Vulnerable Urban Populations Research Articles

Air pollution exposure and its impacts on everyday life and livelihoods of vulnerable urban populations in South Asia

Urban populations in South Asia are regularly exposed to poor air quality, especially elevated concentrations of fine particulate matter (PM2.5). However, the potential differential burden for the urban poor has received little attention. Here, we evaluate the links between occupation, patterns of exposure to PM2.5, and the impacts at an individual and household level for vulnerable populations in Lahore (Pakistan), Kathmandu (Nepal), and Mandalay (Myanmar). We conduct personal exposure measurements and detailed interviews, identifying a wide range of impacts at individual and household levels. Low-income populations are concentrated in occupations that expose them to higher concentrations. Individuals report a range of adverse health impacts and limited capacities to reduce exposure. The lost income, compounded with the costs of managing these health impacts and limited opportunities for alternative employment, can deepen the socioeconomic vulnerability for the household. Reducing these risks requires targeted interventions such as improved social safety nets.

High-impact weather and urban flooding in the West African Sahel – A multidisciplinary case study of the 2009 event in Ouagadougou

On September 1st 2009 an extreme high-impact weather event occurred in Burkina Faso that had significant impacts upon the capital city Ouagadougou and its inhabitants. Subsequent reporting and research has however not focused on the contributing socio-economic and hydrological factors and the role of global warming and climatic change remains uncertain. This reflects a paucity of evidence attributing such extreme weather events to climate change for the West Africa region and limits the knowledge base for urban planning to climate-related risks which pose serious threats. This case study provides a holistic assessment of the most extreme urban hydrometeorological event recorded in the West African Sahel, that links synoptic conditions to climate change and through to hydrological impacts on vulnerable urban populations. The intention is to inform regional decision-makers on climate change and flood-generating high-impact weather events at the urban scale and to bridge the gap between what scientists understand as useful and decision-makers view as useable at the city scale by providing interdisciplinary answers to key questions raised by local stakeholders.Such an approach was shown to foster enhanced dialogue and engagement with stakeholders, while also providing a focus for communicating science at variable time- and spatial scales and between disciplines to improve understanding of how global processes have localised consequences. This reveals that Ouagadougou remains vulnerable to climate change and that such extreme weather events will become more frequent. But it is also demonstrated the complexity of attributing extreme events at such localised ‘urban’ scales to atmospheric phenomena affected by global climate change. Regional climate models are evolving and becoming more able to represent such extreme weather phenomena at suitable scales, enabling improved representation of climate-driven changes on such events, improving the ability for short-range forecasts in the future. Frameworks for managing flood risks however remain weak and under-resourced and there is limited capacity to manage flood risk from such events, particularly when rapid urbanisation amplifies vulnerability concerns. Recommendations are made to improve flood-resilience to future storms.

Rainfall and other meteorological factors as drivers of urban transmission of leptospirosis.

BackgroundLeptospirosis is an important public health problem affecting vulnerable urban slum populations in developing country settings. However, the complex interaction of meteorological factors driving the temporal trends of leptospirosis remain incompletely understood.Methods and findingsFrom March 1996—March 2010, we investigated the association between the weekly incidence of leptospirosis and meteorological anomalies in the city of Salvador, Brazil by using a dynamic generalized linear model that accounted for time lags, overall trend, and seasonal variation. Our model showed an increase of leptospirosis cases associated with higher than expected rainfall, lower than expected temperature and higher than expected humidity. There was a lag of one-to-two weeks between weekly values for significant meteorological variables and leptospirosis incidence. Independent of the season, a weekly cumulative rainfall anomaly of 20 mm increased the risk of leptospirosis by 12% compared to a week following the expected seasonal pattern. Finally, over the 14-year study period, the annual incidence of leptospirosis decreased significantly by a factor of 2.7 (8.3 versus 3.0 per 100,000 people), independently of variations in climate.ConclusionsStrategies to control leptospirosis should focus on avoiding contact with contaminated sources of Leptospira as well as on increasing awareness in the population and health professionals within the short time window after low-level or extreme high-level rainfall events. Increased leptospirosis incidence was restricted to one-to-two weeks after those events suggesting that infectious Leptospira survival may be limited to short time intervals.

Reducing asthma exacerbations in vulnerable children through a medical–legal partnership

Background Asthma health disparities are widely recognized, with worse outcomes in children from low income families. In a Medical-Legal Partnership (MLP), an attorney is embedded in a healthcare setting to address social determinants of health. We studied whether an MLP could impact asthma exacerbation rates in a vulnerable urban population at an academic children’s hospital. Methods The study population comprised children with asthma who were referred to the MLP between 2013 and 2017. We compared healthcare utilization for asthma exacerbations managed in primary care, emergency department and inpatient settings in the year before and year after MLP intervention. Results 98 children with asthma were included in the study. The mean total encounters per person per year decreased from 1.16 to 0.66 (relative reduction 44.2%, p < 0.01). The largest effect was on hospitalizations, with a reduction from 0.33 to 0.10 hospitalizations per patient per year (relative reduction 69.7%, p < 0.01). Encounters for asthma exacerbations in the primary care office and emergency department also decreased but these changes did not meet statistical significance. Conclusion In a pediatric population with asthma, an MLP intervention was associated with a significant reduction in asthma exacerbation encounters and hospitalizations comparing the year before and after MLP intervention. Further studies are needed to better understand which interventions are most effective, and for which patient groups MLP referral would be particularly useful. MLPs may be an important way to reduce health disparities in patients with asthma and other chronic illnesses. KEYWORDS Management/control; pediatrics

PROSPECTS OF TWINNING CLIMATE CHANGE AND URBAN SUSTAINABILITY ISSUES THROUGH TRANSFORMATIVE ADAPTATION: LESSONS FOR AFRICAN CITIES

In most African cities, existing approaches to tackle climate change and sustainability issues have remained largely weak, piecemeal and fragmented. For example, current adaptation practices are mainly focusing on ‘adapting to’ climatic disturbances instead of ‘adapting with’ the vulnerable urban population. This approach views climate change as the main source of vulnerability and focuses on protecting systems from weather and climatic events. It grossly ignores the social roots of vulnerability and misses out on opportunities such as those that emerge when climatic risks are jointly treated with environmental sustainability concerns. To evade this problem, this paper proposes a shift towards transformative adaptation, an approach that comprehensively attend to the entire urban socio-ecological system. The aim is to contribute to the discourse of inclusive cities by examining the prospects of simultaneously addressing climate change alongside other urban development challenges. Drawing on growing literature and reports on climate change adaptation in cities, I argue that the adjustment approach does not comprehensively address the underlying urban vulnerabilities and fail to match the severity of climate change impacts being experienced. On the contrary, a transformative approach locates urban risk beyond the biophysical environment to the entire urban social-ecological system. Thus, this approach is capable of jointly dealing with climate change and other urban development challenges as it holistically deals with the underlying vulnerability risks in urban settlements while addressing the root causes of urban unsustainability. African cities can draw useful lessons from the benefits that come with a transformative adaptation trajectory.

Managing service hubs in Miami and Osaka: Between capacious commons and meagre street-level bureaucracies

As key sites of governance and poverty management, service hubs are conspicuous inner-city clusters of voluntary sector organizations that serve vulnerable urban populations, including people grappling with homelessness, substance abusers and mental illness. In this paper, we frame service hubs as potentially embodying capacious commons on the one hand, and meagre street-level bureaucracies on the other, reconstituting Lipsky’s individual focus to embrace the agency level. We use a comparative case study approach, focussing on two service hubs – Kamagasaki in Osaka and Overtown in Miami – to show how organizations in each combined, in various ways, the two logics in practice. The results suggest that service hubs acted more as ‘managed commons’, but with some tendencies towards street-level bureaucracy. This conversation between the commons and street-level bureaucracies, and its comparative application to the voluntary sector within service hubs, serve as our primary conceptual and empirical contributions, respectively. We conclude by considering how the two logics overlapped and created hybridized models of poverty management.

Change agency and urban vulnerability: Theological-ecclesial paralysis or deep solidarity

Globally, cities respond differently to their most vulnerable urban populations, notably so during the coronavirus disease 2019 (COVID-19) pandemic. In the City of Tshwane, there seems to be a general paralysis of the church and theological education in relation to urban vulnerability. If the church and theological education are to participate as change agents to help transform urban vulnerability, a deliberate theological praxis and deep urban diaconate – in solidarity with the city’s most vulnerable realities – are proposed. This is done with reference to Harvey Cox’s assertion that the task of the church in the city is that of Diakonos and the provocations of Philippino liberation theologian, Daniel Pilario.Contribution: This article proposes that urban vulnerability and various responses to it need to be reflected upon as a priority, much more deliberately, considering how the entire urban household (oikos) is at risk.

Community health workers augment the cascade of TB detection to care in urban slums of two metro cities in India.

BackgroundTuberculosis Health Action Learning Initiative (THALI) funded by USAID is a person-centered initiative, supporting vulnerable urban populations to gain access to TB services. THALI trained and placed 112 Community health workers (CHWs) to detect and support individuals with TB symptoms or disease within urban slums in two cities, Hyderabad and Bengaluru, covering a population of about 3 million.MethodsCHWs visited the slums once in a fortnight. They conducted TB awareness activities. They referred individuals with TB symptoms for sputum testing to nearest public sector laboratories. They visited those testing TB positive, once a fortnight in the intensive phase, and once a month thereafter. They supported TB patients and families with counselling, contact screening and social scheme linkages. They complemented the shortfall in urban TB government field staff numbers and their capacity to engage with TB patients. Data on CHWs’ patient referral for TB diagnosis and treatment support activities was entered into a database and analyzed to examine CHWs’ role in the cascade of TB care. We compared achievements of six monthly referral cohorts from September 2016 to February 2019.ResultsOverall, 31 617 (approximately 1%) of slum population were identified as TB symptomatic and referred for diagnosis. Among the referred persons, 23 976 (76%) underwent testing of which 3841 (16%) were TB positive. Overall, 3812 (99%) were initiated on treatment and 2760 (72%) agreed for regular follow up by the CHWs. Fifty-seven percent of 2952 referred were tested in the first cohort, against 86% of 8315 in the last cohort. The annualized case detection rate through CHW referrals in Bengaluru increased from 5.5 to 52.0 per 100 000 during the period, while in Hyderabad it was 35.4 initially and increased up to 118.9 per 100 000 persons. The treatment success rate was 87.1% among 193 in the first cohort vs 91.3% among 677 in the last cohort.ConclusionsCHWs in urban slums augment TB detection to care cascade. Their performance and TB treatment outcomes improve over time. It would be important to examine the cost per TB case detected and successfully treated.

Assessment of Integrated Child Development Services (ICDS) at Grass Root Level in an Urban Area, Raigad District, Maharashtra

Background: ICDS is an integrated program intended for Maternal and Child Care which adopts a holistic, lifecycle approach. Its main focus is on health, nutrition and education. Urban ICDS caters to the vulnerable urban slum population. Despite the program running for four decades its impact on its beneficiaries is still slow. The Anganwadi worker and helper are the grass-root functionaries running this program through Anganwadi centre. Hence this study was conducted to assess the functioning of the Anganwadi centre. Methodology: A Descriptive Cross-sectional study was conducted at all 15 urban-ICDS Anganwadi Centres of Khopoli during September-November 2019. The Anganwadi workers and helpers were interviewed regarding their sociodemographic details, knowledge and challenges perceived to run the centre. Observational Checklist designed based on guidelines and standard proforma for monitoring of the ICDS projects was used to assess infrastructure, equipment and registers. Results: Out of 14, 11(78.57%) Anganwadi workers had more than a decade experience. Indoor space of 600 sq.ft was available in 7(46.67%) centres. Toilets with running water were available in 9(60%) Anganwadi Centres and 6(40%) were linked to the school. Functional Salter’s weighing scale was available in 11(73.33%) Anganwadi centres. All 12 registers were available in 9(60%) Anganwadi centres. The utilization of services by pregnant women was the highest. Partially immunized children were present in 2(13.33%) Anganwadi centres. The service gap was highest (100%) with health check-up. Conclusions: There is a gap in the availability of infrastructure and utilization of some services. Keywords: urban ICDS, Maharashtra, Service gap.

Geography and Demographics of Extreme Urban Heat Events in Santa Clara County, California

Summer heat waves inNorthern California continue to break records for extreme temperatures and put vulnerable urban populations at increasing risk for adverse health impacts. An analysis of Landsat land surface temperature data was conductedin this study to better understandthe geography and demographics of extreme urban heat events in Santa Clara County and the city of San Jose, California. The influence of several urban cover features including streets/roadways, parcel sizes and densities, impervious surfaces, and irrigated shrub/lawn cover were determined for county-wide surface heat patterns in early August 2020. Results showed that the surface temperature of the largest impervious (high-asphalt) surface features was significantly higher, at a mean value of 45°C, than the majority of the other areas across the entire county. In contrast, urban tracts with even partial coverage by irrigated green lawns, shrubs, and small trees had notable cooling effects on summer surface temperatures. Social demographic and household population variables from the U. S. Census Bureau were correlated against satellite surface temperature by census tract to reveal significant associations of family structure and education levels with local neighbourhood heat conditions.

A Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System's Initiative to Expand Treatment Access During the COVID-19 Pandemic.

Objectives:The purpose of this study was to assess the feasibility and clinical impact of telemedicine-based opioid treatment with buprenorphine-naloxone following the Coronavirus disease 2019 pandemic.Methods:Participants included in this retrospective analysis consisted of adult New York City residents with opioid use disorder eligible for enrollment in the NYC Health+Hospitals Virtual Buprenorphine Clinic between March and May 2020 (n = 78). Follow-up data were comprised of rates of retention in treatment at 2 months, referrals to community treatment, and induction-related events.Results:During the initial 9 weeks of clinic operations, the clinic inducted 78 patients on to buprenorphine-naloxone and completed 252 visits. Patient referrals included non-NYC Health + Hospitals (n = 22, 28.2%) and NYC Health + Hospitals healthcare providers (n = 17, 21.8%), homeless shelter staff (n = 13, 16.7%), and the NYC Health + Hospitals jail reentry program in Rikers Island (n = 11, 14.1%). At 8 weeks, 42 patients remained in care (53.8%), 21 were referred to a community treatment program (26.9%), and 15 were lost to follow-up (19.2%). No patients were terminated from care due to disruptive behavior or suspicions of diversion or misuse of Buprenorphine. Adverse clinical outcomes were uncommon and included persistent withdrawal symptoms (n = 8, 4.3%) and one nonfatal opioid overdose (0.5%).Conclusions:Telemedicine-based opioid treatment and unobserved home induction on buprenorphine-naloxone offers a safe and feasible approach to expand the reach of opioid use disorder treatment, primary care, and behavioral health for a highly vulnerable urban population during an unprecedented natural disaster.

Flood vulnerability and slum concentration mapping in Indian city of Kolkata: A post Amphan analysis

ABSTRACT The landfall of super cyclone Amphan, which affected Southern West Bengal and Orissa in 2020 and devastated human life, exposed the failure of urban infrastructure. On May 20, 2020, the storm alone recorded a rainfall of 236 mm in 24 h in Kolkata, capital city of West Bengal, pushing the total rainfall of May to 359.1 mm while averaged value of precipitation in May (2010–2019) stands at 117.5 mm. So, it further calls for relooking at climate preparedness for the Indian cities. In 2015 also, severe floods had affected more than six million people across the country of India alone, with over 250,000 people evacuated. In this context, the urban flood risks and major contributing factors in the Indian city of Kolkata have been discussed in this paper. The recurrence of floods and the exploration of causes repeatedly point to a situation of increased precipitation due to climate change, worsened by unregulated urbanization. The vulnerability assessment and calculation of Flood Vulnerability Index (FVI) for Kolkata is also conducted. It reveals the differential degree of vulnerability of city dwellers depending on location and infrastructure. The study leads to form a data base to infer characteristics and determine priority settings for the vulnerable urban population living in slums located in poorly drained areas of the city. A basin-wise analysis in KMC area reveals major urbanization coupled with decaying drainage system in the vulnerable basins as the main reason for aggravated flooding situation.

Implications for Using Mobile Ecological Momentary Assessment to Collect Climate Data from Vulnerable Urban Populations

This work documents the use of Ecological Momentary Assessment (EMA) to gather data on household behaviors related to outdoor temperatures. In order for urban decision-makers to take effective action to address heat events, they must understand vulnerable residents’ current practices in relation to outdoor temperature. However, vulnerable residents are often excluded from research and can be difficult to reach. EMA allows researchers to gather data in real time and in a subject’s natural environment, which reduces recall bias and improves ecological validity. In this study, EMA was used via a mobile phone app to gather information on home cooling behaviors from residents in vulnerable neighborhoods. Few participants reported making changes to their indoor environments apart from adjusting the thermostat. Despite low participation, the experience of conducting this research has resulted in valuable “lessons learned”. These lessons are used to inform implications and considerations for future use of EMA with vulnerable populations.

Abstract 16520: Predictors of Thirty Day Readmission in a Vulnerable and Underserved Urban Heart Failure Population

Introduction: Heart failure (HF) readmission quality metrics disproportionately impact reimbursement in safety net hospitals. Prior research has demonstrated the effect of medical comorbidities on readmission, however, there is a paucity of data on predictors of readmission in vulnerable and underserved HF patients. We sought to evaluate the effect of demographics, medical and social comorbidities on risk of 30 day readmission in an academic safety net hospital in San Francisco. Methods: We performed a retrospective chart review from 2018 to 2020. Patients were included if treated for HF while on inpatient cardiology or medicine services and were assigned an ICD-10 discharge code for HF. Patients less than 21 years old were excluded. Demographics and comorbidities were obtained through evaluation of ICD-10 discharge codes and chart review. Multivariate modeling was used to determine predictors of 30 day readmission. Results: The study population included 383 patients in which the mean age was 60±13 years and 73% (n=282) were male. 44% (170) were Black, 23% (88) were Latinx, 33% (127) were not housed, 97% (371) had public insurance, and 21% (81) had a diagnosis of mental illness. 46% (177) had CAD, 76% (291) hypertension, and 36% (177) DM. Substance use was common with 30% (114) using methamphetamines, 36% (138) cocaine, 18% (69) opioids, and 35% (135) alcohol. On multi-variate analysis, EF less than 40% (75%, 285) was the only medical comorbidity associated with an increased risk of readmission (OR 1.86, 1.1-3.1, p= 0.018). Social variables associated with increased risk of readmission included identifying as Black (OR 2.26, 1.03-5.0, p= 0.043) or Latinx (OR 3.43, 1.41-7.59, p= 0.006), homelessness (OR 3.02, 1.76-5.18, p=&lt;0.001), and specific substance use: methamphetamine (OR 2.23, 1.39-3.57, p=0.001), cocaine (OR 1.63, 1.03-2.57, p= 0.037), opioids (OR 1.81, 1.05-3.13, p= 0.033), and alcohol (OR 2.26, 1.43-3.58, p= 0.001). Conclusion: Race, housing status and substance use were more strongly associated with readmission risk than medical comorbidities in a population of urban, vulnerable and underserved HF patients. Interventions to improve HF readmission metrics should consider addressing racial and social disparities in similar populations.

Addressing Unintentional Exclusion of Vulnerable and Mobile Households in Traditional Surveys in Kathmandu, Dhaka, and Hanoi: a Mixed-Methods Feasibility Study

The methods used in low- and middle-income countries’ (LMICs) household surveys have not changed in four decades; however, LMIC societies have changed substantially and now face unprecedented rates of urbanization and urbanization of poverty. This mismatch may result in unintentional exclusion of vulnerable and mobile urban populations. We compare three survey method innovations with standard survey methods in Kathmandu, Dhaka, and Hanoi and summarize feasibility of our innovative methods in terms of time, cost, skill requirements, and experiences. We used descriptive statistics and regression techniques to compare respondent characteristics in samples drawn with innovative versus standard survey designs and household definitions, adjusting for sample probability weights and clustering. Feasibility of innovative methods was evaluated using a thematic framework analysis of focus group discussions with survey field staff, and via survey planner budgets. We found that a common household definition excluded single adults (46.9%) and migrant-headed households (6.7%), as well as non-married (8.5%), unemployed (10.5%), disabled (9.3%), and studying adults (14.3%). Further, standard two-stage sampling resulted in fewer single adult and non-family households than an innovative area-microcensus design; however, two-stage sampling resulted in more tent and shack dwellers. Our survey innovations provided good value for money, and field staff experiences were neutral or positive. Staff recommended streamlining field tools and pairing technical and survey content experts during fieldwork. This evidence of exclusion of vulnerable and mobile urban populations in LMIC household surveys is deeply concerning and underscores the need to modernize survey methods and practices.

The service hub as bypassed social infrastructure: evidence from inner-city Osaka

ABSTRACT We shed light on understudied social infrastructure by focusing on the service hub, those conspicuous clusters of voluntary sector organizations designed to help the most vulnerable urban populations. Using Kamagasaki, Osaka as an exploratory case study, we find that the service hub acts as a distinctly inner-city social infrastructure marked by very close proximity of clients and services, as well as high accessibility, mutuality, and provisionality, and clear motivations to ensure day-to-day survival. But the conversation between service hub and social infrastructure indicates that our case study must be understood as a bypassed infrastructure, unsung and out-of-sync with the market (but increasingly less so with the state). Kamagasaki suggested an social infrastructure of castoffs, standing apart and increasingly incompatible with current urbanism and its emphasis on privatization, gentrification, and neoliberal co-optation, or even with the older “infrastructural ideal” of the Fordist era, with its emphasis on large-scale universality.

Local solutions by slum communities to deal with summer water scarcity: Learning from Indore, India

Abstract Issue Government of India's, NITI Aayog reports that 600 million people in India face extreme water stress. Slums and similarly vulnerable urban populations face huge challenges in accessing water for basic needs, increasing in summers. Indore is an extreme water stressed city in India. Methods During Urban Health Resource Centre's (UHRC) program work in slums, including women's groups UHRC forms and trains in 2018 we learnt of acute water scarcity in summers. Women in 16 slums were motivated to evolve and implement possible solutions. Most slum dwellers provide services on low wages to the city. With public bore-wells drying-up, in Feb.- May 2019 UHRC helped women's groups' submit community requests, reminders to elected ward representatives and Municipal offices for free water tankers. UHRC motivated slum families to collectively negotiate with private providers to reduce cost, systematise water supply for more families. In 4 peri-urban slums we strengthened water access relationship between farmers and slum dwellers. Results During Feb.-May 2019 10 of the 16 slums received free water tankers from Municipal Corporation. More population of 4 peri-urban slums accessed water from farmer's tube-well. Slum families evolved coping mechanisms of storing more general use water in underground tanks or many cans. Families with larger storage shared water with needy families demonstrating social cooperation. Lessons Trained and mentored slum women's groups gently negotiating with elected ward-level politicians and municipal officials helps in provision of free water tankers in summers. This strategy to get govt. water supply in slums is adaptable in fast growing Indian cities. Owing to geographical proximity, rural-urban cooperation can help slums in city's fringes obtain water from farmer tube-wells used for irrigation. Fostering community cooperation helps more needy families get water. Key messages Slum communities develop local mechanisms to access and store water which need to be understood by civil society organisations and Government to improve solutions for water supply in summer months. Slum women emerge as dynamic actors to improve the lives of both women and men (Sen, 2000). In this case women help negotiate for and foster community cooperation for water, store more water.

Shifting from “Community-Placed” to “Community-Based” Research to Advance Health Equity: A Case Study of the Heatwaves, Housing, and Health: Increasing Climate Resiliency in Detroit (HHH) Partnership

Extreme summertime heat is a significant public health threat that disproportionately impacts vulnerable urban populations. Research on health impacts of climate change (including increasing intensity, duration, and frequency of hot weather) is sometimes designed and implemented without the involvement of the communities being studied, i.e., “community-placed” not “community-based.” We describe how the Heatwaves, Housing, and Health: Increasing Climate Resiliency in Detroit (HHH) partnership engaged relevant communities by integrating a community-based participatory research (CBPR) approach into an existing, academic-designed research project through a steering committee of community and academic partners. Using a case study approach, we analyze program documentation, partnership evaluation questionnaires, and HHH steering committee meeting notes. We describe the CBPR process by which we successfully collected research data in Detroit during summer 2016, engaged in collaborative analysis of data, and shared results with Detroit residents. Evaluations of the partnership over 2 years show community involvement in research; enhanced capacities; success in securing new grant funding; and ways that CBPR strengthened the validity, relevance, and translation of research. Engaging communities as equal partners using CBPR, even after a study is underway, can strengthen research to understand and address the impacts of extreme heat on health and equity in urban communities.

RAPID antiretroviral therapy: high virologic suppression rates with immediate antiretroviral therapy initiation in a vulnerable urban clinic population.

Little is known about long-term viral suppression rates for patients who start antiretroviral therapy (ART) soon after diagnosis. We describe virologic outcomes from the San Francisco-based Ward 86 Rapid ART Program for Individuals with an HIV Diagnosis (RAPID) ART program. Retrospective review of clinic-based cohort. In 2013, Ward 86 adopted immediate ART at the first visit after HIV diagnosis. Patients were referred from testing sites, offered same or next-day intakes, and received multidisciplinary evaluation, support, and insurance enrollment/optimization. Patients were provided ART starter packs and close follow-up. Demographics and labs were extracted from medical records. Subsequent viral loads were obtained from public health surveillance data. Kaplan-Meier curves summarized distribution of times to first viral suppression; viral suppression rates at last viral load recorded were calculated. Of 225 patients referred to RAPID ART from 2013 to 2017, 216 (96%) were started on immediate-ART: median age 30; 7.9% women; 11.6% African-American, 26.9% Hispanic, 36.6% white; 51.4% with substance use; 48.1% with mental health diagnoses; 30.6% unstably housed; baseline median CD4 cell count 441 cells/μl median viral load 37 011. By 1 year after intake, 95.8% achieved viral suppression to less than 200 cells/μl at least once. Over a median follow-up time of 1.09 years (0-3.92), 14.7% of patients had viral rebound, but most (78%) resuppressed. Viral suppression rates were 92.1% at last recorded viral load. In an urban clinic with high rates of mental illness, substance use and housing instability, immediate ART provided through a RAPID program resulted in viral suppression at last viral load measurement for more than 90% of patients over a median of 1.09 years. RAPID ART for vulnerable populations is acceptable, feasible, and successful with multidisciplinary care and municipal support.

Modelling and analysis of the flood risk at Cavaillon City, Haiti

In Haiti, the vulnerability of urban populations in river flood corridors has disastrous socio-economic consequences on the living conditions of these communities. Mapping of areas prone to this type of risk is not sufficiently developed in Haiti, which complicates the implementation of strategies for the effective management of flood risk. This paper presents a methodological approach allowing to draw up a risk map of the city of Cavaillon, which is confronted to periodic flooding by the Cavaillon river flowing through the city. The reconstruction of the riverbed and floodplain geometry using a differential GPS and a novel drone-based photogrammetry technique made it possible to construct a hydraulic model of the river and to calculate the flow in the river for scenarios corresponding to different periods of return. The vulnerability of the different areas in the city was established using an Analytic Hierarchy Process. Various criteria of vulnerability were identified and their respective weight progressively determined from discussions between local decision-makers. Finally, considering the extent of the inundated area following recent Hurricane Matthew that particularly affected the zone, a vulnerability mapping was drawn for the town of Cavaillon.