POINT OF CONTACT FOR THIS DOCUMENT:
Tables
Refugees And Aslyum Seekers By Geographic Region, July 1991
Monthly Crude Mortality Rates, 1978-1991
Monthly Crude Mortality Rates, 1982-1990
Monthly Crude Mortality Rates, 1984-1985
Prevalence of acute undernutrition, Refugee Populations
Prevalence Of Acute Undernutrition, Famine-affected Populations
Prevalence Of Acute Undernutrition, Displaced Populations
Micronutrient Deficiency Disease Outbreaks in Refugee Camps
Figures
Countries With Major Refugee Populations
Countries With Major Internally Displaced Populations
Crude Mortality Rates For Persons In Refugee Camps
Major Causes Of Death In Refugee Populations
Major Causes Of Death In All Ages
Major Reported Causes Of Death In Children
Mortality Rates In 41 Refugee Camp Populations
PEM Prevalence In Children
Measles Mortality In Wad Kowli Refugee Camp
Proportion Of Outpatients With Diarrhea
Cholera Cases And Deaths In Gannet
Cholera Cases Reported in Nyamithutu Camp
Hepatitis Cases Reported Among All Age Groups
The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333.
Centers for Disease Control
William L. Roper, M.D., M.P.H., Director
The material in this report was prepared for publication by: International
Health Program Office
Joe H. Davis, M.D., Director
Division of Technical Services
Andrew A. Vernon, M.D., Director
Division of International Liaison
Robert J. Baldwin, Director
The production of this report as an MMWR serial publication was coordinated
in:
Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc., Director
Richard A. Goodman, M.D., M.P.H., Editor, MMWR Series
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Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.
Copies can be purchased from Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402-9325. Telephone (202)783-3238.
Rita M. Malkki, M.P.H.
Technical Support Division
International Health Program Office
The experts listed below contributed to the preparation of this publication:
Paul A. Blake, M.D., M.P.H.
Enteric Diseases Branch
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Lisa A. Lee, V.M.D., M.P.H.
Technical Support Division
International Health Program Office
Eric E. Mast, M.D., M.P.H.
Hepatitis Branch
Division of Viral and Rickettsial Diseases
National Center for Infectious Diseases
Phillip I. Nieburg, M.D., M.P.H.
International Activity
Division of HIV/AIDS
National Center for Infectious Diseases
Dixie E. Snider, Jr., M.D. M.P.H.
Assistant Director for Science
National Center for Prevention Services
Richard W. Steketee, M.D., M.P.H.
Malaria Branch
Malaria Epidemiology and Control Activity
National Center for Infectious Diseases
Roland W. Sutter, M.D., M.P.H.&TM
Division of Immunization
National Center for Prevention Services
Ronald J. Waldman, M.D., M.P.H.
Strengthening of Epidemiological and Statistical Services Unit Health
Situation and Trend Assessment Division
World Health Organization
Ray Yip, M.D., M.P.H.
Division of Nutrition
National Center for Chronic Disease Prevention and Health Promotion Special contributions were made by:
Molly (Mary Susan) Bardsley
Research Assistant
Emory University School of Public Health
AFB Acid-Fast Bacilli ALRI Acute Lower Respiratory Infection ARDS Adult Respiratory Distress Syndrome ARIs Acute Respiratory Infections BCG Bacille Calmette-Guerin CFR Case-Fatality Ratio CMR Crude Mortality Rate CNS Central Nervous System CSB Corn-soya Blend CSF Cerebral Spinal Fluid CSM Corn-soya Milk DPT Diphtheria-Pertussis-Tetanus DSM Dry Skim Milk E-Z Edmonston-Zagreb Vaccine EIS Epidemic Intelligence Service EPI Expanded Programs on Immunization G-6-PD Glucose-6-Phosphate Dehydrogenase Hb Hemogolobin HEM High Energy Milk HIS Health Information System HIV Human Immunodeficiency Virus IU International Units Kcal Kilocalories MCH Maternal and Child Health MOH Ministry of Health MSF Medecins Sans Frontieres MUAC Mid-Upper Arm Circumference NGO Nongovernmental Organization OPV Oral Polio Vaccine ORS Oral Rehydration Solution ORT Oral Rehydration Therapy PAHO Pan American Health Organization PEM Protein Energy Malnutrition PHC Primary Health Care PVO Private Voluntary Organization SFP Supplementary Feeding Program SMX Sulfamethoxazole SP Sulfadoxine-Pyrimethamine STD Sexually Transmitted Disease TB Tuberculosis TFP Therapeutic Feeding Program TMP Trimethoprim TT Tetanus Toxoid UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations International Children's Emergency Fund
USAID United States Agency for International Development
WFH Weight-For-Height WHO World Health Organization WSB Wheat-soya Blend
These reports and guidelines have been developed by a number of CDC professionals working with international organizations and public health agencies, such as, the Pan American Health Organization, the United Nations High Commissioner for Refugees, the United States Agency for International Development, and the private voluntary organization's of refugee situations. These reports and guidelines reflect our belief that appropriate, cost-effective disease prevention technology can be rapidly applied in most situations that will impact positively the lives of the affected populations. The recommendations underscore our organizational interest and commitment to a global health agenda that will improve the health status of people worldwide. International disaster preparedness and refugee activities are collaborative efforts. CDC efforts are performed jointly with many other governmental, nongovernmental, and international organizations. It is my hope that public health professionals involved in dealing with these issues will find this information useful in their planning, training, and emergency preparedness efforts.
William L. Roper, M.D., M.P.H., Director
Centers for Disease Control
CDC has had a long-standing institutional commitment to the problem of famine-affected, refugee, and displaced populations for many years. During the Nigerian Civil War in the 1960s, 20 Epidemic Intelligence Service officers helped maintain public health programs for millions of displaced civilians, who were deprived of their basic needs by that war. Since then, CDC has provided technical assistance to relief agencies working in most of the world's major refugee emergency communities including those in, for example, Ethiopia, Kenya, Malawi, Pakistan, Somalia, Sudan, Thailand, Turkey, and West Africa. CDC, United Nations agencies, countries of asylum, and private voluntary organizations (PVOs) have attempted to adapt traditional epidemiologic techniques and public health programs to the realities of refugee camps and scattered, famine-affected communities. As a result, a considerable body of knowledge and experience has accumulated and has been documented in various issues of the MMWR. This report represents a compilation of this knowledge for dissemination and for providing guidance on certain technical subjects for those involved in future relief programs.
By necessity, this document is unable to cover all aspects of emergency relief. The recommendations provided here will not be effective unless they are supported by adequate preparedness planning, coordination, communications, logistics, personnel management, and relief worker training. Even more critical is ensuring access by relief workers to internally displaced populations -- many needy communities are caught in areas of contested sovereignty. Unless the international community can devise ways of providing assistance to communities in these circumstances, it will be impossible to implement these basic public health programs. Finally, the situation of refugees and displaced persons is a timely reminder of the clear interface between public health and social justice. The most effective measure to prevent the high mortality experienced by these populations would be to eliminate the causes of the violence and conflict from which they fled.
Joe H. Davis, M.D.
Associate Director for International Health
Director International Health Program Office
Centers for Disease Control
Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues
Since the early 1960s, most emergencies involving refugees and displaced persons have taken place in less developed countries where local resources have been insufficient for providing prompt and adequate assistance. The international community's response to the health needs of these populations has been at times inappropriate, relying on teams of foreign medical personnel with little or no training. Hospitals, clinics, and feeding centers have been set up without assessment of preliminary needs, and essential prevention programs have been neglected. More recent relief programs, however, emphasize a primary health care (PHC) approach, focusing on preventive programs such as immunization and oral rehydration therapy (ORT), promoting involvement by the refugee community in the provision of health services, and stressing more effective coordination and information gathering. The PHC approach offers long-term advantages, not only for the directly affected population, but also for the country hosting the refugees. A PHC strategy is sustainable and strengthens the national health development program.
(Figure 1) Countries with major refugee populations (Table 1) Refugees and asylumseekers by geographic region, July 1991 (Figure 2) Countries with major displaced populations, estimated global total: 16- 20 million
The purpose of this report is to describe the public health consequences of famine and population displacement in developing countries and to present the most current recommendations on public health programs of major importance. Refugee and Displaced Populations
The 1951 United Nations Convention defines a refugee as "Any person who owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable, or owing to fear is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable, or having such fear is unwilling to return to it" (3). In 1969, the Organization of African Unity expanded this definition to include persons fleeing from war, civil disturbance, and violence of any kind (4).
These definitions, however, exclude persons who leave their country of origin to seek economic betterment, as well as persons or groups who may flee their homes for the above or other reasons, yet remain within the borders of their own country. There are few, if any, international regulations covering these internally displaced populations, yet it is estimated that more than half of all displaced persons worldwide are living within the borders of their home country (5).
Famine is usually caused by the amplification of a pre-existing condition characterized by widespread poverty, intractable debt, underemployment, and high malnutrition prevalence. Under these conditions, a large percentage of the population may routinely experience starvation. When additional burdens related to the production or availability of food arise, generalized starvation occurs rapidly. In recent years, frequent crop failures in Ethiopia, Somalia, Sudan, and the Sahelian countries of Africa have been attributed to progressive deterioration of the environment, including deforestation, desertification, and poor agricultural practices.
Populations experiencing famine may or may not displace themselves in order to improve food availability. Initially, male family members may migrate to cities or neighboring countries to seek employment. During a full-scale famine, whole families and villages may flee to other regions or countries in a desperate search for food. In most of the major population displacements of the past 20 years, however, people have been forced to flee because of fear for their physical security caused by war or civil strife. Famine in the absence of violence has generated few of the world's refugees.
The leading and intermediate indicators will be useful if they trigger early interventions aimed at ensuring adequate food supplies for the population and at maintaining the purchasing power of vulnerable groups. These measures have included temporary government subsidies for food crops, "food-for-work" programs; government-run, fixed-price food shops; rural employment schemes; the distribution of drought-resistant seeds; and the release of food reserves.
Effective early warning systems might help avert major population movements, thereby allowing local government and international and private voluntary organizations (PVOs) to provide assistance in situ without major disruption in traditional social structures and lifestyle patterns. Affected communities can be surveyed, needy households identified, food and other relief supplies distributed, and major epidemics averted with greater ease and effectiveness in a stable population than in a temporary refugee settlement. National early warning systems have proved effective in preventing famine during the past decade in India and Botswana (8). When populations are forced to migrate en masse, they usually end up in camps or urban slums characterized by overcrowding, poor sanitation, substandard housing, and limited access to health services. These conditions hamper the effective and equitable distribution of relief supplies and promote the transmission of communicable diseases.
The CMRs reported in various refugee, internally displaced, and famine-affected (but nondisplaced) populations, respectively, during the emergency phase of relief operations in the past 15 years are listed in ( Table 2), (Table 3), and (Table 4). These rates are compared with baseline CMRs reported for nonfamine-affected and nondisplaced populations, or, in the case of refugees, with CMRs in their country of origin. CMRs in these tables are expressed as deaths per 1,000 per month to reflect the short reporting periods; comparison rates have been extrapolated from annual CMRs published by the United Nations Children's Fund (UNICEF) (13). Although CMRs reported in refugee emergencies have not been adjusted for age and sex, it is unlikely that demographic differences between refugee and non-refugee populations account for the excess mortality found among many of the latter.
Monthly CMRs recorded immediately after the initial influx of Cambodian refugees into Thailand (1979), Ethiopian refugees into Somalia (1980), and Ethiopian refugees into eastern Sudan (1985) were 8.1 to 15.2 times the expected rates. The early death rate among Kurdish refugees in Turkey in April 1991 was 18 times the baseline rates in both Iraq and Turkey. In contrast, among Mozambican refugees in Malawi in 1987, camp-based CMRs were one-third lower than the national CMR reported for Mozambique. A movement of 50,000 refugees from Burundi into Rwanda in 1988 also resulted in minimal mortality once asylum had been attained. The rate of improvement in camp populations has varied considerably. For example, mortality rates decreased rapidly in Cambodian refugee camps in Thailand in 1979-1980 and in the Kurdish camps of Turkey in 1991, but only slow improvement occurred during the initial 8 months in Somalia (1980) and in Sudan (1985). In eastern Ethiopia in 1988-1989, initially low mortality rates among Somali refugees increased after 6 months, reaching a peak at 9 months (Figure 3). Overall, less than 1% of Cambodian refugees in Thai camps died during the first 12 months; 9% of refugees in eastern Sudan died during the same period of time (1).
Political and security factors often obstruct the accurate documentation of death rates among internally displaced populations; however, a few situations have been well documented. In Mozambique (1983), Ethiopia (1984-1985), and Sudan (1988), CMRs estimated by surveillance or population-based surveys of internally displaced persons ranged between 4 and 70 times the death rates in nondisplaced populations in the same country. In the Korem area of Ethiopia, CMRs recorded among camp populations displaced by famine in 1985 were 7-10 times those of settled villagers in a similar highland zone affected by the famine. In Monrovia, the capital of Liberia, the death rate among civilians displaced during the 1990 civil war was 7 times the pre-war death rate (Holland MSF, unpublished data, January 1991).
As in stable populations in developing countries, age-specific death rates in displaced and refugee populations are highest in children less than 5 years of age. A mortality survey of Kurdish refugees at the Turkey-Iraq border during 1991 revealed that 63% of all deaths occurred among children less than 5 years of age, who comprised approximately 18% of the population (11). Although absolute death rates are highest in infants less than 1 year of age, the relative increase in mortality during emergencies may be highest in children 1-12 years of age (1).
A study of 42 refugee populations completed in 1989 examined acute protein energy malnutrition (PEM) prevalence and crude unadjusted monthly mortality rates, gathered from 1984-1988. Analysis of the data showed a strong positive association between PEM prevalence and CMRs. Populations with PEM prevalence rates of less than 5% had a mean CMR of 0.9/1,000/month. Refugee populations with PEM prevalences of greater than or equal to 40%, however, experienced a mean CMR of 37/1,000/month with a range of 4/1,000/month to 177/1,000/month ( Figure 7). The rate ratio between the lowest and highest CMR values was 40.7 (14).
The close correlation between malnutrition prevalence and crude mortality during a relief operation for Somali refugees in eastern Ethiopia in 1988-1989 is clearly demonstrated in (Figure 8. Malnutrition prevalence was estimated by serial, cross-sectional, cluster sample surveys of children less than 5 years of age, and monthly death rates were estimated retrospectively by a population-based survey in August 1989. During the period of high malnutrition prevalence and high mortality (March-May 1989), food rations provided an average of approximately 1,400 kilocalories (kcal)/person/day instead of the recommended minimum of 1,900 kcal/person/day (9). Likewise, in eastern Sudan in 1985, inadequate amounts of food (1,360-1,870 kcal/person/day) were distributed to Ethiopian refugees during the first 5 months after their arrival in the camps. Malnutrition rates, as well as mortality rates, remained high during this period (Figure 3) ( Table 5). In addition, a severe measles outbreak in the Sudanese camps added to the high mortality (21).
The prevalence of moderate to severe acute undernutrition in a random sample of children less than 5 years of age is generally a reliable indicator of this condition in a population. Since weight is more sensitive to sudden changes in food availability than height, nutritional assessments during emergencies focus on measuring WFH. Also, WFH is a more appropriate measurement for ongoing monitoring of the effectiveness of feeding programs. As a screening measurement, the mid-upper arm circumference (MUAC) may also be used to assess acute undernutrition, although there is not complete agreement on which cutoff values should be used as indicators. Nutritional assessment methods are fully described in the Rapid Nutrition Assessment Manual. *
* Available from the International Health Program Office (IHPO), CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.
Anthropometric indices such as WFH and height-for-age are interpreted by comparison with a "reference population". Index values are assigned a "Z-score" based on the number of standard deviations above or below the median value in the reference population. Currently, the World Health Organization (WHO) recommends the use of the CDC/NCHS reference population for nutritional assessments in all countries (22). Before the mid-1980's, anthropometric data was reported as a percentage of the median of the reference population value. Current international guidelines, however, recommend the use of Z-scores to report nutritional assessment data. Tables in this report define acute undernutrition on the basis of percentage median in order to allow comparisons of recent data with data from surveys performed before the mid-1980s.
In a well-nourished population in which WFH values are distributed normally (i.e., the reference population), approximately 3% of children less than 5 years of age will have WFH Z-scores of less than -2. For less developed countries with lower "normal" nutritional intake levels, 5% of the children may have a Z-score less than -2 when compared with the reference population median, particularly at certain times of the year. Relief organizations agree that a nutritional emergency exists if greater than 8% of the children sampled have a Z-score less than -2. An excess of even 1% of children with Z-scores less than -3 indicates a need for immediate action. Acute PEM prevalence rates have been high in recent famine-affected populations, especially in Africa (Table 6).
In addition, acute undernutrition prevalence rates have been elevated in many displaced and refugee populations during the past 12 years, ranging as high as 50% in eastern Sudan in 1985 (Table 5) and (Table 7). PEM rates have decreased rapidly in situations where effective emergency relief operations have been mounted promptly, i.e., Thailand (1979) and Pakistan (1980). However, in other emergencies, such as in Somalia (1980) and Sudan (1985), PEM rates have remained high (greater than 20%) for 6-8 months. Of even greater concern is the observation that acute undernutrition rates among Somali refugees in Ethiopia (1988-1989) actually increased 6 months after a relief program was launched. Although most high acute undernutrition prevalence has been associated with inadequate food rations, it appears that malnutrition developed among Kurdish children 1-2 years of age in Turkey within a period of 1-2 months, primarily because of the high incidence of diarrheal diseases in the camps (10). Among internally displaced civilian populations, high PEM prevalence has been associated with the intentional use of food as a weapon by competing military forces (30).
The use of serial anthropometry surveys as monitoring tools has certain limitations when mortality rates are high. For example, an analysis of anthropometric data from two cross-sectional surveys in a refugee camp in Sudan in 1985 initially implied a relatively stable nutritional situation. In January, the prevalence of acute malnutrition in children less than 5 years of age was 26.3%; in March, the rate was 28.4%. During these two months, almost 13% of the children in the camp died, mainly from measles and diarrheal diseases. In this instance, the elevated child mortality rate masked diminished nutritional status in the population. Many malnourished children in the first survey, who had died, were "replaced" in the second survey sample by surviving children whose nutritional status had meanwhile deteriorated (31). Thus, anthropometry data need to be interpreted in the context of concurrent mortality rates.
Famine-affected and displaced populations often have low levels of dietary vitamin A intake before experiencing famine or displacement, and therefore, may have very low vitamin A reserves. Furthermore, the typical rations provided in large-scale relief operations lack vitamin A, putting these populations at high risk. In addition, some communicable diseases that are highly incident in refugee camps -- measles and diarrheal diseases -- rapidly deplete vitamin A stores. Depleted vitamin A stores need to be adequately replenished during recovery from these diseases to prevent the deficiency from becoming clinically important.
Active surveillance for scurvy among Ethiopian refugees in Somalia and Sudan in 1987 revealed cumulative incidence rates of up to 19.8% in some camps, with initial onset reported between 3-10 months after the arrival of the refugees (32). Cross-sectional surveys performed in 1986-1987 reported point prevalence rates as high as 45% among females and 36% among males; prevalence increased with age. The prevalence of scurvy was associated with the period of residence in camps, and the time exposed to rations lacking in vitamin C. In 1989, a population survey of children less than 5 years of age in Hartisheik camp in eastern Ethiopia in 1989 found the prevalence of clinical scurvy to be 2% (19). The international community has not developed an adequate strategy to prevent scurvy in refugee camps at the Horn of Africa, as demonstrated by an outbreak that took place among adult males (former Ethiopian soldiers) in a camp in eastern Sudan during 1991 (Bhatia R, personal communication, October 1991).
A 1987 study among refugees in Somalia demonstrated an anemia prevalence rate of 44%-71% among pregnant women, with that proportion being even greater if only women in the third trimester of pregnancy were considered. The cutoff point for hemoglobin concentration in this study was 10 g/dL; with the WHO cutoff of 11 g/dL, the prevalence would have been greater. Among children 9-36 months of age, 59%-90% were below the 10 g/dL cutoff. The inadequacy of the general ration was identified as the major factor causing iron deficiency anemia in this population. In a 1990 study, the prevalence rate of anemia was 13% among children less than 5 years of age in an Ethiopian camp for Somali refugees (Save the Children Fund UK, unpublished data). In addition to dietary iron deficiency, the high incidence of malaria in many refugee populations probably contributes to the high prevalence of anemia in children. This high prevalence of anemia found in some refugee populations may not be significantly greater than that found in local, non-refugee populations, since the latter group has been poorly documented. Nevertheless, anemia may be an additional important preventable risk factor for high mortality in refugee populations. The high prevalence of anemia is often correlated with a subset of the population with severe anemia (hemoglobin (Hb) less than 5 g). Severe anemia in itself can be a major cause of mortality for young children and pregnant women during the peripartum period.
Densely populated camps with poor sanitation, inadequate clean water supplies, and low-quality housing all contribute to the rapid spread of disease in refugee settings. In addition, the interaction between malnutrition and infection in these populations, particularly among young children, has contributed to the high rates of morbidity and mortality from communicable diseases. Available and affordable technology could prevent much of this morbidity and mortality either through primary prevention (e.g., immunization, adequate planning, and sanitation) or through appropriate case management (e.g., treatment of dehydration caused by diarrhea with oral rehydration salts and continued feeding).
Improvements in camp sanitation and water supply were probably responsible for this trend. Although the etiologies of diarrheal illness during refugee emergencies have not been well documented, the responsible pathogens are most likely to be the same agents that cause diarrhea in non-refugee populations in developing countries. In one study in a camp for famine victims in Ethiopia, of 200 patients with diarrhea, 15.6% had positive cultures for Escherichia coli (pathogenicity not specified by authors), 3.5% for Shigella spp., and 2% for Salmonella spp. (44).
Afghan refugees living in the North-West Frontier Province of Pakistan have a higher incidence of clinical malaria than that observed among the local population. A comparison of the epidemiologic trends of malaria between the refugees and the local population over a period of several years demonstrated that the increased rate of malaria illness among refugees was a result of having resettled in an area of higher transmission than that from which they had fled. Because of their limited exposure history, the Afghan refugees had lower levels of immunity to malaria illness than did the local population (51). Few deaths associated with malaria have been reported in this population because the majority of cases have been associated with Plasmodium vivax, a milder form of malaria than that caused by Plasmodium falciparum, the form that is more commonly reported in African camps.
During an 18-month period, greater than 6,000 cases were reported. Between March and October of 1991, a major outbreak of hepatitis occurred among Somali refugees living in Kenya's Liboi camp; a total of 1,700 cases were reported, yielding an attack rate of 6.3%. The overall CFR was 3.7% and in pregnant women the CFR was 14%. Hepatitis was responsible for one of every five deaths in the camp during that time period. The hepatitis E virus was identified in stool and serum specimens from ill patients. The Ethiopian and Kenyan outbreaks were associated with inadequate water supply. In both camps, refugees had access to an average of only 1-3 liters of clean water/person/day (the United Nations High Commissioner for Refugees (UNHCR) recommends a minimum of 15 liters/person/day) (53).
Preparedness requires that planning for emergencies be included as an integral part of routine health development programs in countries where sudden population displacements might occur. These programs include:
Health Information System
Female health workers should be trained and employed to provide culturally appropriate health education both at MCH clinics and within the community, and to refer pregnant women to the clinic for antenatal care. At least some of these health workers should be recruited from among traditional birth attendants in the community. Antenatal care should include screening for high-risk pregnancies and providing iron and folic acid supplementation (as well as iodine supplementation in areas of endemic goiter), tetanus toxoid immunization, and health education. Postnatal care should include nutritional supplementation, counselling on family spacing, provision of contraceptives, and education about breastfeeding and infant care. In certain cultural situations, curative care may need to be provided to all women of child-bearing age in a setting physically segregated from male outpatient facilities.
Before the field visit, relevant information relating to the status of the incoming refugees, as well as the available resources of the host community, should be obtained from local ministries or organizations based in the capital city. Any maps of the area where the refugees are arriving and settling should likewise be obtained. Aerial photographs will also be of value, but may be considered sensitive by the military of the host country. International organizations like UNICEF, WHO, and the Red Cross/Red Crescent may also have demographic and health data concerning the refugee population.
In preparation for the field visit, establish whether food, medical supplies (including vaccines), or other relief supplies have been ordered or procured by any of the relief agencies involved. Additionally, the following conditions should be included in a field assessment.
Sources of information. Local government officials or camp authorities may be able to provide registration records. If no registration system is in effect, one should be established immediately. Information recorded should include the names of household heads, the number of family members by age and sex, former village and region of residence, and ethnic group, if applicable.
Refugee leaders may also have records, particularly if entire villages have fled together. In certain situations, political groups may have organized the exodus and may have detailed lists of refugee families.
A visual inspection of the settlement may provide a general impression of the demographic composition of the population. However, information obtained in this manner should be used judiciously as it is likely to provide a distorted view of the situation.
It may be necessary to conduct a limited survey on a convenience sample in order to obtain demographic information. Beginning at a randomly selected point, survey a sample (e.g., 50) of dwellings. Visit every fifth or 10th house until the predetermined number of houses have been surveyed. At each house, record the number of family members, the age and sex of each person, and the number of pregnant or lactating women. This process will establish an initial estimate of the demographic composition of the population. Estimate the number of persons in each house, as well as the total number of houses in the settlement, to gain a provisional estimate of the camp population. At the very least, this quick survey should give a rough estimate of the proportion of the total population made up of "vulnerable" groups; i.e., children less than 5 years of age and women of child bearing age. To determine the total population, a census may need to be conducted later.
Sources of information. Obtain documents and reports from the host government, international organizations, and nongovernment organizations pertaining to endemic diseases and public health programs in the displaced population's region of origin.
Interview refugee leaders, heads of households, women leaders (e.g., traditional midwives), and health workers among the refugee population.
Seek information from development agencies, private companies, missionaries, or other groups having experience with the displaced population.
Sources of nutritional information. If refugees are still arriving at the site:
Why this information is needed. In the initial stages of a population displacement, mortality rates, expressed as deaths/10,000/day, are a critical indicator of improving or deteriorating health status.
In many African countries, the daily CMR (extrapolated from published annual rates) is approximately 0.5/10,000/day during non-emergency conditions. In general, health workers should be extremely concerned when CMRs in a displaced population exceed 1/10,000/day, or when less than 5 years of age mortality rates exceed 4/10,000/day.
Sources of mortality information. Check local hospital records and the records of local burial contractors. Interview community leaders.
Establish a mortality surveillance system. One approach is to designate a single burial site for the camp, which should be monitored by 24-hour grave watchers. Grave watchers should be trained to interview families, using a standard questionnaire, and then to record the data to determine gender, approximate age, and probable cause of death.
Other methods of collecting mortality data include registering deaths, issuing burial shrouds to families of the deceased to ensure compliance, or employing volunteer community informants who report deaths for a defined section of the population.
Demographic data are absolutely essential for calculating mortality rates. These provide the denominator for estimating death rates in the entire population and within specific vulnerable groups, such as children less than 5 years of age.
The population needs to be assured that death registration will have no adverse consequences (e.g., ration reductions). Morbidity
The information required includes age- and sex-specific data regarding the incidence of common diseases of public health importance, i.e., measles, malaria, diarrheal diseases, and ARI, as well as diseases of epidemic potential such as hepatitis and meningitis. The data should be collected by all health facilities, including feeding centers.
Why this information is needed. Data on diseases of public health importance may help plan an effective preventive and curative health program for refugees. These data will also facilitate the procurement of appropriate medical supplies and the recruitment and training of appropriate medical personnel, as well as focus environmental sanitation efforts (e.g., toward mosquito control in areas of high malaria prevalence).
Sources of morbidity information. Review the records of local clinics and hospitals to which refugees have access.
Where a clinic, hospital, or feeding center has already been established within the camp, examine patient records or registers and tally common causes of morbidity. Interview refugee leaders and health workers within the refugee population.
A simple morbidity surveillance system should be established as soon as curative services are established in the camp. Feeding centers should be included in the surveillance system. Community health workers should be trained as soon as possible to report diseases at the community level.
The initiation of certain public health actions should not be delayed until the disease appears. For example, measles immunization should be implemented immediately. Do not wait for the appearance of measles in the camp. Also, oral rehydration centers should be routinely established in all situations.
Efforts to evaluate food supplies should include:
Food logistics. Assess transport and fuel availability, storage facilities (size, security), and seasonal conditions of access roads.
Feeding programs. Follow these guidelines to evaluate feeding programs:
(*) Adapted from : WHO Emergency Relief Operations. Emergency Preparedness and Response: Rapid Health Assessment in Sudden Population Displacements. WHO, in collaboration with CDC and other WHO Collaborating Centers for Emergency Preparedness and Response. Geneva: January 1990.
Preparation
Health information should be reported on a simple, standardized surveillance form. (A sample form, adapted from WHO Emergency Relief Operations, is located at the end of this section.) Each health facility should be held accountable for completing the reporting form at the appropriate interval and for returning it to the person or agency charged with compiling the reports, analyzing the information, and providing feedback. Each refugee settlement or camp should have a person responsible for coordinating the HIS. Forms should be translated into the appropriate local language(s) if community health workers are involved in information collection.
Health facilities should keep a daily record of patients; age, sex, clinical and laboratory diagnosis, and treatment should be specified. If personnel time is limited, a simple tally sheet should be used. In addition, the patient should be issued a health record card on which the date, diagnosis, and treatment are recorded. Each time a patient contacts the health-care system, whether for curative or preventive services, this should be noted on the health record card. Laboratory data should accompany diagnostic information whenever possible. Collecting Processing, Storing, and Shipping Diagnostic Specimens in Refugee Health-Care Environments * provides an overview of procedures for collecting and processing diagnostic specimens in the field.
* Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.
Data collection should be limited to that information that can and will be acted upon. Information that is not immediately useful should not be collected during the emergency phase of a refugee relief operation. Overly detailed or complex reporting requirements will result in noncompliance.
The most valuable data are generally simple to collect and to analyze. Standard case definitions for the most common causes of morbidity and mortality should be developed and put in writing. The data collected will fall into one of the following categories: a) demographic, b) mortality, c) morbidity, d) nutritional status, and e) health program activities.
Population. Camp registration records should provide most of the demographic information needed. If registration records are inadequate, a population census may be necessary. Conducting a census is often politically sensitive and may be delayed by the administrative authorities for a long period of time. Consequently, innovative methods may need to be devised. For example, organize a nutritional screening of all children less than 5 years of age. Count the children and estimate the percentage of the total population less than 5 years of age by doing a sample survey. From this information, estimate the total population size. For other methods to determine population size and structure see "Rapid Health Assessment".
It is important that population figures be updated on a regular basis, taking into account new arrivals, departures, births, and deaths. The total population is used as the denominator in the calculation of disease incidence, birth, and death rates. This total is also necessary to determine requirements for food and medical supplies and to estimate program coverage rates. Information about the population structure is needed to calculate age- and sex-specific morbidity and mortality rates, to estimate ration requirements, and to determine the target population for specific interventions, i.e., antenatal care and immunizations.
The rate of new arrivals and departures gives an indication of the stability of the population and will influence policy decisions about long-term interventions, such as TB therapy. This information is also used to predict future resource and program needs.
A birth registration system is usually simple, since the community expects an increase in the family food ration as a result of a new birth. Births might be reported in the community to volunteer health workers or traditional birth attendants. Alternatively, if good antenatal care services are established, follow-up of pregnant mothers will allow for a relatively complete registration of births. Examples of mortality surveillance systems are described in "Rapid Health Assessment". Deaths may be underreported if there is a fear of possible ration reduction; thus, an agreement might be negotiated with camp authorities not to decrease rations after a death occurs at least during the emergency phase. Arrivals and departures should be monitored through the camp registration system.
Mortality. Each health facility should keep a log of all patient deaths (with cause of death and relevant demographic information) and report the deaths on a standardized form. Because many deaths occur outside of the health-care system, a community-based mortality surveillance system should be established. Such a system may include the employment of grave watchers, the routine issuance of burial shrouds, and the use of community informants (see "Rapid Health Assessment").
Death rates are the most specific indicators of a population's health status and are the category of data to which donors and relief agencies most readily respond. During the emergency phase of a relief operation, death rates should be expressed as deaths/10,000/day to allow for detection of sudden changes. In refugee camps, relief programs should aim at achieving a CMR of less than 1/10,000/day as soon as possible. This rate still represents approximately twice the "normal" CMR for non-displaced populations in most developing nations and should not signal a relaxation of efforts. After the emergency phase, death rates should be expressed as deaths/1,000/month to reflect the usual reporting frequency and to facilitate comparison with baseline, non-refugee death rates.
Age- and sex-specific mortality rates will indicate the need for interventions targeted at specific vulnerable groups. During the early stage of a relief operation, specific death rates for persons less than 5 years of age and greater than 5 years of age may suffice. Later, further disaggregation by age may be feasible -- for example, less than 1 year, 1-4 years, 5-14 years, and greater than 15 years. Different male- and female-specific death rates may reflect inequitable access to resources or health services. Cause-specific mortality rates will reflect those health problems having the greatest impact on the refugee community and requiring the highest priority in public health program planning.
Morbidity. Health facilities and feeding centers should report morbidity information on the same form on which mortality is reported. Each disease reported in the system must have a written case definition that will guide health workers in their diagnosis and ensure the validity of data. Where practical, case definitions that rely on clinical signs and symptoms should be tested periodically for sensitivity and specificity as compared with a laboratory standard (e.g., malaria).
Knowledge of the major causes of illness and the groups in the affected population that are at greatest risk allows for the efficient planning of intervention strategies and the most effective use of resources. Morbidity rates are more useful than a simple tallying of cases, as trends can be followed over time, or rates compared with those from different populations. The monitoring of proportional morbidity (e.g., percentage of all morbidity caused by specific diseases) may be useful when specific control measures are being evaluated, although caution is needed in the interpretation of trends. A relative decrease in disease-specific proportional morbidity may merely reflect an absolute increase in the incidence of another disease.
Nutritional status. Data regarding nutritional status can be obtained through a nutritional assessment survey or a mass screening exercise. Surveys should be repeated at regular intervals to determine changes in nutritional status; however, not so frequently as to obscure true differences between surveys. All children less than 5 years of age should undergo a nutritional screening upon arrival at the camp and should continue to be weighed and measured monthly at MCH clinics in the camp. Information collected during these screenings should be included in HIS reports. If the initial screening identifies high prevalence rates of undernutrition, cross-sectional surveys should be repeated at intervals of 6-8 weeks until the undernutrition prevalence rate is below 10%. Thereafter, surveys every 6-12 months will suffice, unless routine surveillance data indicate that nutritional status has deteriorated. Measurement of nutritional status is described in the Rapid Nutrition Assessment Manual. (*)
(*) Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.
The prevalence of acute malnutrition acts as an indicator of the adequacy of the relief ration. A high prevalence of malnutrition in the presence of an adequate average daily ration may indicate inequities in the food distribution system, or high incidence rates of communicable diseases (e.g., measles and diarrhea). The presence of nutritional deficiency disorders (i.e., pellagra, anemia, or xerophthalmia) indicates the need for ration supplementation.
Programs. Each health facility should keep a log of all activities. Immunizations should be recorded in a central record, as well as on the person's health record card. Records of health sector activities will be useful in determining whether certain groups in the population are underserved, and in planning measures to reach a broader population base. Although approximate immunization coverage may be estimated from the number of vaccine doses administered, the preferred method is by annual population surveys.
The standard requirement of 1,900 kcals is based on the following demographic structure of a population:
Guidelines for ration distribution
SFPs are designed to help prevent severe malnutrition and to rehabilitate moderately malnourished persons. SFPs are not intended to be used as a method of targeting food during an emergency phase. Similarly, SFPs are inappropriate as a long-term supplement to an inadequate general ration.
Implementation of a SFP is necessary under the following circumstances:
The following groups should be targeted for inclusion in a SFP:
Caloric requirements. A SFP should provide at least 500 kcal and 15 g protein/day in one or two feedings.
High energy milk (HEM), a calorie-dense milk mixture, may be used in a SFP.
One milliliter of HEM provides 1 kcal of energy. The formula below makes 5 L
of HEM:
420 g dried skimmed milk,
250 g sugar,
320 g oil, and
4.4 L water
If the general ration is inadequate (less than 1,900 kcal/person/day), the supplementary ration should provide 700-1,000 kcal/person/day in two to three feedings.
Types of SFPs. SFPs fall into two categories, either on-site feeding or take-home rations. Listed below are some of the advantages and disadvantages of each type of SFP (1).
On-site feeding. "Wet" rations are prepared by SFP staff and served to recipients in the feeding center. Listed below are the advantages of wet rations:
Therapeutic feeding programs (TFPs) are considered a medical intervention, the purpose of which is to save lives and restore the nutritional health of severely malnourished children. The recommendations listed below are adapted from the procedures for selective feeding (2).
Enrollment criteria. Children should be enrolled in a TFP if they meet one of the following criteria:
Ideally, the recommended daily allowances for all essential nutrients should be provided in the general rations. However, specific measures may be necessary to provide certain micronutrients.
Vitamin A
Risk factors for vitamin A deficiency. Provide vitamin A supplements whenever any of the following conditions are present:
Anemia. The prevalence of anemia can be determined through a rapid anemia survey using a portable Hb photometer (HemoCue system).
The CDC has established the following criteria for defining anemia:
Iron/folic acid. Routine iron/folate supplements should be provided to all pregnant and lactating women through antenatal and postnatal clinics. Female health workers should be employed to seek out pregnant and lactating women and encourage their participation in these programs.
Vitamin C. Fortification of foods with vitamin C is problematic because vitamin C is unstable. Further study is needed on the appropriate vehicle for fortification. The best solution is to provide a variety of fresh foods either by including them in the general ration or by promoting access to local markets. In addition, local cultivation of vitamin C-containing foods should be encouraged. Patients with clinical scurvy should be treated with 250 mg of oral vitamin C two times daily for 3 weeks.
Niacin. Maize-eating populations are at greatest risk for niacin deficiency, which causes pellagra. Recent studies of pellagra outbreaks among refugee populations found groundnut consumption, garden ownership, and home maize milling (as an indicator of higher socioeconomic status) to be protective factors. Niacin-fortified flour should be included in the general ration. The process of fortifying maize flour with niacin is simple and relatively inexpensive.
Clinical cases of pellagra can be treated with nicotinamide. The recommended treatment schedule is 100 mg three times daily for 3 weeks. The total daily dose of nicotinamide should not exceed 600 mg. Where the diet is deficient in niacin, vitamin B complex tablets can be used to prevent pellagra.
Iodine. If the general ration is naturally deficient of iodine, fortification of items such as salt or monosodium glutamate should be considered.
Brown RE, Berry A. Prevention of malnutrition and supplementary feeding programs. In: Sandler RH, Jones TC, eds. Medical care of refugees. New York: Oxford University Press 1987:124.
CDC. Outbreak of pellagra among Mozambican refugees Malawi, 1990. MMWR 1991;40:209-13.
Desenclos JC, Berry AM, Padt R, Farah B, Segala C, Nabil AM. Epidemiological patterns of scurvy among Ethiopian refugees. Bull WHO 1989;67:309-16.
Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO 1988;66:689-97.
Peel S. Nutritional aspects of refugee assistance. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care--a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta: CDC, 1983:121-7.
Peel S. Selective feeding procedures. Oxfam Working Paper no.1. Oxford, 1979.
Seaman J, Rivers J. Strategies for the distribution of relief food. J. R. Statist. Soc. 1988;151:464-72.
United Nations Administrative Committee for Coordination, Subcommittee on Nutrition, and the International Nutrition Planners Forum. Nutrition in times of disaster. Presented as a report of an International Conference; September 27-30, 1988; Geneva, Switzerland.
UNHCR/WFP. Guidelines for calculation food rations for refugees. Geneva/Rome. August 1991.
Wallstam E, Nieburg P, Eie E, Lendorff A. Donated foods and their use in refugee-assistance operations. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care--a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta: CDC, 1983:129-33.
Yip R, Gove S, Farah BH, Mursal HM. Rapid assessment of hematological status of refugees in Somalia: the potential value of hemoglobin distribution curves in assessing iron nutrition status. Presented at the APHA annual meeting, October 20, 1987.
Diphtheria, tetanus toxoids (TT) and pertussis vaccine (DTP), oral polio vaccine (OPV), and bacille Calmette-Guerin (BCG) vaccinations are recommended. None should not be undertaken, however, unless the following criteria are met: the population is expected to remain stable for at least 3 months; the operational capacity to administer vaccine is adequate, and the program can be integrated into the national immunization program within a reasonable length of time.
It is essential that adequate immunization records be kept. At the very minimum, personal immunization cards (i.e., "Road to Health" cards) should be issued. In addition, a central register of all immunizations is desirable.
In refugee populations fleeing from countries with high immunization coverage rates, measles immunization should still be accorded high priority. Studies of urban populations (e.g., Kinshasa, Zaire) and densely populated refugee camps (e.g., camps in Malawi) have shown that large outbreaks of measles may still occur even if vaccine coverage rates exceed 80%. For example, in a camp of 50,000 refugees, approximately 10,000 would be children less than 5 years of age. If the vaccine coverage rate was 80% and vaccine efficacy was 90%, approximately 2,800 children in this camp would still be susceptible to measles. In addition, certain countries achieved high coverage in the 12 to 23 month age group, leaving large numbers of older children unprotected.
Program management. Responsibilities for each aspect of the immunization program need to be explicitly assigned to agencies and persons by the coordination agency.
The national EPI should be involved from the outset of the emergency. National guidelines regarding immunization should be applied in refugee settings.
A pre-immunization count should be conducted to estimate the number of children eligible for vaccination. This should not be allowed, however, to delay the start of the vaccination program.
Choice of vaccine. The standard Schwarz vaccine is recommended. The use of medium or high titer Edmonston-Zagreb (E-Z) vaccine is not yet recommended for refugee populations, since there are still concerns about its safety.
Target population. During the emergency phase, defined as that time during which the CMR is higher than 1/10,000/day, all children ages 6 months-5 years should be vaccinated upon arrival at the camp.
In long-term refugee health programs, vaccination should be targeted at all children ages 9 months-5 years, except during outbreaks when the lower age limit should again be dropped to 6 months.
Any child who has been vaccinated between the ages of 6 and 9 months should be revaccinated as soon as possible after reaching 9 months of age, or 1 month later if the child was 8 months old at first vaccination.
If there is insufficient vaccine available to immunize all susceptible children, the immunization program should be targeted at the following high-risk groups, in order of priority:
Undernutrition is not a contraindication for measles vaccination! Undernutrition should be considered a strong indication for vaccination. Similarly, fever, respiratory tract infection, and diarrhea are not contraindications for measles vaccination. Unimmunized persons who are infected with HIV should receive the vaccine. Measles vaccine should also be administered in the presence of active TB (1).
Outbreak control. Measles immunization programs should not be stopped or postponed because of the presence of measles in the camp or settlement. On the contrary, immunization efforts should be accelerated.
Among persons who have already been exposed to the measles virus, measles vaccine may provide some protection or modify the clinical severity of the disease, if administered within 3 days of exposure.
Isolation of patients with measles is not indicated in an emergency camp setting.
Case management. All children who develop clinical measles in refugee camps should have their nutritional status monitored and be enrolled in a feeding program if indicated.
Children with measles complications should be administered standard treatment, e.g., ORT for diarrhea and antibiotics for acute lower respiratory infection (ALRI).
If they have not received vitamin A during the previous month, all children with clinical measles should receive 200,000 IU vitamin A orally. Children less than 12 months of age should receive 100,000 IU. This should be repeated every 3 months as part of the routine vitamin A supplementation schedule.
Children with complicated measles (pneumonia, otitis, croup, diarrhea with moderate or severe dehydration, or neurological problems) should receive a second dose of vitamin A on day 2.
If any eye symptoms of vitamin A deficiency are observed (xerosis, Bitot's
spots, keratomalacia, or corneal ulceration), the following treatment
schedule should be followed:
200,000 IU oral vitamin A on day 1.
200,000 IU oral vitamin A on day 2.
200,000 IU oral vitamin A 1-4 weeks later.
Children less than 12 months of age receive half doses.
Outbreak identification and control. If an outbreak of meningococcal meningitis is suspected, early priority should be given to the determination of etiology and serogroup. This may be accomplished through the use of latex agglutination tests. It is also important to determine antibiotic resistance patterns. Cerebral spinal fluid (CSF) or petechial washings should be placed in suitable transport media and kept at 37 C during transport to a local or regional laboratory with the capacity to perform the needed analysis. If transport media are unavailable, CSF specimens should be placed in a test tube and transported at body temperature as soon as possible.
After an outbreak has been confirmed, a presumptive diagnosis of meningococcal meningitis among persons with suggestive symptoms and signs can be made by visual inspection of CSF from lumbar punctures; CSF will appear cloudy in probable cases. Clinical characteristics include fever, severe headache, neck stiffness, vomiting, and photophobia.
Endemic rates of meningococcal disease vary by geographic area, season, and age; thus it is not possible to define a rate that can be applied universally to identify an epidemic disease. In one study, an average incidence rate of disease that exceeded 15 cases/100,000/week for a period of 2 consecutive weeks was predictive of an epidemic (defined as greater than 100 cases/100,000). Since this threshold may only be valid for populations greater than 100,000 and because the population in a refugee camp may be unknown, a doubling of the baseline number of cases from 1 week to the next over a period of 3 weeks may be used as a rough indicator of a meningitis outbreak.
Vaccination. Vaccination of refugees against meningococcal meningitis during non-epidemic periods is generally not considered to be an effective measure because of the short duration of protection in young children. If there are compelling reasons to believe that the refugee population is at high risk for an epidemic, preventive vaccination before the meningitis season may be warranted.
In the event of an outbreak, vaccination should be considered if the following criteria are met:
Because cases of meningococcal meningitis are likely to cluster geographically within a refugee camp, it may be most efficient to focus the vaccination campaign on the affected area(s) first. Although the target group for immunization should be determined from the epidemiology of the specific outbreak, vaccination of children and young adults between the ages of 1-25 years will generally cover the at-risk population.
Chemoprophylaxis. Mass chemoprophylaxis is ineffective for control of epidemic meningococcal disease and is to be discouraged in a refugee setting.
If chemoprophylaxis is to be instituted, the following guidelines should be implemented:
Ceftriaxone and ciprofloxacin may be used as alternatives to rifampicin. These drugs, like rifampicin, are expensive and are generally not considered appropriate in a refugee setting. Because of widespread resistance, sulfonamides should not be used unless susceptibility tests show the organism to be sensitive. Widespread use of rifampicin may encourage drug resistance and could cause iatrogenic morbidity due to adverse drug reactions.
Treatment. IV-administered penicillin, which requires relatively intensive nursing care and medical equipment, is the treatment of choice for meningococcal disease in developed countries. However, in areas where such intensive care is not possible, a single intramuscular (IM) dose of long-acting chloramphenicol in oil suspension (Tifomycin) upon admission has been demonstrated to be effective. The dosage should be adjusted for age as follows:
Febrile seizures are common in small children, and acetaminophen (paracetamol) in either oral suspension or rectal suppositories should be administered to patients upon admission.
Selected Reading
CDC monograph. Allegra DT, Nieburg P, Eriksen H, Thousig O, Grabe M. Measles Outbreak, Khao I-Dang Refugee Camp, Thailand. In: Allegra DT, Nieburg P, Brabe M, eds. Emergency refugee health-care--a chronicle of experience in the Khmer assistance operation 1979- 1980. Atlanta, GA:1983;49-55.
Moore PS, Toole MJ, Nieburg P, Waldman RJ, Broome CV. Surveillance and control of meningococcal meningitis epidemics in refugee populations. Bull WHO 1990;68:587-96.
CDC monograph. Preblud SR, Horan JM, Davis CE. Meningococcal disease among Khmer refugees in Thailand. In: Allegra DT, Nieburg P, Brabe M, eds. Emergency refugee health-care -- a chronicle of experience in the Khmer assistance operation 1979-1980. Atlanta GA: 1983;65-9.
CDC monograph. Preblud SR, Nieburg P, Allegra DT. Vaccination programs for refugees. In: Allegra DT, Nieburg P, Brabe M, eds. Emergency refugee health-care -- a chronicle of experience in the Khmer assistance operation 1979-1980. Atlanta GA: 1983;135-40. CDC monograph. Toole MJ, Foster S. Famines. In: Gregg MB, ed. The public health consequences of disasters 1989. Atlanta GA: 1989;85.
United Nations Children's Fund (UNICEF). Assisting in emergencies: a resource handbook for UNICEF field staff. New York: United Nations Children's Fund, 1986:269-77.
The following recommendations relating to water and sanitation are largely based on the UNHCR Handbook for Emergencies (1) and Environmental Health Engineering in the Tropics (2).
Water. In general, the supply of adequate quantities of water to refugees in a camp setting has greater overall impact on health than a supply of small quantities of microbially pure water. The provision of adequate quantities of water is particularly effective in the prevention of bacillary dysentery. Nevertheless, whenever possible, sources of clean water should be sought or disinfection systems established. An additional health benefit derived from the provision of ample supplies of water, at a convenient distance from the camp, is the decrease in the daily workload of women, upon whom the burden of water collection usually falls.
Appropriate water sources should be identified before refugees arrive in an area. An adequate water supply is a crucial component of attempts to prevent disease and protect health and, as such, should be among the highest priorities for camp planners and administrators.
Standards. WHO has set standards for the microbiological quality of water supplies. These are as follows:
When surface water is used as a communal source, covered storage will allow suspended particles to settle on the bottom, improving the quality of the water. Longer standing times and higher temperatures will yield a greater improvement in water quality.
Filtration and chlorination may require considerable effort and resources, but should be considered if the situation warrants.
Although boiling is an effective means of removing water pathogens, it is not generally a practical solution in refugee camps where fuel supplies are limited.
As a short-term measure during an emergency (e.g., a cholera outbreak, and when treatment of all water sources is not feasible), purification agents (such as chlorine) may be distributed to each household. In this way, water can be treated in household storage containers. However, a massive education effort is required and such measures usually cannot be maintained for longer than a few weeks.
Water storage containers with narrow necks or covers that prevent people from introducing their hands into the container are likely to reduce further contamination of water once it is stored in the home. The use of separate containers to store water for drinking and water for washing is preferable.
Supply. The chosen water supply should be adequate to meet the needs of the camp year-round. Seasonal variations in rainfall and in camp population should be taken into consideration when selecting a water source.
The UNHCR recommends that a minimum quantity of 20 L of water/person/day be provided. Health clinics, feeding centers, and hospitals require 40-60 L/patient/day.
Ideally, no individual dwelling should be located greater than 150 m from a water source. At any greater distance, the use of water for hygiene is greatly diminished.
Sanitation. Camp sanitation plans should be drawn up before refugees arrive. Because of the crucial role it plays in disease prevention, sanitation should be an early priority for camp planners.
Community attitudes and cultural practices regarding sanitation and disposal of excreta are vital to the success of a sanitation project and should be taken into careful consideration.
All efforts should be made to separate garbage and human waste from water and food supplies. Excreta should be contained within a specific area. Defecation fields may be used as a short-term measure until a more appropriate sanitation system can be implemented. This is particularly suitable in hot, dry climates.
The design and installation of latrines should also take into consideration the attitudes and practices of the refugee population. Latrines should be located so as to remove the possibility of contamination of the water source.
Latrines that are poorly maintained will not be used. For this reason, personal or family latrines are the best solution. However, limitations on building supplies, money, and space may make this impossible. If communal latrines are to be used, no more than 20 people should share one latrine and responsibility for maintaining cleanliness should be clearly assigned.
Breast-feeding. Breast-feeding is an effective measure for preventing diarrheal illness among infants. Exclusive breast-feeding for the first 4-6 months of a baby's life, and continued breast-feeding until the child is 2 years of age, should be encouraged through educational campaigns targeted at pregnant and lactating women. Distribution of milk products should be restricted, and feeding bottles should never be distributed within a camp (see "Nutrition").
Personal hygiene. Community health education should reinforce the importance of handwashing with soap and of general domestic and personal hygiene, in particular safe food-handling practices. Soap should be made readily available by relief agencies.
Assessment of dehydration and fluid deficit through careful physical examination should receive particular attention. Fever, rapid breathing, and hypovolemic shock may accompany severe dehydration.
Careful monitoring of the patient's weight and the signs of dehydration throughout the course of therapy will help assess the adequacy of rehydration. Adults with acute, dehydrating diarrhea should be carefully assessed by a physician to rule out cholera.
Management of patients. In the camp setting, all patients with diarrhea should be encouraged to report to a clinic or health post for assessment, advice on feeding, fluid intake, and diarrhea prevention. The treatment of dehydration should always be initiated in the clinic. Ideally, a central clinic should be supplemented with several small ORT centers in the camp, staffed by trained community health workers.
Prevention of dehydration. Case management should focus on the prevention of dehydration under two sets of circumstances: a) when a patient with diarrhea shows no signs of dehydration, b) when a patient has already been treated for dehydration in the ORT corner and is being released from medical care. Management of patients in these situations includes the following.
ORS. Mothers should be shown how to mix and give ORS and initially be given a 2-day supply. The amount to be given at home is as follows.
Continued feeding. Infants who are breast-fed should continue to receive
breast milk. If an infant is receiving milk formula in a feeding center, the
milk should be diluted with an equal volume of clean water until the diarrhea
stops.
For children greater than 4-6 months of age:
For babies who are unable to drink but are not in shock, a nasogastric tube can be used to administer ORS solution at the rate of 15 mL/kg body weight/hour. For infants in shock, a nasogastric tube should be used only if IV equipment and fluids are not available.
Reassessment. The patient's hydration status should be reassessed after 3-4 hours, and treatment continued according to the degree of dehydration at that time. Note: If the child is still dehydrated, rehydration should continue in the center. The mother should offer the child small amounts of food.
If the child is less than 12 months of age, the mother should be advised to continue breast-feeding. If the child is not being breast-fed, 100-200 mL of clean, plain water should be given before continuing the ORS. Older children and adults should consume plain water as often as they wish throughout the course of rehydration with ORS solution.
Nutritional maintenance. Infants should resume feeding as outlined above. For children greater than 4-6 months old and adults, feeding should begin as soon as the appetite returns. Energy-rich, easily digestible foods will help maintain their nutritional status. There is no reason to delay feeding until the diarrhea stops and there is no justification for "resting" the bowel through fasting. Note: Children enrolled in SFPs or TFPs who develop diarrhea with dehydration should be fed HEM diluted with ORS in a ratio of 1:1, alternating with plain ORS. The overall volume of fluid should be calculated according to the child's weight and degree of dehydration.
Use of chemotherapy. Antimicrobial drugs are contraindicated for the routine treatment of uncomplicated, watery diarrhea. Specific indications for their use include:
Anti-diarrheal agents are contraindicated for the treatment of diarrheal disease. Stimulants, steroids, and purgatives are not indicated for treatment of diarrheal disease and may produce adverse effects.
Any increase in the number or severity of cases, change in the type of diarrhea, rise in diarrhea-specific mortality, or change in the demographic breakdown of the cases should be reported. A case definition for cholera should be established for the purpose of surveillance. Any suspected cholera cases should be reported immediately.
Sample case definitions for cholera and dysentery are provided below.
* Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.
Epidemics
In the event of an outbreak of cholera, early case-finding will allow for rapid initiation of treatment. Aggressive case-finding by trained community health workers should be coupled with community education to prevent panic and to promote good domestic hygiene.
Treatment centers should be easily accessible. Most patients can be treated with ORS alone in the local clinic and still achieve a CFR less than 1%. If the attack rate for cholera is high, it may be necessary to establish temporary cholera wards to handle the patient load. Health centers should be adequately stocked with ORS, IV fluids, and appropriate antibiotics. Health workers must be trained in the management of cholera.
Surveillance should be intensified and should change from passive to active case-finding. The number of new cholera cases and deaths should be reported daily, along with other relevant information (e.g., age, sex, location in camp, length of stay in camp).
Treatment
The goal of cholera treatment is to maintain the CFR at less than 1%.
Rehydration therapy
Rehydration needs to be aggressive. However, careful supervision is necessary to prevent fluid overload, especially when children are rehydrated with IV fluids. Most cases of cholera can be treated through the administration of ORS solution (see "Patient Assessment" and "Guidelines for Rehydration Therapy". Persons with severe disease may require IV fluid, which should be administered following the guidelines outlined in "Diarrheal Diseases".
Antibiotics
Antibiotics reduce the volume and duration of diarrhea in cholera patients. Antibiotics should be administered orally. Doxycycline should be used when available in a single dose of 300 mg for adults and 6 mg/kg/day for children less than 15 years of age. Tetracycline should be reserved for severely dehydrated persons, who are the most efficient transmitters because of their greater fecal losses. Tetracycline should be administered according to the following schedule.
Epidemiologic investigation
Epidemiologic studies to determine the extent of the outbreak and the primary modes of transmission should be conducted so that specific control measures can be applied. The CFR should be monitored closely to evaluate the quality of treatment.
Case-control studies may be undertaken to identify risk factors for infection. Environmental sampling, examination of food, and the use of Moore swabs for sewage sampling may be useful to confirm the results of epidemiologic studies and define modes of transmission.
Control and prevention
Health education. The community should be kept informed as to the extent and severity of the outbreak, as well as educated on the ease and effectiveness of treatment. Emphasis should be placed on the benefits of prompt reporting and early treatment. The community should be advised about suspected vehicles of transmission. The need for good sanitation, personal hygiene, and food safety should be stressed. Health workers involved in treating cholera patients need to observe strict personal hygiene, by washing their hands with soap after examining each patient. Smoking should be prohibited in cholera wards and clinics.
Water supply. Any water supplies implicated through epidemiologic studies should be tested. Any contaminated water sources should be identified and access to those sources cut off. Alternative sources of safe drinking water should be identified and developed as a matter of urgency.
Food safety. Community members should be informed of any food item that has been implicated as a possible vehicle of transmission. Health education messages regarding food preparation and storage should be disseminated.
During an outbreak, feeding centers should be extremely vigilant in the preparation of meals because of the potential for mass infection. Food workers should have easy access to soap and water for handwashing. Food workers should always wash their hands after defecating, and any food worker who is experiencing diarrhea should be prohibited from working.
Chemoprophylaxis. Mass chemoprophylaxis is not an effective cholera control measure and is not recommended. Although the WHO Guidelines for Cholera Control suggest that chemoprophylaxis may be justified for closed groups (such as refugee camps), CDC studies indicate that focusing on other preventive activities (i.e., providing an adequate water supply, improving camp sanitation, and providing adequate and prompt treatment) results in a more effective use of resources. If resources are adequate and transmission rates are high (greater than 15%), consideration should be given to providing a single dose of doxycycline to immediate family members of diagnosed patients.
Vaccines. Currently available vaccines are not recommended for the control of cholera among refugee populations. The efficacy of these vaccines is low and the duration of protection provided is short. Vaccination campaigns divert funds and personnel from more important cholera control activities and give refugee and surrounding populations a false sense of security.
Drugs of choice. Treatment guidelines for shigellosis are listed below.
Because multiresistant strains of Shigella have become widespread and because Shigella strains can rapidly acquire resistance in endemic and epidemic settings, it is advisable that periodic antibiotic susceptibility testing be performed by a reference laboratory in the region. Note: WHO does not recommend mass prophylaxis or prophylaxis of family members as a control measure for shigellosis.
Treatment guidelines for amebiasis are as follows:
World Health Organization. A manual for the treatment of acute diarrhoea. Geneva: Diarrhoeal Diseases Control Programme, 3rd. ed., 1990.
CDC. Shigella dysenteriae Type 1 Guatemala, 1991. MMWR 1991;40:421,427-8.
Keusch GT, Bennish ML. Shigellosis: recent progress, persisting problems and research issues. Pediatr Infect Dis J 1989;8:713-9.
Smith M. Water and sanitation for disasters. Trop Doct 1991;21(suppl 1):30-7.
World Health Organization. Guidelines for cholera control. 1991;80.4;Rev. 2.
Information on previous exposure can be obtained from the refugees themselves, or more detailed information on previous exposure to specific species can be obtained through international channels via WHO.
Within a camp, the proportion of fever illness attributable to malaria at a particular time can be determined by obtaining thick and thin blood smears from a sample of consecutive clinic patients with a history of recent fever (e.g., 50 children less than 5 years of age). The malaria infection prevalence rate among these patients can then be compared with a control group that is free of the signs and symptoms of malaria.
Laboratory examination will determine whether malaria illness is caused by Plasmodium falciparum or Plasmodium vivax.
Personal protection. The use of protective clothing, insecticide-impregnated bed nets, and insect repellents will help limit human exposure to malaria-infected mosquitoes.
Residual insecticides. Periodic spraying of the inside surfaces of permanent dwellings may reduce transmission. The use of residual insecticides, however, may be toxic to those involved in spraying and can also be detrimental to the environment. Spraying can be expensive and time consuming. Careful consideration should be given to the technical aspects of spraying, local vector behavior and susceptibility, personnel training, safety, and community motivation before undertaking such a program.
Source reduction. The elimination of breeding sites by draining or filling may reduce the density of vectors in the area. Knowledge of the local vectors is essential to ensure that source reduction efforts are effectively targeted.
Ultra low-volume insecticide spraying. Adult mosquitoes may be killed through frequent fogging with nonresidual insecticides. Fogging is generally repeated on a daily basis.
Gametocidal drug use. Gametocidal drugs (e.g., primaquine) are not generally recommended for use in refugee camps.
Selection of control strategies will depend upon the local epidemiologic factors, availability of resources, and environmental and cultural factors.
Diagnosis. If possible, a thick blood smear and Giemsa stain should be the basis for the diagnosis of malaria. These smears will also provide the basis for transmission surveillance in camps or geographic areas. If the patient load exceeds the capability of the laboratory to perform thick smears on all suspected cases, a system of microscopic diagnosis for a percentage of suspected cases should be established. When diagnoses are made by locally trained microscopists in small field laboratories, a randomly selected sample of both positive and negative slides should be sent to a reference laboratory for verification in order to maintain quality control.
When laboratory facilities are not available, clinical symptoms (paroxysmal fever, chills, sweats, and headache) and signs (measured fever) are the best predictors of malaria infection. In situations in which year-round high malaria endemicity has been established, all episodes of fever illness can be assumed to be caused by Plasmodium falciparum. However, health workers should bear in mind other causes of fever, including pneumonia, ALRI, or meningitis. In areas where transmission is highly seasonal, surveys should be conducted each year at the beginning of the high transmission season.
The presence of Plasmodium on blood smears does not prove that malaria is the cause of febrile illness, even in areas where malaria is highly prevalent. Other causes should be considered and ruled out.
Treatment with chemotherapy. In areas without chloroquine resistance, the oral regimen of chloroquine usually employed in the treatment of uncomplicated attacks of malaria is as follows:
When laboratory analysis is performed, the first dose of chloroquine should be administered when the blood smear is taken. The patient should be instructed to return the second day for the results of the smear. If the smear is positive, chemotherapy should be continued. If the smear is negative and the patient remains febrile, other causes of fever should be identified.
If supervised therapy during a 3-day period is not possible, the first dose of chloroquine should be given under supervision and the additional doses may be given to the patient with appropriate instructions.
Patients who remain symptomatic longer than 3 days into therapy should have a repeat thick smear examined. Alternative therapy should be instituted if the degree of parasitemia has not diminished markedly by this time.
In areas with chloroquine resistance, treatment of patients may be the same as in areas of chloroquine-sensitive malaria; or may include an alternative first-line drug. Additional care in the follow-up of patients is required.
Children with high fevers should be frequently sponged with tepid water. Patients should increase their intake of fluids as the febrile illness will most likely be accompanied by mild dehydration. Patients with signs of moderate dehydration should be given ORS.
Expatriates working in an endemic area should be on weekly chloroquine (300 mg chloroquine base) during the entire period of exposure and for an additional 6 weeks after leaving the area. In areas where chloroquine resistance is documented, prophylaxis with mefloquine is recommended (250 mg weekly dose).
Management of severe malaria. The following guidelines for the management of severe malaria are based upon those prepared by the MOH in Malawi.
Outpatient setting. If severe malaria is diagnosed in an outpatient setting, the patient should be referred for hospitalization. However, treatment should begin immediately and not be delayed until the patient has been transferred.
If the patient can swallow, sulfadoxine-pyrimethamine (SP) tablets (500 mg-25 mg) should be administered orally in the following doses according to the patient's age.
If the patient cannot swallow or is vomiting repeatedly, an IM injection of quinine dihydrochloride (10 mg/kg) should be administered. This can be repeated every 4 hours for two additional doses, and every 8 hours thereafter if a long delay is anticipated for transport of the patient to a hospital.
The patient's fever should be reduced by sponging with lukewarm water or by using paracetamol or aspirin. Patients should be given ORS. In a patient who cannot drink, administer 20 mL/kg ORS with one teaspoon of glucose powder via naso-gastric tube every 4 hours.
If convulsions occur, administer 0.2 mL/kg paraldehyde by IM injection. If convulsions recur, repeat the treatment. If convulsions persist, give the patient a phenobarbitone 10-mg/kg IM injection.
In a child with altered consciousness or repeated convulsions, the physician should perform a lumbar puncture if possible. If the CSF is cloudy, treatment for meningococcal meningitis is indicated and anti-malarial treatment should be discontinued. If a lumbar puncture cannot be performed, treatment for meningitis should be administered while continuing treatment for malaria.
Inpatient setting. The following tests should be performed immediately upon admission: thick blood film, hemoglobin, blood glucose, and lumbar puncture. If hemoglobin is below 4 g/dL, blood grouping and cross-matching should be done.
If the patient can swallow, give oral SP as described above. If the patient cannot swallow or has persistent vomiting, give IV-administered quinine as follows:
Blood transfusion is indicated when Hb less than 4 g/dL, or Hb less than 6 g/dL is detected and the patient has signs of heart failure (i.e., dyspnea, enlarging liver, gallop rhythm).
The administration of steroids has an adverse effect on outcome in cerebral malaria. Therefore, steroids are no longer recommended.
For some patients (especially children), blood transfusion may be lifesaving. Recent studies indicate that blood transfusion should be given for Hb less than 4 g/dL or Hb less than 6 g/dL in the presence of symptoms of respiratory distress. Because of the potential for HIV or hepatitis B transmission, blood transfusion should be reserved for medical emergencies for which no alternative treatment exists. Facilities for screening blood for HIV antibodies are rare in refugee camps. Whenever feasible, patients requiring transfusion should be transferred to hospitals where such facilities exist.
The anemia of malaria is not associated with iron loss, and replacement is helpful only if a coexisting iron deficiency exists. Folic acid replacement may be helpful during the recovery period when rapid erythrocyte replacement occurs.
In the presence of oliguria, a fluid challenge followed by furosemide injection can help to differentiate acute renal failure from prerenal causes. If renal failure is demonstrated, fluid intake must be limited to daily replacement of insensible loss plus urine/vomitus volume in the previous 24 hours. Protein intake should be limited to less than 30 mg/day, and all drug doses should be adjusted for renal failure.
Selected Reading
Ministry of Health. Malawi guidelines for the management of malaria. Malawi, October 1991.
CDC. Steketee RW, Campbell CC. Control of malaria among refugees and displaced persons. Atlanta, GA:1988 (unpublished).
During the emergency phase of a refugee relief operation, TB activities should be limited to the treatment of patients who present themselves to the health-care system and in whom tubercle bacilli have been demonstrated by sputum smear examination.
Case identification. Passive case-finding will be most efficient in the refugee setting. Patients with respiratory symptoms (chest pain, cough) of greater than 3 weeks' duration, hemoptysis of any duration, or significant weight loss should have a direct microscopic examination of their sputum for AFB. If the sputum smear is negative for AFB but pulmonary TB is still suspected, the patient should be given a 10-day course of antibiotics and then be re-examined after 2-4 weeks. Specific anti-TB chemotherapy should not begin unless the presence of AFB has been confirmed. Symptomatic family members of an identified patient should also have sputum specimens examined.
Children who show signs and symptoms compatible with TB and who are either: a) a close contact of a patient with a confirmed case of TB, or b) tuberculin skin-test positive (in the absence of a BCG vaccination scar) should undergo a full course of anti-TB treatment if they do not respond to an appropriate regimen of alternative antibiotics.
Case management. The selection of a first-line chemotherapy regimen should generally be consistent with the national policy set forth by the host country MOH. However, it should be recognized that the crowded conditions of a refugee camp may foster an abnormally high rate of transmission. Additionally, uncertainty exists regarding the duration of stay in the country of asylum, and it may be more difficult to maintain adherence to an extended therapy regimen. Short-course therapy (6 months) should be considered for use in a refugee camp even when the national policy prescribes a longer course of treatment, provided the additional expense is not prohibitive.
Before enrolling refugees in a TB treatment program, consideration should be given to the stability of the populations and the capacity of the health-care program to supervise therapy and to follow-up patients who do not adhere to treatment. Administration of anti-TB drugs to persons in whom adherence is likely to be sporadic will foster increased drug resistance in that population.
The following drugs are used for the treatment of TB with chemotherapy: isoniazid, rifampin, pyrazinamide, streptomycin, ethambutol, and thiacetazone. The selection of a particular treatment regimen must take into consideration the organism susceptibility, cost, and duration of therapy. The decision regarding implementation of a specific therapeutic regimen will generally be made by the UNHCR in consultation with the MOH of the host government.
Case-holding. Whenever possible, chemotherapy should be observed by a health-care provider, especially during the first 2-3 months of treatment. Treatment efficacy should be assessed through a series of sputum smears. Patients participating in observed therapy who do not respond to treatment and whose sputum smears remain positive for AFB after 2 months should be reviewed by a physician and should begin a second-line treatment regimen.
Enrolling TB patients in a SFP may improve adherence to the treatment regimen and acts as a point of contact for follow-up.
The success of a TB control program depends on good management and close supervision. The responsibilities of staff assigned to the program need to be clearly defined, adequate records of patient progress should be maintained, and a system to follow-up patients who do not adhere to treatment should be established. The cooperation of the community is essential for success. A community education program should be established to help ensure adherence.
BCG vaccination should be administered as part of the comprehensive immunization schedule and not as a separate TB control activity. BCG vaccination is contraindicated for persons with symptomatic HIV infection, but can be administered to asymptomatic persons.
Selected Reading
Rieder HL, Snider DE, Toole MJ, et al. Tuberculosis control in refugee settlements. Tubercle 1989;70:127-4.
Davis CE, Allegra DT, Buhrer M. Tuberculosis control programs, Sakaeo and Khao I-Dang. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care -- a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta GA: CDC;1983:61-4.
An accurate assessment of available laboratory facilities is necessary in order to identify appropriate sites for microbiologic confirmation of an epidemic and to address deficiencies that may hamper an investigation.
Appropriate specimen containers and transport media should be procured. Arrangements should be made to meet the need for additional technical support.
A recognized administrative and reporting structure should be established, with a clear chain of command and delegation of responsibility. Lines of command should be well defined, and specific persons should be assigned responsibility for addressing the media and acting as liaisons to the camp leaders and the refugee population.
Current maps showing settlements, water sources, transport routes, and health facilities should be made available to investigators.
Confirming the diagnosis. The diagnosis of an epidemic disease should be confirmed using standard clinical or laboratory techniques. However, once the presence of an epidemic is established, it is not necessary to confirm the diagnosis for each person before treatment. Ongoing laboratory confirmation of a sample of cases is generally sufficient.
Determining the number of cases. A workable case definition must be established in order to determine the scope of the outbreak. The sensitivity and specificity of the case definition depend upon:
Time, place, and person. Certain information should be collected from each patient, or from their families, and recorded in a register. This should include:
Prepare a graph showing the number of cases per day. This "epidemic curve" will indicate the point at which the outbreak first occurred, the magnitude of the outbreak, the incubation period, and possible modes of transmission.
Using a current map of the camp, mark the residence or section of the camp of each case as it is reported. This will allow investigators to identify clusters of patients and may help to pinpoint a common source of infection.
A breakdown of cases by age, gender, length of stay in camp, vaccination status, if pertinent, and perhaps ethnic group will enable investigators to identify those groups or persons who are at highest risk for infection.
Testing a hypothesis. As preliminary data are collected and analyzed, a hypothesis on the causative exposure should be developed and tested. A case-control study and analysis will help determine likely risk factors and sources of exposure. Laboratory analysis of environmental samples may be used to confirm a suspected source of infection.
Preparing a report. Meetings should be held regularly with camp administrative officials, UNHCR and NGO representatives, local health officials, and refugee community leaders to discuss the evolution of the outbreak and to stress current control measures. In some cases, a written report may be necessary before any control and prevention efforts are undertaken. The report should include an estimate of the magnitude and health impact of the outbreak in numbers of projected cases and deaths. It should also include an estimation of the need for outside assistance and supplies. A written report will also provide a valuable record for use in future investigations. Moreover, the written report can serve as a useful teaching tool.
Control and prevention
As the epidemiologic investigation progresses, it is important that decision-makers be informed as to the findings so that appropriate control measures may be instituted. Continued disease surveillance will determine the effectiveness of control measures.
Selected Reading
CDC Monograph. Toole MJ, Foster S. Famines. In: Gregg MB, ed. The public health consequences of disasters 1989. Atlanta, GA: 1989.
TABLE 1. Refugees and asylum seekers by geographic region, July 1991 =============================================================================== Area of asylum Total refugee population ------------------------------------------------------------------------------- Africa 5,100,000 East Asia and the Pacific 1,400,000 Europe and North America 3,400,000 Latin America and the 1,100,000 Caribbean Middle East and Southwest Asia 17,100,000 ------------------------------------------------------------------------------- Source: UNHCR, 1992. ===============================================================================
TABLE 2. Monthly crude mortality rates (CMRs) in selected refugee populations, with
baseline CMRs from countries of origin, 1978-1991
===================================================================================================
Host
Month/year (ref) country Country of origin Baseline CMR Refugee CMR
---------------------------------------------------------------------------------------------------
Jun-Dec 1978 (1) Bangladesh Burma (1.0) 6.3
Oct 1979 (1) Thailand Cambodia (2.5) 31.9
Aug 1980 (1) Somalia Ethiopia (2.0) 30.4
Jan-Mar 1985 (1) Sudan Ethiopia (2.0) 16.2
Sep 1985 (1) Sudan Chad (1.6) 24.0
Jan-Jun 1987 (1) Malawi Mozambique (1.5) 1.0
Sep 88-Aug 89 (9) Ethiopia Somalia (1.8) 3.8
Jul 1990 (9) Ethiopia Sudan (1.7) 6.9
Jun 1991* Ethiopia Somalia (1.8) 14.0
Apr 1991 (10) Turkey Iraq (0.7) 12.6
---------------------------------------------------------------------------------------------------
*Bhatia R, personal communication.
===================================================================================================
TABLE 3. Monthly crude mortality rates (CMRs) among selected internally displaced
populations, 1982-1990
=========================================================================================
Baseline CMR Displaced
Month/year (ref) Country (death/1,000) population CMR
-----------------------------------------------------------------------------------------
Nov 82-0ct 83 (1) Mozambique 1.4 8.0
Oct-Dec 1984 (1) Ethiopia (Korem) 2.0 60-90
Oct 84-Jan 85 (11) Ethiopia (Harbu) 2.0 147
Jul 1988 (1) Sudan 1.7 90
Jan-Dec 1990* Liberia 1.1 7.1
-----------------------------------------------------------------------------------------
*Holland MSF, unpublished data.
=========================================================================================
Table 4. Monthly crude mortality rates (CMRs) among selected nondisplaced
famine -affected populations, 1984-1985
==============================================================================================
Baseline CMR Famine-affected
Month/year (ref) Country/region (deaths/1000) CMR
----------------------------------------------------------------------------------------------
Oct 84-Jan 85 (12) Ethiopia(Shoa) 2.0 8.8
Jan-Dec 85 (11) Sudan (Darfur) 1.7 3.3
Jan-Dec 85 (11) Sudan (N.Kordofan) 1.7 7.8
==============================================================================================
TABLE 5. Prevalence of acute undernutrition (<80% median weight-for-height)
among children <5 years of age in refugee populations
===================================================================================================
Host Country Prevalence (%)
Dates (ref) country of Origin Population acute undernutrition
---------------------------------------------------------------------------------------------------
1979 (15) Thailand Kampuchea 31,900 10.0-18.0
1980 (16) Somalia Ethiopia 700,000 21.7-28.4
1984-85 (17) Pakistan Afghanistan 2,500,000 2.3-3.5
1988 (18) Malawi Mozambique 400,000 2.1-6.1
1988-89 (19) Ethiopia Somalia 400,000 12.9-29.5
1990 (20) Guinea Liberia 400,000 5.3
1990* Ethiopia Sudan 25,000 45.0
1991+ Kenya Somalia 50,000 29.0
1991 (10) Iraq/Turkey Iraq 400,000 4.1
Border
---------------------------------------------------------------------------------------------------
*UNHCR-Kenya. MacAskill J, December 1991.
+CDC. Toole M, trip report, July 1990.
===================================================================================================
TABLE 6. Prevalence of acute undernutrition (<80% of median weight-for-height)
among children <5 years of age in famine-affected populations
===================================================================================================
Population Prevalence (%)
Dates (ref) Affected region affected acute undernutrition
---------------------------------------------------------------------------------------------------
1983 (23) Mauritania 1,600,000 11.6-22.5%
1984-85 (24) Niger (5,400,000)* 9.8-13.7%
1985 (25) Burkina Faso (7,200,000)* 5.7-10.6%
1985 (26) Chad (4,500,000)* 25.8-56.0%
1985 (27) Somalia unspecified 11.2-23.5%
1990 (28) Haiti unspecified 4.2%
---------------------------------------------------------------------------------------------------
*Population given is national population.
===================================================================================================
TABLE 7. Prevalence of acute undernutrition (<80% of median weight-for-height)
among children <5 years of age in internally displaced populations
===================================================================================================
Population Prevalence
Date (ref) Country/region affected acute undernutrition
---------------------------------------------------------------------------------------------------
1983 (29) Mozambique 12-28%
1985 (11) Ethiopia (Korem) 800,000 70%
1988 (30) Sudan (Khartoum) 750,000 23%
1988 (30) Sudan (S. Darfur) 80,000 36%
1990* Liberia (Monrovia) 500,000 35%
---------------------------------------------------------------------------------------------------
*Holland MSF, unpublished data.
===================================================================================================
TABLE 8. Micronutrient deficiency disease outbreaks in refugee camps, 1984-1991
=========================================================================================
Disease Year (ref) Location Prevalence (%)
-----------------------------------------------------------------------------------------
Scurvy 1984 (32) Sudan 22.0
1985 (32) Somalia 6.9-44.0
1989 (19) Ethiopia 1.0-2.0
1991 (33) Sudan NA
Xerophthalmia 1985 (34) Sudan NA
Beriberi 1985 (1) Thailand NA
Pellagra 1989 (35) Malawi (11 camps) 0.5
1990 (35) Malawi (11 camps) 6.3
Iron Deficiency
Anemia 1990* Syria, Jordan, 54.5-73.9
West Bank & Gaza (children)
12.5-62.5
(women)
1990+ Ethiopia 10.0-13.0
-----------------------------------------------------------------------------------------
*CDC, unpublished data.
+SCF, unpublished data.
=========================================================================================
