In 2012, Texas surpassed Arizona in migrant deaths. The majority of deaths occurred in the Rio Grande Valley, specifically in Brooks County, Texas. Brooks County is one of the poorest in the state and was overwhelmed with deaths, without appropriate resources to follow the state laws pertaining to the investigation of unidentified human remains. Until 2013, most remains that were not immediately identified were buried without collecting DNA samples and the location of burials was not recorded. Our paper outlines the difficulties searching for these burials, the struggles of the families of the missing, and the collaborative approaches to facilitating identifications in South Texas. Community outreach combined with geophysical surveys guide which cemeteries are in need of exhumations. Once cemeteries are surveyed, archaeological methods are employed to exhume remains and document burials. Remains are taken to the Forensic Anthropology Center at Texas State for processing, analysis, and identification efforts. Undergraduate and graduate students clean remains and wash clothing and personal effects.After skeletal analysis, all information regarding the remains, including photographs of personal effects, are uploaded to the National Missing and Unidentified Persons System (NamUs) and a DNA sample is submitted to the University of North Texas for inclusion in the Combined DNA Index System (CODIS) DNA database. However, CODIS lacks DNA family reference samples from many families of the missing due to families living outside the US or because they do not feel comfortable providing a DNA sample in the presence of law enforcement. Therefore, it is necessary to work with non-governmental organizations who specialize in collecting missing persons reports and DNA samples from the families of the missing. Working collaboratively with multiple agencies, identification of migrant remains is possible. In 1994, President Bill Clinton enacted a United States Border Patrol (USBP) strategy called “Prevention through Deterrence” in an attempt to deter migration at the US/Mexico border. This strategy funnelled migrants into Arizona’s Sonora Desert resulting in thousands of migrant deaths in the years that followed. Between 1991 and 2012, a total of 2238 migrants died attempting to cross the border in Arizona and is likely an underestimation of actual deaths [In 2012, Texas surpassed Arizona in migrant deaths for the first time with a surge of migrants fleeing violence from Central America. Further, according to USBP statistics, Texas has a higher percentage of females and unaccompanied minors that attempt to cross the border . For theThe purpose of this article is to focus on identification strategies for migrants that die in South Texas. Because not all unidentified human remains are sent to a medical examiner’s office, positive identification and repatriation is challenging.On May 1, 2013, a woman named Marta Iraheta, spoke to a crowd in Houston about her nephew Elmer who was dehydrated, hurt, and left to die in the South Texas desert . Elmer wIn Brooks County, remains of suspected migrants were sent to a funeral home for autopsy services and identification efforts from 2006 to 2013. If the remains were not identified by the funeral home, they were buried. The Justices of the Peace in Brooks County have legal jurisdiction over the unidentified human remains and by state law are required to keep track of the final disposition of the remains. Despite being the law, recording the final disposition of unidentified remains was not enforced, and no one tracked where Elmer or any other human remains were buried. In 2012, grassroots organizations, including the Migrant Right’s Collective, began protesting in Brooks County and were specifically concerned that unidentified human remains were not being sampled for DNA. Eventually, protests and lobbying of state senators by these non-governmental organizations allowed Brooks County to obtain additional funding to send all unidentified human remains to the Webb County Medical Examiner’s Office, located approximately an hour and a half away. Brooks County is among the poorest counties in Texas and did not have the funds to pay for transportation and contracted autopsy services prior to funding from the state. Although unidentified remains have routinely been seen by a medical examiner since 2013, the practice of burial at Sacred Heart without DNA sampling and without recording the specific location of burials since 2006  has left many long-term dead buried somewhere in the cemetery without the possibility of identification and repatriation.Elmer disappeared in 2012, the year that Brooks County recorded approximately 130 deaths. From 2009 (the year that Sheriff’s Office began to collect searchable records) through 2013, the county found and buried 326 individuals. It is unknown how many individuals were buried in the years prior to official record keeping. While the TCCP mandates that the final disposition of unidentified human remains must be recorded by the Justice of the Peace and documented on a death certificate, Elmer’s burial along with all the other unidentified burials were not recorded. Although temporary markers were used to mark some graves, the riding lawn mowers used to maintain the cemetery often displace the markers and they may be replaced in the wrong location or never replaced at all. Even though it was known that Elmer was buried in Sacred Heart, it was not possible to locate his grave due to lack of burial records for the cemetery and burial practices within the county.What happened to Elmer is representative of what happened to most of the migrants that died in Brooks County prior to 2013. Elmer’s story exemplifies the invisibility of migrants and the trauma endured by families that have no power within the local and state agencies that have failed to follow the state laws.Operation Identification or OpID. The goal of OpID is to locate, identify, and repatriate unidentified human remains found on or near the South Texas border through community outreach, forensic anthropological analysis, and collaboration with governmental and non-governmental organizations while training the next generation of forensic anthropologists.In 2013, volunteer exhumations took place at Sacred Heart directed by Baylor University (Dr Lori Baker) and University of Indianapolis (UINDY) (Dr Krista Latham). The exhumations began in areas that contained grave markers indicating “unidentified” and “unknown” remains. A total of 68 remains were exhumed. In total, 45 remains were brought to Texas State University for forensic anthropological analysis and identification efforts, under an effort named https://forensicbordercoalition.org/). Temporary markers are often displaced or have paper documentation which easily fades, and records are not readily available to pinpoint the location of burials of unidentified human remains. Discovering the specific cemeteries where migrants are buried and locating individual burial locations within each cemetery is a challenging task. The FBC has been searching for burials of suspected migrants since 2015 through community outreach, public records requests, and cemetery surveys. OpID works with the FBC to facilitate the exhumations of burials that are suspected to be unidentified migrants.Since 2016, OpID and UINDY volunteers have exhumed remains in Brooks, Starr, and Willacy Counties . In JanuFrom the information gathered by the FBC and knowledge gained from previous exhumations concerning general placement of suspected migrants within each cemetery , areas of high-probability or regions of interest are noted. Prior to exhumations, each region of interest within a cemetery is mapped using a survey grade mapping instrument, either a Real-Time Kinematic (RTK) GPS system or a total station, and areas of interest are subjected to Ground Penetrating Radar (GPR) survey. Since many of the migrants are buried in body bags rather than coffins or containers, processed GPR data often do not present strong, clearly interpretable anomalies. In addition, soil conditions at some of the cemeteries of interest are poorly suited for GPR scanning. For example, the soil at the Rio Grande City County Cemetery is classified as a very gravelly loam transitioning to cemented material , which iSystematic use of GPR and geolocation information of burials found through exhumation efforts provide a robust data set for improving the detection of these types of burials in future exhumations. Once areas of interests are mapped and scanned, archaeological excavation techniques are used to exhume remains. While some cemeteries are straightforward, with burials being organized according to rough plot lines at consistent depths, some cemeteries require more extensive archaeological experience to readily observe, interpret, and follow soil disturbances to locate and exhume the unidentified buried there.Once remains are located, exposed, photographed, and mapped using GPS they are removed from the ground and placed inside a new body bag and given a unique case number. Next, the remains are subject to a field intake which includes preliminary investigation of the contents of the body bag or other burial container. During intake, an external examination is completed which includes documentation of the condition of remains, scars, tattoos, evidence of DNA sampling, and personal effects inventory. Documentation includes written notes and photographs.The outer most body bag is then sealed and placed in a secure location for the duration of field work. Depending on the circumstances in the field and the scale of the exhumations being undertaken, personal effects may be removed from the remains during intake, then bagged and labelled immediately with the case number. This step may be done to expedite processing upon return to the lab. All personal effects are stored in a freezer prior to cleaning in an effort to mitigate any damage which may be caused by decompositional fluid.All remains are then transported to the Forensic Anthropology Center at Texas State (FACTS). The majority of remains are stored at the Forensic Anthropology Research Facility (FARF) until room is available for processing the remains in the Osteological Research and Processing Laboratory (ORPL). Decompositional research at FARF is conducted only on remains of individuals who have donated themselves or the next of kin has donated and proper consent has been given. FARF acts only as a secure holding facility for exhumed migrant remains. Once the remains are brought to ORPL, a lab intake is conducted prior to processing. This intake consists of opening the body bag in the processing lab, locating and inventorying all remains, removing and photographing any personal effects still with the remains, screening decomposition fluid and/or dirt for small or fragmentary bones or personal effects, and noting the condition of remains. Contemporaneous notes are taken and the entire process is photo-documented. Any personal effects discovered during lab intake procedures are bagged, labelled, and placed in the freezer with all other unprocessed personal effects to prevent further deterioration.www.namus.gov) along with any information gleaned through skeletal analysis.The bones are placed in a steam-jacketed kettle with water and a mild detergent to help loosen remaining soft tissue. A small amount of disinfectant is also added to the water to kill any harmful microorganisms which may be present. Upon removal from the kettle, the bones are cleaned at an autopsy sink and laid to dry for skeletal analysis. After skeletal analysis, a left fifth metatarsal is removed for DNA profiling. If a metatarsal is not available, then a vertebra is selected. If the case consists solely of a cranium, a section of the petrous portion is cut for DNA sample submission. If no other small bones are available, a section of a long bone is submitted. Metatarsals have thus far have been successful at yielding full STR profiles with only a few cases requiring resubmission. Once the remains have been analyzed and a DNA sample obtained, they are placed in a cardboard box and curated pending identification. The personal effects are washed in five-gallon buckets with plungers and line dried. Once dried, the clothes and personal effects are photographed and uploaded to the National Missing and Unidentified Persons System .Circumstances regarding the case, including the location the remains were found, is included in the report and uploaded to NamUs. Many families know the date last known alive and may know an approximate last-known-alive location because of cell phone conversations or from geolocation information from photos sent to family members. This information is important to archive if a genetic association is made, as all antemortem and postmortem information along with the DNA report must be reviewed for consistency. Therefore, obtaining case information along with missing persons’ information from the South Texas Human Rights Center and from the local sheriff’s office has been extremely important in facilitating identifications.Because OpID has standard data collection procedures, data are then available that can help address broad research questions concerning the overall health of these migrants and where they come from in addition to potentially providing supportive evidence for why they migrant . For example, graduate student research has addressed limb proportionality and health , geograpWorking within the United States, there are federal tools available for missing and unidentified persons that can be utilized both directly and indirectly by forensic anthropologists, specifically NamUs and Combined DNA Index System (CODIS). All cases exhumed from South Texas that are considered part of OpID are input into NamUs. For unidentified persons (UPs), NamUs contains information regarding where and when the remains were found, demographic characteristics, photographs of clothing, and other personal effects (if available), whether DNA has been submitted to CODIS, a dental chart, as well as other information pertaining to the case. For missing persons (MPs), NamUs contains the full suite of information found on a missing person’s report, including where and when the person was last known alive, basic demographics and unique characteristics, a facial photograph, known medical conditions, surgeries and/or implants, a dental chart, and whether a family DNA reference sample (FRS) has been submitted to CODIS.CODIS is made up of a series of databases that contain DNA from missing individuals or their family, unidentified human remains, and DNA from criminal offenders, arrestees, and crime scenes. CODIS is further broken down into local DNA index system (LDIS), state DNA index system (SDIS), and national DNA index system (NDIS) databases. CODIS was founded and is owned by the FBI and in Texas, state laws require DNA from all unidentified human remains be sent to the University of North Texas Center for Human Identification (UNTCHI) for DNA profiling and upload to CODIS. Texas has one of the few labs in the country accredited to upload unidentified human remains DNA profiles into CODIS. Because UNTCHI receives money from the federal government , they provide this service for free to all states. CODIS software works to find genetic associations by routinely comparing the short tandem repeats (STR) profiles from the unidentified human remains sample to FRS and the criminal offender database. Although, according to CODIS policy, FRS genetic profiles are never compared against criminal offender, arrestee, and crime scene profiles.www.namus.gov). Law enforcement presence may deter members of the undocumented population from reporting a missing person. Additionally, undocumented individuals may also be reluctant to have their DNA in a database owned by the federal government. Furthermore, families in Latin America that are missing a loved one are unable to get their DNA sample into CODIS for continuous cross-referencing under current regulations and protocols. Therefore, while DNA samples are submitted to CODIS from unidentified human remains, CODIS lacks the many FRS necessary to generate genetic associations that will lead to positive identification.In order for a family to submit DNA for inclusion to CODIS, a law enforcement officer from an investigative agency  must be present at the time the DNA sample is obtained , the Migrant Rights Collective and the South Texas Human Rights Center, work with Harris County to provide a safe space for anyone to report a missing person known to have gone missing at or around the South Texas border. The NGOs help to spread the word within the community that the Missing Day provides a safe space where citizenship status is not questioned. Here the Migrant Rights Collective and South Texas Human Rights Center obtain a missing person’s report from the family and then the family gives consent to have their DNA sample taken and uploaded to CODIS. OpID has a total of 13 identifications resulting from genetic associations within CODIS. Over half of the CODIS genetic associations are direct results of the non-governmental associations work during the Missing Day.Each year, the Harris County Institute of Forensic Sciences hosts a The remaining identifications from OpID come from working with another NGO, the Equipo Argentino de Antropología Forense (EAAF). The EAAF has been working along the US/Mexico border since 2009 . They alThe EAAF has FRS from families of the missing and CODIS has DNA samples from unidentified human remains. However, due to policy restrictions within the United State federal system, it is currently not possible to conduct, large-scale DNA cross-referencing, despite 5 years of negotiations. If the DNA profiles from both systems were routinely cross-referenced on a large scale, hundreds if not thousands of individuals could be identified and repatriated to their families.In the fall of 2013, student volunteers began to wash clothing. Several days later, a brown plaid shirt and black sneakers associated with case number 0387 were drying in the processing lab. At that time, there were only eight NamUs entries for missing persons last known alive in Brooks County. In looking over the MP reports in NamUs, one entry was for Elmer. Elmer’s NamUs entry provided witness testimony from a coyote (a paid guide to help migrants cross the border and arrive at a specified destination) who stated that Elmer had a hurt leg and someone tied a brown plaid shirt around his knee. Elmer was left underneath a tree near Falfurrias because he could no longer walk and he was dehydrated.Based on the description of the brown plaid shirt, a further comparison of antemortem (MP) information was checked against the anthropology report and the full listing of personal effects. All circumstantial evidence suggested that OpID case 0387 and Elmer were likely one in the same. Elmer had dental records available, which is rare for the migrant cases. Dr James P. Fancher, certified by the American Board of Forensic Odontology, compared the antemortem and postmortem data and concluded they were one in the same. While a dental identification is sufficient in most cases, the EAAF had a DNA sample on file and chose to pursue a DNA identification. Elmer’s family reported him missing in August of 2012 and the EAAF collected DNA from the family at that time. After discussion with EAAF, a bone sample was sent to a private lab for genetic profiling and compared to Elmer’s FRS. All costs associated with genetic analyses were paid for by the EAAF. Based on the genetic comparison, along with the comparison of antemortem and postmortem data and a forensic odonotology exam, a positive identification was concluded, giving Elmer his name back.Because the Justice of the Peace (JP) has jurisdictional authority within Brooks County, an identification report was written by the EAAF, and a request was submitted to the JP in charge of the case to approve and sign the identification report so the name could be legally changed on the death certificate and Elmer could be repatriated to his family in El Salvador. The El Salvadoran consulates in the cities of Houston and McAllen both assisted with the logistical issues and the finances associated with repatriation.The majority of Texas counties are under jurisdiction of the JP as there are only 13 county medical examiner offices in the state. While a medical examiner can provide autopsy and identification services and has the authority to make a positive identification, it can be more difficult for the 241 counties outside of the medical examiner system, especially for the counties in South Texas faced with a high death toll. With regard to migrant deaths in South Texas, successful identification and repatriation require collaboration between multiple agencies, institutions of higher education, local and international non-governmental organizations, local law enforcement, USCBP, and consulates.To date, three large-scale exhumations have taken place in the Sacred Heart Burial Park in Brooks County. The first in May of 2013, the second in June of 2014, and the third in January of 2017. The first two exhumation seasons focused on areas where temporary burial markers indicated the location of unidentified burials and ultimately those two field seasons yielded 122 set of human remains; an additional 44 set of human remains were recovered from a funeral home storage area. From 2013 through 2014, OpID was 100% volunteer based and while casework and identifications advanced, the work was slow. In 2015, OpID received funding to hire a post-doc and part-time lab assistant to reduce the backlog of processing and casework; the amount of case reports written tripled with the hires. Funding is not guaranteed each year, but has been steady since 2015. At this time, there are 270 cases at Texas State associated with OpID.In January of 2017, OpID and UINDY conducted another field season at Sacred Heart Burial Park. A total of eight markers were visible and guided where the work would begin. In one exhumation area, approximately the size of an average plot, with a single marker present, three individuals were recovered. Several days into field work, a groundskeeper who worked for the county informed the authors that there were several other areas that contained burials and indicated their location. One such area was situated at the intersection of two cemetery roads and temporary burial markers were no longer present. The groundskeeper indicated he knew three people were buried there, roughly in a row, because his riding lawnmower pulled the markers out of place and he forgot to replace them. Geophysical data were collected using GPR. Once excavated, this area which reportedly contained the remains of three individuals, actually contained eight.An example of the combination of GPR data with high-resolution GPS mapping of this area is presented in The other area pointed out by the groundskeeper still had three temporary markers in place. These markers were recorded using GPS to be exhumed during a later field season. At the end of the January field season, 24 individuals were exhumed, and additional areas of interest were located, while initially thinking only eight burials would be exhumed. Towards the end of the field season, a man approached MKS and told her he dug many of the graves of the unidentified by hand and indicated other areas of interest that need to be exhumed. Based on this informant testimony, what was learned during the 2017 field season , and the fact that there were at least 6 additional years of burials within Sacred Heart prior to 2012, more extensive/exhaustive search strategies were needed.In March of 2018, a pedestrian search of the entire cemetery grounds was conducted , during During the pedestrian survey another informant (community member) indicated that he remembered multiple burials of unidentified people in one of the areas already identified by OpID as high probability requiring additional investigation. Due to the preponderance of informant testimony, unaccounted for remains based on Sherriff’s office records, and GPR data currently being analyzed, subsequent exhumations will be planned at Sacred Heart Burial Park to ensure that all unidentified migrants buried there are afforded due effort towards identification, as prescribed under the law.The large number of deaths occurring along the US-Mexico border represents a growing humanitarian crisis in both Arizona and Texas. After the attempt to secure the border using the strategy of "Prevention through Deterrence" initiated in 1994, migrants trying to enter the United States were pushed out of urban areas and funnelled into remote and dangerous terrain, resulting in mass fatalities in the region. For Texas, the epicentre of this crisis is situated in Brooks County, near the location of a US Customs Border Patrol Checkpoint. Due to the relatively small population within the county, death investigation falls to the Justice of the Peace. Although the Texas Code of Criminal Procedures Chapters 49 and 63 requires Medical Examiners and Justices of the Peace to conduct an inquest, submit DNA for identification purposes, and record the final disposition of any unidentified remains, the law was not routinely followed in Texas, particularly regarding suspected migrant remains.Because of the fragmented system in Texas and failure to follow state laws, many unidentified human remains were not analyzed by forensic specialist (pathologist or anthropologist) and were buried without DNA sampling. In these cases, exhumations are necessary although the question of where to exhume and how many are in need of exhumation is a difficult question to answer. To locate migrant burials, it is necessary to use a multidisciplinary approach, including ethnographic research methods to ascertain memory recall, geophysical and archaeological approaches, and historic and public records searches. Furthermore, a transnational and collaborative approach to facilitate positive identification is necessary as not one institution or agency could solely take care of locating, exhuming, identifying, and repatriating unidentified human remains in Texas. To date, 29 individuals have been positively identified through this multi-disciplinary and collaborative approach.


Few investigations to date have analyzed the epidemiology of Hansen’s disease (leprosy) in the United States, and in particular, if birth location is related to multibacillary versus paucibacillary leprosy. We collected data on 123 patients diagnosed with leprosy in Georgia from the National Hansen’s Disease Program from 1923—January 2018. A logistic regression model was built to examine the relationship between country of origin (U.S.-born or immigrant) and the type of leprosy. While the model showed no significant relationship between country of origin and type of leprosy, being Asian or Pacific Islander was associated with a higher odds of multibacillary disease . Furthermore, since the early 1900s, we found an increasing trend of leprosy reports in Georgia among both domestic born and immigrant residents, despite the overall decrease in cases in the United States during the same time period. More research is therefore necessary to further evaluate risk for multibacillary leprosy in certain populations and to create targeted interventions and prevention strategies. Leprosy is often believed to not be an issue in many countries. However, the disease is still very much a problem globally, and in the past several decades has been on the rise in the United States. Frequently the disease is misdiagnosed several times before appropriately treated. Although newly diagnosed cases in the United States only remain around 160 every year, there is limited investigation of leprosy in the United States. As the concern over transmission from armadillos continues to rise, coupled with the increase in connectedness of the global population, it is important to be able to identify populations at higher risk for the more infectious form of leprosy, multibacillary leprosy, for targeted interventions. The researchers sought to investigate which populations are at higher risk for this more infectious form, while also describing the history of cases in the state of Georgia. By adding to the body of literature on leprosy in the United States, it is the hope that more research will be produced that provides a better understanding of the disease trends within the country, while also enabling more targeted interventions. Mycobacterium leprae (M. leprae), which can affect the skin, peripheral nerves, mucosa of the upper respiratory tract, and the eyes[Leprosy  is an uncommon infectious disease that has been affecting people since ancient times. It is caused by the bacillus,  the eyes. It comm the eyes. Hansen’ the eyes.M. leprae occurs through droplets from the nose and mouth during close and frequent contact with untreated patients, usually those with multibacillary infection[Dasypus novemcinctus), which is the only other mammalian reservoir of M. leprae and the only known environmental reservoir within the Americas[Leprosy is classified by histopathology from a skin biopsy, or by clinical presentation when a biopsy is not available, 3. In tinfection. Studies Americas, 5. Lepr Americas.-7 per million people), which is consistent with the number of cases reported in prior years[Global leprosy burden affects low- and middle-income countries predominately, with about 200,000 cases reported annually. India, ior years.The United States has a long history of leprosy, even before its founding, tracing back to the Acadian people from Canada who migrated to French Louisiana in the mid 1700s. In 1917Currently, most of the cases of leprosy seen in the United States are among immigrants from countries with higher leprosy endemicity. In factThere are very few studies that examine the differences in PB and MB leprosy among immigrants and U.S. born citizens. Because MB disease is associated with a higher risk of complications and secondary transmission, it is important to understand the patterns of disease manifestations and epidemiologic characterizations of this type of leprosy. WhetherData on age, ethnicity, location of birth, type of leprosy diagnosed, and sex were extracted from leprosy surveillance reports of cases in Georgia from 1923 to January 2018. This data came from the NHDP Center in Baton Rouge. Leprosy is a reportable disease in Georgia and is monitored primarily through passive surveillance. An example of the current surveillance form used can be seen in Appendix 1 (S1 Appendix). Inclusion into the study was any patient from any year on record who was a resident of Georgia or was reported by a clinic in Georgia.Chi-squared tests and t-tests were done, where appropriate, to assess bivariate differences between the domestic and foreign-born populations. A multivariate logistic regression model was then built, with multibacillary (versus paucibacillary) leprosy as the outcome and birth location as the exposure of interest, controlling for several variables . Birth location was defined as the birth place of the patient, with domestic cases referring to patients who were born in one of the 50 U.S. states, and abroad locations referring to patients who were not born in the United States and displayed symptoms either before or after moving to the United States. Age and sex were included because MB is typically more common in older adults and men, respectively, 21, 22.This study was approved exempt from review by the Emory University Institutional Review Board. SAS version 9.4  was utilized for analysis.Of the 138 cases that met inclusion criteria at the National Hansen’s Disease Program, 123 cases (89.13%) were included in the final model for all years. The 15 cases not included had missing data for one or more of the variables and were thus excluded in this complete case analysis. Of the 123 cases, 39 (31.71%) were born domestically and 84 (68.29%) were born abroad . For botLocation of birth was not significantly associated with the type of leprosy in the logistic regression model  when controlling for age, sex, and ethnicity . HoweverIn the model built using data after 1995, 55 of tThis novel analysis of leprosy cases in the state of Georgia revealed several notable findings. The younger average age of the population born abroad compared to the domestically born cases is of note, as it shows the greater risk of infection younger populations face in their home countries. Given the higher prevalence of leprosy in many countries of origin for foreign-born cases as compared to the U.S., this makes sense. The incM. leprae[The fact that those of Asian and Pacific Islander ethnicity are at greater odds of MB disease is of note. One explanation could be that there is a higher likelihood of MB disease in Asian and Pacific island countries, suggesting factors such as host genetics, micronutrient deficiencies, the limited gene pool of an island nation, or other co-morbidities that depress the immune response to M. leprae. These iM. leprae. AdditioM. leprae. HoweverIn the model built using data after 1995, birth location was again not associated with type of leprosy , but being Asian and Pacific Islander still showed a statistically significant association with MB leprosy . Additionally, age was shown to have a statistically significant relationship with PB leprosy, but with the aOR so close to 1, this is likely not clinically meaningful . Also, in the past 10 years, there has been more evidence of armadillo reservoirs of infection including the southern U.S., Mexico, and even in Brazil, which is the country with the second highest number of cases globally, 27–34. There are several limitations to this study. While leprosy is a reportable disease in Georgia, there is always the potential for underreporting of cases. We would assume that the surveillance data is a complete population of those that have leprosy living in Georgia, but there are likely missed cases due to missed data entry on surveillance reports, individuals who are misdiagnosed and therefore not reported, or those who do not seek care. With such a small number of cases, the loss of 15 cases due to incomplete data also could have significantly impacted the results. The overall small study sample could limit the ability to discover a significant association.There were several variables that we would have liked to include in the model, but were unable to attain data on. First, we would have liked to know about potential prior armadillo contacts and contact with known infected leprosy patients. While it is not known how armadillos transmit infection, contact with armadillos has been found to be associated with Hansen’s disease, 33, 34.Because the sample used is only of cases from Georgia, we cannot generalize these findings to leprosy cases from other states. A more complete study should be done utilizing all cases from the 50 states to better assess the relationship between birth location and type of leprosy diagnosed. This would also give a more holistic view of the epidemiology of leprosy in the United States. Unfortunately, due to limitations in data collection and data use, we were unable to utilize data from all states.As it stands, leprosy research, specifically research that focuses on United States leprosy patients, is fairly limited. In an increasingly globalized world where movement of people is easier now than ever before, leprosy cases will continue to appear all around the world. The upward trend of cases seen since the 1970s in Georgia and the increasing rates of immigration into the state are an impetus for further study of this reemerging disease which can cause severe disability and around which persistent stigma exists. AlthougS1 File(PDF)Click here for additional data file.


Long bone fractures are common injuries caused by trauma and are a common cause for referral to hospitals. Little consideration has been given to the impact of long bone fractures in adults despite the World Health Organization’s statement that such injuries cause substantial morbidity in low- and middle-income countries.This review targeted published studies conducted from 1990 to 2017 that examined the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults.This scoping review involved a systematic literature search using key terms in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight and Ebscohost Research databases and Google Scholar.From a total of 297 publications, 19 met the inclusion criteria: four publications focused on the impact of fractures of the humerus, one publication looked at ulna fractures, six publications focused on distal radius fractures, five looked at femur fractures and three focused on tibial fractures.Long bone fractures have a considerable impact on many facets of a patient’s life. In some cases, the fracture prevents patients from working and meeting financial obligations. The injury limited previously normal social interactions and pre-injury functioning. Future research should examine the impact of long bone fractures in Africa, as there were very limited studies, which were identified. More than 90% of injuries, particularly fractures of the extremity, occur in LMICs.2 Some studies have indicated that road traffic accidents cause 68.14% of fractures in some LMIC countries. Falls are also a serious public health problems worldwide because they can also cause re-injury. Some studies have demonstrated that falls have a prevalence of 21.8% and 35.1%.5 The burden of long bone fractures impacts society through the loss of productivity, the direct and indirect costs of treatment and the additional contribution to morbidity and mortality. The management and treatment of long bone fractures add significantly to the expenses of any health care system because of the cost of surgery, possible rehospitalisation and the physical rehabilitation of patients.6Numerous studies and reports by the World Health Organisation indicate that injury is a substantial cause of morbidity and mortality in low- and middle-income countries (LMICs).7 As the standard of health and lifestyle improves in LMICs, one can expect that the older population, who are more prone to falls and fractures, will be greatly affected. Therefore, the burden is expected to rise substantially. We sought to answer the following question: what effect do long bone fractures have on the psychological, social, financial, occupational and physical health of patients?Depressive symptoms such as catastrophic thinking, changes in appetite and sleep pattern are common after a fracture.Literature searches were conducted in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight Ebscohost Research databases and Google Scholar to avoid missing other relevant articles not published in a journal. The reference lists of all chosen publications were also searched to source additional publications that may not have appeared in the search results. The search terms used were the following: impact of long bone fractures and/or psychological impact of long bone fractures and/or social impact of long bone fractures and/or financial impact of long bone fractures and/or occupational impact of long bone fractures and/or physical impact of long bone fractures and/or impact of humerus fractures and/or impact of radius fractures and/or impact of ulna fractures and/or impact of femur fractures, impact of tibia fractures and/or impact of fibula fractures.Publications that were published in English only were included in the review. The inclusion criteria concentrated on studies that included participants aged 18 years and older who sustained one long bone fracture because of injury or pathology. For this review, only six long bones were included: the humerus, radius, ulna, femur, tibia or fibula. Both qualitative and quantitative studies published in English were included.The study needed at least one outcome, that is, the psychological, social, financial, occupational or physical impact of the long bone fracture. Studies conducted before 1990, or those that did not reveal the age of participants or the name of the fractured bone, were excluded from the study.To reduce bias, both authors (S.S. and M.N.) screened all titles and abstracts while being guided by the inclusion and exclusion criteria. Disagreement was resolved through discussion and final consensus. Publication bias was reduced by considering studies with limited sample sizes and studies with non-statistically significant results. Google Scholar was also searched to source grey literature.The study selection involved three steps:In the first step, keywords and screening of titles were searched that returned 286 publications. Eleven publications were identified through a search of the reference lists. A total of 297 publications were included after exclusion criteria and duplicates were excluded.The second step was the screening of the titles and abstracts, which was performed by the second reviewer that resulted in 267 publications being excluded. Five additional publications were excluded by the second reviewer after screening of the titles and abstracts.9 The MMAT is presented in Appendix 1. Only studies with a score of 50% or more were included. Six publications were excluded after being assessed using MMAT. Approximately 25 minutes was spent on the appraisal of each article. Finally, 19 eligible publications were included in the analysis.Full-text screening was performed on 30 records. After full-text screening, five publications were excluded. This resulted in 25 publications having been assessed using the mixed-methods appraisal tool (MMAT) version 2018, a reliable critical appraisal tool that allows researchers to assess the methodological quality of publications because critical appraisal is an important aspect of scoping reviews.The PRISMA 2009 flow diagram tool was used to demonstrate the search process see . A standThis review is part of a PhD thesis, which has been reviewed by the Biomedical Research Ethics Committee, under the protocol reference number BE 583/16. The title of the thesis is ‘The perceived psychological, social, financial, occupational and physical impact of long bone fractures in adults in KwaZulu-Natal’. The study enrolled 821 research participants from nine hospitals. To our knowledge, there is no other study investigating this topic. The purpose of this review is to gather information on this topic.31The average age of participants in all studies was 63.7 years. The earliest study was conducted in 1997 and the latest study was in 2016. Three studies were set in Japan, three in Canada, one in Australia, one in France, one in Austria, one in Norway, four in the United Kingdom, and three in the United States of America, two of which were in New York City and one in Grand Rapids. Orthopaedic research regarding the psychological, social, financial and occupational impact of long bone fractures in LMICs has unfortunately been very limited because these countries have mainly focused on infectious and nutritional illnesses.The sample size ranged from 9 to 609 respondents per study. In some studies, the respondents had a surgical orthopaedic intervention. Four studies focused on fractures of the humerus, one on ulna fractures, six on distal radius fractures, five on femur fractures and three on tibial fractures. Most of the studies focused on distal radius and femur fractures. Three studies focused on the physical impact of proximal humerus fractures, one on the physical and occupational impact of ulna fractures, two on the physical and occupational impact of long bone fractures, two on the physical impact of distal radius fractures and one on the physical and psychological impact of distal radius fractures. Four studies focused on the physical impact of femoral fractures; one on the physical and social impact of femur fractures; one on the financial, occupational and social impact of tibia fractures; one on the physical impact of tibia fractures; and one on the physical, financial, social, psychological and occupational impact of tibia fractures. There were very few studies on the impact of fibula fractures, but none of them met the criteria for this systematic review. Most of the studies focused on the physical impact of the long bone fractures.33 The biopsychosocial model (BPSM) offers a broader and holistic approach for healthcare professionals to understand human behaviour, disease and infirmities.33 The biopsychosocial approach should be applied after a patient sustains a fracture and this may aid in addressing other factors that might influence an individual’s recovery. The BPSM comprises three dimensions that can be used to assess post-fracture outcomes: biological, psychological and social factors. The biological dimension deals with the physical impact of the fracture.33 The psychological dimension comprises the psychodynamic factors affecting patients after the fracture and the social dimension examines the external influences such as support from family and friends, financial influences and possible changes to job or loss of income after the fracture. Research from high-income countries suggests that timely and adequate treatment leads to quicker recovery. Various authors have suggested that health care resources and finances of the patient also influence a patient’s recovery.34 To accurately understand the impact of long bone fractures, the BPSM was adopted as the analytical framework. The literature supports this framework as fractures affect the biological, psychological and social aspects of a patient’s life (see The World Health Organization states that ‘health is a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity’.life see .The results will therefore be presented under three headings, namely, psychological and social, financial and occupational and physical impact of long bone fractures.35 Depression is common following injury and may adversely affect clinical outcomes. Further to this, a failure to return to the level of functioning before the fracture may cause symptoms of depression.35 Trickett and colleagues’27 qualitative study described how patients felt after an open tibial fracture. All patients were fearful of falling and were conscious of the aesthetic appearance of the fractured limb. Two patients described using alcohol as a means of coping with the circumstances surrounding the injury. In contrast, MacDermid and colleagues14 found that distal radius fractures had minimal effect on the patient’s psychological state. In a 2017 study by Grenier et al.36 it was found that the presence of a fear of falling causes dysfunction in the neural networks connected to motor imagery abilities, and therefore these patients are more susceptible to re-injury. Fearful patients may not comply with the physical rehabilitation which may reduce one’s ability to complete activities of daily living leading to an increase in patient dependency. Glover and colleagues37 advise that the most effective approach to managing fear of falls is psychological and physical intervention. Kammerlander et al.22 found that 23% of patients were physically unable to leave their home after sustaining a distal femoral fracture and as a result were not able to socialise. In 2012, Trickett and colleagues27 also confirmed that a tibial fracture prevented previously normal social interactions. This lack of social support may contribute to injury reoccurrence, rehospitalisation and higher personal and societal health care costs. The use of caregivers with a health care background is a useful way of lending emotional support to patients to reach their recovery goals.38Psychological sequelae are common after long bone fractures and include post-traumatic stress disorder, depression and anxiety.28 examined the financial implications of tibial fractures after 6–20 months and found that 29% of patients returned to work at the anticipated time of recovery, 36.8% reported selling possessions to pay their expenses and 42.1% used social welfare initiatives. It was noted that all patients in white-collar jobs returned to work sooner than others, whereas only 14.3% of blue-collar workers returned to work at the last follow-up visit. Forty-two percent of patients used friends and family as a source of financial aid. Only 29.2% of patients returned to work at a mean follow-up of 11.8 months.28 Trickett and colleagues27 described how the inability to work, following a tibial fracture, led to financial implications. Larsen and colleagues39 suggest that fractures of the lower extremity limit positive results, such as returning to work and performing activities of daily living independently. Returning to work is regarded as an important outcome in orthopaedic treatment. Mackenzie et al. state that patients who return to work sooner are usually younger and have higher social support.40 Coulibaly and colleagues20 found that in isolated ulna shaft fractures, 87% of patients returned to a pre-fracture level of activity or work. MacDermid and colleagues17 described the days lost from work following a distal radius fracture. Patients with a limited range of motion were less likely to return to work. The average number of weeks lost from work was 9.5. Trickett and colleagues27 indicated that many non-retired patients wanted to return to work soon after a tibial fracture because of the inability to financially provide for themselves and to return to normality. One patient described how he had to adapt his duties and hours of work after the injury to remain involved at work.Volgas and colleagues41 confirm that patients with fractures of the lower extremity return to work later compared to those with fractures of the upper extremity.Sluys and colleagues42 The possible implications of not receiving appropriate and timely treatment after sustaining a fracture are malunion, avascular necrosis, fat embolism syndrome and prolonged immobility.4 Fractures with injury extension to the soft tissue, nerve or vasculature may cause complex regional pain syndrome.43 An important consideration in the initial management of fractures is a clinical pathway for pain management. Pain is often dependent on a host of factors that may or may not be because of the severity of the fracture. Good pain management facilitates patient comfort and reduces anxiety, allowing for a better orthopaedic assessment and compliance with the rehabilitation plan.42Pain is one of the main symptoms of a fracture that causes the patient to seek medical attention after the initial injury. Swelling, reduced mobility of the affected joint and deformity of the limb are common causes of pain. Some fractures are associated with less pain, resulting in some patients presenting late for treatment.42Upper extremity long bone fractures often affect activities such as personal hygiene, eating and writing, especially if the dominant limb is fractured. Frail geriatrics may require additional support during the period of immobilisation. Swelling following fracture is a common contributor of pain that is exacerbated by a tight plaster cast, but this could be managed by elevation of the arm and monitoring the swelling. Lower limb long bone fractures often result in an inability to carry out activities of daily living and usually affect employment, especially if the patient requires mobility in their occupation. Many patients with lower limb fractures require hospitalisation.44 There can be significant joint degeneration after severe joint injury such as an articular fracture.4Osteoarthritis is a long-term complication of fractures, especially in the lower limbs, and can lead to chronic pain. Approximately 12% of all patients seeking treatment for symptomatic arthritis reported previous injury to the joint.This scoping review aimed to investigate the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults. The psychological impact of long bone fractures includes fear of falling and, therefore, limiting participation in physical activities, being conscious of the aesthetic appearance of the affected limb, post-traumatic stress disorder, acute stress disorder, depression and anxiety. Fractures can also impact the patient’s social life because of limited mobility that compromises social activity. Patients reported selling possessions and making use of social assistance programmes to pay for expenses incurred as a direct result of the fracture. Some used friends and family as a source of financial aid. Physical discomfort, pain, immobilisation, deformity and the nature of some fractures result in prolonged absence from work. Patients with limited range of motion were less likely to return to work without vigorous physical rehabilitation. Those who were gainfully employed expressed a need to return to work to honour their financial obligations and as a signal of the gradual return to normality.The fracture prevented patients from returning to previous level of activity for many months, with pain being the common reason for this.45 Further to this, equal access to orthopaedic care and surgery in many African countries remains a challenge because of the shortage of health care practitioners and limited resources.The public health impact of fractures includes increases in physical impairments and psychological symptoms of fear of re-injury and post-traumatic stress disorder.46 Another important public health consideration is that in some instances, a proximal femur fracture places the individual at a high risk of sustaining another fracture. This may create additional costs to the individual because of possible rehospitalisation and loss of work.45As many countries in Africa are already struggling with poverty, human immunodeficiency virus and a shortage of health care workers, sustaining an injury can place an added burden on patients.This review only included studies published in English as it would have been costly and time-consuming to enlist the services of many translators for various languages. This review shows the need for studies that include younger participants. We acknowledge that we may have missed important evidence because of our inclusion and exclusion criteria.According to the World Health Organization, 90% of injuries occur in LMICs, such as those in Africa. Therefore, there is a need for more studies to assess the financial, occupational, social and psychological impacts of long bone fractures because there are many studies that only have documented the physical impact of long bone fractures, particularly in Africa. The impact of fractures in LMICs could be magnified because of poorly developed trauma care and limited social infrastructure.Long bone fractures have a considerable impact on the physical outcome of patients. In some cases, the fracture prevents patients from working and meeting financial obligations. In many cases, the injury limited previously normal social interactions and pre-injury functioning. The findings should be considered while training health workers and providing counselling to orthopaedic patients.


Stunting is a global burden affecting nearly 160 million children younger than five years of age. Whilst the linkages between nutrition and stunting are well recognized, there is a need to explore environmental factors such as water and sanitation, which may influence feeding practices and result in potential infection pathways. This paper explores the linkages between stunting and water, sanitation and hygiene (WASH) factors in Ethiopia, which is a relatively understudied context. The research draws upon baseline data for children under the age of five from 3200 households across four regions in Ethiopia as part of a wider study and integrated program led by the United Nations Children’s Fund (UNICEF). Using World Health Organization (WHO) z-scoring, the average stunting rate in the sample is 47.5%. This paper also takes into account demographic and social behavioural factors such as the age, gender of children, and gender of the primary caregiver, in addition to handwashing behaviour and drinking water facilities. The evidence recommends efforts to improve handwashing behaviour for mothers and children with a focus on access to clean water. Higher stunting rates with an increase in the age of children highlight the need for continued interventions, as efforts to improve nutrition and WASH behaviours are most effective early on in promoting long-term health outcomes for children.  In 2016, 158 million children younger than 5 years were mildly, moderately, or severely stunted . SustainGlobally, stunting rates are declining slowly with the largest improvements in Asia and Latin America. However, Africa is the only region where the number of stunted children has risen from 50% to 59% between 2000–2016, which highlights the urgency of the challenge , with 28The definition of nutrition defined by the United Nations Children’s Fund (UNICEF) conceptual framework provides a multifactorial understanding of nutrition in which to frame stunting: “Nutritional status is influenced by three broad factors: food, health and care . OptimalThere is some research that renders the linkage between stunting and Integrated Water, Sanitation and Hygiene (WASH) practices more nuanced in many low and middle income countries (LMICs) in Africa and Asia. One study identified a lack of correlation with stunting, attributing it to what is presently classified as enteric environmental dysfunction. Unsanitary conditions have been linked with stunting through multiple mechanisms and pathways such as repeated diarrhea, infection pathways, and environmental enteric dysfunction (EED) . HumphreThe aim of this paper is to explore associations between stunting and WASH factors, accounting for descriptive factors  that are specific to the Ethiopian context in order to inform the design and implementation efforts that address stunting in context. Data for this project is baseline data as part of a wider five-year project jointly implemented by the Government of Ethiopia and UNICEF in collaboration with The Integrated Water, Sanitation and Hygiene (WASH), Multiple Use Water and Sanitation Services (MUS), and Community-Based Nutrition (CBN) program. The project focused on deploying an integrated approach to counter stunting that addresses nutritional, hygiene, and WASH factors. This paper begins with a summary of the literature on known determinants of stunting, showing where there is an opportunity to address the gap in the association with WASH in the Ethiopian context. The Methods and Materials section summarizes the approach from the context of the study within the wider integrated project and the approach used to explore WASH and other social determinants in the Ethiopian context using the baseline data collected by UNICEF. The Results section presents the correlations and results of linear regression, which are followed by a discussion that places the results in dialogue with the background literature, recommendations, and areas for further exploration. The paper concludes with a summary. Contrary to common belief, stunting is complex and not solely a result of food insecurity: many children in food-secure environments are stunted because of inappropriate feeding and care practices, poor health services, or and/or poor sanitation . This seDemographic factors, income growth, food production, and women’s education are important contextual considerations for long-term solutions to undernutrition . PopulatWhile this study is focused on contextual factors, it would be remiss not to present the evidence related to stunting that considers the temporal dimension, namely that the prevalence of the most damaging effects of undernutrition occur during pregnancy and in the first two years of life . This isIn addition to nutritional factors, maternal health and temporal dimensions of stunting, demographic variables such as gender and socioeconomic status, as well as environmental factors are found to have links to stunting. A cross-sectional study in the northwest of Ethiopia links factors such as child age, occupational status of the household head, family size, and education level of the father with stunting . AnotherOther contextual factors such as ethnicity were found to predict chronic undernutrition, particularly when children are reared in disadvantaged ethnic groups. These results come from a cross-sectional comparative study in Nepal  as well With regard to environmental factors such as access to water and sanitation, there is some evidence for an association with a reduction in the rate of diarrhea, which is also a predictor for child nutrition. One such study included a multi-village project in Ethiopia, where 11 villages were selected for interventions on health, education, WASH, or an integrated approach using health, education, and WASH . The intThe integrated WASH, Multiple Use Water and Sanitation Services (MUS) and Community-Based Nutrition (CBN) program, a five-year project jointly implemented by the Government of Ethiopia and UNICEF, aims to respond to factors associated with stunting in an integrated manner. A key objective of this large-scale rural program is to address the combined risks of chronic malnutrition and poor access to WASH services and water for local agricultural production, which is linked to improved food security, child health, and reproductive and sexual health outcomes . This fiThe analysis is a subset of a wider controlled trial that includes WASH and Multiple Use Services (MUS) activities integrated with Community-Based Nutrition (CBN) interventions, operational research, and the dissemination of knowledge products carried out by UNICEF and the Government of Ethiopia. Ethical clearance for the study was obtained by UNICEF from the Federal Ministry of Health and Federal Ministry of Water (August 2013). Both ministries also provided feedback and peer reviewed the questionnaire implemented in this study. This project is situated within the wider objective of increasing the impact on the reduction of stunting and other health outcomes through an integrated approach. Whilst water supply, sanitation, and hygiene interventions were implemented with a view to improving child health, it was anticipated that a significantly wider impact on stunting and food security would be secured by combining these interventions with a community-based nutrition (CBN) package. In the baseline stage, the objective of the wider project was to establish representative baseline data on the selected indicators in 30 WASH/CBN kebeles, which is the smallest administrative district level in Ethiopia, in four regions , Oromiya, and Tigray) and to incorporate defined methods, indicators, and research techniques to include both WASH and nutrition data. Variations between sub-regions are noted in overall rates of stunting; however, the further analysis of variations and differences at a sub-regional level was identified as beyond the scope for this specific study. As this investigation was part of a wider intervention-based study, the selection of the sub-regions was conducted for the purpose of delivering the intervention across the intervention and control groups. See The results of this paper draw upon the baseline data collected between June and August 2013. As this study does not examine the impact of the interventions, the end-line data was not included in this paper. The sample focuses on individual-level data for children under five years of age, and household-level data in order to capture factors related to water, sanitation, weight, age, and the height of children.The subset of data used for this study is drawn from a baseline survey from 3200 households from 80 different kebeles, the smallest administrative unit in Ethiopia, using a cross-sectional methodology . The basThe 80 kebeles (40 each from the intervention and control sites) were sampled using the proportion of the intervention groups for each of the regions . Each kebele consists of at least 500 families. The cluster groupings of kebeles (woredas) include 30 intervention and 92 control groups in the four regions, which were purposefully selected by UNICEF based on their funding mechanism by either the Government of Netherlands or the Canadian International Development Agency. For the 30 intervention woredas, UNICEF provided a list of 576 kebeles that formed the basis for sampling. The sample was divided into 40 clusters and a weighted percentage was attributed to each of these three different interventions. Based on the proportion of kebeles in each intervention group  and the proportion of kebeles in each region , the number of kebeles required for the sampling was determined. For the 92 control woredas, there is a list of 2158 kebeles that formed the basis for sampling. The number of kebeles to be sampled per region was determined using the same proportional distributions as the intervention groups . Sampling was conducted in consultation with the village leader to determine households with children. The sampling interval was determined by dividing the total number of households with a child by the number of households to be interviewed. Then, the team selected a random number between one and the sampling interval. This random number indicated the first household to be surveyed. The team interviewed the household administering the WASH household questionnaire, including any children under 5 and their mothers/caregivers. Then, the team moved to the next random household . Data collection continued in this way until the village boundary was reached . As necessary, the team would return to the center, take the 90-degree line from the first line, and continue to sample the random households, repeating again as necessary. If a member of the household was not present, the team would go back later and continue to visit the household until the team left the area. If the household could not be interviewed, the household would be replaced by another by continuing the sampling method.). The team counted the households in the selected direction starting with one and moving until the house with the selected random number was reached.UNICEF was concerned about the enumerator effect, which can possibly result in biased data collection. Hence, for each questionnaire administered, the study included a double data collection approach. For each interview conducted, two enumerators separately recorded the data obtained in two separate questionnaires, such that each interview would have two separate completed questionnaires. After every third interview conducted by a pair, enumerators were rotated so that different pairings were formed. This allowed the data obtained by each enumerator to be individually analyzed, compared for percent agreement, and provided opportunities to identify if there was one or more poorly performing enumerators. To address potential recall and response bias, responses were triangulated to identify inconsistent patterns. Age of children was recorded in months, while for women it was recorded in years. For many rural households, it is often difficult to accurately assess the age of children. Where a birth certificate or vaccination card was not available for the child and/or the mother is unsure of the child’s age, the field team members discussed with the mother events that happened around the birth of their children. With this information, the enumerators linked the responses to a pre-prepared calendar of local events to work out the age of the child. Age heaping refers to the generalization of specific ages into preferable ages by respondents. Age heaping is often caused by the respondent being unsure of their exact age, reluctant to provide it, and/or where there is a cultural preference for certain numbers—for example, those ending in ‘0′ or ‘5′. Age heaping is often higher where there are high levels of illiteracy and where the recording of births is not common practice. In Ethiopia, age heaping is most likely caused by a respondent being unaware of their child’s exact age, and subsequently generalizing to a number that feels plausible. This has significant implications for determining the correct nutritional status of children in this study. However, there are ways of minimizing the problem, most of which involve increasing the specificity when requesting the age or working through proxies, including data on age being derived from answers to a two-part question  to minimize the effect of age heaping. As the most reliable evidence, research teams requested to see the birth certificate of the child, or the child’s baptized date for the households of Orthodox followers; where these were not available, the research teams requested the child’s vaccination cards, which should indicate the date of birth, or at least the date of first injections. From these documents, the field team tried to work out and record the age. Where neither of these official documents were available, proxies such as determining time-related data from a local calendar of events was used. Overall, local language speakers formed part of the field teams to help estimate age accurately. The field staff were trained to elaborate the respondent’s answer to as specific a date as possible. If the mother replied that they gave birth around a festival, for example, the interviewer will ask them to remember if it was before, during, or after the festival, and its relative closeness to the proceeding or succeeding events.While the study does not present a baseline evaluation or monitor the performance of the program itself, the data collection is embedded in the context of an integrated approach to tackling stunting.The survey instrument included a WASH and stunting questionnaire administered in every one of the 40 intervention and the 40 control kebeles. Measurements used to assess stunting included anthropomorphic outcome variables such as weight, height, and age. To assess associations between stunting and WASH factors, z-scores are used to generate a linear regression model that represents these associations using an F-test for goodness of fit. The authors acknowledge that depending on which reference is used, in this case the WHO reference, the stunting rate varies. While this variation is not ideal, the benefit is that it does allows for comparison with a wider range of studies, as the WHO reference is commonly utilized. The authors also acknowledge that there are limitations to applying the WHO reference in developing countries. This is taken into consideration; however, for the purpose of standardization and potential comparison with other countries, the WHO reference is used. For anthropometric measurements, the team used the accepted standard-length boards, SECA digital scales, and iodine testing kits supplied by UNICEF. To ensure validity and reliability, the field teams verified the proper functioning and calibration of the measurement instruments before the commencement of fieldwork and on a daily basis before starting their activities. The necessary skills and procedures for the calibration of these instruments was part of specific modules of the field supervisors’ and data collectors’ training. Instruments that were found to be malfunctioning or unreliable were fixed, if possible, or replaced.Height: Length of infants (0–23 months) was measured in a recumbent position to the nearest 0.1 cm using a locally-made board with an upright wooden base and a movable headpiece. The height of children in the 24–35 months age range was measured in a standing, upright position to the nearest 0.1 cm using a locally-made vertical board with a detachable sliding headpiece.Weight: Children were weighed with light clothing and without shoes. In order to weigh children under the age of 3 years, the UNISCALE method was employed using the UNICEF mother/child electronic scale, which requires the mother and child to be weighed simultaneously. . 3. Passing the child to a person nearby. 4. Recording the second reading with just the mother . 5. Noting the difference  is the weight of the child.).Accompanying the household questionnaire, the anthropometric survey was conducted among children under five and women of childbearing age to determine the levels of underweight, wasting, and stunting. The following information was collected through anthropometric measurements:To ensure the validity and reliability of the anthropometric measurements, checks were incorporated into the process see . Key cheStunting estimations were derived using IBM SPSS Statistics software calculated using a WHO anthropometric macro  that comChildren are considered stunted when below −2 standard deviation (SD) and heavily stunted when below −3 from median height for age (HAZ) of a reference population. A combination of linear and hierarchical regression models was used to explore the determinants of stunting and the impact of WASH on stunting. Linear models helped to establish associations in an area where there was currently, at the time, limited study in the region. Hierarchical regression analyses were subsequently used to examine changes in association as more potential confounders were taken into account. There are other modeling approaches that were considered to detect more complex relationships such as logistic regression; however, in a relatively understudied area, early cross-tabulations between stunting and predictors provided a starting point for detecting linear relationships and for further exploration. Linear regression models first assess the strength of the association between stunting and individual factors such as age of the child, age category of the child, gender of the child, and gender of the caregiver. The models presented in the results include single regression analyses and the hierarchical regression analyses. The linear models were used to inform understanding of the variance of each predictor before including in a combined regression model. See The total number of children under five years of age with available data was 2400, with 1200 children 2 * (P1 (1 − P1) + P2 (1 − P2))/(P2 − P1)2], where D, the design effect = 2, P1, the current level of stunting = 0.44, and P2, the expected level of stunting = 0.34, Zα, the confidence level = 1.645, and Zβ, the confidence level for power = 1.645.) within each arm of the study to permit the detection of stunting and diarrhea across the four regions of Amhara, Oromiya, SNNPR, and Tigray. The total stunting rates for boys and girls vary by 3.3%, with a total rate of 45.7% in the sample population . Boys younger than 6 months old generally have lower stunting rates in comparison to girls. However, the trend changes after 6 months old, with 6% and 3.1% more stunting rates in age category 2 and 3, respectively. It is important to note that the total stunting rates increase with age, starting at an average of 27.5% in the first age category, then increasing up to 51.5% between 24–59 months old. Therefore, it is important to underline that the overall stunting rate in the country is most probably higher than the average total of 45.7% detailed, which represents the average for children younger than five years old. There is some variation across the regions, as shown in p < 0.0001). This suggests that socioeconomic, environmental, and nutritional factors vary from one region to another, and that there is a correlation between region and stunting rate in this context. Oromiya shows evidence of lower proportions of children under five who are stunted, as compared with the other regions. SNNPR contains higher proportions of children who are stunted.There is evidence to suggest that the variance in stunting prevalence is significant across regions (Pearson chi-square p = 0.168), as illustrated in There was strong evidence to suggest the variance in stunting prevalence is not significant across gender (Pearson chi-square p < 0.0001), as shown in There is evidence to suggest that the variance in stunting prevalence is significant across primary water source , handwashing before eating (mothers and children), handwashing after defecation (mothers), handwashing with water (mothers and children), and handwashing with water, soap, or ash (mother). Water sources for other household purposes are omitted from the subsequent hierarchical regression model because of high collinearity with drinking water source. The variable representing sanitation facilities for children below five has been included in the hierarchical regression model, as it is the factor with high influence. 2 value). After examining associations using linear regression and identifying evidence for collinearity, washing practices for men, women, children below five, and children above five, three variables were noted to not be statistically significant, which include latrine location, child feces disposal, and handwashing after defecation (children). Mothers handwashing before eating was removed from the overall model, as it was highly variable with children below five handwashing before eating (and had a lower RP) for the combination of predictors.After removing statistically non-significant predictors and checking for collinearity, Caregiver Gender, Age Category, and the following WASH variables are used for the hierarchical regression analysis: drinking water source, handwashing after defecation (mothers), and handwashing before eating (children <5). This paper analyses significant determinants of stunting for children under 5 years of age in the context that emerges from findings from this study in rural Ethiopia and the existing body of literature both in and outside of Ethiopia. WASH factors that feature in this study include handwashing, drinking water facilities, and wider determinants, including children’s age, and the gender of children and caregivers. Age was found to have the strongest correlation to stunting in this study group. This is to be expected, as the symptoms of stunting appear after prolonged inadequate environment and nutrition. These results are consistent with the literature, and strengthen the consensus that earlier interventions in a child’s life are important. While many factors may influence this correlation, the literature suggests improved behavioural practices such as handwashing before eating early on may be important to consider along with other factors closely associated with the age of the child. At the sub-regional level within the region studied, Oromiya had lower levels of stunting proportionally compared with the other sub-regions . Although this analysis goes beyond the scope of the paper, there is a recognition that this is a limitation, and would require further analysis as to the factors that would render this difference. In this study, the gender of the primary caregiver is noted to be a statistically significant predictor of stunting prevalence with the presence of a male caregiver implying a lower prevalence of stunting. This may be explained by a trend that the presence of a male caregiver, in addition to a female caregiver, would suggest overall more resources. However, this social factor only explains 0.6% of the stunting prevalence in this dataset. This result is consistent with another study in Ethiopia where female-headed households had a higher prevalence of stunting in children, which was attributed to a lack of access to livelihood opportunities . With acOverall, the WASH determinants in this sample account for approximately 7% of the variation in stunting. In isolation, this is not the large share of stunting; however, if taken into consideration alongside other nutrition factors such as the quality and quantity of food, addressing structural determinants such as water source and behavioural practices may provide opportunities to have a stronger, more targeted integrated approach to stunting prevention. With these factors in mind, the WASH determinants of interest for stunting in this study are drinking water source, handwashing after defecation (mothers), and handwashing before eating (children). The association with handwashing after defecation can be explained by the fact that women would be the primary handler of the child, and any contamination would likely be passed to the child. For children, handwashing before eating is associated with stunting namely as children would be ingesting unclean water and/or other pathogens. There were several factors such as other household water uses and different uses of soap and water that are significant in the single linear regression; however, these had strong collinearity with factors such as drinking water source (other household water uses) and handwashing with soap (handwashing after defecation). Sanitation may have secondary importance as sanitation facility i.e., faeces disposal, was found to be non-significant. There is an argument that handwashing overall may nullify the effect of sanitation facility, yet likely with some limitations. This suggests that there may be a greater need to prioritize support for good handwashing and hygiene practices in locations with poor-quality sanitation facilities. This finding clashes with the finding of the Ahmadi 2018 study, which identified open defecation, along with child’s sex, age, and region as strongly correlated with stunting . A reasoHandwashing for both children under five and their mothers initially seems to indicate higher rates of stunting with the inclusion of soap not being a stronger influence. A possible explanation for this is that soap is most effective with clean drinking water. Where access to a clean drinking water source is unavailable, the benefits of soap may not be realized. This may indicate the value added by access to clean water and hygiene and handwashing practices in communities with unsafe sanitation facilities. However, it is remiss to not acknowledge that handwashing tends to be over-reported by survey participants . Taking this finding into account, the overestimation of the results of handwashing and its linkage to stunting also needed to be taken into account. Efforts by UNICEF as described in These findings are consistent with literature on the integration of WASH in the prevention of stunting, particularly in reframing undernutrition to include more than food access, quantity, and quality/diversity and to consider broader environmental factors ,17. The Of the demographic and descriptive determinants, child gender is found to be a non-significant predictor of stunting for this study group. The literature on this is mixed, with some studies indicating that child gender has a role to play ,41, althThese findings contribute an evidence base to inform further exploration of linkages between WASH and stunting in the Ethiopian context. Recommendations that emerge from these findings are to reduce the effect of stunting through the promotion of safe drinking water sources and handwashing practices with greater attention to clean water sources, and promoting the use of handwashing after defecation for mothers and before eating, especially for children where there is access to clean drinking water. The strength of this study is the provision of context-specific evidence for associations with stunting that explore specific WASH factors in a context where this has not been explored at this scale. These findings are integrated with demographic and social factors that affect health, which together provide evidence for an integrated approach to tackling the challenge of stunting. This study also draws upon a relatively large sample size for the scale of the country, which suggests that future studies will also need to ensure large enough population samples to have the numbers for establishing claims on whether factors such as livelihood opportunities, the education levels of parents/caregivers, and gender can influence stunting.This study provides an overview of social and WASH determinants for stunting in Ethiopia. With these contributions, there are limitations of this study that should be taken into account for future work. A limitation of this study is the exclusion of end-line data from the analysis. The baseline data in this paper does not provide evidence on stunting and determinants over a period of time, and does not test the value added by UNICEF’s WASH intervention, which was conducted after the collection of the baseline data. In terms of variation by region, the authors acknowledge in the limitations that the differences in regions, how they contrast, and what can be learnt should be explored in further research, although this went beyond the scope of this paper. The sub-regional differences acknowledged between Oromiya for example, which had proportionally lower numbers of children who were stunted, could be explored in an analysis that potentially could isolate risk factors that may be related to demographics, behaviour, and/or a combination of the variables explored here. This is an area of extreme importance for delivering locally tailored interventions; however, for the purpose of this study, this remained at a regional level. Contextual factors such as differences in toilet coverage and quality, population density, humidity, and/or dryness need to be explored in tandem with demographic factors such as ethnicity and religion, as they could also be highly correlated with socioeconomic status. With respect to the over-reporting of handwashing by survey participants, greater efforts should be taken to ensure that measuring behaviour such as handwashing is confirmed through a triangulation of different methods. Future work should consider to what extent wealth and an asset base have an impact on households, especially within vulnerable groups and communities. As noted in the methods, biases such as recall bias, particularly in providing health data related to age, requires planning at the fieldwork stage and robust methodologies such as the one used by UNICEF . There aAreas for further research include exploring the contextual factors, environmental factors, and socioeconomic factors described in the limitations along with sub-regional differences. Exploring fully the collinearity between factors such as the gender of the caregiver and socioeconomic status, for example, may also provide additional insight. Future studies could include analysis of other factors such as livelihood opportunities, the education levels of parents/caregivers, and gender. Examining this in the context of the regional, local differences, cultural and ethnic variations would also lend greater granularity in order to adapt interventions to localized contexts. More broadly, these findings from a research perspective also suggest the need for interdisciplinary research for public health and environmental research agendas, which can improve the overall sustainable development for households through integrated perspectives. Stunting is complex and influenced by multiple factors and structural determinants such as caregiver gender, age, water source, and behavioural practices around handwashing. Demographic and social factors such as the age of the child and gender of the caregiver also contribute to the reality that stunting is complex. While eliminating stunting will not be addressed through tackling WASH factors alone, what this study provides is a starting point for exploring WASH factors in the Ethiopian context and evidence for including WASH factors within an integrated approach to tackling stunting. The study provides programmatic recommendations that include: (1) strengthening efforts to improve handwashing behaviour for mothers and children; (2) prioritizing access to clean water sources; and (3) supporting specific WASH activities that help to better contextualize the timing of handwashing by children and caregivers, and source of water. More broadly, the study is consistent with evidence in the literature to reframe undernutrition to include more than food access, quantity, and quality/diversity, and consider broader environmental factors.This study indicates consistency with recommendations for integrated interventions that improve feeding practices, hygiene behaviours, and the enabling conditions and to embed WASH within a holistic, integrated approach to tackling stunting. This study demonstrates the need for interdisciplinary research at scale to develop joint health, education, and behavioural change interventions that improve feeding practices and offer a holistic, integrated approach to tackling stunting by addressing the environmental factors and designing improvements to address them.


The family Parvoviridae includes an ample and most diverse collection of viruses. Exploring the biological diversity and the inherent complexity in these apparently simple viruses has been a continuous commitment for the scientific community since their first discovery more than fifty years ago. The Special Issue of ‘Viruses’ dedicated to the ‘New Insights into Parvovirus Research’ aimed at presenting a ‘state of the art’ in many aspects of research in the field, at collecting the newest contributions on unresolved issues, and at presenting new approaches exploiting systemic (-omic) methodologies. The family Parvoviridae includes an ample and most diverse collection of viruses. According to formal taxonomy , virusesExploring the biological diversity and the inherent complexity in these apparently simple viruses has been a continuous commitment for the scientific community since their first discovery more than fifty years ago. In addition, the translational implications of research on parvoviruses are relevant. Within the family, some viruses are important human and veterinary pathogens, in need of reliable diagnostic methods and efficient therapeutic, antiviral strategies. Rodent parvoviruses have long been studied not only as model systems, but also as tools for oncolytic therapy. Adeno-associated viruses (AAV) have found their way as sophisticated gene delivery vectors and begin now to display successfully their wide and expanding applicative potential.The Special Issue of ‘Viruses’ dedicated to the ‘New Insights into Parvovirus Research’ aimed at presenting a ‘state of the art’ in many aspects of research in the field, at collecting the newest contributions on unresolved issues, and at presenting new approaches exploiting systemic (-omic) methodologies. Evolution, structural biology, viral replication, virus–host interaction, pathogenesis and immunity, gene therapy, and viral oncotherapy are a selection of topics that have been addressed in articles collected in this Special Issue.Studies on the structural biology of viruses in the family can now collect the results of more than twenty-five years of active research, and about 100 structures resolved at high-resolution level are deposited and available. In this Special Issue, all related information is summarised and discussed in a landmark review paper . PresentChappaparvovirus genus, and chiefly the resulting inference of an ancient evolutionary divergence of members of this genus from other genera in the family, based both on genomic and structural comparative data [Next-generation sequencing (NGS) technologies are now frequently in use and contribute effectively to the discovery of novel viruses in the family, as well as to the definition of their evolutionary relationships. Actually, the family picture of viruses in the family is continuously expanding, and new contributions are presented in this issue too. A most intriguing topic is the growing identification of members in the ive data . A taxonive data , a chappive data  and a deive data . On the ive data . As is aive data .Bombyx mori bidensovirus has been thoroughly investigated and presented [Novel technologies also allow a deeper and systemic inspection of the genetics and expression profile of viruses within infected cells. The methylation status of the AAV2 genome is presented in , showingresented . The traresented  has beenJunonia coenia densovirus with the midgut barriers of caterpillars has been analysed in detail, to yield a picture of the initial phases of infection that involve binding to host glycans and later disruption of the peritrophic matrix, as presented in [The initial phases of virus–cell interaction are a relevant matter of investigation. The interaction of ented in . Concernented in  providesRegarding translational issues, in addition to the engineering of AAVs as very successful gene transduction vectors, there is a long record of studies on the use of protoparvoviruses as oncolytic agents. Two excellent reviews summarise and address the complex issues ,16 of thThe pathogenetic role and clinical implications of human parvoviruses are addressed in two studies presented in this collection, about the role of human bocaviruses and parvovirus B19. In an observational study , a signiFurthermore, concerning a role of parvovirus B19 in the development of cardiomyopathies, the possible effect of telbivudine in reducing the damage to endothelial progenitor cells caused by the presence of B19 is presented . TelbivuAs a conclusive remark, the collection of articles in this Special Issue devoted to ‘New Insights into Parvovirus Research’ and contributed by distinguished researchers should be regarded as significant for two main reasons, among others. First, some of the articles effectively present a ‘state-of-the-art’ overview in some main topics. Then, many articles show how the application of new methodologies, including but not limited to NGS, can be functional to the establishment of novel and more general paradigms in the field. In the near future, research on parvoviruses will certainly yield more answers to still-unresolved issues.