Jamaluddine Z, Chen Z, Abukmail H, Aly S, Elnakib S, et al.
MSF Scientific Day International 2024. 2024 May 16
INTRODUCTION Since 7 October 2023, large-scale military operations in the Gaza Strip have resulted in an escalating public health crisis. Residents of Gaza are mostly displaced from their homes and living in overcrowded conditions with insufficient access to water, sanitation, and food, and health services have been considerably disrupted. To inform humanitarian and decision-making efforts, we aimed to estimate the project excess mortality from traumatic injuries, infectious diseases, maternal and newborn complications, and non-communicable diseases (NCDs) under different future scenarios.
METHODS We used five different models to project excess deaths from February to August 2024, considering three scenarios: (1) an immediate and permanent ceasefire; (2) the status quo, reflecting conditions from mid-October 2023 to mid-January 2024; and (3) a further escalation of the conflict. Using publicly available data and expert consultations, our analysis projected excess deaths resulting under each scenario. A model was developed to determine increased malnutrition (as an underlying cause).
RESULTS Without epidemics, the ceasefire scenario would result in 6550 excess deaths, rising to 58,260 under the status quo, and 74,290 under escalation. With epidemics, these projections rise to 11,580, 66,720, and 85,750, respectively. Under the ceasefire scenario, infectious diseases would be the main cause of excess deaths (1,520 excess deaths without epidemics and 6,550 with epidemics). Traumatic injuries followed by infectious diseases would be the main causes of excess deaths in both the status quo (53,450 due to traumatic injuries; 2,120 due to infectious diseases without epidemics and 10,590 including epidemics) and escalation scenarios (68,650 due to traumatic injuries; 2,720 due to infectious diseases without epidemics and 14,180 with epidemics). Our projections indicate that, even in the best-case ceasefire scenario, thousands of excess deaths would continue to occur, mainly due to the time it would take to improve water, sanitation, shelter conditions, and malnutrition, and restore functioning healthcare services in Gaza. While the total number of estimated excess deaths from maternal and neonatal causes are relatively small (100–330 excess deaths), every loss of a mother has severe consequences for family health and wellbeing. NCDs are projected to cause more deaths (1,680 (ceasefire) –2,680 (escalation) excess deaths) due to a heavily disrupted specialised health services and impeded access to treatment and medications.
CONCLUSION These projections underscore the critical and urgent need for an immediate ceasefire to mitigate the alarming excess mortality in Gaza. The severity of the ceasefire scenario cannot be understated, with over 6–11 thousand excess deaths projected. Decision-makers must act swiftly to prevent further loss of life and address the dire humanitarian situation in Gaza.More
INTRODUCTION Hepatitis E (HEV) genotypes 1 and 2 are the common cause of jaundice and acute viral hepatitis that can cause large-scale outbreaks. HEV infection is associated with adverse fetal outcomes and case fatality risks up to 31% among pregnant women. An efficacious three-dose recombinant vaccine (Hecolin) has been licensed in China since 2011 but until 2022, had not been used for outbreak response despite a 2015 WHO recommendation. The first ever mass vaccination campaign against hepatitis E in response to an outbreak was implemented in 2022 in Bentiu internally displaced persons camp in South Sudan targeting 27,000 residents 16–40 years old, including pregnant women.
METHODS We conducted a vaccination coverage survey using simple random sampling from a sampling frame of all camp shelters following the third round of vaccination. For survey participants vaccinated in the third round in October, we asked about the onset of symptoms experienced within 72 hours of vaccination. During each of the three vaccination rounds, passive surveillance of adverse events following immunisation (AEFI) was put in place at vaccination sites and health facilities in Bentiu IDP camp.
RESULTS We surveyed 1,599 individuals and found that self-reported coverage with one or more dose was 86% (95% CI 84–88%), 73% (95% CI 70–75%) with two or more doses and 58% (95% CI 55–61%) with three doses. Vaccination coverage did not differ significantly by sex or age group. We found no significant difference in coverage of at least one dose between pregnant and non-pregnant women, although coverage of at least two and three doses was 8 and 14 percentage points lower in pregnant women. The most common reasons for non-vaccination were temporary absence or unavailability, reported by 60% of unvaccinated people. Passive AEFI surveillance captured few mild AEFI, and through the survey we found that 91 (7.6%) of the 1,195 individuals reporting to have been vaccinated in October 2022 reported new symptoms starting within 72 hours after vaccination, most commonly fever, headache or fatigue.
CONCLUSIONS We found a high coverage of at least one dose of the Hecolin vaccine following three rounds of vaccination, and no severe AEFI. The vaccine was well accepted and well tolerated in the Bentiu IDP camp community and should be considered for use in future outbreak response.More
INTRODUCTION Since April 15, 2023, fighting erupted in Sudan between the army led by General Abdel Fattah al-Burhan and the paramilitary Rapid Support Forces (RSF) under the command of General Mohamed Hamdan Dogolo, known as Hemeti. This war has caused a major humanitarian crisis in Sudan, with violent fighting spreading throughout the country, particularly in Darfur, and aggravating pre-existing inter-community tensions.
By the end of March, almost 30,000 civilians had fled to Chad in search of safety. By September 2023, according to data from the United Nations High Commissioner for Refugees (UNHCR), clashes between military and paramilitary forces had driven more than 420,000 people to flee to Chad in successive waves, of whom around 327,000 had settled in the Ouaddaï province. Chadian refugees and returnees live in very precarious conditions, with limited access to primary healthcare, water and food. Little recent data is available on the mortality, nutritional status, and vaccination coverage of refugee populations in camps in eastern Chad, particularly in Toumtouma, Ourang and Arkoum camps. The results of these surveys are essential for Médecins Sans Frontières (MSF) to better plan its humanitarian interventions, coordinate effectively with other actors, and communicate about the refugee crisis in eastern Chad.
METHODOLOGY Three cross-sectional surveys were carried out, the first with systematic random sampling in Toumtouma camp from August 7 to 13, and the next two with cluster random geospatial sampling in Ourang camp from August 17 to 22 and Arkoum camp from August 30 to September 4, 2023. Each survey covered retrospective mortality, frequency and type of violent events experienced, nutritional status of children aged 6 to 59 months, and measles vaccination coverage among children aged 6 months to 14 years. The recall period ran from January 1 to the day of the survey, i.e., a minimum of 210, 228 and 241 days respectively. Two phases were considered: 1) the pre-crisis phase (Toumtouma: January 1 - March 14, 2023 / Ourang and Arkoum: January 1 - April 14, 2023) and 2) the crisis phase (Toumtouma: March 15 - day of survey / Ourang and Arkoum: April 15 - day of survey). In Toumtouma camp, the crisis phase started earlier due to inter-community tensions that erupted end of March in West Darfur and drove important population displacements towards Chad.
RESULTS Retrospective mortality: In Toumtouma camp, of the 1,032 households included (i.e., 6,372 people), 59.7% were refugees, 35.9% returnees and 4.4% displaced persons. The crude mortality rate (CMR) was significantly higher in phase 2 (CMR: 0.58 deaths/10,000 people/day [95% CI: 0.43 - 0.74]) than in phase 1 (CMR: 0.20 deaths/10,000 people/day [95% CI: 0.07 - 0.33]). Eighty-nine percent of those who died were men. Violence (77%; n=48) was the main cause of death reported, followed by diarrhea (6%; n=4) and respiratory infection (5%; n=3). Among the deaths, 68% occurred in their town or village of origin, 21% during displacement and 11% in an unknown location. Most people who died came from El Geneina (40%), Tandulti (35%) and Umm Dam (16%) in Darfur.
In Ourang camp, of the 1032 households included (i.e., 6302 people), 99.0% were refugees and 1.0% returnees. The CMR was significantly higher in phase 2 (CMR: 2.25 deaths/10,000 people/day [95% CI: 1.77 - 2.74]) than in phase 1 (CMR: 0.11 deaths/10,000 people/day [95% CI: 0.02 - 0.20]). Eighty-three percent of those who died were men (3.88 deaths/10,000 people/day [95% CI: 3.01 - 4.76] in phase 2). Violence (82%; n=147) was the main cause of death reported, followed by measles (5%; n=9). Among the deaths, 69% occurred in their town or village of origin, 25% during displacement and 6% in Adre, Chad. Most people who died came from El Geneina (96%) in Darfur.
In Arkoum camp, of the 1029 households included (i.e., 5324 people), 98.4% were refugees, 1.3% displaced and 0.4% returnees. The CMR was significantly higher in phase 2 (CMR: 0.67 deaths/10,000 people/day [95% CI: 0.46 - 0.89]) than in phase 1 (CMR: 0.15 deaths/10,000 people/day [95% CI: 0.03 - 0.26]). Seventy-seven percent of those who died were men; the mortality rate among men was 1.14 [95% CI: 0.72 - 1.55] in the second phase. Violence (50%; n=28) was the main cause of death reported, followed by diarrhea (16%; n=9). Among the deaths, 52% occurred in their town or village of origin, 27% during displacement, 5% after their arrival in Chad and 16% in an unknown location. Most people who died came from Mistre (54%) and Kongu (29%) in Darfur.
Frequency and main causes of violence: Among households in Toumtouma, Ourang and Arkoum camps, the overall frequency of violence was 3.3%, 11.7% and 4.4% respectively. The main types of violence were beatings (71.0% in Toumtouma, 71.1% in Ourang, and 79.7% in Arkoum), and shootings (27.1% in Toumtouma, 34.7% in Ourang, and 15.1% in Arkoum).
Prevalence of acute malnutrition: Among children aged 6-59 months, the prevalence of global acute malnutrition (GAM) according to MUAC and/or bilateral oedema was 5.5% [95% CI: 4.1 - 7.5] in Toumtouma, 11.3% [95% CI: 9.2 - 13.8] in Ourang, and 11.6% [95% CI: 9.5 - 14.5] in Arkoum camp. Rates of severe acute malnutrition (SAM) were 2.3% [95% CI: 1.4 - 3.6] in Toumtouma, 4.8% [95% CI: 3.6 - 6.4] in Ourang, and 4.6% [95% CI: 3.4 - 6.3] in Arkoum.
Measles vaccination: Measles vaccination coverage among children aged 6 months to 14 years was estimated at 58.6% [95% CI: 56.9 - 60.3] in Toumtouma, 75.9% [95% CI: 71.3 - 79.9] in Ourang, and 63.6% [95% CI: 58.2 - 68.7] in Arkoum.
CONCLUSIONS In the three camps investigated, excess mortality was observed among households during the crisis phase (phase 2), with a significant difference in CMR due to deaths from violence among men. Among households living in Toumtouma camp, the CMR more than doubled and among households in Arkoum camp, it more than tripled. The population in Ourang camp seems to have been particularly affected by the violence, with CMR 20 times higher than in the pre- crisis period and mortality rates exceeding the standard emergency threshold (1 death/10,000 people/day). The vast majority of deaths occurred on the sites of origin or during displacement towards Chad (89% in Toutouma, 94% in Ourang and 79% in Arkoum). GAM and SAM prevalences among 6-59-month-olds were high in Ourang and Arkoum camps, with an alarming SAM prevalence of over 4%. In addition, the measles vaccination coverage, which ranged from 59% to 76% across the camps surveyed, was insufficient to prevent outbreaks.More