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.

Human insecurity and child deaths in conflict: evidence for improved response in Yemen.

BACKGROUND: Since the beginning of the ongoing conflict in Yemen, >23 000 air strikes and >100 000 fatalities have been recorded. Data from Yemen Data Project linked >1300 child fatalities and >900 child injuries to air raids. However, there is little literature on the effect of the protracted armed conflict on the pattern of child mortality using data from small-scale surveys. We aimed to identify the pattern of the death rate for children aged <5 years ('under-5') and its relationship with human insecurity in Yemen. METHODS: We created a human insecurity index (i.e. severely insecure vs insecure) for the 22 governorates in Yemen from 2015 to 2019, using data from the Armed Conflict Location and Event Database. We matched this insecurity index with the corresponding under-5 mortality data from the Complex Emergency Database. We analysed the relationship between the under-5 death rate (U5DR) and the insecurity level using a Bayesian finite mixture model in order to account for unobserved heterogeneity in clustered finite subsets of a population. RESULTS: We extracted 72 surveys and 77.8% (n = 56) were included in this study. The mean of the recall period for mortality was 106 days with a standard deviation of 93 days. We identified two subpopulations: Subpopulation I-high average number of child deaths and Subpopulation II-low average number of child deaths. The log posterior mean of the U5DR is 1.10 (95% credible intervals: 0.36, 1.82) in the severely insecure group in Subpopulation I and 3-fold the estimate in Subpopulation II. However, in Subpopulation II, we found no association between the insecurity level and the U5DR. CONCLUSION: The pattern of child deaths is crucial in understanding the relationship between human insecurity and the U5DR.

"Strengthening data quality and reporting from small-scale surveys in humanitarian settings: a case study from Yemen, 2011-2019".

BACKGROUND: Under-five death rate is one of the major indicators used in assessing the level of needs and severity of humanitarian crisis. Over the years, a number of small-scale surveys based on Standardized Monitoring and Assessment of Relief and Transitions methodology has been conducted in Yemen, these serve as a guide for policy maker and the humanitarian community. The aim of this study is to identify critical methodological and reporting weaknesses that are easy to correct and would improve substantively the quality of the results. METHODS: We obtained seventy-seven surveys conducted across 22 governorates in Yemen between 2011 and 2019 and divided the analysis period into pre-crisis (2011-2014) and crisis period (2015-2019) for comparison. We analysed survey qualities such as sampling methodology, completeness of reporting of Under-five death rate and mortality sample size for children less than five (children < 5) years old. RESULTS: Seventy-seven (71.9%) out of 107 surveys met the eligibility criteria to be included in the study. The methodological quality and reporting are as varied as the surveys. 23.4% (n = 18) met the criteria for quality of sampling methodology, while 77.9%(n = 60) presented required information for the estimation of required mortality sample size and 40.3%(n = 31) met the quality check for reporting of Under-five death rate. CONCLUSIONS: Our assessment indicated that there is no strict adherence to the sampling methodology set out in Standardized Monitoring and Assessment of Relief and Transitions guidelines, and reporting of mortality and sample size data. Adherence to methodological guidelines and complete reporting of surveys in humanitarian settings will vastly improve both the quality and uptake of key data on health and nutrition of the affected population.