Incidence and risk factors for Malaria, pneumonia and diarrhea in children under 5 in UNHCR refugee camps: A retrospective study

Background

United Nations High Commissioner for Refugees (UNHCR) refugee camps are located predominantly in rural areas of Africa and Asia in protracted or post-emergency contexts. Recognizing the importance of malaria, pneumonia and diarrheal diseases as major causes of child morbidity and mortality in refugee camps, we analyzed data from the UNHCR Health Information System (HIS) to estimate incidence and risk factors for these diseases in refugee children younger than five years of age.

Methods

Data from 90 UNHCR camps in 16 countries, including morbidity, mortality, health services and refugee health status, were obtained from the UNHCR HIS for the period January 2006 to February 2010. Monthly camp-level data were aggregated to yearly estimates for analysis and stratified by location in Africa (including Yemen) or Asia. Poisson regression models with random effects were constructed to identify factors associated with malaria, pneumonia and diarrheal diseases. Spatial patterns in the incidence of malaria, pneumonia and diarrheal diseases were mapped to identify regional heterogeneities.

Results

Malaria and pneumonia were the two most common causes of mortality, with confirmed malaria and pneumonia each accounting for 20% of child deaths. Suspected and confirmed malaria accounted for 23% of child morbidity and pneumonia accounted for 17% of child morbidity. Diarrheal diseases were the cause of 7% of deaths and 10% of morbidity in children under five. Mean under-five incidence rates across all refugee camps by region were: malaria [Africa 84.7 cases/1000 U5 population/month (95% CI 67.5-102.0), Asia 2.2/1000/month (95% CI 1.4-3.0)]; pneumonia [Africa 59.2/1000/month (95% CI 49.8-68.7), Asia 254.5/1000/month (95% CI 207.1-301.8)]; and diarrheal disease [Africa 35.5/1000/month (95% CI 28.7-42.4), Asia 69.2/1000/month (95% CI 61.0-77.5)]. Measles was infrequent and accounted for a small proportion of child morbidity (503 cases, < 1%) and mortality (6 deaths, < 1%).

Conclusions

As in stable settings, pneumonia and diarrhea are important causes of mortality among refugee children. Malaria remains a significant cause of child mortality in refugee camps in Africa and will need to be addressed as part of regional malaria control and elimination efforts. Little is known of neonatal morbidity and mortality in refugee settings, and neonatal deaths are likely to be under-reported. Global measles control efforts have reduced the incidence of measles among refugee children.     

Malnutrition and micronutrient deficiencies among Bhutanese refugee children--Nepal, 2007

Acute and chronic malnutrition and micronutrient deficiencies have been found in refugee camp populations. In southeastern Nepal, despite consistent access by refugees to general rations, certain micronutrient deficiencies have posed a substantial health burden to the approximately 100,000 Bhutanese residing in seven refugee camps. Limited food diversity, frequent illness, and poor feeding practices have been cited as underlying causes of poor nutritional status in this population. Annual surveys to assess levels of acute malnutrition (i.e., wasting) and chronic malnutrition (i.e., stunting) have been conducted in these camps by the Association of Medical Doctors of Asia (AMDA) and United Nations High Commissioner for Refugees (UNHCR); however, the capacity to reliably evaluate micronutrient deficiencies has not existed locally in the camps. In January 2007, AMDA and CDC, at the request of UNHCR and the World Food Programme (WFP), conducted a nutritional survey of children aged 6-59 months, assessing 1) the prevalence of acute malnutrition, chronic malnutrition, underweight, anemia, and angular stomatitis (i.e., riboflavin deficiency); 2) the cumulative incidence of diarrhea and acute respiratory illness (ARI); and 3) the feeding practices of the children's mothers. This report describes the results of that survey, which indicated that, although acute malnutrition was found in only 4.2% of the children, chronic malnutrition was found in 26.9% and anemia in 43.3%. These findings underscore the importance of monitoring both malnutrition and micronutrient deficiencies and addressing the underlying causes of nutritional deficits.     

Association between nutritional status (MNA®-SF) and frailty (SHARE-FI) in acute hospitalised elderly patients

Objective

This study aimed to explore the association between the impaired nutritional status and frailty in acute hospitalised elderly patients by using two tools, the MNA®-SF (Mini Nutritional Assessment® short-form) and the SHARE-FI (Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe).

Design

Cross-sectional study.

Setting

Acute hospitalised, community-dwelling elderly patients were recruited at internal medicine wards in Vienna, Austria.

Participants

133 men (39%) and women (61%) aged 74 (65–97) years.

Measurements

MNA®-SF was used to investigate malnutrition (<7 points) and patients at risk of malnutrition (8 to 11 points). By using the SHARE-FI, subjects were classified as frail, pre-frail or robust. A factor analysis was applied to identify overlaps between the MNA®-SF and SHARE-FI items. Internal consistency of different dimensions was assessed by using Cronbach’s Alpha.

Results

Malnutrition or risk of malnutrition was found in 76.7% of the total sample and in 46.8% of robust, in 69.0% of pre-frail, and in 93.0% of frail participants. Frailty or prefrailty was found in 75.9% of the total sample and in 45.1% of the subjects with no risk of malnutrition, in 80.9% of subjects at risk of malnutrition, and in 94.1% of malnourished patients. The two used tools show overlaps in three dimensions: (1) nutrition problems, (2) mobility problems and (3) anthropometric items with a moderate to strong internal consistency (Cronbach’s Alpha of 0.670, 0.834 and 0.946, respectively). 64.7% of the total sample (79.5% of frail and 87.9% of malnourished subjects) would participate in a home-based muscle training and nutritional intervention program.

Conclusions

This study underlines the association and the overlap between frailty and impaired nutritional status. There is a high readiness to participate in a program to tackle the problems associated with malnutrition and frailty, especially in those, who would benefit most from it.     

Risk factors for elevated blood lead levels among African refugee children in New Hampshire, 2004

Objectives

Surveillance blood lead screening of refugee children resettled in Manchester, NH, in 2004 revealed that 39 (42%) of 92 children had elevated levels (?10 μg/dL) after resettlement. Furthermore, 27/92 children (29%) had nonelevated screening blood lead levels on arrival (BLL1) but had elevated follow-up blood lead levels 3-6 months after settlement (BLL2). The main objective was to identify risk factors for increasing lead levels among refugee children after resettlement in Manchester in 2004.

Patients and methods

We conducted a cohort study, with completion of household interviews and home assessments for refugee families who had resettled in 2004 in Manchester, NH. Blood lead level (BLL) data were abstracted from the New Hampshire (NH) Childhood Lead Poisoning Prevention Program. To assess acute and chronic malnutrition among refugees, we used anthropometric data from International Organization of Migration documents to calculate nutritional indices.

Results and discussion

Of the 93 African refugee children in 42 families who participated, 60 (65%) had been born in a refugee camp. Median age was 5.5 years at the time of BLL2 measurement. Thirty-six (39%) of the refugee children had BLL2?10 μg/dL. Liberians and those born in refugee camps had higher geometric mean BLL2 than those not Liberian or not born in camps. Younger children and children with nutritional wasting before immigrating to the United States had a greater increase in geometric mean from BLL1 to BLL2, compared to older children and those without nutritional wasting.Follow-up blood lead testing of refugee children, particularly those resettled in areas with older housing stock, as in Manchester, is important for identifying lead exposure occurring after resettlement. Increased attention to improve nutritional status of children in refugee camps and after arrival in the United States and awareness of children who were born in refugee camps should be incorporated into lead-poisoning prevention strategies.     

Does spending on refugees make a difference? A cross-sectional study of the association between refugee program spending and health outcomes in 70 sites in 17 countries

Background

Numerous simultaneous complex humanitarian emergencies strain the ability of local governments and the international community to respond, underscoring the importance of cost-effective use of limited resources. At the end of 2011, 42.5 million people were forcibly displaced, including 10.4 million refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR). UNHCR spent US$1.65 billion on refugee programs in 2011. We analyze the impact of aggregate-level UNHCR spending on mortality of refugee populations.

Methods

Using 2011 budget data, we calculated purchasing power parity adjusted spending, disaggregated by population planning groups (PPGs) and UNHCR Results Framework objectives. Monthly mortality reported to UNHCR’s Health Information System from 2011 to 2012 was used to calculate crude (CMR) and under-5 (U5MR) mortality rates, and expressed as ratios to country of asylum mortality. Log-linear regressions were performed to assess correlation between spending and mortality.

Results

Mortality data for 70 refugee sites representing 1.6 million refugees in 17 countries were matched to 20 PPGs. Median 2011 spending was $623.27 per person (constant 2011 US$). Median CMR was 2.4 deaths per 1,000 persons per year; median U5MR was 18.1 under-5 deaths per 1,000 live births per year. CMR was negatively correlated with total spending (p?=?0.027), and spending for fair protection processes and documentation (p?=?0.005), external relations (p?=?0.034), logistics and operations support (p?=?0.007), and for healthcare (p?=?0.046). U5MR ratio was negatively correlated with total spending (p?=?0.015), and spending for favorable protection environment (p?=?0.024), fair protection processes and documentation (p?=?0.003), basic needs and essential services (p?=?0.027), and within basic needs, for healthcare services (p?=?0.007).

Conclusion

Increased UNHCR spending on refugee populations is correlated with lower mortality, likely reflecting unique refugee vulnerabilities and dependence on aid. Future analyses using more granular data can further elucidate the health impact of humanitarian sector spending, thereby guiding policy choices.

     

Nutritional situation among Syrian refugees hosted in Iraq,Jordan, and Lebanon: cross sectional surveys

Background

Ongoing armed conflict in Syria has caused large scale displacement. Approximately half of the population of Syria have been displaced including the millions living as refugees in neighboring countries. We sought to assess the health and nutrition of Syrian refugees affected by the conflict.

Methods

Representative cross-sectional surveys of Syrian refugees were conducted between October 2 and November 30, 2013 in Lebanon, April 12 and May 1, 2014 in Jordan, and May 20 and 31, 2013 in Iraq. Surveys in Lebanon were organized in four geographical regions (North, South, Beirut/Mount Lebanon and Bekaa). In Jordan, independent surveys assessed refugees residing in Za’atri refugee camp and refugees residing among host community nationwide. In Iraq, refugees residing in Domiz refugee camp in the Kurdistan region were assessed. Data collected on children aged 6 to 59 months included anthropometric indicators, morbidity and feeding practices. In Jordan and Lebanon, data collection also included hemoglobin concentration for children and non-pregnant women aged 15 to 49 years, anthropometric indicators for both pregnant and non-pregnant women, and household level indicators such as access to safe water and sanitation.

Results

The prevalence of global acute malnutrition among children 6 to 59 months of age was less than 5 % in all samples (range 0.3–4.4 %). Prevalence of acute malnutrition among women 15 to 49 years of age, defined as mid-upper arm circumference less than 23.0 cm, was also relatively low in all surveys (range 3.5–6.5 %). For both children and non-pregnant women, anemia prevalence was highest in Za’atri camp in Jordan (48.4 % and 44.8 %, respectively). Most anemia was mild or moderate; prevalence of severe anemia was less than or equal to 1.1 % in all samples of children and women.

Conclusions

Despite the ongoing conflict, results from all surveys indicate that global acute malnutrition is relatively low in the assessed Syrian refugee populations. However, prevalence of anemia suggests a serious public health problem among women and children, especially in Za’atri camp. Based on these findings, nutrition partners in the region have reprioritized response interventions, focusing on activities to address micronutrient deficiencies such as food fortification.

     

Malnourished Children in Refugee Camps and Lack of Connection with Services After US Resettlement

Identifying and addressing malnutrition among US-bound refugee children is an important human rights issue. Failure to address childhood malnutrition can impair cognitive development and productivity. The target population was children aged 6–59 months, originating from eight countries representing 51 % of US-resettled refugees for 2005–2011, living in 22 camps prior to potential US-resettlement. The corresponding camp-level nutritional survey data were evaluated. State Refugee Health Coordinators were surveyed on nutritional assessment, reporting and referrals for their US-refugee medical screenings. From 2004 to 2010, half of the camps (63 total surveys) had global acute malnutrition prevalence over 15 % at least once (surveys not done annually) and anemia prevalence greater than 40 %. The majority of US-refugee medical screenings included height and weight measurements but few used national or WHO standards to evaluate presence or level of malnutrition. Improve overseas camp monitoring and link these nutritional data to US-resettling refugee children to inform potential nutritional interventions. Domestically, use WHO or US growth standards for anthropometrics to determine presence of malnutrition and need for corrective action.     

Malnutrition screening and early nutrition intervention in hospitalised patients in acute aged care: A randomised controlled trial

Objectives

High rates of malnutrition have been reported in the older hospitalized patient population. This is recognised to impact on patient outcomes and health costs. This study aimed to assess the impact of nutrition screening and intervention on these parameters.

Design

Randomised controlled prospective study.

Setting

The study was performed in the acute geriatric medicine wards of the Prince of Wales Hospital, Sydney Australia.

Participants

All patients admitted to these wards under a geriatrician with an expected length of stay of at least 72 hours were considered for the study.

Intervention

Patients were screened on admission for malnutrition using the Mini Nutritional Assessment (MNA) tool and randomly assigned to control or intervention groups. Intervention patients were immediately commenced on a malnutrition care plan (MCP). Control patients were only commenced on a MCP if referred by clinical staff.

Measurements

Length of stay (LOS), weight change and frequency of readmission to hospital were compared between the groups.

Results

143 patients were screened. 119 were identified as malnourished (MN) or at risk of malnutrition (AR). Overall LOS was not different between the two groups (control v. intervention: 13.4 ± 1.3 days v. 12.5 ± 1.2 days, p=0.64). However there was a significant decrease in LOS in the MN (control v. intervention: 19.5 ± 3days v. 10.6 ± 1.6 days, p=0.013) and a trend to reduced readmissions. There was no difference in weight change over admission between the groups. Without screening, clinical staff identified only a small proportion of malnourished patients (35% of MN and 20% of AR).

Conclusions

Malnutrition in the older hospital population is common. Malnutrition screening on hospital admission facilitated targeted nutrition intervention, however length of stay and representations were only reduced in older malnourished patients with an MNA score less than 17.     

Malnutrition and falls risk in community-dwelling older adults

Background and Aims

Falls and fall-related injuries result in reduced functioning, loss of independence, premature nursing home admissions and mortality. Malnutrition is associated with falls in the acute setting, but little is known about malnutrition and falls risk in the community. The aim of this study was to assess the association between malnutrition risk, falls risk and falls over a one-year period in community-dwelling older adults.

Methods

Two hundred and fifty four subjects >65 years of age were recruited to participate in a study in order to identify risk factors for falls. Malnutrition risk was determined using the Mini Nutritional Assessment-Short Form.

Results

28.6% had experienced a fall and according to the Mini Nutritional Assessment-Short Form 3.9% (n=10) of subjects were at risk of malnutrition. There were no associations between malnutrition risk, the risk of falls, nor actual falls in healthy older adults in the community setting.

Conclusions

There was a low prevalence of malnutrition risk in this sample of community-dwelling older adults and no association between nutritional risk and falls. Screening as part of a falls prevention program should focus on the risk of developing malnutrition as this is associated with falls.     

Capture-recapture analysis of all-cause mortality data in Bohol, Philippines

Background

Primary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys.

Methodology

We used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time.

Results and discussion

The data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization.

Conclusions

Our results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas.     

“We need good nutrition but we have no money to buy food”: sociocultural context,care experiences,and newborn health in two UNHCR-supported camps in South Sudan

Background

Determinants of newborn health and survival exist across the reproductive life cycle, with many sociocultural and contextual factors influencing outcomes beyond the availability of, and access to, quality health services. In order to better understand key needs and opportunities to improve newborn health in refugee camp settings, we conducted a multi-methods qualitative study of the status of maternal and newborn health in refugee camps in Upper Nile state, South Sudan.

Methods

In 2016, we conducted 18 key informant interviews with health service managers and front-line providers and 13 focus group discussions in two Sudanese refugee camps in Maban County, South Sudan. Our focus group discussions comprised 147 refugee participants including groups of mothers, fathers, grandmothers, traditional birth attendants, community health workers, and midwives. We analysed our data for content and themes using inductive and deductive techniques.

Results

We found both positive practices and barriers to newborn health in the camps throughout the reproductive lifecycle. Environmental and contextual factors such as poor nutrition, lack of livelihood opportunities, and insecurity presented barriers to both general health and self-care during pregnancy. We found that the receipt of material incentives is one of the leading drivers of utilization of antenatal care and facility-based childbirth services. Barriers to facility-based childbirth included poor transportation specifically during the night; insecurity; being accustomed to home delivery; and fears of an unfamiliar birth environment, caesarean section, and encountering male health care providers during childbirth. Use of potentially harmful traditional practices with the newborn are commonplace including mixed feeding, use of herbal infusions to treat newborn illnesses, and the application of ash and oil to the newborn’s umbilicus.

Conclusions

Numerous sociocultural and contextual factors impact newborn health in this setting. Improving nutritional support during pregnancy, strengthening community-based transportation for women in labour, allowing a birth companion to be present during delivery, addressing harmful home-based newborn care practices such as mixed feeding and application of foreign substances to the umbilicus, and optimizing the networks of community health workers and traditional birth attendants are potential ways to improve newborn health outcomes.

     

Evidence in support of foster care during acute refugee crises

OBJECTIVES: The United Nations High Commissioner on Refugees (UNHCR) and United Nations Children's Fund (UNICEF) policy encourages foster care during refugee emergencies. We examined evidence to support this policy using data from the 1994 Rwandan refugee crisis. METHODS: The association of weight gain and acute illness with family status (foster children vs children living with their biological families) was examined using latent growth curve and repeated measures logistic regression analysis. RESULTS: Weight gain for all children averaged 0.40 kg/month and was associated with child's age but not with family status, child's or caregiver's sex, caregiver's marital status, possession of blankets or plastic sheeting, severe malnutrition, month of enrollment, or acute illness. Illness was not more common among foster children than among children living with their biological families. CONCLUSIONS: This analysis supports the UNHCR/UNICEF recommendation of fostering for unaccompanied children during an acute refugee crisis.     

Factors associated with poor nutritional status among community dwelling Lebanese elderly subjects living in rural areas: Results of the AMEL study

Objectives

This study aimed to assess the nutritional status, measured by MNA, and its association with socio-demographic indicators and health related characteristics of a representative sample of community dwelling elderly subjects.

Design

Cross-sectional study.

Setting

Community dwelling elderly individuals living in rural communities in Lebanon.

Participants

1200 elderly individuals aged 65 years or more.

Measurements

Socio-demographic indicators and health related characteristics were recorded during a standardized interview. Nutritional status was assessed through Mini Nutritional Assessment (MNA). The 5-item GDS score and the WHO-5-A score were used to assess mood, whereas Mini Mental Status (MMS) was applied to evaluate cognitive status.

Results

The prevalence of malnutrition and risk of malnutrition was 8.0% respective 29.1% of the study sample. Malnutrition was significantly more frequent in elderly subjects aged more than 85 years, in females, widowed and illiterate people. Moreover, participants who reported lower financial status were more often malnourished or at risk of malnutrition. Regarding health status, poor nutritional status was more common among those reporting more than three chronic diseases, taking more than three drugs daily, suffering from chronic pain and those who had worse oral health status. Also, depressive disorders and cognitive dysfunction were significantly related to malnutrition. After multivariate analysis following variables remained independently associated to malnutrition: living in the governorate of Nabatieh (ORa 2.30, 95% CI 1.35–3.93), reporting higher income (ORa 0.77, 95% CI 0.61–0.97), higher number of comorbidities (ORa 1.22, 95% CI 1.12–1.32), chronic pain (ORa 1.72, 95% CI 1.24–2.39), and depressive disorders (ORa 1.66, 95% CI 1.47–1.88). On the other hand, better cognitive functioning was strongly associated with decreased nutritional risk (ORa 0.27, 95%CI 0.17–0.43).

Conclusion

Our results highlighted the close relationship between health status and malnutrition. The identification of potential predictive factors may allow better prevention and management of malnutrition in elderly people.     

Critical assessment of refugees’ needs in post-emergency context: the case of Malian war refugees settled in Northern Burkina Faso

Background

Empirically assessing the needs of refugees in camps is critical to the improvement of existing policies and programs that aim at enhancing their well-being. By neglecting the needs of refugees, interventions may fail to capture the complex patterns of refugees’ daily lives within camps. This paper provides a comprehensive assessment of the needs of encamped Malian refugees in Northern Burkina Faso following the 2012-armed conflict. In addition to assessing the needs of Malian refugees, the study aimed to critically assess from an upstream perspective the degree of their involvement in policies and practices that are targeted towards improving their livelihood.

Methods

We took an “upstream” view on the lives of Malian refugees to identify their unmet needs. A purposive sampling strategy was employed to collect data from various media sources, including data aggregated from the website of the United Nations High Commissioner for Refugees (UNHCR). The most populous refugee camp (Mentao) was visited in September 2012 and in-depth group discussion and interviews were conducted with key informants, including nine camp representatives and four officials from the central and decentralized administrations.

Results

Media canvass combined with the UNHCR level 2 census revealed a flawed headcount of refugees, which was 205.4% higher than the real number in Burkina Faso. Although refugees live harmoniously with the natives and their security has been assured, they strongly complained about the number of unused food items distributed. Camps were distributed among humanitarian organizations leading to differential advantage and resources from one camp to another. Additionally, idleness, lack of classrooms facilities for pre-school children and lack of continuous healthcare services were major concerns raised. Further, refugees expressed limited involvement in the planning and implementation of programs that are related to their welfare.

Conclusion

This study revealed that refugees’ voices were not taken into consideration in making tailor-made programs. This calls for more comprehensive surge capacity to deal with refugees’ basic needs. Further, a strong leadership from hoststate should be encouraged to offer equal opportunities to refugees regardless of their camps. Finally, an innovative strategy is needed to build a reliable database that could enhance the design, implementation, monitoring and evaluation of policies and programs.

     

Different components of nutritional status in older inpatients with cognitive impairment

Objectives

To evaluate different components of nutritional status in older patients with cognitive deficit, particularly in those with mild cognitive impairment (MCI).

Design

Cross-sectional study.

Setting and participants

560 elderly subjects aged ?? 65 years consecutively admitted to an acute Geriatric Unit of Apulia region of southern Italy.

Measurements

A standardized comprehensive geriatric assessment was used to evaluate medical, cognitive, affective and social aspects. Nutritional status was assessed using the mini nutritional assessment (MNA). The cognitive function was categorized into three levels ?? MCI, dementia or normal cognition (NoCI) ?? according to the neuropsychological test score.

Results

Subjects with cognitive decline had significantly lower frequency of well-nourished (MCI=10%, dementia=8%, NoCI=22%, p<0.05) and higher frequency of malnourished (MCI=47%, dementia=62%, NoCI=19%, p<0.001) than patients with normal cognition. Similarly, MNA total score, MNA-3 and MNA-4 subscores were significantly lower in patients with MCI and dementia than patients with normal cognition (p<0.001).

Conclusions

These results suggest that cognitive decline may be associated with malnutrition in this sample of hospitalized older patients. Dietary habits (MNA-3) and subjective assessment of self-perceived quality of health and nutrition (MNA-4) are particularly poor also in patients with MCI and could be. very important variables to be considered in the multidimensional evaluation of subjects with cognitive impairment.     

Comparison of nutritional status in the elderly according to living situations

Aim

This study aimed to evaluate the nutritional status of elderly individuals living alone and with their families.

Participants and Method

The sample of the study included 872 elderly individuals who agreed to participate in the study, were aged 65 or over, and lived in Ankara. The data were gathered from a survey, using face-to-face interviews. The Mini Nutritional Assessment (MNA) was used in evaluating each individual’s nutrition.

Results

The rate of malnutrition in the study population was 5% while the malnutrition risk was 67%. The rate of malnutrition in the individuals living alone was found to be higher than that of those living with their families. The rates of malnutrition in individuals living alone and with their families were, respectively, 7% and 4%, and the rates of malnutrition risk in individuals living alone and with their families were, respectively, 73% and 66% (p<0.05). In both groups, there were significant relationships between individuals’ ages, BMI values, mid-upper arm circumference (MUAC), and calf circumference measurements and their MNA scores. While there was a negative and significant relationship between age and MNA scores, the relationships between other parameters and MNA scores were positive and significant (p<0.01).

Conclusion

In this study, it was revealed that the nutrition of elderly individuals living alone differs from the nutrition of elderly individuals living with their families. Malnutrition rates were higher in individuals living alone. Raising the awareness of elderly people and their families regarding the need to improve and maintain nutrition would be beneficial.

     

Estimating the cost-effectiveness of nutrition supplementation for malnourished,HIV-infected adults starting antiretroviral therapy in a resource-constrained setting

Background

Low body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region.

Methods

We used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI <16.0 kg/m²), moderate (16.00-16.99 kg/m²), and mild (17.00-18.49 kg/m²) malnutrition categories.

Results

19,247 patients contributed data between May 2004 and October 2010. Quarterly survival and retention were lowest in the BMI <16.0 kg/m² category compared to higher BMI levels, and there was less variation in both measures across BMI strata after 180 days. ART treatment was estimated to cost $556 per year and averted 7.3 disability-adjusted life years. To maintain cost-effectiveness parity with ART alone, a supplement needed to cost $10.99 per quarter and confer a 20% reduction in both 6-month mortality and loss to follow-up among BMI <16.0 kg/m² patients. Among BMI 17.00-18.49 kg/m² patients, supplement costs accompanying a 20% reduction in mortality and loss to follow-up could not exceed $5.18 per quarter. In sensitivity analyses, the maximum permitted supplement cost increased if the ART program cost rose, and fell if patients classified as lost to follow-up at 6 months subsequently returned to care.

Conclusions

Low BMI adults starting ART in sub-Saharan Africa are at high risk of early mortality and loss to follow-up. The expense of providing nutrition supplementation would require only modest improvements in survival and program retention to be cost-effective for the most severely malnourished individuals starting ART, but interventions are unlikely to be cost-effective among those in higher BMI strata.

     

Malnutrition in community-dwelling adults with dementia (Nutrialz Trial)

Objectives

The objective of this study is to assess the nutritional status, measured by the MNA, in community-dwelling elderly individuals with dementia and to identify clinical risk factors for nutritional risk or malnutrition.

Design

Cross-sectional analysis of a cluster randomized clinical trial (Nutrialz).

Setting

Community-dwelling individuals attending dementia clinics.

Participants

940 individuals.

Measurements

The clinical scales assessed were Mini Nutritional Assessment (MNA), Eating Behaviour Scale (EBS), Charlson comorbidity index, Clinical Dementia Rating (CDR), Mini-Mental State Examination (MMSE), Basic Activities of Daily Living (BADL) score, Instrumental Activities of Daily Living (IADL) score, Neuropsychiatric Inventory Questionnaire (NPI-Q), Cornell depression scale and Zarit Caregiver Burden Interview.

Results

5.2% of participants were classified as being malnourished, 42.6% as being at risk of malnutrition and 52.2% as well nourished. Malnutrition by type of dementia was more frequent in Lewy bodies dementia (18.2%) than in the other types. Worse nutritional status is significantly related to more advanced age and worse cognitive, functional and behavioural profile, as well as increased burden for caregivers. Presence of behavioural symptoms is significantly related to worse nutritional level for all NPI-Q symptoms but depression, exaltation, lack of inhibition and irritability. The items more strongly related to malnutrition are appetite/feeding and hallucinations. Dependence in any basic or instrumental ADL is significantly related to higher risk of malnutrition. Dependence on feeding is a strongly related risk factor, while food preparation is only a moderate one. A logistic regression model to predict at risk/malnutrition kept as significant risk factors EBS (Odds Ratio (OR) 0.84, 95%CI 0.78 to 0.91), Cornell (OR 1.12, 95%CI 1.09 to 1.16), the number of dependent BADL (OR 1.29, 95%CI 1.17 to 1.42), age (OR 1.04, 95%CI 1.02–1.06), MMSE (OR 0.95, 95%CI 0.92 to 0.98) and Charlson (OR 1.18, 95%CI 1.05 to 1.34). A similar model built for prediction of malnutrition retained as significant covariables only EBS, Cornell and the number of dependent BADL.

Conclusion

These results will allow a better understanding of the clinical stage previous to malnutrition. An adequate diagnosis and treatment of identified modifiable factors like functional impairment, eating behaviours and depression could delay or avoid malnutrition.     

Epidemiological patterns of scurvy among Ethiopian refugees

In the Horn of Africa, scurvy is a serious public health problem for refugees who are dependent on standard relief food (cereals, legumes, and oil). To assess the risk factors and to quantify the potential magnitude of scurvy among these displaced communities, we reviewed data collected from 1985 to 1987 by relief programmes in five refugee camps in Somalia and one in the Sudan. Outbreaks of clinical scurvy occurred among refugees in all the camps from 3 to 4 months after their arrival. The incidence of scurvy in two camps was, respectively, 14% over a period of 4 months and 19.8% over a period of 18 months. Prevalences of scurvy estimated from random population samples in the six study camps ranged from 13.6% to 44%. The risk of developing scurvy increased significantly with the length of time that refugees had been in the camps and was also significantly higher among those who were older and among females, particularly those of childbearing age. The prevalence of scurvy among refugees was similar, irrespective of whether or not they had attended supplementary feeding programmes. The control measures that were implemented had a moderate and slow impact on the disease. In both Somalia and the Sudan the relief food distributed to the refugees was almost completely deficient in vitamin C, while the environment where the camps were located precluded an adequate supply of fresh food. To avoid scurvy among refugee communities in this area of Africa it is therefore recommended that vitamin C supplements be added to the relief food at an early stage of a crisis.