Public Health risks during an emergency

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1 INTERNATIONAL SUMMER SCHOOL 2011 Public Health risks during an emergency Médecins Sans Frontières (MSF) Wednesday, 22 nd June 2011

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7 PUBLIC HEALTH INTERVENTION AIMS TO REDUCE MORTALITY

8 The 10 top priorities in the Emergency phase 1. Initial assessment 2. Measles immunization 3. Water and sanitation 4. Food and nutrition 5. Shelter and site planning 6. Health care in the emergency phase 7. Control of communicable diseases and epidemics 8. Public health surveillance 9. Human resources and training 10. Coordination

9 1. Initial assessment Geo-political context Description of the population Characteristics of the environment Major health problems Requirements in terms of human and material resources Operating partners

10 Major health problems and indicators Presence of diseases with epidemic potential (cholera, measles, shigellosis, hepatitis, etc) Mortality rates and causes of mortality Morbidity data on the most common diseases (measles, diarrhoeal diseases, ARI, malaria) Prevalence of acute malnutrition Data on vaccine coverage

11 2. Measles immunization Measles is a major cause of childhood mortality throughout the world (1 out of 10 children affected dies in Developing World) All children aged between 6/12 and years should be vaccinated (6/12-15 years approx % of the total population) A vaccination campaign should be coupled with Vitamin A supplementation. Follow up by establishing routine immunization programme (EPI)

12 Joint effort medical logistical department - Estimate size of the population and target population - Vaccine and immunization kits available and sufficient - Well established cold-chain!!!! - Selection and training of staff - Careful and expert Supervision - Data collection

13 In emergency setting, there are three immunization programmes Measles immunization (mass immunization) Recomended in a refugee camp (close community) All children between 6/12 and 15 years age regardless of their immunization status Specific immunization campain Whenever an infectious disease with potential epidemic is present in the area (meningites, yellow fever, measles, etc) Target population: all ages EPI: Extended Programme of Immunization (difterite, tetanus,whooping cough, poliomyelitis, measles, tubercolosis)

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18 3. Water, hygiene and sanitation WATER Ensure sufficient quantities of water supply: QUANTITY & QUALITY

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21 WHY? Dehydration! Control of diseases due to poor hygiene (i.e. scabies) Prevention of water-borne diseases (diarrhoeal diseases have high mortality) Control of diseases transmitted by vectors (i.e. mosquitoes, lices, ticks, etc)

22 Water: sufficient water quantity First days: 5 liters of water per person per day Next stage: liters of water per person per day 1 hand-pump for persons 1 tap for persons A maximum of 6-8 taps per distribution unit

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27 Sanitation & hygiene Excreta control Waste water control Solid waste control Disposal of dead Personal hygiene Vector control

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29 Excreta control Initial phase One latrine or trench per persons As soon as possible One latrine per 20 persons or One latrine per family

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31 4. Food and nutrition Food availability and accessibility Health and nutritional status (nutritional survey among children 6 months - 5 years of age) Feeding programmes

32 WHY? Food shortages and nutritional problems are frequent in emergency situations Malnutrition increases vulnerability to diseases (especially measles) WHO? Groups at higher risk of malnutrition: - CHILDREN UNDER 5 YEARS - PREGNANT & LACTATING WOMEN - ELDERS - CHRONICALLY SICK PERSONS

33 NUTRITIONAL SURVEY INDICATOR: Prevalence of acute malnutrition in children under 5 years age PREVALENCE RATE between 5 and 10% is alarming! How to measure malnutrition: MUAC (middle upper arm circumference) Weight for height index Bilateral oedema

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36 H E I G H T

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38 O E D E M A

39 GENERAL FOOD DISTRIBUTION aims to ensure adequate food rations for all (2100 kcal a day per person) Not in MsF mandate SELECTIVE FEEDING PROGRAMMES SFPs (Supplementary feeding programme) stable malnourished children (<80% of normal w/h) TFPs (Therapeutic feeding programme) sick, unstable malnourished children (<80% of normal w/h)

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42 SUPPLEMENTARY FEEDING PROGRAMMES (SFPs) High quality of food is provided to supplement diet BLANKET SFPs: to prevent an increase in malnutrition and mortality rates - Children under 5 years - Pregnant and lactating women - Socially &/or medically needy individuals - Elderly people TARGETED SFPs: to prevent those who are moderate malnourished from becoming severely malnourished - Children discharged from TFP - Moderately malnourished children

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46 THERAPEUTIC FEEDING PROGRAMMES (TFPs) To provide severely malnourished children with FULL NUTRITIONAL REQUIREMENTS and MEDICAL care - INTENSIVE PHASE: 24/h care unit - CONTINUATION PHASE: day care unit, nutritional treatment and medical follow up - NB: High Protein Milk Plumpynuts

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50 5. Shelter and site planning Site planning and improvements should take place as early as possible in order to minimize overcrowding and make it possible to organize efficient relief services

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52 Site selection A site should be selected with a view to: Security Access to water Provide adequate space (30 sqm) Environmental health risks Local population

53 6. Health care in the emergency phase AIM: to help reduce excess mortality / morbidity 4 LEVELS OF HEALTH CARE: -Referral Hospital - Central Health Facilities: 1/ Peripheral Health Facilities (Health post or clinic): 1/ Home visitors (outreach)

54 Planning the health care system Existing health facilities and accessibility Population figures Disease patterns and potential outbreaks to be anticipated Specific health problems within the population Available resources, especially human resources National health policies of host country and an organization chart

55 Health care system in emergency should fullfil: Provide curative treament for most common communicable killer diseases Reduce suffering Capacity to carry out active case finding Cope with high demand of curative care Provide easy access to different levels of care Deal with majority of illnesses at basic level Contribute to surveillance activities Combine both curative and preventive services Be flexible enough to adapt to any changes in the situation

56 Components in a field hospital Triage and registration Out-patient Department Pharmacy Dressing room Lab In-patient Department Minor surgery Antenatal care, Basic obstetric care, Sexual violence Feeding center Isolation unit CHW system Water and sanitation Waste disposal

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67 MSF hospital in Bunia/DR Congo From January to June persons treated for sexual violence 4% men Age from 4 months to 80 years rape survivors helped in Bunia since 2003 and increasing

68 7. Control of communicable diseases and epidemics Population vulnerable because of overcrowding poor water supply and sanitation inadequate shelter poor nutritional status and immunity, no health services, no coping mechanisms Spreads very easily, higher incidence and mortality rates

69 The most common diseases 50-95% of the mortality in a camp is caused by 4 communicable diseases: Diarrhoeal diseases Acute Respiratory Infections Measles Malaria with malnutrition as aggravating factor. Can be prevented and cured with little means.

70 Case definition Put in place general preventive measures Set up health facilities for the early management of cases Organize outreach activities: active case finding & screening Specific guidelines and contingency plan available Health KITS for rapid standard response Epidemiological Surveillance

71 DIARRHOEAL DISEASES (waterborne diseases) - Safe water - Personal hygiene (wash your hands!) - Quick treatment to prevent dehydration CHOLERA! Specific guidelines for diagnosis, treatment CTC cholera treatment centres Massive logistic and HR effort MEASLES (airborne disease) - Vaccination - Isolation - Early treatment of complications

72 ACUTE RESPIRATORY DISEASES (airborne disease) -Proper shelter, blankets distribution -Prevent overcrowding -Improve nutritional status, Vit A supplement -Immunization -Early and adequate treatment MALARIA (vector transmitted disease) -Vector control: site planning, shelters, water control, insecticides -Mosquito nets, repellent, -Early diagnosis and treatment

73 Other diseases to be controlled Meningitis Hepatitis Haemorrhagic fevers Japanese encephalitis Typhoid fever Influenza Leishmaniasis Plague Human african trypanosomiasis Schistosomiasis Poliomyelitis Whooping cough Tetanus Scabies Conjunctivitis Guinea worm

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77 Outbreak control Attack and reduce the sources of infection to prevent spreading of the disease. (Isolation, treatment) Protect susceptible groups (Immunisation, bednets) Interrupt transmission to minimise the spread. (Vector control, health education, disinfection)

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79 8. Public health Surveillance Monitor mortality and morbidity Alert for outbreaks / epidemics Monitor efficacy of interventions Provide data for planning THE SURVEILLANCE SYSTEM MUST BE: Simple Flexible Regular Accurate Standardised

80 INDICATORS Crude Mortality Rate: Normal situation: <1 death / people pr. day Emergency situation:> 1 death/ people pr. day Under 5 yrs Mortality Rate: Normal situation: <2 death/ people pr. day Emergency situation: > 2 death/ people pr. day Morbidity, demography Indicators on food, shelter, water, sanitation, NFI

81 9. Human resources and training HR is the most important for the programme How many persons are needed Clear job descriptions Educational level Different ethnic groups Salary and working conditions

82 International staff (expatriates) : Consolidated experience Trainers (medical personnel, administrators, epidemiologists, communication officers, etc) National staff : Medical (medical doctors, nurses, CHW community Health Workers, nutritionist, etc.) Non medical (logisticians, drivers, administrators, translators, etc)logisti, autisti, amministrativi, traduttori, etc.)

83 Example Vaccination campaign: 60 persons for vacc children/day TFC 500 children: OPD: CTU 100 patients: 250 persons 15 persons 100 persons

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85 10. Coordination INTERNATIONAL ORGANIZATION UN organisations (UNHCR, UNICEF, WFP Other NGO s (Save the Children, Oxfam, World Vision, etc.) Development agencies (DANIDA, GTZ, USAID etc.) Red Cross and Red Crescent (ICRC, Federation, National Societies) NATIONAL / LOCAL Local organisations Local authorities (MOH) Different groups of interest (warlords, tribal leaders etc.)

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88 Post-emergency phase Consolidation of what has been achieved Emergency preparedness Achieving sustainability The 10 top priorities still valid and a good framework

89 Any questions?

90 MSF Medici Senza Frontiere v. Volturno Roma How to contact MSF? Tel Fax Tamara Candiracci Training and Development Officer HR Department Tel

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