Introduction to Public Health in Emergencies II: Overview of Concepts and Indicators

Outcomes of Emergencies  Dislocation of populations  Destruction of social networks, infrastructure and ecosystems  Increased morbidity and mortality  Abuses of human rights  Social and political marginalization

1. Acute - life saving interventions 2. Post-Emergency or Stabilization phase - crisis has peaked 3. Reconstruction/Rehabilitation - re-establishment of infrastructure, improve level of preparedness and skills compared to pre-emergency Three Phases of emergencies

Example: Large scale displacement following conflict Traumatized population Few assets Vulnerable to environmental conditions and to violence

Early phase of an emergency Poor shelter and site location Poor access to water Exposure to vectors No sanitation

Post emergency phase Organized response Decreased congestion Access to safe water and sanitation Health centers, markets, schools

Different Emergency Scenarios Displaced population In organized camps or transit centers Informal settlements Living with host communities Non-displaced but emergency affected May be a combination of scenarios

Example – Aceh Post tsunami >400,000 displaced Hundreds of small camps and public shelters Large number living with host families Non-displaced but affected communities Difficult to estimate population numbers Large amount of movement Difficult to organize response

Camp Settings Pros Services may be easier to provide Easier to estimate population Advocacy Easier to monitor health status Cons Overcrowding may increase risk of disease Dependency Security in camp

Non-camp settings Small camps or no camps at all is ideal, but: Difficult to monitor needs Difficult to estimate affected population Difficult to provide services May pose difficulties to host community

What are the major causes of mortality and morbidity?

–Diarrhea –ARI –Measles –Malaria –Malnutrition

Major Causes of Death in Refugee Populations <5 Years Sudan: Wad Kowli Camp February, 1985 Somalia: Gedo Region, 7 Camps January, 1980 Source: Centers for Disease Control and Prevention, Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues. MMWR, 1992;41(No. RR-13):8. Measles ARI Malaria Diarrhea Other

Cause-specific Morbidity Among Refugees in Accessible Camps in Southern Guinea: January-April 2001 Aged 0-4 years (N=19,700) Aged 5 years + (N=37,433)

Proportionate Mortality of Refugees in a Developed Country Kosovo: Feb ’98 –Jul ‘99

What are the public health priorities in an emergency?

Public Health Priorities in the Emergency Phase: 1. Initial Assessment 2. Measles Immunization 3. Water & Sanitation 4. Food & Nutrition 5. Shelter, Site Planning & Energy 6. Health Care in ER Phase 7. Control of Communicable Disease & Epidemics 8. Public Health Surveillance 9. Human Resources & Training 10. Coordination/Camp Management

Use of indicators in humanitarian emergencies

Indicators used in Emergencies How do we monitor the health status of the population? –Acute malnutrition –Mortality How do we monitor access to services and effectiveness of the response? –SPHERE standards

Indicators in Emergencies Nutritional indicators: prevalence of wasting –Weight for Height Z scores (surveys) % of median (admission to feeding programs) –MUAC (screening) Mortality indicators –Crude Mortality Rate (CMR) –Under 5 Mortality Rate (<5 MR)

Categories of Acute Malnutrition for prevalence estimates (children 6-59 months) Global Acute Malnutrition (GAM): Moderate & Severe Combined < 80% or < -2 Z-scores or nutritional edema Severe Acute Malnutrition (SAM): < 70% or < -3 Z-scores or nutritional oedema

Benchmarks for interpreting prevalence rates of acute malnutrition Situation Prevalence of GAM (z-score < -2) Acceptable< 5% Poor5 – 9% Serious10 – 14% Critical> 15%

Association between crude mortality rates and the prevalence of low weight for height for children under 5 in 41 refugee camps *Source: Toole, Malkki, 1992

Mortality Rates Important objective tool in assessment and monitoring First widely used in emergencies in 1980s Derivation: doubling of baseline mortality for sub Saharan Africa of 0.5/10,000/day Evolve with phases of an emergency Ratio of <5MR:CMR important

Mortality Thresholds Crude mortality rate (CMR) > 1 death/ 10,000 people/day Or doubling of baseline CMR < 5 mortality rate (<5 MR) > 2 death/ 10,000 children/day Or doubling of baseline U5 MR

CMR: reference values “normal” in developed countries:0.2 per 10,000 per day “normal” in developing countries:0.5 “ “ “ crisis under control:< 1.0 “ “ “ very serious:> 1.0 “ “ “ out of control:> 2.0 “ “ “ famine, major epidemic, catastrophic:> 5.0 “ “ “ Ajiep, South Sudan, in 1998:26.0 “ “ “ Rwanda, 1994: “ “

Daily CMR Emergency Phase: Deaths/10,000/day CountryCMR*Baseline Thailand (1979) Somalia (1980) Sudan (1985) Malawi (1986) Ethiopia (1989) Ethiopia (1991) Northern Iraq (1991) Kenya (1992) Somalia (1992) Zaire (1994) Southern Sudan (1998) Kosovo (1999) Ethiopia (2000) Source: U.S. Centers for Disease Control and Prevention

= 9 1 deaths X 10,000 / 10 days 33,000 people CMR = total # of deaths x 10,000 / No. days total population = 2.8 deaths / 10,000 / day How Do We Calculate CMRs?

What is the CMR and < 5 MR* in deaths/10,000/day if there were 91 deaths in a population of 33,000 persons over a 10 day period? Children <5 make-up 20% of population and 60 deaths were in children <5. How Do We Calculate CMRs?

What is the < 5 MR* in deaths/10,000/day if there were 91 deaths in a population of 33,000 persons over a 10 day period? Children <5 make-up 20% of population and 60 deaths were in children <5. How Do We Calculate CMRs?

= 60 deaths X 10,000 / 10 days 6,600 people U5MR = total # of deaths U5 10,000 / No. days total <5 population = 9.1 deaths / 10,000 / day How Do We Calculate U5MRs

Excess Mortality Mortality in excess of baseline levels Total number of deaths as opposed to mortality rate Simpler to understand than mortality rates Effective in raising public awareness Examples –Democratic Republic of Congo –Iraq

SPHERE Launched in 1997 Standardized indicators for core areas of humanitarian response Improve quality of the response Improve accountability

SPHERE Indicators For Water and Sanitation At least 15 liters per person per day Maximum distance to nearest water point is 500 meters Queuing time at a water source is no more than 15 minutes <= 20 persons per latrine 250 g of soap per person per month

SPHERE Indicators For Case Management cholera: 1% or lower – Shigella dysentery: 1% or lower – typhoid: 1% or lower Measles <5%

SPHERE Indicators for Health Services One community health worker per ,000 population; One peripheral health facility (for approximately 10,000 population) One clinician per 50 consultations per day.

Questions?