51
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Mortality Rates above Emergency Threshold in Population Affected by Conflict in North Kivu, Democratic Republic of Congo, July 2012–April 2013

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement. Médecins-Sans-Frontières (MSF) returned to provide primary healthcare in July 2012. To better understand the impact of the ongoing conflict and displacement on the population, a retrospective mortality survey was conducted in April 2013. A two-stage randomized cluster survey using 31 clusters of 21 households was conducted. Heads of households provided information on their household make-up, ownership of non-food items (NFIs), access to healthcare and information on deaths and occurrence of self-reported disease in the household during the recall period. The recall period was of 325 days (July 2012–April 2013). In total, 173 deaths were reported during the recall period. The crude mortality rate (CMR) was of 1.4/10,000 persons/day (CI95%: 1.2–1.7) and the under-five- mortality rate (U5MR) of 1.9/10,000 persons per day (CI95%: 1.3–2.5). The most frequently reported cause of death was fever/malaria 34.1% (CI95%: 25.4–42.9). Thirteen deaths were due to intentional violence. Over 70% of all households had been displaced at some time during the recall period. Out of households with someone sick in the last two weeks, 63.8% sought health care; the main reason not to seek health care was the lack of money (n = 134, 63.8%, CI95%: 52.2–75.4). Non Food Items (NFI) ownership was low: 69.0% (CI95%: 53.1–79.7) at least one 10 liter jerry can, 30.1% (CI95%: 24.3–36.5) of households with visible soap available and 1.6 bednets per household. The results from this survey in Walikale clearly illustrate the impact that ongoing conflict and displacement are having on the population in this part of DRC. The gravity of their health status was highlighted by a CMR that was well above the emergency threshold of 1 person/10,000/day and an U5MR that approaches the 2 children/10,000/day threshold for the recall period.

          Author Summary

          The area of Walikale, in the eastern province of North Kivu, Democratic Republic of Congo has been experiencing ongoing conflict, violence and population displacement in recent years. Médecins Sans Frontières (MSF) has been working in this part of DRC since July 2012 and decided to document the impact of the conflict on the population by estimating the number of deaths that had occurred in this community between July 2012 and April 2013. Thirty-one villages (with 21 households each) were randomly selected; households were asked to report on the number of deaths, cases of disease, access to health care and ownership of items such as bednets and jerry cans. The overall mortality rate during the period was 1.4 deaths/10,000 person per day, which exceeded the emergency thresholds of 1/10,000 per day. In children under five years this was 1.9/10,000/day; close to the emergency thresholds of 2/10,000/day for this age group. Malaria and diarrhea were commonly reported causes of death and disease. Access to health care was limited due to financial constraints and ownership of bednets and jerrycans very low. The impact of the conflict in the health status of people in this part of DRC therefore appeared to be quite dramatic.

          Related collections

          Most cited references4

          • Record: found
          • Abstract: found
          • Article: not found

          Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo.

          Studies from the Eastern Region of the Democratic Republic of the Congo (DRC) have provided anecdotal reports of sexual violence. This study offers a population-based assessment of the prevalence of sexual violence and human rights abuses in specific territories within Eastern DRC. To assess the prevalence of and correlations with sexual violence and human rights violations on residents of specific territories of Eastern DRC including information on basic needs, health care access, and physical and mental health. A cross-sectional, population-based, cluster survey of 998 adults aged 18 years or older using structured interviews and questionnaires, conducted over a 4-week period in March 2010. Sexual violence prevalence and characteristics, symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), human rights abuses, and physical and mental health needs among Congolese adults in specific territories of Eastern DRC. Of the 1005 households surveyed 998 households participated, yielding a response rate of 98.9%. Rates of reported sexual violence were 39.7% (95% confidence interval [CI], 32.2%-47.2%; n = 224/586) among women and 23.6% (95% CI, 17.3%-29.9%; n = 107/399) among men. Women reported to have perpetrated conflict-related sexual violence in 41.1% (95% CI, 25.6%-56.6%; n = 54/148) of female cases and 10.0% (95% CI, 1.5%-18.4%; n = 8/66) of male cases. Sixty-seven percent (95% CI, 59.0%-74.5%; n = 615/998) of households reported incidents of conflict-related human rights abuses. Forty-one percent (95% CI, 35.3%-45.8%; n = 374/991) of the represented adult population met symptom criteria for MDD and 50.1% (95% CI, 43.8%-56.3%; n = 470/989) for PTSD. Self-reported sexual violence and other human rights violations were prevalent in specific territories of Eastern DRC and were associated with physical and mental health outcomes.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Update on mortality in the Democratic Republic of Congo: results from a third nationwide survey.

            The humanitarian crisis in the Democratic Republic of Congo (DRC) has been among the world's deadliest in recent decades. We conducted our third nationwide survey to examine trends in mortality rates during a period of changing political, security, and humanitarian conditions. We used a 3-stage, household-based cluster sampling technique to compare east and west DRC. Sixteen east health zones and 15 west zones were selected with a probability proportional to population size. Four east zones were purposely selected to allow historical comparisons. The 20 smallest population units were sampled in each zone, 20 households in each unit. The number and distribution of households determined whether they were selected using systematic random or random walk sampling. Respondents were asked about deaths of household members during the recall period: January 2006-April 2007. In all, 14,000 households were visited. The national crude mortality rate of 2.2 deaths per 1000 population per month (95% confidence interval [CI] 2.1-2.3) is almost 70% higher than that documented for DRC in the 1984 census (1.3) and is unchanged since 2004. A small but significant decrease in mortality since 2004 in the insecure east (rate ratio: 0.96, P = .026) was offset by increases in the western provinces and a transition area in the center of the country. Nonetheless, the crude mortality rate in the insecure east (2.6) remains significantly higher than in the other regions (2.0 and 2.1, respectively). Deaths from violence have declined since 2004 (rate ratio 0.7, P = .02). More than 4 years after the official end of war, the crude mortality rate remains elevated across DRC. Slight but significant improvements in mortality in the insecure east coincided temporally with recent progress on security, humanitarian, and political fronts.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              NTDs in the Heart of Darkness: The Democratic Republic of Congo's Unknown Burden of Neglected Tropical Diseases

              The Democratic Republic of Congo may have one of the world's highest burdens of neglected tropical diseases, but nationwide there is a dearth of surveillance activities and available epidemiologic data about these conditions. The Democratic Republic of Congo (DR Congo) is a vast nation of almost one million square miles (about the size of Greenland or one-quarter the size of the United States, and the second largest country in Africa) and more than 70 million people located in the heart of Africa (Figure 1). For at least the last hundred years, the neglected tropical diseases (NTDs) have made a significant impact on the history of the Congo Basin. Despite a navigable river system, early European attempts to explore the Belgian Congo during the nineteenth and early twentieth centuries were blocked because of the high prevalence of human African trypanosomiasis (HAT) and other NTDs [1]. Indeed, the horrific effects of epidemic sleeping sickness were described in detail by Joseph Conrad in Heart of Darkness [2]. 10.1371/journal.pntd.0002118.g001 Figure 1 Map and location of the Democratic Republic of Congo. From CIA Factbook, https://www.cia.gov/library/publications/the-world-factbook/maps/cg_largelocator_template.html, accessed December 31, 2012. When it was known as Zaire during the last quarter of the twentieth century, the resulting dissolution of health systems and public health infrastructure contributed to the reemergence of HAT [3]. In 1998, the year following the overthrow of Mobutu Sese Seko, the number of reported cases peaked at 26,000 (the highest in the world) [3]. Even today, the DR Congo has the greatest number of cases of HAT anywhere in Africa and worldwide [4], [5], as the nation has yet to recover from years of conflict, extreme violence, and massive human migrations [6]. Beyond sleeping sickness, the decades of conflict and breakdowns in health infrastructure have contributed to the high prevalence of several major NTDs [6], although paradoxically conflict may not be a significant factor in the emergence of malaria and HIV/AIDS in DR Congo [7], [8]. In Table 1 we attempted to summarize the limited information currently available for the DR Congo. Our best information to date suggests that DR Congo may have the largest number of leprosy cases in Africa, and possibly the second or third highest number of cases of several high-prevalence NTDs, including intestinal helminth infections, lymphatic filariasis, and schistosomiasis [9], [10]. Because of its huge jungle population of nonhuman primates and other potential and actual animal reservoir hosts, the DR Congo is also believed to be the origin of several important emerging viruses of humans. According to some investigators, human HIV/AIDS first emerged in DR Congo [11], [12], as did strains of Chikungunya virus [13], Crimean-Congo hemorrhagic fever (CCHF, [14]), Ebola virus [15], monkeypox [16], and a novel rhabdovirus (Bas-Congo virus) [17]. 10.1371/journal.pntd.0002118.t001 Table 1 NTDs in DR Congo1. Disease Estimated Number of Cases Rank in Africa Hookworm Infection 31 million2 2nd Schistosomiasis 15 million3 3rd Ascariasis 23 million2 3rd Trichuriasis 26 million2 2nd Lymphatic Filariasis 49 million at risk4 2nd Human African Trypanosomiasis 10,269–18,5925 1st Leprosy 3,6216 1st 1 Modified from [10]. 2 de Silva NR, Brooker S, Hotez PJ, Montresor A, Engles D, et al. (2003) Soil-transmitted helminth infections: updating the global picture. Trends Parasitol 19 (12): 547–551. 3 Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J (2006) Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk. Lancet Infect Dis 6(7): 411–425. 4 World Health Organization (2011) Available: http://www.who.int/neglected_diseases/preventive_chemotherapy/lf/db/index.html?units=minimal&region=all&country=cod&countries=cod&year=2011. Accessed 20 June 2013. 5 Higher number from [5]. 6 World Health Organization (2012) Global leprosy situation 2012. Wkly Epidemiol Rec 87: 317–328. Despite the public health importance of DR Congo's NTDs, there is much more that we do not know than we do know about both the high-prevalence NTDs and the emerging viruses in the Congo Basin. Shown in Figure 2 is a recent map of the distribution of African schistosomiasis survey locations published by Hürlimann et al. in PLOS Neglected Tropical Diseases in 2011 [18]. More than 90% of the world's cases of schistosomiasis are currently found in sub-Saharan Africa. What is striking is the dearth of schistosomiasis surveillance activity in Central Africa and particularly in the DR Congo. A similar situation is also apparent for the soil-transmitted helminth infections. Shown in Figure 3 is a map from the Global Helminth Atlas of the distribution of ascariasis, trichuriasis, and hookworm in DR Congo [19]. The map reveals a reasonable level of sampling at the mouth of the Congo River and near the capital, Kinshasa, but only a single surveillance site in the interior of the country—a country as vast as Greenland! Therefore most of our estimates for schistosomiasis and soil-transmitted helminthiases disease burdens in DR Congo are based on an extreme paucity of surveillance data, particularly active surveillance targeted to high-prevalence areas. Much the same is true for ongoing polio surveillance efforts in the country [6]. 10.1371/journal.pntd.0002118.g002 Figure 2 Distribution of African schistosomiasis survey locations published by Hürlimann et al. in PLOS Neglected Tropical Diseases in 2011 [18] . 10.1371/journal.pntd.0002118.g003 Figure 3 Distribution of soil-transmitted helminth infections in DR Congo. Map from Global Atlas of Helminth Infections, http://www.thiswormyworld.org/maps/democratic-republic-of-the-congo, accessed December 29, 2011. The absence of NTD disease surveillance is itself a threat to the people of the DR Congo and indeed to global public health. Time and again DR Congo has shown us how this nation represents the cradle of a number of important emerging and reemerging viral infections [11]–[17], including some with pandemic potential. Epidemic infections there have impeded polio elimination efforts just as they previously thwarted vaccine eradication campaigns for smallpox more than 30 years ago [6]. The high prevalence rate of NTDs, together with emerging viral infections, suggests that DR Congo is also a key sentinel site to detect the emergence of important coinfections, such as HIV/AIDS and schistosomiasis [20]. There is an urgent need to implement a comprehensive program for disease active and targeted surveillance comprised of studies to examine the high-prevalence NTDs, including the major helminth infections (e.g., intestinal helminth infections, schistosomiasis, lymphatic filariasis, and onchocerciasis) and key protozoan and bacterial NTDs (e.g., intestinal protozoan infections and toxoplasmosis, leprosy, Buruli ulcer, and typhoidal and non-typhoidal salmonellosis) [10]. While the Ministry of Public Health for the DR Congo deserves important credit for its key efforts to fight NTDs such as HAT, lymphatic filariasis, ochocerciasis, and schistosomiasis [21], they could be expanded and better supported by international donors. Equally important are studies to monitor the emergence of key viral infections, including arboviral infections (e.g., yellow fever, dengue, Chikungunya, and CCHF), filoviruses, poxviruses, rhabdoviruses, and retroviruses. Geographic information systems and remote sensing will become important tools for this expanded program targeting both the high-prevalence NTDs and emerging viruses [22], [23]. Studies by a number of investigators have demonstrated the feasibility of conducting high-level and sophisticated disease surveillance in DR Congo. While working there is challenging, as it is in many conflict and post-conflict sub-Saharan African countries, the Ministry of Public Health of DR Congo has time and time again demonstrated initiative and willingness to expand NTD disease surveillance and control activities. Indeed, through support of the United States Agency for International Development (USAID), DR Congo is poised to begin an ambitious program of NTD mapping and integrated disease control focused on mass drug administration for a number of its highest prevalence diseases [24]. Implementation of an ambitious NTD control program in DR Congo portends exciting possibilities to reduce the prevalence and intensity of many of the high-prevalence NTDs there, thus making a huge impact on the burden of disease in sub-Saharan Africa. The World Health Organization and its regional office for Africa are also actively working with the DR Congo government to improve health through control of NTDs and other infections [25], while the Belgian Development Agency is actively committed to rural development [26]. In parallel, there are equally compelling reasons to expand disease surveillance for the emerging viruses in DR Congo, which represent imminent threats to the populations of Africa and may ultimately exhibit pandemic potential [27]. Expanded programs for health systems research strengthening and operational research are also urgently needed and would make an important contribution toward addressing the Millennium Development Goals.
                Bookmark

                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS Negl Trop Dis
                PLoS Negl Trop Dis
                plos
                plosntds
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, USA )
                1935-2727
                1935-2735
                September 2014
                18 September 2014
                : 8
                : 9
                : e3181
                Affiliations
                [1 ]Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands
                [2 ]Zone de Santé, Walikale, North Kivu, Democratic Republic of Congo
                [3 ]Médecin Inspecteur Provinciale, Goma, North Kivu, Democratic Republic of Congo
                [4 ]Médecins Sans Frontières, Operational Centre Amsterdam, Quartiers Les Volcans, Goma, North Kivu, Democratic Republic of Congo
                University of Washington, United States of America
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: AICM KB PS DB JS CK AL. Performed the experiments: AICM PS DB. Analyzed the data: AICM. Contributed reagents/materials/analysis tools: AICM AL. Wrote the paper: AICM AL. Critical review of the manuscript: KB JS CK DB AL.

                Article
                PNTD-D-13-02048
                10.1371/journal.pntd.0003181
                4169374
                25233090
                a44121c1-5466-4e95-9e2f-d1330d927126
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 27 December 2013
                : 11 August 2014
                Page count
                Pages: 8
                Funding
                The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors received no specific funding for this study.
                Categories
                Research Article
                Medicine and Health Sciences
                Epidemiology
                Health Care
                Socioeconomic Aspects of Health
                Public and Occupational Health
                Global Health

                Infectious disease & Microbiology
                Infectious disease & Microbiology

                Comments

                Comment on this article