In humanitarian crisis settings, there appears to be a polarization of the focus of intervention types, with evidence of vector control interventions (e.g., ITNs) largely derived from South Asia and Africa, while evidence on human-focused interventions (e.g., antimalarials) primarily originating from Southeast Asia. Given that humanitarian crises are so context-specific, with intervention targets varying by both human (e.g., cultural, behaviour) and environmental (e.g., availability of water) attributes, it would be advantageous to ensure that all pathways involved in malarial transmission are detailed in a given context. There is a clear gap in evidence of vector control interventions in Southeast Asian context/populations, while there is an even larger dearth of evidence of antimalarials in African and South Asian settings.
There are many gaps in the evidence on NTD interventions in humanitarian settings. This is particularly troubling in light of the fact that of the four NTDs slated for elimination by 2020, only one intervention (against trachoma) was conducted in these settings. In terms of global burden, schistosomiasis received more attention but research on soil-transmitted helminths was largely conducted in relation to patriation overseas (even if the initial antihelminths were administered in the crisis setting – i.e., these studies were largely conducted as a condition of ensuring entrance to the destination country). Perhaps due to its striking morbidity, visceral leishmaniasis received the vast majority of attention in these settings but it is worth noting that these studies were conducted nearly two decades ago. Polio is of particular concern in humanitarian settings, as the distribution of wildtype polio is currently restricted to areas undergoing sustained and extreme pressures due to both armed conflict as well as natural disasters: Afghanistan, Northern Nigeria, and Pakistan. A recent high quality retrospective case-control analysis has provided the polio community with the most current estimates of how and where to target vaccination efforts in these settings (O’Reilly 2014). The utter dearth of literature on evidence of polio interventions in humanitarian settings is especially problematic since on May 5th 2013 WHO declared polio a Public Health Emergency of International Concern (Gulland 2013). Given that the final frontiers where WPV 1 and 3 are humanitarian crisis settings, it is critical that the humanitarian community do what it can to ensure successful implementation of the global programme’s goals.
In terms of communicable diseases as a whole, the quantity and quality of existing evidence largely corresponds to the burden (prevalence) or severity of particular diseases. Thus it is perhaps unsurprising that the majority of evidence on interventions in these settings relates to tuberculosis or respiratory illnesses, diarrhoeal diseases, or vaccine preventable diseases (measles, DTP). A recent review on infectious disease outbreaks in fragile states highlighted the common occurrence of certain communicable diseases (e.g., yellow fever) for which there have been significant outbreaks but little corresponding research (Bruckner and Checchi, 2011). The inability to secure laboratory confirmation has also led to a dearth of high quality research in certain communicable diseases (e.g. diarrhoeal or vector borne diseases, apart from malaria) when a specific pathogen can definitively be identified.
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