Health Sector Actions in Emergencies

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WHO

WESTERN PACIFIC REGIONAL OFFICE

_____________________

An Overview of Health Sector Actions

in Emergencies

3rd draft

October 2003


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Emergency Health Care Page 2 of 29

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November 2009

Contents

1. Introduction..................... ............ ............. .............. ............. ............. ............. .............. ............. ............ .............. ......... 4

2. General Planning Issues ............ ............. ............ .............. ............. ............ .............. ............. .............. ............ ............ 4

2.1 Assessing the impact of a hazard................................................................................................................42.1.1 Concepts 4

2.1.2 Information in the Assessment 52.1.2.1 Classification of Victims ......................................................................................................................52.1.2.2 Classification of Damage in Emergency Situations .............................................................................62.1.3 Determining Response Priorities 62.1.3.1 Priority Relief Needs ............................................................................................................................62.1.3.2 Secondary Relief Needs........................................................................................................................72.1.3.3 Management of Logistics, Transport and Communications.................................................................72.1.3.4 Epidemiological Surveillance...............................................................................................................72.1.3.5 Public Information and Community Participation................................................................................72.1.3.6 Monitoring, Evaluation and Reporting.................................................................................................72.1.3.7 Rehabilitation and Reconstruction........................................................................................................72.2 The Health Sector Role in Preparing for an Emergency Response............................................................82.2.1 Co-ordination 82.2.2 Readiness 82.2.3 Warning Phase 92.3 The Disaster Assessment Report...............................................................................................................102.3.1 The First Report 102.3.2 Interim Report 112.3.3 Final Report 122.3.4 Consolidated Annual report 122.4 Demography ............................................. .................................................. ..............................................122.5 Determining Priorities for Service Provision in Population Displacements............................................122.6 Vulnerability Analysis and the Health Sector ............................................. ..............................................132.6.1 Assessment of Risk 142.7 Tools for Health Assessments ........................................... .................................................. ......................152.7.1 Epidemiology 162.7.1.1 Mortality Rate.....................................................................................................................................172.7.1.2 Procedures for calculating mortality rates..........................................................................................173. Specific Response Issues................ ............. ............ .............. ............. .............. ............ ............. .............. ............. ..... 18

3.1 Health Sector Responsibilities..................................................................................................................183.1.1 Disease Control 183.1.2 Immunisations 183.1.3 General Health Care 183.1.3.1 Estimating needs.................................................................................................................................183.1.4 Medical Supplies 193.1.4.1 Overall policy .....................................................................................................................................193.1.4.2 Medical Kits .......................................................................................................................................193.1.4.3 Donations............................................................................................................................................20

3.1.5 Vaccines 203.1.6 Care of the dead 213.1.7 Foreign Medical Teams 213.2 Overview of Common Health Problems ............................................. ................................................ ......213.2.1 Trauma 213.2.2 Estimating medical needs 213.2.2.1 Hospital Capacity Assessment............................................................................................................223.2.2.1.1 Hospital Treatment Capacity (htc)...................................................................................................223.2.2.1.2 Hospital Surgical Capacity (hsc) .....................................................................................................223.2.2.2 Hospital Resource Management.........................................................................................................223.2.3 Estimating surgical needs 23


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Preamble

Throughout history, natural disasters have exacted a heavy toll of death and suffering. Duringthe past 20 years, they have claimed about 3 million lives world-wide, have adversely affectedthe lives of at least 800 million more people, and have resulted in property damage exceeding$23 billion. The future appears to be even more frightening. Increasing population density inflood plains, and in seismic- and hurricane-prone areas points to the probability of future catas-trophic natural disasters with millions of casualties.1

The purpose of this paper is to give an understanding to non-health professionals of the kind ofreference information needed for assessing the condition of populations at risk of death, injury ordisease immediately before and during an emergency. It also attempts to give an understanding ofhow the health sector uses this information to develop appropriate response plans which are basednot only on identifying priorities but equally importantly, on accepted international standards forthe provision of emergency health and medical relief. Although national disaster managementagencies are not responsible for detailed sectoral assessments, this reference material is useful fortheir staff to:

Understand the needs, concerns and constraints that are faced by different sectors tryingto work together under difficult circumstances;

Understand the technical information provided by sectoral experts; Evaluate the overall situation using specific information submitted by different sectors; Determine global response priorities and allocate resources appropriately; Anticipate potential future problems; Inform the public and report comprehensively to government leaders.

1. Introduction

In an ideal situation, effective emergency management occurs when each administrative unit of acountry has its own functional plan for response to any hazard. This requires each district and mu-nicipality to have its own indigenous capacity for response, through decentralised ambulance, fire-service, police and other emergency management services. Planning for this capacity is done

within the context of a national and sub national planning process. When activated, it is supple-mented by national resources when necessary.

However, few developing countries have the ability to plan down to the district level, nor do theyhave the administrative culture of formulating procedures which delegate the necessary authorityto that level. Therefore, the focus of this module will be the first sub national level i.e. provinces(regions, Governorates etc.) and major municipalities. It is in this context that the word local isused here. As countries develop socially and economically, they will be in a better position to takeemergency management programmes to communities at the level of districts, towns and villages.

2. General Planning Issues

2.1 Assessing the impact of a hazard2.1.1 ConceptsThe aim of this paper is to outline general principles for undertaking an assessment of the impactof a hazard on a particular population at a particular time in terms of the health sector. A detaileddiscussion of assessment criteria for a variety of specific health scenarios (floods, epidemics,

1 From The Nature of Disaster: General Characteristics and Public Health Issues by Eric Noji, Centres forDisease Control, Atlanta, USA ;


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chemical accidents etc.) can be found in the World Health Organisation publication, Rapid As-sessment Protocols.

The purpose of any assessment is to give decision makers information that will allow them tomake timely and appropriate interventions to:

save lives;

minimise injury and illness; prevent escalation or spread; prevent secondary hazards; inform the public.

The assessment identifies who and where are the victims, and estimates gaps between their needsand local resources i.e. it relates the number of victims to the capacity for services to cope withthem, and it identifies future areas where risk may evolve.

One of the commonest faults with assessments is collecting too much data and/or irrelevant infor-mation. It is important that Ministry of Health (MOH) policy defines clearly which information isneeded at the different stages of the management of an emergency. Data should be analysed to de-fine:

the causative factors of the health problems; the extent of the problems; the likely trends; constraints (geographic, political, social, logistical, organisational etc); priorities for action; resources and length of time needed for deployment and implementation.

Assessment is only one part of the information gathering process. The process includes:

evaluation; monitoring; surveillance; reporting.

Since information will be collected by many different people from a variety of sources, it is essen-tial that a standardised collection and analysis formatis used. It is impossible to collate and inter-pret data that has been presented in different formats using different standards and different termi-nology. One of the most critical responsibilities of a national emergency management authority isto standardise how data is collected and presented, and to publish forms to be used by local staff indata collection.

2.1.2 Information in the AssessmentThe assessment involves the collection of two key categories of information

Classification of the victims; Classification of damage to infrastructure and/or interruption of services.

2.1.2.1 Classification of Victims

In order to prioritise the allocation of scarce resources in the soonest possible time, it is essential toclassify the victims. The following are considered essential to survival and are called lifelines:

water; food;


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assist in search and rescue; first aid and transport of casualties; acute medical and surgical care; care of the displaced and vulnerable; security of water supply; assist in provision of shelter, warmth and clothing.

2.1.3.2 Secondary Relief Needs

The health sector action to be undertaken includes steps to improve the capabilities of serviceswhere deficiencies are indicated. This is accomplished by increasing stocks of materials and sup-plies, providing auxiliary or alternative power sources with supplies of fuel, acquiring additionalrepair equipment, and recruiting and briefing personnel, volunteers, retired professionals, and othersimilar workers.

assist in provision of food and fuel; assist in the provision of facilities for sanitation and personal hygiene control of communicable disease; control of vectors and pests; psychological care;

disposal of dead humans and dead or injured animals.

2.1.3.3 Management of Logistics, Transport and Communications

Use of health sector resources in logistics, transport and communications should be co-ordinatedwith all other sectors to maximise efficiency of the operation.

2.1.3.4 Epidemiological Surveillance

Epidemiology is a key planning tool in the health sector

morbidity number of illnesses priorities include trauma, diarrha , ARI, measles, no-tifiable diseases;

mortality number of dead;

laboratory support; water quality; nutrition; vectors; overall planning and decision making; overall reporting, monitoring and evaluation.

2.1.3.5 Public Information and Community Participation

These are very important aspects of the management of all emergencies.

2.1.3.6 Monitoring, Evaluation and Reporting

It is very important that standard formats are prepared and issued by the Ministry of Health. Staff

need to be briefed on how to use the forms and given guidelines for their use and submission.

2.1.3.7 Rehabilitation and Reconstruction

As part of the overall plan, the health sector must have guidelines and mechanisms for estimatingcosts for:

replacement and repair; restocking;

and it must also:


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review the emergency plan, local policy and administrative procedures; review overall development policy and planning review; undertake retraining both technical and administrative.

2.2 The Health Sector Role in Preparing for an Emergency Response

Response to emergencies has three phases:

relief; care and maintenance; recovery - rehabilitation and reconstruction.

Each phase has priorities, strategies and technical issues specific to that phase. There is no clearpoint at which one phase ends and the next begins it will vary according to many factors, and ina widespread disaster, senior emergency managers can find themselves involved in all 3 at thesame time, in different parts of the affected area.

This paper will discuss issues relevant to local response activities. The responsibilities of thehealth sector at Provincial level are as follows:

co-ordination; technical planning; resources and logistics; training and research; public information.

2.2.1 Co-ordinationOne of the most important areas of emergency management is to participate in committees for co-ordination. The levels at which co-ordination is needed are as follows:

within sectors; between sectors;

with international agencies; with community leaders and interest groups such as NGO; between districts; between districts and provinces; between provinces;

In this framework, mutual support and other co-operative arrangements are initiated. Agreementswith related services, academic institutions, the military and civil defence agencies encompass theexchange or assignment of personnel, equipment, information and supplies of the various co-operating groups. The co-ordination of reconnaissance and assessment, taking inventories, stan-dardising stock lists, training and so forth also are covered in the agreements. Responsibilitiesshould be defined and assigned, and legal limitations of co-operation should be considered.

2.2.2 ReadinessIt is important to maintain an updated file of essential information. This information should beorganised so that each administrative sub unit of the Province has its own file. This informationincludes:

any existing national, provincial or district emergency profiles; vulnerability analyses; inventory of resources and deficits; maps;


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update information on businesses which stock or make materials essential for relief(boats, plastic sheeting, rope, tents etc.);

In this phase, the Co-ordinator will call a meeting of the emergency management committee andensure that each person knows their duty and has to hand the information that she needs. Shortfallsin essential staff and resources are estimated, arrangements made to address those shortfalls andthe contingency plans reviewed for each sector.

When the Co-ordinator is satisfied that her staff are properly prepared, she will brief her superiorson the level of readiness and her estimate of needs. She must be prepared with information for herssuperiors so that neighbouring districts can be requested to be ready to assist. She would also pro-vide information that would help make a decision to request international assistance. Should it bedecided that evacuation of certain population groups might become necessary, it is the duty of theMOH to ensure that basic services for health care, water and sanitation are available and able tocope with the expected load. If a good response plan has been activated, the site for emergencyshelter will have been already selected and would only require final preparation during the warn-ing phase.

The site should be checked with those responsible for shelter for health factors in the accommoda-

tion, the proposed feeding plan, personal hygiene arrangements, water supply, sanitation, the dis-posal of wastes and vector control. The special needs of mental hospitals, prisons, orphanages andother vulnerable institutions should be checked. The latest information is needed on populationdensity, health and demographic profiles, hazard map, risk map, resources map including staffresidences, access road maps and routine maintenance activities which affect the condition of, andavailability of, key resources. Information also needs to flow to the public, from the public, tohigher authorities, to staff, to liaison staff, the media, to other agencies.

The costs in human suffering in a disaster can be reduced by local government measures whichensure that important community resources such as bus stations, produce markets and truckingcentres are sited in areas which are protected from hazards and are not the cause traffic congestionor bottlenecks which will block emergency response vehicles. Vulnerability can be unnecessarily

increased by inadequate consideration given to the needs of animals and their environments. Fi-nally, private agents or bodies which can augment local capabilities during emergencies should beidentified, and a list of local consultants or institutions which can be called upon in emergenciesshould be compiled. All of these measures should be repeated at least once a year.

2.3 The Disaster Assessment Report

The report fulfils several functions it is a request for assistance, it provides information to deci-sion makers, it contributes to future training exercises, it is an input to any policy review that maketake place and it contributes to maintaining databases and statistics.

In addition to determining the format and the data to be collected, policy makers need to determinein advance:

who files the report district, province, department;

how often within 4 hours then daily;

when is it required all events with >10 casualties;

where does it go province and centre;

who consolidates the information special report, annual report.

2.3.1 The First ReportResponsible: District Medical Officer;


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Classification Mandatory for all events with more than 10 casualties (killed and in-jured);

Send To Provincial Medical Officer and MOH.

1. What happened:

event, date, time, area involved, total population, number and severity of affected,

casualties.

2. What is the caseload:

acute medical (injured) - first aid only, hospital outpatient only, inpatient; public health (affected); disability; social (total population).

3. What resources are available:

Level of functioning of pre-existing capacity of services and infrastructure: ( e.g. 100%, 50%, 0%)

access; structures; water supply; energy supply; personnel; equipment; medical supplies; laboratory and blood bank; x ray; hospital beds; specialist care - spinal unit, burns unit, intensive care; transport; communications.

4. What resources are needed

Specify type, quantity and time period:

personnel; equipment; medical supplies; health care delivery buildings; laboratory and blood bank;

x ray; hospital beds; specialist care - spinal unit, burns unit, intensive care; transport; communications; electricity; water;

Attach district emergency profile (mandatory reporting every 6 months)


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2.3.2 Interim ReportAs above, filed every 24 hours at the same time each day by the DMO.

2.3.3 Final ReportFiled by the Provincial Medical Officer:

1. What happened?

2. How was it managed?3. What were the lessons learned?

2.3.4 Consolidated Annual report1. What are the trends?

2. How are lessons learned being implemented?

2.4 Demography

In the absence of a proper census of a population receiving relief, planning for all aspects of emer-gency care can be based on an internationally accepted understanding of a typical population. Thisis composed of:

51% are female; 34.6% are under 15 years of age; 12.4% are under 5 years of age; 4.0% are under 1 year old; 0.4% are under one month; 26.2% are females 15-44 years of age; 2.4% are pregnant females; 2.6% are lactating mothers; 2.5% are females aged 15 (need tetanus booster); 7.2% are over 60 years of age.

2.5 Determining Priorities for Service Provision in Population Displacements

The following matrix can be used to help prioritise response activities in an emergency as-sociated with displacement of a large population. It describes the needs of victims (not agencies)for the various stages in an emergency in those cases where there has been significant populationdisplacement in a developing country. The time frame indicates the maximum time it should taketo have the basic elements of a particular service in place. In a more developed country, the timeframe will probably be shorter and may contain different emphases, but the needs will be basicallythe same.


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Stage Time-

frame

Services Health Sector Priorities

Immediate first 24hours

search and rescue;

shelter;

food;

water;

public information;

triage;

first aid;

acute medical and surgical services;

Short-term one week security;

environmental health ser-vices such as personal hy-giene, sanitation, waste dis-posal, etc.;

energy (fuel, heating, light);

epidemiological surveillance;

care of the dead;

general curative care services;

control of diarrha and acute respiratorydiseases;

nutritional surveillance;

(providing measles vaccination and VitaminA supplements is often a priority in thisphase);

Mediumterm

one month protection (legal and physi-cal);

transport;

communications;

restoration of preventative health care ser-vices such as EPI, MCH, etc.;

restoration of priority disease control

programmemes such asTB

, malaria etc.; (re) establishment of a health information

system;

Long term Threemonths

education;

agriculture;

employment;

social services;

environmental protection.

rehabilitation;

training;

health information and health educationprogrammemes;

This chart can be completed by an agency for each emergency. Once the needs have been defined

for the victims, the same process needs to be carried out using the same matrix to define the needsof the agency if it is to provide that service efficiently an effectively.

2.6 Vulnerability Analysis and the Health Sector

Vulnerability is normally understood in terms of social indicators (age, sex, income). However, thehealth sector has much to offer in determining vulnerability. In doing so, the health sector uses in-formation that it already collects, plus certain key social indicators, to identify those within a givencommunity who are especially vulnerable to hazards. This allows Emergency Preparedness andResponse Programmes to target these groups in non-emergency times, so as to address the factorswhich make them vulnerable. In an emergency, the information can be used to direct relief actionsto these pre-identified groups on a priority basis.

Countries are often called vulnerable. This is a misleading use of the word, since it is impossible toassess the vulnerability of a whole country in anything other than theoretical terms. For practicalpurposes, the label vulnerable is best applied to particular groups within certain communities.Both development and emergency response occur at community level, so planners and emergencymanagers need information at that level.


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In the emergency management context, vulnerability can be defined as:

factors (of the community) that increase the chances of that community being unable tocope during an emergency; e.g. the level of underdevelopment of the community; i.e. itis one of the factors which determine that a hazard will become a disaster.

2.6.1 Assessment of RiskNot all hazards create an emergency and not all those exposed to a hazard will be a casualty or

even affected2. What determines when or if an emergency occurs and who or what is damagedwhen a hazard meets a community is not simply luck or fate outcome is to a great extent deter-mined by a complex set of factors which collectively generate what we call risk and unlike luck orfate, we now have tools which allow us to estimate levels of risk quite accurately. Factors whichare reliably associated with a known outcome are called determinants. There are certain determi-nants of hazard and community that we can identify in order to indicate a relative level of risk andwe can then undertake measures to reduce risk. We can then go back and reassess risk, to deter-mine if our actions have actually influenced the risk.

In the emergency management context, a risk assessment is:

the quantitative study of the determinants of hazard related events in communities.3

In assessing risk, there are two major sets of determinants:

Susceptibility - called a locator it describes the probability of exposure to a particularhazard. It is a general statement of risk for a community and is used to locate areaswhere further assessment is needed, such as for vulnerable groups. For instance, thefirst step in undertaking a study of the effects of flooding would be to identify commu-nities that are susceptible to flooding it would be a waste of time and resources tocarry out research in areas when flooding doesnt happen.

Vulnerability called an identifier this identifies groups within susceptible communi-ties that have certain characteristics which increase their probability of a negative out-come in comparison with other members of the community.

In general terms, a risk assessment of a community should define the following visible outputs.Each of the elements can be given either a quantitative or qualitative value. Once the elements ofrisk have been defined, the impact of prevention, mitigation and preparedness can then be assessedas having, or not having, reduced vulnerability over time.

the risk of death; the risk of injury (mental and physical); the risk of disease (mental and physical); the risk of secondary hazards (fire, disease etc.); the risk of contamination; the risk of displacement;

the risk of loss of property; the risk of loss of income; the risk of breakdown in security; the risk of damage to infrastructure;

2 This analysis parallels the exposureinfection-disease-death or survival model in the biology of communica-ble diseases. It can be illustrated with the glasses of water exercise.

3See the definition of epidemiology.


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the risk of breakdown in essential services.

In this context, it can be seen that a risk assessment for hazards and disasters can only be meaning-ful when it is applied to communities. It cannot be easily applied to a whole country. For the healthsector specifically, vulnerable groups are people who are a) members of a community which issusceptible to a hazard and b) at special risk because of their health status.

To find these groups, it is essential to work in terms of communities. For practical purposes, acommunity is defined as everyone living within a small, legally defined administrative area, suchas a thana, a district or a municipality. Larger units such as states or provinces are too heterogene-ous and diverse to allow practical application of the information that is collected. Once the admin-istrative level has been decided, a list is drawn up of all those communities, with population dataand the emergency management information that is needed. In emergency preparedness pro-grammes, the next step is to determine the level of ambition that is to be the goal of any interven-tion. This is dependant on the available resources and the operational constraints. You may choseto identify and work with the bottom 10% of the vulnerable districts in one state only or in thewhole country, or, with a higher level of ambition, you may chose the bottom 20%.

Once the level of ambition is decided, the districts which fall within that level are identified for

each of the nine key health indicators e.g. the bottom 10%. The objective is to find out the districtswith the worst coverage. A second list is then drawn up identifying districts that are susceptible tohazards, based on known risks (a chemical factory) or historical data (previous floods). Again alevel of ambition is decided e.g. to work with districts whose annual risk is greater than 90%. Thisinformation is then correlated with the first list and those districts which have both a high suscep-tibility to the hazard andwhere peopleare vulnerable because of poor health indicators are thehigh risk group. They are then targeted by development programmes in order to raise coverage orimprove access to services.

Since the constituents of the vulnerable groups is fluid and hazards evolve over time, the processneeds to be carried out on a regular basis to identify communities in need. Upper limits for inter-ventions should also be set i.e. if a point is reached whereby all communities in the country have

measles coverage above 90%, then measles coverage could be dropped from the surveillance pro-gramme. In an emergency, these lists also provide up to date information to emergency managers,so that affected districts can receive timely and appropriate health interventions.

2.7 Tools for Health Assessments

The aim of the health assessment is to determine mortality and morbidity rates, health needs and toestablish response recommendations and priorities. The principle tool used by health workers incollecting information is epidemiology.

Factors contributing to health, or lack of it, in a displaced population must be determined by estab-lishing the pattern of disease, the effect of cultural and social influences on the health of the popu-lation, and the effectiveness4 of the existing health services. The key to an effective assessment and

surveillance programme is good information. Information can be collected by direct observation orfrom secondary sources, such as reports from health workers. Sample surveys reveal symptomsand disease patterns and indicate their distribution within a community. Ideally in a disaster, massscreening on arrival at an evacuation area should always be done as it is the most reliable methodof collecting data but it is not always possible as immediate relief of suffering is the first priority.

4 Range of services, coverage, penetration, caseload, follow-up, referrals, active/passive case-finding, promo-tion/education, etc.


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For refugees, mass screening sometimes can be conducted at a camp during the registration proc-ess, but it is more often done once the emergency phase is under control.

A centrally co-ordinated surveillance system must be established quickly to identity problems intime for preventative action. For example, the incidence of diarrha may be an important indicatorof environmental problems. To be fully effective, surveillance requires rapid access to laboratoryservices. Very simple lab services at the community level are usually adequate but good referral

and quality control systems for both patient care and specimens is an essential component of anyprevention, treatment and surveillance network.

Community reporting is an essential tool for the monitoring of disease patterns and planning ofservices. National health authorities may require specified 'notifiable' communicable diseases to bereported at once. Individual record cards are used for recording immunisations and the treatment ofillnesses. These cards should be kept by the displaced person, and in the case of young children, bythe mother.

2.7.1 EpidemiologyEpidemiology is:

the quantitative study of the determinants of health related events in human populations.

Epidemiology is a specialised form of statistics. Epidemiologists are public health professionalswho usually work for Government departments or academic institutions. They are normally con-cerned with routine monitoring the health status of populations and advising policy makers on cur-rent trends. In emergencies the same statistical tools can be used to investigate the effects of theevent on the health of a population. As such, the role of the epidemiologist is to present informa-tion in a form that decision makers can use to address the situation.

The role of the epidemiologist in emergency management is to:

Identify vulnerable groups in advance; Predict the health impact of known hazards on known populations; Assess the needs of an affected population; Match available resources to immediate needs; Prevent further adverse health effects; Evaluate a relief effort; Contribute to future emergency planning.

To be able to function, an epidemiologist has few needs. She does need, however, rigid applicationof definitions, as information cannot be collected from multiple sites and multiple sources unlesseveryone involved has exactly the same understanding of the key terms involved. In health thereare fixed epidemiological definitions of most conditions (e.g. child, measles, hospital, policy)called the case-definition. However, there are no universally accepted definitions of many terms,such as emergency or disaster. This is not a major constraint to epidemiologists working in a spe-cific emergency, but the lack of standard terminology makes wider trend analysis, especially whencomparing the impact of similar events on different populations, almost a worthless exercise. Simi-lar problems occur with definitions of other common emergency-related words such as affected,casualty, damaged, displaced, vulnerable, etc.

A common fault in reporting of emergencies is to use raw data for analysis e.g. reporting that anearthquake killed 1,234 people. This is meaningless as well as useless to anyone except journalists.To be practical and meaningful, data needs to be expressed in two main forms, called indicators:


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Rates the number of cases per unit of population this tells you what is happeningnow and how big (or how serious) the problem is e.g. in a cyclone, a district with 2500killed at a rate of 250/1000 is more in need that one with 5000 killed at a rate of50/1000;

Trends this compares one rate with another over a period of time it tells you whathas happened up to now, how your interventions are doing, what might happen in thenear future or how this emergency compares with other similar events e.g. in the 5

years since our project started, floods have injured an average of 19/1000 in District Xbut in the ten years prior to our project, an average of 123/1000 people were killed eachyear in the same population; therefore we can say our interventions have been success-ful.

Some other terms are very important in epidemiology. These are:

Incidence this is a rate which tells the number of new cases of a disease in a given pe-riod of time;

Prevalence this is a rate which tells the number of existing cases of a disease presentin a community at any given time;

Endemic this describes diseases which are always present in a community; they may

be constantly present (holo-endemic), with seasonal or periodic fluctuations. They cancause large numbers of cases each year e.g. malaria (hyper-endemic) or very few e.g.rabies (hypo-endemic).

Epidemic this describes the appearance of diseases which are not usually present in acommunity as well as any unusual increase in the incidence of an endemic diseases(malaria can be endemic and also cause epidemics). Epidemics are public health emer-gencies because they affect large numbers of people in a short period and thus canquickly overwhelm health systems or because they have very serious social and eco-nomic consequences if not contained. Not all infectious agents cause epidemics - cer-tain micro-organisms are classified as causes ofdiseases of epidemic potential, andeach of them has different thresholds for being declared epidemics.

Outbreak this describes an increased number of cases of an infectious disease of suf-

ficient magnitude to cause concern, but not enough to create an emergency.

2.7.1.1 Mortality Rate

The Mortality Rate (death rate) is the single most important indicator of serious stress (e.g. ill-ness, malnutrition) in a displaced population. Knowing the causes of death is crucial since ithelps set priorities for appropriate relief and prevention interventions.

In a displaced population served by well-run relief efforts, overall mortality rates should not ex-ceed 1.5 times those of the host population. In general, even initially high mortality rates shouldfall to or below 1.0 per 10,000 per day within 4-6 weeks of beginning a basic support programmethat provides sufficient food, water, immunisation, simple health care, and other immediate needs.Mortality Rates exceeding 2.0 per 10,000 population per day indicate a very serious situation and

immediate action needs to be taken. Death rates should be calculated over an extended period,ranging from one week to a month. Since it may be difficult to determine the total population, asample size of 20-30 families is recommended.

2.7.1.2 Procedures for calculating mortality rates

Mortality Rate = Deaths/10,000/day = Number of deaths x 10,000/Number of days x Population

For example: if 21 deaths have occurred over a 7-day period in a displaced population of 5,000people, the mortality rate would be calculated as follows:


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Mortality Rate = 21x10,000/7 x 5000 = 210,000/35,000 = 6which is expressed as 6 deaths per 10,000 per day

To convert to the number of deaths per 1,000, which is the preferred method of public health per-sonnel and epidemiologists, divide the rate above by 10 (0.6 deaths per 1000 per day).

A mortality rate greater than 1.0/10000/day is considered a medical emergency. The normal

death rate in a developing country is about 0.5/10,000/day.

3. Specific Response Issues

3.1 Health Sector Responsibilities

3.1.1 Disease ControlThe risk to an individual of both contracting and transmitting a communicable (infectious) dis-eases is increased by overcrowding, poor environmental conditions, and the often poor initial stateof health of the population. The infectious organism however, must first be present to spread.Measures to improve environmental health conditions are, therefore, very important. These meas-ures include providing enough safe water, washing facilities and soap, proper disposal of excretaand garbage, controlling rodents and vectors of disease, as well as informing and educating the

population on general public health issues.

3.1.2 ImmunisationsThe only immunisation required during the early weeks of an emergency is for young childrenagainst measles (all children between six months and 15 years of age). This is a high priority evenwhen resources are scarce, and all children should receive the vaccine even if they have had it be-fore. If significant malnutrition is present, it is absolutely essential to implement a vaccinationprogramme as soon as possible. All other necessary immunisations e.g. Diphtheria-Tetanus-Pertussis (DTP), Tetanus (TT) Polio (OPV) and Tuberculosis(BCG) should be given later, once facili-ties allow, and to the extent possible within the framework of the existing Expanded Programme ofImmunisation (EPI) of the (host) government.

The chart below illustrates immunisable diseases that might be present during a displaced personemergency situation, the relative value of an immunisation programme for each disease, and theage group target for each type of immunisation programme.

DISEASE NAME OF VACCINE PRIORITY IN AN EMERGENCY TARGET AGE GROUP

Measles Measles ++++ Under 15 years

Polio OPV ++ Under 5 years

Diphtheria DPT ++ Under 5 years

Pertussis DPT ++ Under 5 years

Tetanus DPT ++ Under 5 years

Tetanus TT ++ Females over 15 years

Tuberculosis BCG + Under 5 years

Cholera Cholera 0 No vaccination neededTyphoid Typhoid 0 Vaccination arely needed

Meningococcus Meningococcal Use only in outbreaks Children 2-15 years

3.1.3 General Health CareDisplaced people must be given an opportunity to share in the responsibility for their own health.This has been shown many times to have a positive effect on the morale and overall mental state ofpeople confined in restricted circumstances. Services should be operated with rather than for thedisplaced people. Strong emphasis should be placed on the training and/or upgrading of the medi-cal skills of selected displaced people, particularly in their former roles within the community (e.g.


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traditional healers and midwives). As a general principle, the order of preference for selectinghealth personnel, in co-operation with the national services, is displaced people first, experiencednationals or residents next, and finally, outsiders. Most emergencies will require some combinationof these sources. An important consideration may be the government's attitude toward foreignmedical personnel, including the recognition of qualifications and authority to practice medicine.

3.1.3.1 Estimating needs

The first level of health care for displaced people is the community health worker ( CHW), who isresponsible for a small section of the population and works among them to provide outreach ser-vices such as home visits, case finding, referrals and follow up. She is also responsible for basiccommunity-wide preventive measures, including public health information, promotion and educa-tion. The CHW should be a displaced person with appropriate training, who can identify health andnutritional problems and refer patients to a clinic if simple on-the-spot treatment is not possible.She also should be able to explain in appropriate cultural terms general public health and adminis-trative interventions which need the assistance and co-operation of the community, such as massvaccinations and undertaking surveys.

As a general rule, one CHW can serve 50-100 families. A clinic should be established for every 5-10,000 displaced people. The clinic should be staffed by one nurse and 2-3 displaced people or na-

tional health workers. The next level would be a health centre for each displaced person settle-ment. The centre should have a limited number of beds for overnight stays at a ratio of approxi-mately one bed per 5,000 displaced people. The health centre should be staffed by two doctors,and 8-10 nurses per 20,000 displaced people. One doctor should work in the centre while the othercovers clinic level activities. A district hospital normally can serve a maximum base population of200,000 people.

It can be estimated that 1% of a displaced population will see a health worker each day, 1% ofthose examined will need hospitalisation and 1 hospital bed is needed for every 1000 people. It isalso known that the average consultation in a clinic takes 7 minutes, a CHW can see about 30 peo-ple per day, a nurse 50 people and a doctor 40 people. With these guidelines, it is easy to estimatefacility, staffing and material needs for any given population.

There may also be a regional/district hospital with staff assisted by doctors and nurses from theemergency organisation that handles complicated maternity cases and surgical emergencies on re-ferral from the settlement.

If possible, establishing special hospitals for displaced people should be avoided. They are skilled-labour intensive, provide only curative services, rarely continue to function once outside support iswithdrawn and are inappropriate for long-term needs. Once established they are extremely difficultto close. Such hospitals, therefore, should only be provided if a clear and continuing need existsthat cannot be met by existing or strengthened national hospitals.

"Portable field hospitals" have several disadvantages including: the complicated logistics of trans-

porting and set up, high cost and inappropriate systems and equipment that are overly sensitive anddependent on electricity. Field hospitals are rarely satisfactory for meeting continuing needs. Theymay, however, be very useful for meeting acute needs (in earthquakes or civil conflict) where inju-ries requiring surgical intervention are the major problem.

3.1.4 Medical Supplies3.1.4.1 Overall policy

The World Health Organisation (WHO) has developed an standard list of essential drugs and medi-cal supplies for use in an emergency. They recommend that all Ministries of Health formally adoptthis list as policy and set up supply management systems whereby these items can be made avail-


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able rapidly and efficiently in times of emergency. The best way to do this is to ensure that theseitems are held in buffer stocks at key points around the country. Buffer stocking ensures that itemswith expiry dates are rotated that essential relief supplies are as close as possible to where theymay be needed and that they are integrated into a logistics system that already exists (as opposedto setting up special systems during a crisis).

3.1.4.2 Medical Kits

Also developed by WHO is a kit for sending these basic health relief items to international disasters.Its contents are calculated to meet the common medical needs of a population of 10,000 personsfor three months. It is packaged as the New Emergency Health Kit, a standard that has beenadopted by all reputable international relief organisations and many national authorities as a reli-able, appropriate, inexpensive, and quickly available source of essential drugs and health equip-ment needed urgently in an emergency situation. The Kit consists of two different units of drugsand medical supplies: the Basic Unit (10 units per kit) and the Supplementary Unit (1 unit per kit).

The 10 Basic Units contain drugs, medical supplies and some essential equipment for use by pri-mary health care workers with limited training. Each Basic Unit is designed for a population of1000 for 3 months, weighs 45 kg and has a volume of 0.2 cubic metres. It contains twelve drugs,none of which are injectable. Simple guidelines are included to help the training of personnel in

the proper use of the drugs.

The Supplementary Unit is designed for a population of 1000 for 3 months, weighs 410 kg and is 2cubic meters in volume. It contains drugs and medical supplies to be used only by professionalhealth workers and doctors. It does not contain any drugs or supplies from the basic units andtherefore can only be used as a supplement to the Basic Unit Kit. The full Emergency Health Kitincludes 10 Basic Units and one Supplementary Unit, weighs approximately 860 kg and is 4 m 3 involume. An entire kit could be strapped into the back of a pickup. In an emergency, the kit can berequested through any WHO office and it will be delivered within 3-4 days. The cost of a completekit in 1998 was about $5,000 excluding freight costs.

3.1.4.3 Donations

Emergency medical supplies and medical equipment should draw on in-country resources and dis-tribution channels to the greatest extent possible. Provided local purchase is possible and not un-usually expensive, cash contributions are the best way to meeting immediate needs.

Unsolicited donations of drugs may present a problem, as their quantity and quality may varygreatly and they rarely arrive in time to meet urgent needs. In general, drug donations should berefused as they may consist of small quantities of mixed drugs, free samples, expired medicines,inappropriate vaccines and drugs identified only by brand names or in a foreign language. The costof transporting, storing, sorting and distributing them is born by the recipient, and the workloadinvolved diverts already overworked staff from more pressing needs.

If needed, medical supply donations should be specifically requested on an item by item basis.

They are best used to supplement stocks in central warehouses to replace what has already beensent to the field or to send to unaffected areas if their routine supplies have been diverted to thedisaster area.

3.1.5 VaccinesMass vaccination campaigns are rarely required after a disaster. The priority is always to restorenormal services. However, in situations where people have been displaced and have become refu-gees, measles vaccination of children under 5 may be a priority. Vaccinations for cholera and ty-phoid are NEVER required.


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It should be noted that most vaccines require refrigeration and careful handling to remain effective.Without a Cold Chain, the refrigerated transportation system for vaccines from manufacturer toindividual, the immunisation programme will be ineffective. Storage facilities located at the central(capital city) and regional level should have temperature alarms and backup (emergency) genera-tors.

3.1.6 Care of the deadThe collection, identification and disposal of dead bodies is not normally a health sector responsi-bility, but it is worth mentioning here as there are many issues that concern the public related tohealth and dead bodies.

It is a common misconception, always propagated enthusiastically by the media after a disaster,that dead bodies are a source of epidemics. In fact epidemics are very rare after disasters, and theyare never caused by dead bodies. When they have occurred, it has been due to inadequate attentionbeing paid to ensuring that survivors have access to clear water and sanitation.

Care of the dead is a very important aspect of emergency management, but not for public healthreasons. We have social and cultural obligations to ensure that the dead are treated with respectand disposed of according to the rites and traditions of their culture. Mass burials, spraying anti-

septics at disaster sites and use of lime powder on bodies are not public health requirements andserve not only to further distress already traumatised survivors but also to waste the time of emer-gency staff, who would be much better employed in taking care of the living.

3.1.7 Foreign Medical TeamsOccasionally, a countrys health care system can be so overwhelmed as to necessitate the govern-ment requesting foreign personnel to assist. This decision should not be taken lightly foreignersunfamiliar with local customs, language, living conditions and medical culture can be more of aproblem than a help. If requested, they should be assigned to medical and health facilities awayfrom the disaster area, to replace local staff temporarily reassigned to the relief operation.

3.2 Overview of Common Health Problems

Health is defined by the World Health Organisation in terms of well-being rather than illness. Thisdefinition includes aspects of psychological trauma that are particularly relevant to emergencymanagement.

The following provides information on diseases common to emergency situations where a largenumber of people have been displaced. It includes information on the symptoms, transmission, andpossible curative and/or preventative measures that can be introduced for these diseases.

An important point to note is that among the all diseases discussed in this section, 80-90% of alldeaths in displaced populations are caused by the following five conditions:

Malnutrition;

Measles; Acute respiratory infections; Diarrha; Malaria.

All of these conditions are already common in areas prone to hazards and are exacerbated when adisaster occurs. The presence of one makes the risk of contracting any of the others higher so thatthe effects are compounded rapidly.


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3.2.1 Trauma3.2.2 Estimating medical needsThe flowing data is from the CRED disaster database for the period 1990-2000. All that is needed isto know the population of the affected area to make an initial estimates of likely medical, surgical,water and food needs in a given population. Actual needs can be assessed and addressed as infor-mation starts to flow.

Hazard% affected

population killed% affected population

injured injured: killed

Transport mass accident 49.6% 23.6% 0.47

Tsunami/storm urge 4.42% 1.14% 0.26

Earthquake 0.51% 1.68% 3.28

Slides (mud, land, snow) 0.45% 0.11% 0.23

Tropical storms 0.09% 0.13% 1.37

All storms (+snow, wind) 0.08% 0.13% 1.71

Volcano 0.04% 0.02% 0.47

Forest fires 0.02% 0.02% 1.41

Flood 0.01% 0.06% 8.36

Epidemic 0.68% n/a n/a

Drought 0.001% n/a n/a

3.2.2.1 Hospital Capacity Assessment

For hospitals that already exist, there areempirical guidelines for assessing the capacity of a hospi-tal to absorb a large number of casualties. It is important for hospitals to recognise their limits soas to avoid becoming overloaded.

These figures are guidelines only. Each hospital must prepare its own emergency plan and estab-lish its own capacity assessment criteria that correctly reflect its own situation. It is important toreassess capacity each year, based on actual experience and also because new resources and facili-ties may have been added.

3.2.2.1.1 Hospital Treatment Capacity (HTC)

In general, the maximum capacity of a hospital to absorb seriously injured (triage red) casualtiescan be calculated at 3% of the number of beds e.g. a 500 bed hospital can handle a maximum of 15serious patients per hour, including time for assessment, urgent radiology and clinical investiga-tions, diagnosis, initial treatment and transfer to surgery, a ward or another hospital. If the HTC isexceeded, the management of seriously ill patients will be unacceptably delayed and morbidity andmortality will increase.

Those despatching casualties to a hospital from an incident should be aware of the capacities of allthe hospitals that are receiving injured people. All hospitals should have backup arrangements sothat when they have filled all their beds, another hospital can take over.

Patients with special needs (burns, spinal injuries, etc.) should be sent to a specialist unit as soonas possible after stabilisation.

3.2.2.1.2 Hospital Surgical Capacity (HSC)

Surgical capacity is an estimate of how many operations the hospital can perform over a 12 hourperiod.


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HSC = number of operating rooms x 7 x 0.255

for a 12 hour period.

This allows for change over time, re-supplying and re-equipping and staff rotation.

3.2.2.2 Hospital Resource Management

WHOprovides guidelines on how to calculate amounts of renewable resources that will be needed inan emergency6. For equipping and supplying field hospitals and other temporary medical facilities,ICRC have excellent guidelines.

3.2.3 Estimating surgical needsThe following is taught by military medical specialists working in disasters with significant num-bers of trauma cases:

60% of injured dont need surgical treatment in a hospital they need simple first aidor primary medical care;

25% of injured will die regardless of treatment (95% die before they reach hospital); 15% of injured will die or survive depending on the treatment they receive.

3.2.4 Priority Diseases3.2.4.1 Measles

Measles is the number two killer of children under 5 after a disaster. It is a highly contagious viralinfection spread by coughing. It is characterised initially by fever, cough, running nose and redeyes, This is followed after 3-7 days by a dusty red, blotchy rash which begins on the face and thenextends over the rest of the body and lasts for 4-6 days. Measles is a disease that can result in veryhigh mortality, especially in an undernourished population. The incubation period is about 10 daysfrom exposure to disease to onset of first symptom.

The infected individual can re-infect others from the first appearance of symptoms, until four daysafter the appearance of a rash. However, once a person has had measles, she will develop a lifelongimmunity. Measles vaccine should be given before an outbreak occurs, ideally as soon as the dis-placed persons can be assisted. If significant malnutrition is present, it is absolutely essential toimplement a measles vaccination programme as soon as possible. If vaccine supplies are limited,the top priority is to vaccinate all malnourished and hospitalised children. Vitamin A given at thetime of vaccination will enhance the protection of the child.

Since measles is such a highly contagious disease, it is likely that most susceptible individualshave been exposed, and are already incubating the disease by the time several cases have been re-ported. It is important not to waste vaccine and manpower trying to stop the spread of measles in acamp where the disease is already established because it takes approximately one week after vac-cination for a child to develop immunity to measles. The attention should instead be focused onpopulations where measles has not yet appeared, especially villages immediately surrounding theinfected area.

3.2.4.2 Acute Respiratory Infections

Acute Respiratory Infection (ARI ) is a spectrum of diseases ranging from bronchitis to pneumoniathat is caused by a variety of viruses and bacteria. It is marked by rapid breathing, cough and oftenfever. It may be mild or may progress rapidly to death, especially among malnourished children.

5the average operating room performs 7 procedures per 12 hour period over the whole year. But many seri-ously injured patients requiring surgery at the same time reduces the efficiency of an operating theatre to 25%of normal.

6The New Emergency Health kit;


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ARI is more likely when there is cold, rain, inadequate blankets and clothing, poor ventilation andover-crowding. The best preventative strategy is to provide adequate space, shelter, clothing blan-kets and ventilation. For severe cases, the treatment is antibiotics.

3.2.4.3 Diarrha

Diarrha is the most common fatal childhood diseases world-wide. Malnourished children are par-ticularly prone to diarrha and its complications of dehydration and shock. If untreated, it is fre-

quently fatal. Diarrha is transmitted through contaminated food and water. There are many dis-eases that cause diarrha most are caused by viruses (which is why antibiotics are useless) butsome are caused by bacteria (cholera, typhoid and shigella), and protozoa (giardia and amba).Dysentery is a form of diarrha caused by amba or shigella where blood is lost as well as fluid.

Antibiotics rarely affect the course of childhood diarrha. Diarrha generally is self-limited and iffluids and electrolytes (water, salt, bicarbonate, potassium, etc.) can be replaced by mouth, the ill-ness will run its course and the patient will survive . Treatment can be done at home with packetscontaining the proper mixture of electrolytes (Oral Rehydration Salts - ORS).

If diarrha, other than cholera or typhoid, is suspected to be a major problem, the followingmeasures should be taken by the health authorities or other responsible specialised agencies:

Confirm the problem by reviewing morbidity and mortality data. Additional informa-tion, such as location of patients, the length of time in the camp and the source of fam-ily water supplies can help pinpoint the source of infection.

Check the adequacy and purity of water supply to determine if there is any actual or po-tential contamination of water supplies by human fces.

Stress the importance of oral rehydration therapy (ORS); Intravenous fluids are rarely needed.

3.2.4.4 Malaria

Malaria is caused by a parasite called Plasmodium that lives in the saliva ofAnopheles mosqui-toes. Plasmodium invades human blood cells to complete its life cycle. There are four types of

Plasmodium, but Vivax and Falciparum are the most common. Vivax is generally not a life-threatening disease, but Falciparum can be rapidly fatal and requires prompt treatment. The usualsymptoms of malaria are fever, chills, headache and sweats that can progress to kidney and liverfailure, shock and even coma. Fever and delirium, disorientation or coma should be assumed tobe malaria and treated promptly in an area known to have Falciparum malaria.

If malaria is suspected, the following measures should be taken by the health authorities or otherresponsible specialised agencies:

Confirm the diagnosis. If laboratory confirmation is not available it can be assumed thatrecurrent fever, chills and headache in a known malaria area is malaria until provenotherwise.

Assess the risk of disease. The major threat to health arises in non-immune populationswho may be forced to flee from a setting where malaria is not a problem (especially in

urban areas) to jungle, swamps or other areas where malaria transmission is occurring. Assess prevalence and seventy: Analyse laboratory data, if available, to determine number of confirmed cases by

type (Vivax or Falciparum); Check morbidity and mortality records;

Institute control measures:


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If it can be assumed that malaria may be or might become a problem (during themalaria season), mosquito spraying, or other appropriate control measures in theconcerned areas, and close surveillance for possible malaria, should be instituted.

If malaria is already a major problem, mosquito control becomes more urgent.Consideration should also be given to prophylaxis of the entire population withanti-malarial drugs (if this is possible) until mosquito control programmes can beinstituted.

3.2.5 Other DiseasesThe following diseases may also cause problems in an emergency:

Cholera; Diphtheria; Tetanus; Whooping cough; Intestinal parasites; Meningitis; Polio; Skin infections;

Tuberculosis; Typhoid.

3.2.5.1 Cholera

Cholera is an acute intestinal disease characterised by sudden onset of profuse watery diarrhawith occasional vomiting. It is caused by a bacteria (Vibrio Cholera) that releases a toxin into theintestines. Transmission occurs through ingestion of water contaminated with fces. To a lesserextent, food contaminated by water, soiled hands, and even flies can spread the disease. Person-to-person spread generally does not occur. The incubation period for cholera is usually 2-3 days, butcan be from a few hours to as long as 5 days. Patients generally carry the cholera bacteria in theirstools only while they are having diarrha and for a few days after recovery. Although long-termcarrier states have been described, incidence is quite rare.

Not everyone who is exposed gets cholera as a very high dose of bacteria is needed to become ill.Only about 10% of those exposed will get ill and of those, about 1% will die. Therefore, most in-fected individuals will have mild diarrha or even no symptoms at all and only in some cases willdiarrha be so severe as to lead to dehydration and even death. The recommended treatment is re-hydration with ORS by mouth.

A cholera vaccine is available but current vaccines provide protection in only about 50% of casesand protection lasts only a few months. WHO does not recommend mass vaccination during epi-demics, as initial immunisation requires two doses of vaccine given 4 weeks apart, which is toolong to be of use in an acute situation. It cholera is suspected, the following measures should betaken by the health authorities or other concerned agencies:

1. Report suspected cases to national public health authorities;2. Confirm the diagnosis by culturing stool samples from suspected cases. Regional

public health laboratories or a hospital lab in the capital city should be able to helpconfirm this diagnosis by testing the samples;

3. Check the hygiene loop to be sure water is safe and is protected from sewage con-tamination (the source of the infection in most cases);

4. Vaccine does not prevent the spread of cholera!

3.2.5.2 Diphtheria


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Diphtheria is generally not a problem in tropical countries. It is usually characterised by a patch orpatches of a greyish membrane in the throat. It is caused by a bacteria (Clostridium diphtheri)that releases a toxin in the throat. Diphtheria can be easily prevented by DTP vaccination.

3.2.5.3 Tetanus

Tetanus is a severe infection caused by a bacteria (Clostridium tetani) that releases a toxin in awound. It is characterised by painful muscular contractions, especially of the jaw and neck mus-

cles. In developing countries, this disease is almost always fatal. Tetanus is transmitted throughspores introduced into the body during injury, usually a puncture wound contaminated with soil orfces, but also through burns and trivial wounds. Neonatal (infant) tetanus continues to occur inlarge numbers in developing countries because of unsterile cutting of the umbilical cord or tradi-tional practices such as covering the cord stump with unsterile items (e.g. cow dung). Tetanus can-not be transmitted person-to-person. The incubation period is about 10 days.

Tetanus can be effectively prevented by mass vaccination of infants, adolescent girls and pregnantwomen.

3.2.5.4 Whooping Cough

Whooping Cough is a bacterial disease (Bordetella Pertussis) common in children throughout the

world. It begins with a runny nose and an irritating cough. The cough gradually becomes worseover 1-2 weeks and lasts for 1-2 months. Whooping Cough can be a severe disease and fatal, espe-cially in non-immunised malnourished children less than one year of age. Diphtheria and Whoop-ing Cough are transmitted through the air from respiratory secretions of infected patients. The in-cubation period for both can last from 7-10 days. The period of communicability is the first threeweeks of illness. DTP (Diphtheria-Tetanus-Pertussis) vaccine is available and highly protectiveagainst these three diseases. The vaccine must be given in three separate injections at least fourweeks apart.

3.2.5.5 Intestinal Parasites

Intestinal parasites are extremely common in developing countries. A majority of the populationcan be infected with one or more parasites, of which the most common are usually Ankylostoma,

Ascaris, Giardia, and Trichuris. Many of those infected will appear perfectly healthy, but fever,anmia, abdominal pain, vomiting and exacerbation of malnutrition can occur with heavy infesta-tions. These parasites are transmitted when walking barefoot on soil contaminated by fces or byeating food with unwashed hands. Intestinal parasitic infections should assume a very low priorityin the emergency phase.

3.2.5.6 Meningitis

Meningitis is a disease caused by a by a variety of viruses, bacteria and parasites, including ma-laria. It is characterised by fever, stiff neck and headaches. If left untreated, it can progress rapidlyto coma, and death in up to 50% of those infected. Some types of meningitis are highly contagious,especially those due to certain bacteria (Meningococcus and Haemophilus) and are spread bycoughing and sneezing. An outbreak of meningococcus is a public health emergency as it causes

high levels of morbidity and mortality. Ascertaining the specific cause of meningitis is often veryimportant since, with meningococcal meningitis, it may be appropriate to treat, or perhaps vacci-nate, high risk groups with an antibiotic.

3.2.5.7 Poliomyelitis

Polio is not normally a problem in an emergency although it may appear as a consequence of poorhygiene in temporary camps. It is an acute infection caused by a virus (Poliomyelitis) and is char-acterised by fever, malaise, headache, nausea and vomiting, and stiffness of the neck and back,. Asmall proportion of those infected will develop paralysis, usually of one leg. Polio can range in


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severity from an infection without any symptoms to meningitis to paralytic disease and even deathdue to paralysis of the muscles of respiration.

The paralysis of polio is typically asymmetrical (i.e. involving only one leg or one arm). In dis-placed persons situations, the diagnosis is generally made on symptoms alone, since laboratorydiagnosis involves the difficult task of isolating the virus from fces or saliva. Polio is spread byclose contact with infected individuals, and rarely by food or water. In developing countries, older

children and adults are usually immune to polio, having had contact with the virus during child-hood. The incubation period for polio is from 3-21 days, but commonly 7-12 days. Even a fewcases of paralytic polio indicate an epidemic and should be treated by a mass childhood vaccina-tion campaign with oral polio vaccine. Oral polio vaccine is safe, inexpensive, has few side effectsand is easy to administer.

WHO and UNICEF are currently operating a world-wide campaign against polio and expect to eradi-cate it early in this century.

3.2.5.8 Skin Infections

Skin infections are generally a low priority in the emergency phase of the relief operation; butsince these infections may be an indication of deficiencies in the supply of soap and water, and of

overcrowding, they should be investigated.

Scabies is a common skin infection in displaced person, especially for those living incrowded conditions with inadequate water supplies for washing. Scabies is caused by amite and is characterised by intense itching and small sores caused by the mite burrow-ing under the skin;

Impetigo (bacterial infection of the skin) is a highly contagious skin infection commonin displaced people.

3.2.5.9 Tuberculosis

Tuberculosis (TB)is usually not an illness that needs to be considered in the first few weeks of adisplaced person emergency. The disease is caused by a bacteria (Mycobacterium tuberculosis)

spread by coughing. It can take years to develop after exposure. It is a chronic, progressively de-bilitating disease most commonly involving the lungs and is characterised by fever, cough withsputum production and weight loss. TB is usually not a rapid fatal disease except in AIDS patientsand very young children who can die of disseminated TB or TB meningitis.

Although TB may not be a first priority in an emergency, it should not be forgotten. Crowdedcamps provide a fertile ground for transmission of the disease. IfTB is suspected, the followingmeasures should be taken by the health authorities or agency concerned:

1. Attempt to confirm the diagnosis. TB can be easily diagnosed by a laboratory tech-nician if a microscope is available. If laboratory confirmation is not available,assume that fever and cough that persists for more than three weeks is TB until

proven otherwise.3. If sputum smears can be done, examine laboratory records to determine the totalnumber of smears examined and the number found to be positive for TB.

4. Check morbidity and mortality records to assess the number of deaths attributableto TB, Check also the number of patients reporting to the hospital, or clinic,with fever and chronic cough.

5. IfTB is a major problem, a treatment and control programme should be instituted bythe moh or an experienced agency and case finding should begin.

6. Consideration should be given to starting a BCG vaccination programme. Sinceyoung children are at high risk of developing severe and rapidly progressive


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cases, BCG vaccine should be targeted at the young, especially children underone year of age.

WHO has developed a very successful treatment regime for TB called DOTS, which can deliver up to90% cure. IfTB is a problem in an emergency situation, the local WHO office can provide valuableassistance.

3.2.5.10Typhoid

Typhoid is caused by a bacteria (Salmonella typhi). It is characterised by fever, headache, malaiseand, occasionally, a mild rash on the trunk. Constipation occurs more commonly than diarrha.Typhoid is spread by food or water, contaminated by fces or urine from a patient or carrier of thedisease. Flies can also transmit the disease. The incubation period is 1-3 weeks.

Usually the typhoid bacteria is excreted in the stool while the patient is sick. About 70% of pa-tients will excrete bacteria for three months, and 2-5% become permanent carriers. As with choleravaccine, typhoid immunisation is not recommended in displaced person situations or followingnatural disasters. The vaccine requires two doses one month apart to be effective.

In an outbreak situation, vaccination programmes can be harmful since they divert scarce re-

sources and attention that should be directed to ensuring safe food and water supplies. If a typhoidoutbreak is suspected, the following measures should be taken by the health authorities.

Confirm the diagnosis; Ensure the water supply is safe and protected from contamination.

3.2.5.11Typhus

Typhus is a disease caused by a bacteria that is spread by ticks and lice and it is characterised byfever and a rash. It is commoner in cold climates where people live in overcrowded conditionswhere they are unable to wash properly or change their clothes regularly. Treatment is with antibi-otics and prevention is by improving the living conditions of the population.

4. Summary

Major emergencies, which arise when hazards interact with communities, and which are com-prised of mass casualty events, disasters and complex emergencies, are a threat to public health,public safety, security and humandevelopment. It is essential that, if lives, property and the envi-ronment are to be protected, an organised approach is taken to the management of major emergen-cies. This is done through developing Hazard Mitigation and Prevention, Emergency Preparednessand Vulnerability Reduction Programmes, each of which address different aspects ofrisk.

The management of risk in communities should be a fundamental component of any human devel-opment programme if it is to be sustainable, in that risk management addresses factors which im-pede or retard development. The health sector is a key partner in the management of communityrisk because so many of the effects of a hazard have a direct impact on health and because many ofthe causes of vulnerability can be addressed through health sector development programmes. Thehealth sector was the first to take an organised approach to emergency management and has giventhe emergency management community many of the concepts and tools that they use.

Emergency management capability is a basic need in any community but it often a neglected com-ponent of public health systems. If health is to achieve its full expression7, policy makers need to

7not just absence of disease but the attainment of well-being (WHO)


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encourage and empower local health staff to play an active role in community initiatives to reducerisk and protect development.

Health Sector Actions in Emergencies

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