Health needs of older people in humanitarian settings are poorly documented, negatively affecting the appropriateness of health services they receive. This Review identified the major health needs of older people across humanitarian contexts, including non-communicable diseases and mental health conditions (eg, psychological distress and depression). Barriers to health care of older people included inaccessibility of health-care services; shortage of appropriate health care; insufficient availability of medications and medical equipment; poor geriatric expertise of health-care staff, health policy makers, and health authorities; and age discrimination by health-care personnel. Individual factors included low mobility, poor health literacy, dependence on others for access to care, and self-directed ageism. The participation of older people in shaping health-care services was highlighted as a facilitator of age-inclusive care. Several understudied areas related to the health needs of older people in humanitarian emergencies in low-income and middle-income countries were exposed. We urge governments, academic institutions, humanitarian organisations, and other health-care providers to focus their response and research efforts on the health needs of older people in conflict settings; the health needs of older people in humanitarian emergencies in understudied regions; and on neglected issues such as communicable diseases, cancer, neurocognitive disorders, sexual and reproductive health, genitourinary conditions, and nutrition. The participation of older people in the design, implementation, and evaluation of health-care services is essential to ensure accessibility, appropriateness, and acceptability of care.

Humanitarian emergencies disproportionally affect older people. Although defining an older person by an age range can help alert us to emerging or changing needs and potential vulnerabilities during humanitarian emergencies, ageing is not necessarily synonymous with increasing vulnerability, and individual variations exist due to the heterogeneity of older people. In general, reduced access to safety, health services, clean water, and appropriate food puts older people at increased risk of poor health outcomes during humanitarian emergencies, including disability, injury, malnutrition, and mental health issues. The theoretical framework presented in this Personal View explains how ageism, further compounded by intersecting oppression, leads to the exclusion of older people from the preparedness, response, and recovery phases of humanitarian emergencies. The exclusion of older people is discriminatory, violates core humanitarian and bioethical principles, and leads to an epistemic injustice. We suggest that humanitarian actors implement participatory approaches with older people in humanitarian contexts. Through these approaches, solutions will be identified by and together with older people, leading to community-driven and context-appropriate ways to include the needs and strengths of older people in the preparedness, response, and recovery phases of humanitarian emergencies.

Background This study evaluated an early warning, alert and response system for a crisis-affected population in Doolo zone, Somali Region, Ethiopia, in 2019–2021, with a history of epidemics of outbreak-prone diseases. To adequately cover an area populated by a semi-nomadic pastoralist, or livestock herding, population with sparse access to healthcare facilities, the surveillance system included four components: health facility indicator-based surveillance, community indicator- and event-based surveillance, and alerts from other actors in the area. This evaluation described the usefulness, acceptability, completeness, timeliness, positive predictive value, and representativeness of these components. Methods We carried out a mixed-methods study retrospectively analysing data from the surveillance system February 2019–January 2021 along with key informant interviews with system implementers, and focus group discussions with local communities. Transcripts were analyzed using a mixed deductive and inductive approach. Surveillance quality indicators assessed included completeness, timeliness, and positive predictive value, among others. Results 1010 signals were analysed; these resulted in 168 verified events, 58 alerts, and 29 responses. Most of the alerts (46/58) and responses (22/29) were initiated through the community event-based branch of the surveillance system. In comparison, one alert and one response was initiated via the community indicator-based branch. Positive predictive value of signals received was about 6%. About 80% of signals were verified within 24 h of reports, and 40% were risk assessed within 48 h. System responses included new mobile clinic sites, measles vaccination catch-ups, and water and sanitation-related interventions. Focus group discussions emphasized that responses generated were an expected return by participant communities for their role in data collection and reporting. Participant communities found the system acceptable when it led to the responses they expected. Some event types, such as those around animal health, led to the community’s response expectations not being met. Conclusions Event-based surveillance can produce useful data for localized public health action for pastoralist populations. Improvements could include greater community involvement in the system design and potentially incorporating One Health approaches.

Background A protracted Ebola Virus Disease (EVD) epidemic in the eastern Ituri, North and South Kivu provinces of the Democratic Republic of Congo (DRC) caused 3470 confirmed and probable cases between July 2018 and April 2020. During the epidemic, the International Federation of Red Cross and Red Crescent Societies (IFRC) supported the DRC Red Cross and other local actors to offer safe and dignified burials (SDB) for suspected and confirmed EVD cases, so as to reduce transmission associated with infectious dead bodies. We conducted a retrospective cohort study of the SDB service’s performance in order to inform future applications of this intervention. Methods We analysed data on individual SDB responses to quantify performance based on key indicators and against pre-specified service standards. Specifically, we defined SDB timeliness as response within 24 h and success as all components of the service being implemented. Combining the database with other information sources, we also fit generalised linear mixed binomial models to explore factors associated with unsuccessful SDB. Results Out of 14,624 requests for SDB, 99% were responded to, 89% within 24 h. Overall, 61% of SDBs were successful, somewhat below target (80%), with failures clustered during a high-insecurity period. Factors associated with increased odds of unsuccessful SDB included reported community and/or family nonacceptance, insecurity and suspensions of the EVD response, low health facility coverage and high coverage of radio and telephony. Burials supported by mobile Civil Protection (local authorities) and/or static, community-based ‘harm reduction’ teams were associated with lower odds of failure. Conclusions A large-scale, timely and moderately performant SDB service proved feasible during the challenging eastern DRC EVD response. Burial teams that are managed by community actors and operate locally, and supported rather than owned by the Red Cross or other humanitarian organisations, are a promising modality of delivering this pillar of EVD control.

Background: ODK provides software and standards that are popular solutions for off-grid electronic data collection and has substantial code overlap and interoperability with a number of related software products including CommCare, Enketo, Ona, SurveyCTO, and KoBoToolbox. These tools provide open-source options for off-grid use in public health data collection, management, analysis, and reporting. During the 2018–2020 Ebola epidemic in the North Kivu and Ituri regions of Democratic Republic of Congo, we used these tools to support the DRC Ministère de la Santé RDC and World Health Organization in their efforts to administer an experimental vaccine (VSV-Zebov-GP) as part of their strategy to control the transmission of infection. Method: New functions were developed to facilitate the use of ODK, Enketo and R in large scale data collection, aggregation, monitoring, and near-real-time analysis during clinical research in health emergencies. We present enhancements to ODK that include a built-in audit-trail, a framework and companion app for biometric registration of ISO/IEC 19794-2 fingerprint templates, enhanced performance features, better scalability for studies featuring millions of data form submissions, increased options for parallelization of research projects, and pipelines for automated management and analysis of data. We also developed novel encryption protocols for enhanced web-form security in Enketo. Results: Against the backdrop of a complex and challenging epidemic response, our enhanced platform of open tools was used to collect and manage data from more than 280,000 eligible study participants who received VSV-Zebov-GP under informed consent. These data were used to determine whether the VSV-Zebov-GP was safe and effective and to guide daily field operations. Conclusions: We present open-source developments that make electronic data management during clinical research and health emergencies more viable and robust. These developments will also enhance and expand the functionality of a diverse range of data collection platforms that are based on the ODK software and standards.

Additional file 8. Technical characteristics of tools as identified from the review, survey, and tool developers’ websites/direct contact. Dataset that describes the technical characteristics of the electronic tools as identified from the systematic review (2010–2020), survey or from review of software websites or contact with software developers. Where no data were found on a particular characteristic of a tool, “don’t know” was entered in the database and where a tool only had one function (data collection or management or analysis), “NA” for not applicable was added to the relevant columns. The Samaritan’s Purse Reporting System was excluded from this database on request from the organisation.

BACKGROUND:Following an influx of an estimated 742,000 Rohingya refugees in Bangladesh, Médecins sans Frontières (MSF) established an active indicator-based Community Based Surveillance (CBS) in 13 sub-camps in Cox's Bazar in August 2017. Its objective was to detect epidemic prone diseases early for rapid response. We describe the surveillance, alert and response in place from epidemiological week 20 (12 May 2019) until 44 (2 November 2019).METHODS:Suspected cases were identified through passive health facility surveillance and active indicator-based CBS. CBS-teams conducted active case finding for suspected cases of acute watery diarrhea (AWD), acute jaundice syndrome (AJS), acute flaccid paralysis (AFP), dengue, diphtheria, measles and meningitis. We evaluate the following surveillance system attributes: usefulness, Positive Predictive Value (PPV), timeliness, simplicity, flexibility, acceptability, representativeness and stability.RESULTS:Between epidemiological weeks 20 and 44, an average of 97,340 households were included in the CBS per surveillance cycle. Household coverage reached over 85%. Twenty-one RDT positive cholera cases and two clusters of AWD were identified by the CBS and health facility surveillance that triggered the response mechanism within 12 hours. The PPV of the CBS varied per disease between 41.7%-100%. The CBS required 354 full-time staff in 10 different roles. The CBS was sufficiently flexible to integrate dengue surveillance. The CBS was representative of the population in the catchment area due to its exhaustive character and high household coverage. All households consented to CBS participation, showing acceptability.DISCUSSION:The CBS allowed for timely response but was resource intensive. Disease trends identified by the health facility surveillance and suspected diseases trends identified by CBS were similar, which might indicate limited additional value of the CBS in a dense and stable setting such as Cox's Bazar. Instead, a passive community-event-based surveillance mechanism combined with health facility-based surveillance could be more appropriate.

BackgroundODK provides software and standards that are popular solutions for off-grid electronic data collection and are the basis of related products like CommCare, Enketo, Ona, SurveyCTO and KoBoToolbox. In combination with the use of statistical analysis software such as R, these tools provide fully open-source options for off-grid use in public health data collection, management, analysis and reporting.ResultsNew functions were developed to facilitate the use of ODK, Enketo and R in large scale data collection, aggregation, monitoring and near-real-time analysis during clinical research in health emergencies. We present open-source enhancements to ODK that include a built-in audit-trail, a framework and companion app for biometric registration of ISO/IEC 19794-2 fingerprint templates, enhanced performance features, better scalability for studies featuring millions of data form submissions, increased options for parallelisation of research projects, and pipelines for automated management and analysis of data. We also developed novel encryption protocols for enhanced web-form security in Enketo. During the 2018-2020 Ebola epidemic in the North Kivu & Ituri regions of Democratic Republic of Congo, ODK, Enketo and R were leveraged to support the DRC Ministère de la Santé RDC and World Health Organization in their efforts to administer an experimental vaccine (VSV-Zebov-GP) as part of their strategy to control the transmission of infection. Against the backdrop of a complex and challenging epidemic response, our enhanced platform of open tools was used to collect and manage data from more than 280,000 eligible study participants who received VSV under informed consent. These data were used to determine whether the VSV-Zebov-GP was safe and effective and to guide daily field operations.ConclusionsWe present open source developments that make electronic data management during clinical research and health emergencies more viable and robust. These developments will also enhance and expand the functionality of a diverse range of data collection platforms (Ona, KoBoToolbox etc.) that are based on the ODK software and standards.FundingThis research is funded by the Department of Health and Social Care using UK Aid funding and is managed by the NIHR (PR-OD-1017-20001).

Background The International Health Regulations require member states to establish “capacity to detect, assess, notify and report events”. Event-based surveillance (EBS) can contribute to rapid detection of acute public health events. This is particularly relevant in low-income and middle-income countries (LMICs) which may have poor public health infrastructure. To identify best practices, we reviewed the literature on the implementation of EBS in LMICs to describe EBS structures and to evaluate EBS systems. Methods We conducted a systematic literature search of six databases to identify articles that evaluated EBS in LMICs and additionally searched for grey literature. We used a framework approach to facilitate qualitative data synthesis and exploration of patterns across and within articles. Results We identified 778 records, of which we included 15 studies concerning 13 different EBS systems. The 13 EBS systems were set up as community-based surveillance, health facility-based surveillance or open surveillance (ie, notification by non-defined individuals and institutions). Four systems were set up in outbreak settings and nine outside outbreaks. All EBS systems were integrated into existing routine surveillance systems and pre-existing response structures to some extent. EBS was described as useful in detecting a large scope of events, reaching remote areas and guiding outbreak response. Conclusion Health facility and community-based EBS provide valuable information that can strengthen the early warning function of national surveillance systems. Integration into existing early warning and response systems was described as key to generate data for action and to facilitate rapid verification and response. Priority in its implementation should be given to settings that would particularly benefit from EBS strengths. This includes areas most prone to outbreaks and where traditional ‘routine’ surveillance is suboptimal.

Despite continued efforts to improve health systems worldwide, emerging pathogen epidemics remain a major public health concern. Effective response to such outbreaks relies on timely intervention, ideally informed by all available sources of data. The collection, visualization and analysis of outbreak data are becoming increasingly complex, owing to the diversity in types of data, questions and available methods to address them. Recent advances have led to the rise of outbreak analytics, an emerging data science focused on the technological and methodological aspects of the outbreak data pipeline, from collection to analysis, modelling and reporting to inform outbreak response. In this article, we assess the current state of the field. After laying out the context of outbreak response, we critically review the most common analytics components, their inter-dependencies, data requirements and the type of information they can provide to inform operations in real time. We discuss some challenges and opportunities and conclude on the potential role of outbreak analytics for improving our understanding of, and response to outbreaks of emerging pathogens. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This theme issue is linked with the earlier issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.

Background: Sexually transmitted infections (STIs) pose a serious public health problem globally. The rapid spread of mobile technology creates an opportunity to use innovative methods to reduce the burden of STIs. This systematic review identified recent randomised controlled trials that employed mobile technology to improve sexual health outcomes.Methods: The following databases were searched for randomised controlled trials of mobile technology based sexual health interventions with any outcome measures and all patient populations: MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, NHS Health Technology Assessment Database, and Web of Science (science and social science citation index) (Jan 1999-July 2014). Interventions designed to increase adherence to HIV medication were not included. Two authors independently extracted data on the following elements: interventions, allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. Trials were assessed for methodological quality using the Cochrane risk of bias tool. We calculated effect estimates using intention to treat analysis.Results: A total of ten randomised trials were identified with nine separate study groups. No trials had a low risk of bias. The trials targeted: 1) promotion of uptake of sexual health services, 2) reduction of risky sexual behaviours and 3) reduction of recall bias in reporting sexual activity. Interventions employed up to five behaviour change techniques. Meta-analysis was not possible due to heterogeneity in trial assessment and reporting. Two trials reported statistically significant improvements in the uptake of sexual health services using SMS reminders compared to controls. One trial increased knowledge. One trial reported promising results in increasing condom use but no trial reported statistically significant increases in condom use. Finally, one trial showed that collection of sexual health information using mobile technology was acceptable.Conclusions: The findings suggest interventions delivered by SMS interventions can increase uptake of sexual health services and STI testing. High quality trials of interventions using standardised objective measures and employing a wider range of behavioural change techniques are needed to assess if interventions delivered by mobile phone can alter safer sex behaviours carried out between couples and reduce STIs.