Emergency Capacity Building Project

1. Emergency Capacity Building Project Health in Emergencies

2. The Control of Communicable Diseases

3. Communicable Diseases • 51-95% of all reported deaths in refugee populations • In emergency settings we can predict and prepare for the following: • Acute respiratory infections (ARI), diarrhoeal diseases (cholera, dysentery) - the most common • Vaccine-preventable diseases (measles and meningitis) still a problem • Malaria and TB • HIV – may not have disease burden of the above but much more attention is needed in emergency settings

4. Global Health Facts • 11 million children under 5 die every year • 6 million die every year of preventable diseases • HIV/AIDS kills 6,000 people and another 8,200 get infected every day • More than 2.6 billion people do not have basic sanitation • More than 1 billion people don’t have access to safe drinking water

5. Major Causes of Death in Conflict Affected Populations

6. Why we get sick Host disease Agent Environment

7. Assessing Vulnerability Determinants of risk (people) Health sector vulnerability… 9 indicators % access to health care % under 5’s vaccinated against measles Under 5’s inadequately nourished Under 5 mortality rate % access to clean water % access to sanitation % with adequate housing % with formal employment % females literate Contribution to the wider multi-sectoral assessment of risk Strength of the local HS Potential source of problems Ability to recover and keyhealth messages

8. Communicable Diseases • Overcrowding • diarrhoeal diseases, ARI • Inadequate quantity and quality water • diarrhoeal diseases, typhoid, scabies • Poor sanitation and waste management • vector borne diseases, typhoid, scabies • High levels of malnutrition • Compromised immunity, TB, measles, ARI • Low levels of vaccination coverage • measles, meningitis, yellow fever

9. Communicable Diseases • Population may bring infection with them from their home environment or from areas they have passed through e.g. malaria • The disease may be present in the new environment or host community; refugees who have not acquired immunity are at greater risk e.g. malaria or cholera • Disease may surface in the camp itself e.g. due to overcrowding or poor sanitation

10. Who gets sick • not everyone is exposed to the agent • not everyone who is exposed gets infected • not everyone who is infected gets sick • not everyone who gets sick dies

11. Diarrheal Diseases • Major cause of mortality in acute phase of emergency • Important cause of morbidity in post-emergency phase • Caused 70% of deaths among Kurdish refugees and 90% of deaths among Rwandan refugees in Goma • Most diarrheal illness is NOT caused by cholera or dysentery • BUT cholera and shigella only cause of major diarrhoeal outbreaks in emergencies

12. Transmission of Diseases from Faeces

13. Causes of Diarrhoeal Disease Outbreaks • Common sources of infection are: • Polluted water sources • Contamination of water during transport and storage (through faecally soiled hands) • Shared water containers and cooking pots • Scarcity of soap • Contaminated food

14. Treatment

15. Prevention and Control of Dysentery Standard diarrhoea prevention and control measures • Safe drinking water • Safe disposal of excreta • Personal hygiene: information on personal hygiene and handwashing with soap • Food safety • Breast-feeding – promotion and practical support to enable mothers to continue breastfeeding • Special attention to disinfection and hygienic practices in health facilities

16. Cholera - Basic Facts • Classical cholera may live in the environment; water is an important reservoir • Most infections are mild or asymptomatic; only up to 25% result in clinical illness, of which 10% at most are severe • Contaminated water, food, shellfish, and fruit & vegetables implicated in transmission • Funeral ceremonies & feasts may be associated with transmission

17. ...ingredients for epidemics... • External conditions • gatherings • forcedmigrations • environment • Climatic conditions • seasonal rains • floods • dry season Cholera outbreak • Living conditions • over-crowding • sanitation • water supply • unsafe food Political context • Cultural beliefs • & behaviour (funerals) • Poverty

18. Factors Favouring Cholera Transmission in this Outbreak . • Inadequate water supply • An average of 6.75L/per person per day in the new caseload. • Proper hygiene measures such as hand-washing and utensil washing not able to be practiced • Poor latrine coverage • 55 persons per stance • The more people sharing a latrine the greater the risk of contamination • Using a latrine may have been a risk factor for transmission

19. Factors Favouring Cholera Transmission • Firewood shortage • 35,000 people competing for firewood • Stoves were not fuel efficient- firewood used very quickly. • Reheating food difficult • Mozambican refugees- shown that the greater the number of times households cooked per day the less the risk of cholera • Lack of non-food items • No non-food items (jerry cans, plates, cups, cooking pots) distributed • Soap only distributed once the outbreak started • Major contributing factor to poor food-handling and water storage practices.

21. Control • Health education • Surveillance • Prevention • Adequate water (quality and quantity); chlorination is crucial (water supply or water containers) • Adequate sanitation and disposal of excreta • Promotion of personal and community hygiene • Safe food handling • Adequate fuel to reheat food • Good handwashing practices among food handlers • Adequate non-food items • Hygiene measures in health centers

22. Control Prevention (cont’d) • Safe funeral practices - disinfection and hygiene measures are essential during funerals • funeral held within hours of death • disinfect the corpse • wash hands after handling corpse • trained heath worker to supervise funeral • avoid funeral feasts • Social mobilisation • Active case finding and health education

23. Environmental Control

24. Infection Control

25. Acute Respiratory Infections (ARI) • Always a major cause of mortality in children • Major cause of mortality and morbidity in emergency situations, especially among malnourished children • Most deaths occur a few days from onset because of late or no treatment • The risk of death from pneumonia is highest in infancy: the younger the child, the higher the risk

26. Risk factors • Low birth Rate • Malnutrition • Poor breastfeeding practices: • Poor ventilation in shelters and indoor air pollution • Overcrowding • Inadequate immunization:

27. Prevention • Immunization with measles • Promote exclusive breastfeeding for first six months • Adequate nutrition • Reduce indoor smoke – chimneys • Site planning (avoid overcrowding, adequate ventilation) • Hand washing - may play a role in reducing pneumonia incidence

28. Measles • Major cause of death in emergency settings and all efforts should be made to prevent outbreaks • An acute viral illness transmitted by droplet infection • Highly contagious! Basic Reproductive Rate (average number of persons infected by one case if no one is immune) = 15 • Overcrowding contributes to the rapid spread of the illness • Morbidity and mortality is particularly high if nutritional status is poor, Vitamin A deficient and younger age (6-9 mths)

29. Measles Prevention Two components of Measles Prevention in Emergencies: • Supplemental vaccination in early stages of emergency • Measles outbreak detection and control

30. Who Should be Vaccinated Against Measles? • In emergency situations the lower age limit for vaccinations is 6 months rather than the usual 9 months • SPHERE advocates that children up to and including the age of 14 should be vaccinated • In an acute emergency, at a minimum, aim for greater than 95% coverage in children six months to under five • DON’T Forget Vitamin A!

31. Tuberculosis • Displacement/conflict may disrupt treatment and increase mortality and transmission • Overcrowding and malnutrition may promote transmission in refugee and IDP camps • In countries with a high prevalence of HIV infection may increase incidence of new clinical and infectious cases and promote transmission • But TB is NOT a leading cause of mortality in acute phase of emergencies

32. Treatment • TB not a priority in initial phase • Need security, stability of population and funding and major causes of morbidity and mortality under control • Priority is treatment of sputum smear positive cases • Remember a poorly managed TB control program is worse than no programme!

33. Factors that Increase The Risk of Malaria in Complex Emergencies? • Population movement and displacement (immunity and exposure) • Environmental deterioration (vector breeding) • Ongoing conflict (access)

34. Malaria • More than 80% of current complex emergencies are in malaria-endemic areas • Major cause of preventable morbidity and mortality

35. Malaria Mosquito

36. Treatment Protocols Taking anti-malarial drugs

37. Prevention - Vector Control • Impregnated Mosquito Nets • Indoor residual spraying of insecticide (“house spraying”) • Site selection and planning

38. Misting and Spraying Photo: WHO/TDR/Bahar

39. Factors Increasing the Risk of Malaria in Complex Emergencies Poor or absent housing (exposure) Location of camps or settlements e.g. placing camp in well-known flood plain or areas near water (vector breeding)

40. Principles of Communicable Disease Control in Emergencies • Rapid assessment • Prevention • Surveillance • Outbreak control • Disease management

41. Prevention • Non food items • Fuel, appropriate and sufficient water containers and cooking pots distribution associated with reduced risk of cholera and other diarrhoeal diseases • Soap distribution 250g/person per month • Health education and sensitization on maintenance of safe water, personal hygiene, and latrine use are vital • Vector control depending on type of shelter, human behavior and vector behavior • Indoor residual spraying and insecticide treated nets • Environmental measures such as draining of standing water • Community health care workers trained to identify main disease problems, refer and provide health information

42. Surveillance • First stage of outbreak preparedness is a surveillance system with an early warning mechanism to: • ensure the early reporting of cases • to monitor disease trends • to facilitate prompt detection and response to outbreaks • Diseases of major morbidity and mortality and outbreak-prone only • Standard agreed case definitions and standard reporting forms • Data flow mechanism with analysis and feedback • Early warning mechanism with appropriate thresholds for action

43. Surveillance

44. Public Information Faeces + Water = Typhoid

45. But…

46. Six Core Prevention Measures • Site planning and shelter • Adequate space within and between shelters (SPHERE) • Safe and adequate quantity of water • 15 litres per person per day (drinking, cooking, bathing) • Sanitation, safe excreta disposal and management of solid waste • < 20 person per latrine and system of maintenance • Adequate general ration and selective feeding when indicated • Malnutrition increases risk and severity of infection • Measles vaccination is a PRIORITY • Basic health care

47. What not to do: • Starting with vector control before people have access to treatment • Fogging (larviciding) or simply dumping ITNs or insecticide treated plastic sheeting • Distributing untreated nets or not planning for (re)treatment • Planning programmes in isolation of other malaria partners

48. HIV & AIDSin Emergencies

49. HIV & AIDS • HIV stands for? • Human Immunodeficiency Virus • AIDS stands for? • Acquired Immunodeficiency Syndrome • HIV and AIDS are not the same thing • 4 bodily fluids that carry HIV? • Semen, vaginal fluid, blood, breast milk • Most common means of transmission? • Unprotected sexual intercourse • Mother to child transmission? • Before and during birth • Breast feeding

50. HIV Prevalence among adults per country at the end of 2005