surveillance and response emergency and humanitarian action world health organization update from...
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Surveillance and ResponseSurveillance and ResponseEmergency and Humanitarian ActionEmergency and Humanitarian Action
World Health OrganizationWorld Health Organization
Update from FYR Update from FYR Macedonia: Surveillance Macedonia: Surveillance
in Kosovar refugee in Kosovar refugee populationpopulation
Dr Eric Noji, WHODr Eric Noji, WHOE Noji/EHA
Purpose of missionPurpose of mission19 April - 1 may 199919 April - 1 may 1999
1. 1. Establish health surveillance systemEstablish health surveillance system
2. Ensure epidemic preparedness measures2. Ensure epidemic preparedness measures
3. Organise laboratory support for 3. Organise laboratory support for confirmation of suspected casesconfirmation of suspected cases
4. Establish epidemic response mechanism4. Establish epidemic response mechanism
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What initial information What initial information would you want to know?would you want to know?
Kosovar refugee Kosovar refugee population population 4 May 19994 May 1999
Former Yugoslav
Republic of Macedonia: 204,070
Albania: 396,300
Montenegro: 61,900
Bosnia-Herzegovina 15,000
Total 677,270source: UNHCR
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Refugees in FYR Refugees in FYR MacedoniaMacedonia4 May19994 May1999
Camp population 99,850source: UNHCR
Host family population 93,370source: Macedonian Red Cross
Arrivals 3 May 11,600
Total 204,070
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Refugees in FYR Macedonia Refugees in FYR Macedonia by campby camp
28 April199928 April1999Stankovac I (Brazda)Stankovac I (Brazda) 27,90027,900
Stankovac IIStankovac II 16,00016,000
Blace reception centreBlace reception centre 3,000 3,000
BojaneBojane 4,000 4,000
NeprostenoNeprosteno 7,400 7,400
SenokosSenokos 2,400 2,400
RadusaRadusa 400 400
CegraneCegrane under constructionunder construction
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What would you like to What would you like to know about the situation know about the situation
in the camps?in the camps?
ShelterShelterAll camps at maximum capacityAll camps at maximum capacity
Security problemsSecurity problems
Implications on healthImplications on health
Recommended minimum 30m2/personRecommended minimum 30m2/person
Brazda camp: built for 10,000Brazda camp: built for 10,000
On 4 May had 31,000 refugees - 9m2On 4 May had 31,000 refugees - 9m2
Radusa camp: 4.4m2Radusa camp: 4.4m2
Neprosteno camp: 12.2m2Neprosteno camp: 12.2m2
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WaterWater
Brazda camp - water pumped from stream Brazda camp - water pumped from stream near campnear camp
15L/person/day15L/person/day
Cegrane camp - water transported in tanks Cegrane camp - water transported in tanks from local town supplyfrom local town supply
20L/person/day20L/person/day
Radusa - 28L/person/day Radusa - 28L/person/day
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FoodFoodDistribution by WFPDistribution by WFP
Food items: BreadFood items: Bread
Canned beef/fishCanned beef/fish
Pulses, sugarPulses, sugar
Cooked food/vegetables in smaller campsCooked food/vegetables in smaller camps
Cegrane camp - 30 April - WFP delivered 15,000 Cegrane camp - 30 April - WFP delivered 15,000 loaves of bread loaves of bread
6.2MT canned meat/fish6.2MT canned meat/fish
48,720 human daily rations48,720 human daily rations
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SanitationSanitationRecommended minimum standard - 20 Recommended minimum standard - 20
persons per latrine in emergency phasepersons per latrine in emergency phase
Brazda camp - 37 persons per latrineBrazda camp - 37 persons per latrine
Bojane camp - 68 persons per latrineBojane camp - 68 persons per latrine
Cegrane camp - opened 29 April to 8,000 new Cegrane camp - opened 29 April to 8,000 new arrivalsarrivals
By 2 May - 14,000 refugees in campBy 2 May - 14,000 refugees in camp
On 4 May - 450 persons per latrineOn 4 May - 450 persons per latrine
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Health services in campsHealth services in campsStankovac I (Brazda) MSF-H, MDM, Taiwan Hosp.Stankovac I (Brazda) MSF-H, MDM, Taiwan Hosp.
German Red CrossGerman Red Cross
Stankovac IIStankovac II IMC, French Civil ServiceIMC, French Civil Service
Blace Blace MDMMDM
BojaneBojane Turkish Red CrossTurkish Red Cross
NeprostenoNeprosteno Die JohanniterDie Johanniter
SenokosSenokos DOW-USADOW-USA
RadusaRadusa Bulgarian Army, MSF-HBulgarian Army, MSF-H
CegraneCegrane MSF-H, German ArmyMSF-H, German Army
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What needs to be done to What needs to be done to set up a health set up a health
information system?information system?
Health Information Health Information SystemSystem
WHO/MOH/UNHCR/NGOsWHO/MOH/UNHCR/NGOs• Daily Health Report form agreedDaily Health Report form agreed• Case definitionsCase definitions• Reporting mechanisms agreedReporting mechanisms agreed• Electronic database established at WHO Electronic database established at WHO
Skopje officeSkopje office• MOH Communicable disease form MOH Communicable disease form
translated - 44 diseases require reportingtranslated - 44 diseases require reporting
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Data from Daily Health Data from Daily Health ReportsReports
Communicable diseases: 30% of all consultationsCommunicable diseases: 30% of all consultations
Watery diarrhoea 10%Watery diarrhoea 10%
URTI 15%URTI 15%
TB - patients on Rx in Kosovo - 14 identified to date, TB - patients on Rx in Kosovo - 14 identified to date, referred to Institute for Lung Diseases and TB, Skopjereferred to Institute for Lung Diseases and TB, Skopje
Non-communicable diseases: 60-70% of all consultationsNon-communicable diseases: 60-70% of all consultations
Mental health problems - 20%Mental health problems - 20%
NIDDM - prevalence 1-2%NIDDM - prevalence 1-2%
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How do these conditions How do these conditions differ from refugee crises differ from refugee crises
in Sub-Saharan Africa?in Sub-Saharan Africa?
Communicable Diseases in Brazda Refugee Camp, Macedonia 13-23 April 1999
Head lice1%
Scabies1%
Fever of unknown origin (FUO)14%
Other communicable diseases
0%
Bloody diarrhea*0%
Watery diarrhea31%
Upper respiratory tract infections
50%
Pneumonia3%
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Upper Respiratory Tract Infection in Brazda Refugee Camp, Macedonia, 13-23 April 1999
0
10
20
30
40
50
60
70
80
90
100
12.0
4'99
13.0
4'99
14.0
4'99
15.0
4'99
16.0
4'99
17.0
4'99
18.0
4'99
19.0
4'99
20.0
4'99
21.0
4.'9
9
22.0
4.'9
9
23.0
4.'9
9
Date
Ne
w c
ase
s
Less than 5 years
5 years and over
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Watery Diarrhoea in Brazda Refugee Camp, Macedonia 13-23 April 1999
0
10
20
30
40
50
60
12.0
4'99
13.0
4'99
14.0
4'99
15.0
4'99
16.0
4'99
17.0
4'99
18.0
4'99
19.0
4'99
20.0
4'99
21.0
4.'99
22.0
4.'99
23.0
4.'99
Date
Ne
w c
ase
s
Less than 5 years
5 years and over
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Non-Communicable Diseases in Brazda Refugee Camp, Macedonia 13-23 April 1999
Mental health problems 31%
Trauma/Injury17%
Diabetes-insulin dependent
4%
Diabetes-non insulin dependent
6%
Hypertension23%
Chronic cardiac failure4% Chronic renal failure
4%
Pregnancy-related condition
5%
Asthma0%
Chronic obstructive lung disease
6%
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What “process” What “process” indicators would it be indicators would it be important to monitor?important to monitor?
Immunisation coverage Immunisation coverage rates - kosovorates - kosovo
MeaslesMeasles 1992: 67%1992: 67%
1997: 83%1997: 83%
1998: 72%1998: 72%
PolioPolio 1996: 75%1996: 75%
DPTDPT 1996: 76%1996: 76%
BCGBCG 1996: 52% of newborns1996: 52% of newborns
Source:UNICEF, WHO-Pristina, HINAPSource:UNICEF, WHO-Pristina, HINAP
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Mass immunisation Mass immunisation campaignscampaigns
Implemented by UNICEF/MOH/IMC/WHOImplemented by UNICEF/MOH/IMC/WHO
Target group - children<5 who cannot present a Target group - children<5 who cannot present a complete vaccination cardcomplete vaccination card
ScheduleSchedule
Age groupAge group
0-2 months0-2 months BCGBCG
2-9 months2-9 months OPV, DPTOPV, DPT
9-47 months9-47 months OPV, MMROPV, MMR
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Mass immunisation Mass immunisation campaignscampaigns
Total target population: 8,915Total target population: 8,915
Brazda: 26-28 AprilBrazda: 26-28 April
Stankovac II: 30 April - 2 MayStankovac II: 30 April - 2 May
Other camps: 5-6 MayOther camps: 5-6 May
Brazda camp: 2,381/5,447 children immunised but Brazda camp: 2,381/5,447 children immunised but including children with vaccination cards - 85% including children with vaccination cards - 85% coveragecoverage
Neprosteno camp: 381/402 children immunised - Neprosteno camp: 381/402 children immunised - 98%coverage 98%coverage
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What are elements in a What are elements in a good epidemic good epidemic
preparedness plan?preparedness plan?
Epidemic preparednessEpidemic preparedness• Laboratory - Republic Institute for Health Laboratory - Republic Institute for Health
Protection agreed to conduct lab testsProtection agreed to conduct lab tests• WHO Guidelines for management of major WHO Guidelines for management of major
epidemic-prone diseases in Macedonia epidemic-prone diseases in Macedonia developed and distributed to NGOsdeveloped and distributed to NGOs
• WHO Guidelines for collection of laboratory WHO Guidelines for collection of laboratory specimens distributed to NGOsspecimens distributed to NGOs
• Steps for management of outbreaks agreed Steps for management of outbreaks agreed with MOH, UNHCR and NGOs - WHO as lead with MOH, UNHCR and NGOs - WHO as lead investigatorinvestigator
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Main epidemic threats to Main epidemic threats to refugee population in refugee population in
MacedoniaMacedonia• Bacillary dysentery Bacillary dysentery • CholeraCholera• MeaslesMeasles• Meningococcal meningitis Meningococcal meningitis • Hepatitis A Hepatitis A • ScabiesScabies• Haemorrhagic fever with renal syndromeHaemorrhagic fever with renal syndrome
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Bacillary dysentery Bacillary dysentery (Shigellosis)(Shigellosis)
• Major outbreak of Major outbreak of Shigella sonnei Shigella sonnei in 1995in 1995- -
5,500 cases in 19955,500 cases in 1995 in city of Stip with in city of Stip with population 70,000population 70,000
Of stool samples examined in Institute of Of stool samples examined in Institute of Microbiology, Skopje 1995 - 1997Microbiology, Skopje 1995 - 1997
• 60%60% - Shigella sonnei - Shigella sonnei• 40%40% - Shigella flexneri - Shigella flexneri
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Shigella- antibiotic Shigella- antibiotic sensitivitysensitivity
Stool samples tested at Medical Faculty, Stool samples tested at Medical Faculty, Institute of Microbiology, Skopje 1995-Institute of Microbiology, Skopje 1995-19971997
• 19/225 (8.4%) samples were sensitive to 19/225 (8.4%) samples were sensitive to TMP/SMX TMP/SMX
• 203/218 (93.1%) samples were sensitive to 203/218 (93.1%) samples were sensitive to ciprofloxacinciprofloxacin
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CholeraCholera• Last reported case in Macedonia 1989, Last reported case in Macedonia 1989,
imported case from Saudi Arabiaimported case from Saudi Arabia• Endemic status unclearEndemic status unclear• Outbreaks in South east Albania in 1994 (Outbreaks in South east Albania in 1994 (V V
choleracholera O1 El Tor, serotype Ogawa O1 El Tor, serotype Ogawa• outbreak due to heavy faecal outbreak due to heavy faecal
contamination of drinking watercontamination of drinking water• all strains (>60) isolated were resistant to all strains (>60) isolated were resistant to
TMP/SMX and tetracyclines TMP/SMX and tetracyclines
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How would you define an How would you define an “epidemic”?“epidemic”?
Epidemic thresholdsEpidemic thresholds• CholeraCholera• Bacillary dysenteryBacillary dysentery• MeaslesMeasles• Meningococcal meningitisMeningococcal meningitis !!
One (suspected) caseOne (suspected) case
= potential outbreak= potential outbreak
= immediate reporting= immediate reporting
= immediate follow up= immediate follow upE Noji/EHA
Suspected cases of Suspected cases of epidemic-prone diseases epidemic-prone diseases
reported to WHO reported to WHO • Bloody diarrhoea - 12 cases reported from Brazda, no Bloody diarrhoea - 12 cases reported from Brazda, no
lab confirmationlab confirmation
• Measles- 2 suspected cases reported from Stankovec Measles- 2 suspected cases reported from Stankovec IIII
• Meningococcal meningitis - 3 cases, one N. Meningococcal meningitis - 3 cases, one N. meningitidis B in 9 month old babymeningitidis B in 9 month old baby
• Scabies - 28 cases reportedScabies - 28 cases reported
• Varicella (chicken pox) - 6 cases in one campVaricella (chicken pox) - 6 cases in one camp
• Acute jaundice - 3 cases - suspected Hepatitis A- lab Acute jaundice - 3 cases - suspected Hepatitis A- lab confirmation pendingconfirmation pending
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How does one “usually” How does one “usually” diagnose measles in a diagnose measles in a refugee camp setting?refugee camp setting?
Investigation by WHO of Investigation by WHO of suspected case of suspected case of
measlesmeasles• 28 April - 2pm WHO informed by UNHCR of two 28 April - 2pm WHO informed by UNHCR of two
suspected cases of measles in Stankovac II campsuspected cases of measles in Stankovac II camp• 28 April - 3.30pm - WHO/UNHCR team visit camp 28 April - 3.30pm - WHO/UNHCR team visit camp
Suspected cases - AD, 8 months and MM, 6 Suspected cases - AD, 8 months and MM, 6 months, different families but in same tentmonths, different families but in same tent
MM - maculo-papular rash, but no feverMM - maculo-papular rash, but no fever
Blood sample takenBlood sample taken• 29 April - blood sample sent to lab by WHO29 April - blood sample sent to lab by WHO• 30 April - sample IgM and IgG negative30 April - sample IgM and IgG negative
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Is there anything else Is there anything else that needs to be done that needs to be done
once the epidemic once the epidemic investigation has been investigation has been
completed?completed?
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Issues on Communicable Issues on Communicable disease control in refugee disease control in refugee
populationpopulation• High and increasing risk of outbreaksHigh and increasing risk of outbreaks
• Rapid response capacity for deploying Rapid response capacity for deploying field epidemiologists in the event of an field epidemiologists in the event of an outbreak must be availableoutbreak must be available
• Epi has important role in analysis and Epi has important role in analysis and dissemination of surveillance datadissemination of surveillance data
• Epi has crucial role in co-ordination Epi has crucial role in co-ordination between MOH, other UN agencies and between MOH, other UN agencies and NGOsNGOs
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U.S. Department of U.S. Department of Health and Human Health and Human
ServicesServices
Eric K. Noji, M.D., M.P.H.Special Assistant to the US Surgeon General for Disaster Medicine,US Public Health ServicePhone: 202-690-5707 Fax: 202-690-6985Email: [email protected]
For Questions Contact: