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

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

2. 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

3. Three Phases of emergencies 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

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

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

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

7. 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

8. Example – AcehPost 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

9. 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

10. 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

11. What are the major causes of mortality and morbidity?

12. What are the major causes of mortality and morbidity? • Diarrhea • ARI • Measles • Malaria • Malnutrition

13. Major Causes of Death in Refugee Populations <5 Years Somalia: Gedo Region, 7 Camps January, 1980 Sudan: Wad Kowli Camp February, 1985 Measles ARI Malaria Diarrhea Other 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.

14. 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)

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

16. What are the public health priorities in an emergency?

17. 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 Public Health Priorities in the Emergency Phase:

18. Use of indicators in humanitarian emergencies

19. 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

20. 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)

21. 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

22. Benchmarks for interpreting prevalence rates of acute malnutrition

23. 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

24. 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

25. 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

26. 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: 19.4-30.9 “ “

27. Daily CMREmergency Phase: Deaths/10,000/day Country CMR* Baseline Thailand (1979) 10.7 0.5 Somalia (1980) 11.3 0.6 Sudan (1985) 10.1 0.6 Malawi (1986) 1.8 0.5 Ethiopia (1989) 2.4 0.6 Ethiopia (1991) 5.0 0.6 Northern Iraq (1991) 4.2 0.2 Kenya (1992) 7.4 0.6 Somalia (1992) 17.0 0.6 Zaire (1994) 30.0 0.5 Southern Sudan (1998) 20.0 0.6 Kosovo (1999) 1.0 0.1 Ethiopia (2000) 3.2 0.6 Source: U.S. Centers for Disease Control and Prevention

28. How Do We Calculate CMRs? CMR = total # of deaths x 10,000 / No. days total population = 91 deaths X 10,000 / 10 days 33,000 people = 2.8 deaths / 10,000 / day

29. 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.

30. 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.

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

32. 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

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

34. 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

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

36. SPHERE Indicators for Health Services • One community health worker per 500-1,000 population; • One peripheral health facility (for approximately 10,000 population) • One clinician per 50 consultations per day.

37. Questions?