Program-Specific Recommendations
The following content areas are covered in these recommendations:
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Rapid Health Assessment
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Health Information Systems
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Nutrition
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Control of Vaccine-Preventable Diseases
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Control of Diarrheal Diseases
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Malaria Control
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Tuberculosis Control
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Epidemic Investigations
Rapid Health Assessment
Rapid health assessment of an acute population displacement is conducted to:
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Assess the magnitude of the displacement.
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Determine the major health and nutrition needs of the displaced
population.
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Initiate a health and nutrition surveillance system.
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Assess the local response capacity and immediate needs.
Preparations
The amount of time required to conduct an initial assessment of a refugee
influx depends on the remoteness of the location, availability of transport,
security situation in the area, availability of appropriate specialists, and
willingness of the host country government to involve external agencies in
refugee relief programs. In small countries with functioning communications
facilities and secure borders, the assessment might be conducted in 4 days;
in other countries, it might take 2 weeks.
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.
Field assessment
The following demographic information is required to determine the health
status of the population.
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Total refugee or displaced population
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Age-sex breakdown
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Identification of at-risk groups; e.g., children less than 5 years of
age, pregnant and lactating women, disabled and wounded persons, and
unaccompanied minors
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Average family or household size
Why this information is needed. The total population will be used as the
denominator for all birth, death, injury, morbidity, and malnutrition rates
to be estimated later. The total population is necessary for the calculation
of quantities of relief supplies. The breakdown of the population by age and
sex allows for the calculation of age- and sex-specific rates and enables
interventions to be targeted effectively (e.g., immunization campaigns).
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.
Background health information
The information required includes:
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Main health problems in country of origin.
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Previous sources of health care (e.g., traditional healers).
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Important health beliefs and traditions (e.g., food taboos during
pregnancy).
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Social structure (e.g., whether the refugees are grouped in their
traditional villages and what type of social or political organization
exists).
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Strength and coverage of public health programs in country of origin
(e.g., immunization).
Why this information is needed. Effective planning of health services will
depend on this information. Planners need to be aware of traditional beliefs,
taboos, and practices in order to avoid making costly mistakes and alienating
the population.
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.
Nutritional status
The information required includes:
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Prevalence of protein-energy undernutrition in the population less than
5 years of age.
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Nutritional status before arrival in host country.
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Prevalence of micronutrient deficiencies in the population less than 5
years of age.
Why this information is needed. Evidence exists to support the fact that the
nutritional status of displaced populations is closely linked with their
chances of survival. Initial assessment of nutritional status serves to
establish the degree of urgency in delivering food rations, the need for
immediate supplementary feeding programs (SFPs), and the presence of
micronutrient deficiencies that require urgent attention.
Sources of nutritional information. If refugees are still arriving at the
site:
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Initiate nutritional screening of new arrivals immediately.
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Measure all children (or every third or fourth child, if insufficient
trained personnel are available or the refugee influx is too great) for
mid-upper arm circumference (MUAC) or, if time and personnel permit,
WFH. Estimate the proportion of undernourished children using the
methods described in the Rapid Nutrition Assessment Manual. (*)
(*) Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA
30333, 404-639-0308.
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Look for clinical signs of severe anemia and vitamin A, B, and C
deficiencies.
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If refugees are continuing to arrive, set up a permanent screening
program for new arrivals. A screening program also can be used to
administer measles vaccination and vitamin A supplements to new
arrivals.
If refugees are already located in a settlement:
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Walk through the settlement, select houses randomly, and observe the
nutritional status of the children less than 5 years of age. Visual
assessment should only be done by persons who are experienced in the
assessment of malnutrition. The observer should enter the homes as
malnourished children are likely to be bedridden.
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Combine the visual inspection with a rapid assessment of nutritional
status, using either MUAC or WFH measurements. This can be done during
the demographic survey described above. (See "Rapid Health Assessment")
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Review the records of local hospitals treating members of the displaced
population. Note admissions or consultations for undernutrition and
deaths related to undernutrition.
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Interview refugee leaders to establish food availability before
displacement and the duration of the journey from place of origin to
their present location.
In order to gather baseline data for evaluation of nutrition programs, plan
to conduct a valid, cluster sample survey of the population as soon as
possible (within 2 weeks). Appropriate technical expertise will be needed for
the implementation and analysis of the survey.
Mortality rates
The information required includes crude, age-, sex-, and cause-specific
mortality rates.
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.
Environmental conditions
The information required includes:
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Climatic conditions (average temperatures and rainfall patterns).
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Geographic features (soil, slope, and drainage).
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Water sources (local wells, reservoirs, rivers, tanks).
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Local disease epidemiology (endemic infectious diseases, e.g., malaria,
schistosomiasis).
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Local disease vectors (mosquitoes, flies, ticks), including breeding
sites.
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Availability of local materials for shelter and fuel.
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Existing shelters.
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Existing sanitation arrangements (latrines and open areas).
Why this information is needed. Information on local environmental conditions
affecting the health of displaced populations will help relief planners
create priorities for public health programs. Sources of information. This
assessment is made largely by visual inspection. In addition, interviews with
local government and technical specialists will yield important information.
In some cases, special surveys need to be conducted; e.g., entomologists may
need to survey for local disease vectors, and water engineers may need to
assess water sources.
Resources available
Food supplies --
Efforts to evaluate food supplies should include:
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Attempting to assess the quantity and type of food currently available
to the population.
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Calculating the average per capita caloric intake over the period of
time for which records are available, if food is already being
officially distributed.
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Inspecting any local markets for food availability and prices.
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Conducting a quick survey of dwellings and estimating the average food
stores in each household. This should be done during the demographic
survey (see "Rapid Health Assessment"). Look for obvious inequities
between different families or different ethnic or regional groups.
Food sources. Local, regional, and national markets need to be assessed. The
cash and material resources of the displaced population should also be
assessed in order to estimate its local purchasing power.
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:
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Look for any established feeding programs (mass, supplementary, and
therapeutic feedings). These may have been set up by local officials,
PVOs, church groups, or local villagers.
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Assess enrollment and discharge criteria, enrollment and attendance
figures, quantity and quality of food being provided, availability of
water, managerial competence, utensils, and storage.
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Determine whether measles vaccine is being administered.
Local health services. Follow these guidelines for assessing the capabilities
of health services:
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Determine the ease of access by refugees (official attitudes, location,
hours of operation).
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Evaluate the condition and size of facilities.
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Note the extent and appropriateness of medicines, equipment, and
services.
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Determine the type and number of personnel.
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Review cold storage facilities, vaccine supplies, logistics, and
communication systems.
Camp health services. Follow these guidelines for assessing camp health
services:
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Note the type of facility (clinic, hospital, feeding center), as well as
the size, capacity, and structure (tent, local materials).
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Determine the adequacy of health-facility water supply.
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Assess refrigeration facilities, fuel, and generator.
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Assess supplies of essential drugs (whether generic or brandname) and
medical supplies.
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Determine the need for essential vaccines and immunization equipment.
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Note the type of health personnel (doctors, nurses, nutritionists,
sanitarians) and their relevant experience and skills.
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Review storage facilities.
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Assess adequacy of transport, fuel, and communications.
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Locate health workers in refugee population (traditional healers, birth
attendants, "modern" practitioners).
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Determine whether there is a need for interpreters.
Taking action
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An itemized summary of the findings should be prepared, following the
sequence of activities outlined in this document.
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Estimate and quantify the need for outside assistance, based on
preliminary findings.
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Prepare and convey assessment findings to appropriate emergency health
officials at the local, national, and international levels.
Checklist For Rapid Health Assessment (*)
(*) 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
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Obtain available information regarding refugees and resources from host
country ministries and organizations.
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Obtain available maps or aerial photographs.
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Obtain demographic and health data from international organizations.
Field assessment
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Determine total displaced population.
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Determine age and sex breakdown of population.
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Identify groups at increased risk.
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Determine average household size.
Health information
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Identify primary health problems in country of origin.
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Identify previous sources of health care.
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Ascertain important health beliefs and traditions.
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Determine the existing social structure.
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Determine the strength and coverage of public health programs in country
of origin.
Nutritional status
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Determine prevalence of PEM in population less than 5 years of age.
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Ascertain prior nutritional status.
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Determine prevalence of micronutrient deficiencies in the population
less than 5 years of age.
Mortality rates
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Calculate crude, age-, sex-, and cause-specific mortality rates.
Morbidity
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Determine age- and sex-specific incidence rates of diseases that have
public health importance.
Environmental conditions
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Determine climatic conditions.
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Identify geographic features.
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Identify water sources.
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Ascertain local disease epidemiology.
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Identify local disease vectors.
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Assess availability of local materials for shelter and fuel.
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Assess existing shelters and sanitation arrangements.
Resources available
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Assess food supplies and distribution systems.
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Identify and assess local, regional, and national food sources.
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Assess the logistics of food transport and storage.
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Assess feeding programs.
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Identify and assess local health services.
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Assess camp health services.
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