulnerable groups with lower education in both cities.