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‘Honour killing’, the murder of women to preserve family reputation, is well recognised but infrequently systematically researched. This paper has three hypotheses. First, in families where women report an ‘honour killing’ there is more violence against women and girls, second these women are more likely to report more patriarchal gender attitudes than others, and third these families are exposed to higher levels of poverty. We asked (n = 1461) women enrolled in a trial in Afghanistan, and (n = 535) in a population-based sample in the occupied Palestinian Territories (oPT) if there had ever been an ‘honour killing’ in their family. In Afghanistan, 2.3% (n = 33), and the oPT 7.7% (n = 41), reported this. We built separate multivariable logistic regression models for each country, and for married and unmarried women in each country. Among Afghan married women, ‘honour killing’ was associated with borrowing because of hunger (adjusted odds ratio [aOR]8.71, 95%CI 2.27–33.40), easier access to money in emergency (aOR11.39, 95%CI 3.05–42.50), and violence within the family; intimate partner violence (IPV) (aOR3.73, 95%CI 1.12–12.36), and IPV and mother-in-law violence (aOR10.52, 2.60–42.56). For unmarried women in Afghanistan, ‘honour killing’ was associated with easier access money in an emergency (aOR4.06, 95%CI 0.85–19.37), household violence (hit by parent or sibling, or parent and sibling [aOR5.47, 95%CI 0.82–36.70; aOR7.37, 95%CI 1.24–43.86, respectively]); more childhood traumas (aOR1.24, 1.11–1.38), and more patriarchal personal gender attitudes (aOR1.24, 1.00–1.54). In the oPT experiencing IPV (aOR3.07, 1.02–9.23) and borrowing and experiencing IPV (aOR5.89, 1.84–18.79) were risks for married women. For unmarried women borrowing because of hunger was associated with higher risk (aOR2.33, 95%CI 1.18–4.85). Despite limitations–specifically the potential women were reporting the same ‘honour killing’—our analysis suggests ‘honour killings’ are associated with violence, patriarchy, and poverty. Research is needed for the prevention of ‘honour killing’, which must address the root causes. Trial Registration: ClinicalTrials.gov . [ABSTRACT FROM AUTHOR]

Background: Against a backdrop of more than four decades of war, conflict and insecurity, Afghanistan is recognised as suffering from endemic violence and children are exposed to multiple forms of violence, including at the family and school levels. This paper presents the results of an evaluation of school-based peace education and a community-based intervention to change harmful social norms and practices related to gender and the use of violence in conflict resolution, implemented in Afghanistan with the aim of reducing violence against and between children. Methods: The evaluation consisted of a cross-sectional, interrupted time series design with three data collection points over 12 months. Data was collected from students in 11 secondary schools (seven girls’ and four boys’ schools) in Jawzjan province of Afghanistan, with a total of 361 boys and 373 girls sampled at endline. All children were interviewed with a questionnaire developed for the study. Key outcomes included children’s experience of peer violence (both perpetration and victimization) at school, corporal punishment both at home and at school, and observation of family violence. Other outcomes included children’s gender equitable attitudes, attitudes towards child punishment, depression and school performance. Results: Between baseline and endline evaluation points, there were significant reductions in various forms of violence at the school level, including both boys’ and girls’ past month experience of peer violence victimization, peer violence perpetration, and corporal punishment by teachers. There were also significant reductions in boys’ and girls’ experience of corporal punishment at home and observation of family violence, with a particularly strong effect observed among girls. Both boys and girls had significantly more equitable gender attitudes and significantly less violence-supportive attitudes in relation to children’s punishment, and significantly fewer symptoms of depression. Girls’ school attendance was also significantly higher at endline. Discussion: To our knowledge this is the first time that a peace education program has been evaluated in Afghanistan, with or without a community intervention to change harmful social norms and practices related to gender and the use of violence for conflict resolution. The evaluation suggests that the intervention may have led to a reduction in various forms of violence, including children’s peer violence, corporal punishment of children both at school and at home, and in children’s reports of domestic violence against women at the household level. [ABSTRACT FROM AUTHOR]

Background: Four decades of conflict has indelibly impacted the lives of Afghans, exposing many to different forms of trauma. The aim of this paper investigate a hypothesis that (mostly war related) trauma is a key driver of partner violence in Afghanistan. Methods: 1,463 women aged 18–48 were recruited into a randomised controlled trial (RCT) to evaluate a women empowerment intervention in 8 villages of Kabul and Nangarhar provinces. The women were interviewed at baseline. The analysis uses multivariable logistic regression and structural equation modelling (SEM) to describe relationships between measures. Results: 57.4% of women reported exposure to one of four types of trauma: 23.3% an armed attack, 39.4% had felt close to death, 10.6% witnessed a friend or family member being killed and 21.4% witnessed the death of a stranger or someone unknown. Trauma exposure was associated with being older, Pashtan, madrassa educated, and food insecure. Women who were trauma exposed were more likely to have ever experienced IPV, have hit their children in the last 4 weeks, and be hit by a sibling or relative of their husband or their mother-in-law in the last year. They held less patriarchal personal gender attitudes and perceived the community to be more patriarchal. The SEM showed that all pathways between trauma exposure and IPV were ultimately mediated by either (mostly mental) ill-health or quarrelling, but not both of these. There were multiple paths through which trauma exposure impacted women’s past year experience of physical IPV. One was mediated by childhood trauma exposure and a latent variable for ill health. Other paths were mediated by women’s education and personal gender attitudes and ill-health, or else by quarrelling. Trauma exposure was related to lower educational levels. Another path was mediated by less patriarchal personal gender attitudes and ill health. Community gender attitudes was a mediating variable on a path which was also mediated by ill health and another mediated by quarrelling. It was also a mediator on a path which included personal gender attitudes and ill-health. Food insecurity mediated another path with ill health. It was also connected to childhood trauma, community gender attitudes and educational level. Conclusion: Trauma exposure due to conflict will persist until the conflict ends but the impact on women can be ameliorated. This analysis suggests interventions to reduce women’s exposure to IPV should focus on reducing poverty, changing social norms on gender, providing relationship skills to help reduce quarrelling and supporting women’s mental health. [ABSTRACT FROM AUTHOR]

Background: A common means of vaccination coverage measurement is the administrative method, done by dividing the aggregated number of doses administered over a set period (numerator) by the target population (denominator). To assess the quality of national target populations, we defined nine potential denominator data inconsistencies or flags that would warrant further exploration and examination of data reported by Member States to the World Health Organization (WHO) and UNICEF between 2000 and 2016. Methods and findings: We used the denominator reported to calculate national coverage for BCG, a tuberculosis vaccine, and for the third dose of diphtheria-tetanus-pertussis-containing (DTP3) vaccines, usually live births (LB) and surviving infants (SI), respectively. Out of 2,565 possible reporting events (data points for countries using administrative coverage with the vaccine in the schedule and year) for BCG and 2,939 possible reporting events for DTP3, 194 and 274 reporting events were missing, respectively. Reported coverage exceeding 100% was seen in 11% of all reporting events for BCG and in 6% for DTP3. Of all year-to-year percent differences in reported denominators, 12% and 11% exceeded 10% for reported LB and SI, respectively. The implied infant mortality rate, based on the country’s reported LB and SI, would be negative in 9% of all reporting events i.e., the country reported more SI than LB for the same year. Overall, reported LB and SI tended to be lower than the UN Population Division 2017 estimates, which would lead to overestimation of coverage, but this difference seems to be decreasing over time. Other inconsistencies were identified using the nine proposed criteria. Conclusions: Applying a set of criteria to assess reported target populations used to estimate administrative vaccination coverage can flag potential quality issues related to the national denominators and may be useful to help monitor ongoing efforts to improve the quality of vaccination coverage estimates. [ABSTRACT FROM AUTHOR]

Background: Afghanistan’s public health system was neglected during decades of military and civil conflict, and trends in infectious disease occurrence remain poorly characterized. This study examines cyclical and long-term trends of six vaccine-preventable diseases: pneumonia, diarrhea, meningitis, typhoid, measles, and acute viral hepatitis. Methods: Using weekly data collected between 2009 and 2015 through Afghanistan’s Disease Early Warning System, we calculated monthly case counts, and fit a Poisson regression with a Fourier transformation for seasonal cycles and dummy variables for year. Results: We found the greatest incidence of diarrhea and typhoid in the summer, pneumonia in the winter, and measles in the late spring. Meningitis and acute viral hepatitis did not demonstrate substantial seasonality. Rates of pneumonia and diarrhea were constant across years whereas rates of meningitis, typhoid, and acute viral hepatitis decreased. Measles incidence increased in 2015. Conclusions: Communicable disease reporting systems can guide public health operations–such as the implementation of new vaccines, and permit evaluation of health interventions. For example, measles supplementary immunization activities in Afghanistan have not slowed long-term transmission of the disease, but decreases in typhoid fever and acute viral hepatitis are probably tied to improvements in sanitation in the country. [ABSTRACT FROM AUTHOR]

Profiling elemental contents in wheat grains and clarifying the underlying genetic systems are important for the breeding of biofortified crops. Our objective was to evaluate the genetic potential of 269 Afghan wheat landraces for increasing elemental contents in wheat cultivars. The contents of three major (Mg, K, and P) and three minor (Mn, Fe, and Zn) elements in wheat grains were measured by energy dispersive X-ray fluorescence spectrometry. Large variations in elemental contents were observed among landraces. Marker-based heritability estimates were low to moderate, suggesting that the elemental contents are complex quantitative traits. Genetic correlations between two locations (Japan and Afghanistan) and among the six elements were estimated using a multi-response Bayesian linear mixed model. Low-to-moderate genetic correlations were observed among major elements and among minor elements respectively, but not between major and minor elements. A single-response genome-wide association study detected only one significant marker, which was associated with Zn, suggesting it will be difficult to increase the elemental contents of wheat by conventional marker-assisted selection. Genomic predictions for major elemental contents were moderately or highly accurate, whereas those for minor elements were mostly low or moderate. Our results indicate genomic selection may be useful for the genetic improvement of elemental contents in wheat. [ABSTRACT FROM AUTHOR]

This research aims to examine the socio-economic correlates of anemia in women, and potential sources of iron in household diets in Afghanistan. It also examines whether ownership of agricultural (particularly livestock) assets and their use in food production has a role in alleviating anaemia, especially where local markets may be inadequate. We analyse data from the 2010/11 Afghanistan Multiple Indicator Cluster Survey, estimating a logistic regression to examine how anemia status of women is associated with socio-economic covariates. A key result found is that sheep ownership has a protective effect in reducing anemia (prevalence odds ratio of sheep ownership on anemia of 0.83, 95% confidence interval (CI): 0.73–0.94) after controlling for wealth and other covariates. This association is found to be robust to alternative model specifications. Given the central role of red meat in heme iron provision and absorption of non-heme iron, we hypothesise that sheep ownership promotes mutton consumption from own-production in a setting where market-sourced provision of nutritious food is a challenge. We then use the 2011/12 National Risk and Vulnerability Assessment household data to understand the Afghan diet from the perspective of dietary iron provision, and to understand interactions between own-production, market sourcing and mutton consumption. Sheep ownership is found to increase the likelihood that a household consumed mutton (odds ratio of 1.27, 95% CI: 1.15–1.42), the number of days in the week that mutton was consumed (prevalence rate ratio of 1.24. 95% CI: 1.12–1.37) and the quantity of mutton consumed (7 grams/person/week). In the subsample of mutton consumers, households sourcing mutton mostly from own production consumed mutton 1.5 days more frequently on average than households relying on market purchase, resulting in 100 grams per person per week higher mutton intake. Thus this analysis lends support to the notion that the linkage between sheep ownership and anemia risk is at least partly due to consumption arising from own-production in the presence of market incompleteness. [ABSTRACT FROM AUTHOR]

Background: Designing effective public health campaigns in areas of armed conflict requires a nuanced understanding of how violence impacts the epidemiology of the disease in question. Methods: We examine the geographical relationship between violence (represented by the location of detonated Improvised Explosive Devices) and polio incidence by generating maps of IEDs and polio incidence during 2010, and by comparing the mean number of IED detonations in polio high-risk districts with non polio high-risk districts during 2004–2009. Results: We demonstrate a geographic relationship between IED violence and incident polio. Districts that have high-risk for polio have highly statistically significantly greater mean numbers of IEDs than non polio high-risk districts (p-values 0.0010–0.0404). Conclusions: The geographic relationship between armed conflict and polio incidence provides valuable insights as to how to plan a vaccination campaign in violent contexts, and allows us to anticipate incident polio in the regions of armed conflict. Such information permits vaccination planners to engage interested armed combatants to co-develop strategies to mitigate the effects of violence on polio. [ABSTRACT FROM AUTHOR]

Background: Brucellosis and coxiellosis are known to be endemic in ruminant populations throughout Afghanistan, but information about their prevalence and factors that affect prevalence in householders and livestock under diverse husbandry systems and pastoral settings is sparse. Methods/Principal Findings: We conducted a cross-sectional survey to investigate the seroprevalence of brucellosis and Coxiella burnetii in humans and livestock in six secure districts in Herat from 26th December 2012–17th January 2013. A total of 204 households with livestock were surveyed in six Kuchi and five sedentary type villages. Blood samples from 1,017 humans, 1,143 sheep, 876 goats and 344 cattle were tested for brucellosis and Q fever. About one in six households (15.7%) had at least one Brucella seropositive person, about one in eight households (12.3%) had at least one Brucella seropositive animal and about one in four (24.5%) had either seropositive animals or humans. Ninety-seven percent of households had at least one C. burnetii seropositive person and 98.5% of households had one or more C. burnetii seropositive animals. Forty- seven householders had serological evidence of exposure to both C. burnetii and Brucella and eight animals were serologically positive for both diseases. Drinking unpasteurised milk (OR 1.6), treating animals for ticks (OR 1.4), milking sheep (OR 1.4), male gender (OR 1.4) and seropositivity to Brucella (OR 4.3) were identified as risk factors for seropositivity to C. burnetii in householders. Household factors associated with households having either Brucella seropositive animals or humans were Kuchi households (OR 2.5), having ≤4 rooms in the house (OR 2.9) and not owning land (OR 2.9). Conclusions: The results from this study provide baseline information for the planning and monitoring of future interventions against these diseases. The implementation of this study greatly improved collaboration, coordination and capability of veterinary and public health professionals from government, NGOs and donor funded projects. [ABSTRACT FROM AUTHOR]

Afghanistan and Iraq veterans experienced traumas during deployment, and disrupted connections with friends and family. In this context, it is critical to understand the nature of veterans’ transition to civilian life, the challenges navigated, and approaches to reconnection. We investigated these issues in a qualitative study, framed by homecoming theory, that comprised in-depth interviews with 24 veterans. Using an inductive thematic analysis approach, we developed three overarching themes. Military as family explored how many veterans experienced the military environment as a “family” that took care of them and provided structure. Normal is alien encompassed many veterans experiences of disconnection from people at home, lack of support from institutions, lack of structure, and loss of purpose upon return to civilian life. Searching for a new normal included strategies and supports veterans found to reconnect in the face of these challenges. A veteran who had successfully transitioned and provided support and advice as a peer navigator was frequently discussed as a key resource. A minority of respondents—those who were mistreated by the military system, women veterans, and veterans recovering from substance abuse problems—were less able to access peer support. Other reconnection strategies included becoming an ambassador to the military experience, and knowing transition challenges would ease with time. Results were consistent with and are discussed in the context of homecoming theory and social climate theory. Social support is known to be protective for veterans, but our findings add the nuance of substantial obstacles veterans face in locating and accessing support, due to disconnection and unsupportive institutions. Larger scale work is needed to better understand how to foster peer connection, build reconnection with family, and engage the broader community to understand and support veterans; interventions to support reconnection for veterans should be developed. [ABSTRACT FROM AUTHOR]

Introduction: Childhood diarrheal illnesses are a major public health problem. In low-income settings data on disease burden and factors associated with diarrheal illnesses are poorly defined, precluding effective prevention programs. This study explores factors associated with recurrent diarrheal illnesses among children in Kabul, Afghanistan. Methods: A cohort of 1–11 month old infants was followed for 18 months from 2007–2009. Data on diarrheal episodes were gathered through active and passive surveillance. Information on child health, socioeconomics, water and sanitation, and hygiene behaviors was collected. Factors associated with recurrent diarrheal illnesses were analyzed using random effects recurrent events regression models. Results: 3,045 children were enrolled and 2,511 (82%) completed 18-month follow-up. There were 14,998 episodes of diarrheal disease over 4,200 child-years (3.51 episodes/child-year, 95%CI 3.40–3.62). Risk of diarrheal illness during the winter season was 63% lower than the summer season (HR = 0.37, 95%CI 0.35–0.39, P<0.001). Soap for hand washing was available in 72% of households and 11.9% had toilets with septic/canalization. Half of all mothers reported using soap for hand washing. In multivariate analysis diarrheal illness was lower among children born to mothers with post-primary education (aHR = 0.79, 95%CI 0.69–0.91, p = 0.001), from households where maternal hand washing with soap was reported (aHR = 0.83, 95%CI 0.74–0.92, p<0.001) and with improved sanitation facilities (aHR = 0.76, 95%CI 0.63–0.93, p = 0.006). Malnourished children from impoverished households had significantly increased risks for recurrent disease [(aHR = 1.15, 95%CI 1.03–1.29, p = 0.016) and (aHR = 1.20, 95%CI 1.05–1.37, p = 0.006) respectively]. Conclusions: Maternal hand washing and improved sanitation facilities were protective, and represent important prevention points among public health endeavors. The discrepancy between soap availability and utilization suggests barriers to access and knowledge, and programs simultaneously addressing these aspects would likely be beneficial. Enhanced maternal education and economic status were protective in this population and these findings support multi-sector interventions to combat illness. Trial Registration: NCT00548379 [ABSTRACT FROM AUTHOR]

Objectives: Units deployed to armed conflicts are at high risk for exposure to combat events. Many battle casualties (BCs) have been reported in the recent deployment to Afghanistan. The long-term impact of these combat injuries, at their five-year end point, is currently unknown. To date, no systematic inventory has been performed of an identified group of BCs in comparison to non-injured service members from the same operational theatre. Design: Observational cross-sectional cohort study. Setting: Open online survey among Dutch BCs that deployed to Afghanistan (2006–2010). Participants: The Dutch BCs (n = 62) were compared to two control groups of non-injured combat groups (battle exposed [n = 53], and non-battle exposed [n = 73]). Main Outcome Measures: Participants rated their impact of trauma exposure (Impact of Events [IES]), post deployment reintegration (Post Deployment Reintegration Scale [PDRS]), general symptoms of distress (Symptom Checklist 90 [SCL-90]), as well as their current perceived quality of life (EuroQol-6D [EQ-6D]). Also cost effectiveness (Short From health survey [SF-36]) and care consumption were assessed (Trimbos/iMTA questionnaire). Results: Over 90% of BCs were still in active duty. The mean scores of all questionnaires (IES, EQ-6D, SF-36, and SCL-90) of the BC group were significantly higher than in the control groups (p<0.05). The PDRS showed a significantly lower (p<0.05) outcome in the negative subscales. The mean consumption of care was triple that of both control groups. A lower score on quality of life was related to higher levels of distress and impact of trauma exposure. Conclusions: This study showed a clear long-term impact on a wide range of scales that contributes to a reduced quality of life in a group of BCs. Low perceived cost effectiveness matched with high consumption of care in the BC group in comparison to the control groups. These results warrant continuous monitoring of BCs. [ABSTRACT FROM AUTHOR]

Background: Identifying areas that support high malaria risks and where populations lack access to health care is central to reducing the burden in Afghanistan. This study investigated the incidence of Plasmodium vivax and Plasmodium falciparum using routine data to help focus malaria interventions. Methods: To estimate incidence, the study modelled utilisation of the public health sector using fever treatment data from the 2012 national Malaria Indicator Survey. A probabilistic measure of attendance was applied to population density metrics to define the proportion of the population within catchment of a public health facility. Malaria data were used in a Bayesian spatio-temporal conditional-autoregressive model with ecological or environmental covariates, to examine the spatial and temporal variation of incidence. Findings: From the analysis of healthcare utilisation, over 80% of the population was within 2 hours’ travel of the nearest public health facility, while 64.4% were within 30 minutes’ travel. The mean incidence of P. vivax in 2009 was 5.4 (95% Crl 3.2–9.2) cases per 1000 population compared to 1.2 (95% Crl 0.4–2.9) cases per 1000 population for P. falciparum. P. vivax peaked in August while P. falciparum peaked in November. 32% of the estimated 30.5 million people lived in regions where annual incidence was at least 1 case per 1,000 population of P. vivax; 23.7% of the population lived in areas where annual P. falciparum case incidence was at least 1 per 1000. Conclusion: This study showed how routine data can be combined with household survey data to model malaria incidence. The incidence of both P. vivax and P. falciparum in Afghanistan remain low but the co-distribution of both parasites and the lag in their peak season provides challenges to malaria control in Afghanistan. Future improved case definition to determine levels of imported risks may be useful for the elimination ambitions in Afghanistan. [ABSTRACT FROM AUTHOR]

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common inherited enzyme defect and an important problem in areas with Plasmodium vivax infection because of the risk of haemolysis following administration of primaquine to treat the liver forms of the parasite. We undertook a genotypic survey of 713 male individuals across nine provinces of Afghanistan in which malaria is found, four in the north and five in the east. RFLP typing at nucleotide position 563 detected 40 individuals with the Mediterranean mutation 563C>T, an overall prevalence of 5.6%. This varied according to self-reported ethnicity, with prevalence in the Pashtun/Pashai group of 33/369 (8.9%) compared to 7/344 individuals in the rest of the population (2.0%; p<0.001, Chi-squared test). Multivariate analysis of ethnicity and geographical location indicated an adjusted odds ratio of 3.50 (95% CI 1.36–9.02) for the Pashtun/Pashai group, while location showed only a trend towards higher prevalence in eastern provinces (adjusted odds ratio = 1.73, 0.73–4.13). Testing of known polymorphic markers (1311C>T in exon 11, and C93T in intron XI) in a subset of 82 individuals wild-type at C563 revealed a mixture of 3 haplotypes in the background population and was consistent with data from the 1000 Genomes Project and published studies. By comparison individuals with G6PD deficiency showed a highly skewed haplotype distribution, with 95% showing the CT haplotype, a finding consistent with relatively recent appearance and positive selection of the Mediterranean variant in Afghanistan. Overall, the data confirm that the Mediterranean variant of G6PD is common in many ethnic groups in Afghanistan, indicating that screening for G6PD deficiency is required in all individuals before radical treatment of P. vivax with primaquine. [ABSTRACT FROM AUTHOR]

Oral polio vaccine has been used successfully as a powerful tool to control the spread of wild polioviruses throughout the world; however, during replication in under immunized children, some vaccine viruses revert and acquire the neurovirulent phenotypic properties. In this study, we describe the evolution and circulation of Vaccine-Derived Polioviruses (VDPVs) in Helmand province of Afghanistan. We investigated 2646 AFP cases of Afghan children from June 2009–February 2011 and isolated 103 (04%) vaccine viruses, 45(1.7%) wild type polioviruses and six (0.22%) type 2 circulating vaccine-derived polioviruses (cVDPVs). These cVDPVs showed 97.7%–98.2% nucleotide and 98%–98.7% amino acid homology in VP1 region on comparison with Sabin type 2 reference strain. All these cVDPVs had two signature mutations of neurovirulent phenotypes and 12 additional mutations in P1 capsid region that might also have contributed to increase neurovirulence and replication. Phylogenetic analysis revealed that all these viruses were closely related and originated from previously reported Sabin like 2 virus from Pakistan which did not conform to the standard definition of VDPVs at that time. It was also observed that initial OPV dose was administered approximately 9 months prior to the collection of first stool specimen of index case. Our findings support that suboptimal surveillance and low routine immunization coverage have contributed to the emergence and spread of these viruses in Afghanistan. We therefore recommend high quality immunization campaigns not only in affected district Nad Ali but also in the bordering areas between Pakistan and Afghanistan to prevent the spread of cVDPVs. [ABSTRACT FROM AUTHOR]