Earthquake mortality in Pakistan

A strong earthquake, measuring 7.6 on the Richter scale, hit northern Pakistan on 8 October 2005, causing massive destruction, including an official death toll of 73,276. Four cross-sectional surveys were performed in late 2005 to assess mortality before the event, on the day, and subsequently. Two surveys were community-based and two were situated in camps for internally displaced persons. Crude mortality rates were low in the 3.5 months preceding the earthquake (less than 0.1 deaths per 10,000 per day) and slightly higher in the six-to-eight weeks after the earthquake (ranging from 0.10–0.43 per 10,000 per day). On 8 October 2005, approximately two per cent of the population in one community survey died and around five per cent in the other three surveys. Children less than five years and adults more than or equal to 50 years tended to have a higher risk of mortality on the day of the disaster. These results corroborate the high mortality caused by the earthquake.     

Refugee Density and Dependence: Practical Implications of Camp Size

Different refugee camps may have widely differing morbidity and mortality rates. Some of these differences are ascribed to environmental factors. This paper reviews the key issues relating to one environmental factor: the size of the refugee camp, and provides a tentative theoretical framework for examining the effect of camp size on refugees. This effect may not be considered because aid workers chronically underestimate the value of the refugees' contribution to their own survival. Large camps settle great numbers of refugees to the hinterland of the camp and limit their access to resources available there. This may increase refugee dependency and vulnerability. There is some slight evidence from the analysis of data provided by Mercer (1992) that child mortality rates (aged 0–4 years) are positively correlated with camp size (as inferred from child populations). If other factors allow, it might be wise for camp planners to try to limit camps to a size which allows refugees reasonable access to local resources.     

The Mortality Experience of Kurdish Refugees Remaining in Turkey

A survey of one of the camps still holding refugees from Iraq who crossed into Turkey in the spring of 1991 showed that the majority of the population was under 15 years of age and that increased mortality occurred during the first 30 days after the refugees left their homes in Iraq. Infants, young children, and the elderly suffered the highest mortality, with infant mortality rates (IMRs) over the first month of the crisis approximately 18–29 times the MR in Iraq in the late 1980s. Still unexplained is a greater than two-fold excess mortality among males compared with females. Other demographic and health findings are also reported.     

Health Effects of the 1991 Bangladesh Cyclone: Report of a UNICEF Evaluation Team

To assess the impact on health of the cyclone and tidal wave that struck the southern coast of Bangladesh on the evening of 29 April 1991, a team of health professionals visited cyclone affected areas from 4–27 June, 1991. Team members met with health workers and officials of the Government of Bangladesh and with staff pom nongovernmental organizations, and conducted field surveys in two severely affected areas.
Mortality among the 135 households surveyed (pre-cyclone population 1,123) was 14 per cent. At highest risk of deaths were children of less than 10 years (26 per cent mortality) and women of more than 40 (31 per cent mortality). Almost all deaths occurred as a result of drowning from the tidal wave that accompanied the cyclone. Although 95 per cent of the population surveyed had received warning of the cyclone four or more hours before it struck, the 300 existing cyclone shelters had capacity for only 450,000 of the 5,000,000 people affected by the cyclone. Deaths following the cyclone were few. Diarrhea caused by Vibrio cholerae and Shigella dysenteria type 1, both of which are endemic in Bangladesh, occurred in the post-cyclone period. Reports by the national Diarrhea Surveillance System of large increases in diarrheal incidence following the cyclone were difficult to assess because of inconsistencies in pre-and post-cyclone reporting methods. No increase in other infectious diseases was identified.
Although water availability had been a major concern following the cyclone, the tubewell system was functioning well in the area that was surveyed. Distribution of relief assistance by the Government of Bangladesh and by non-governmental organizations was good, with 95 per cent of families surveyed receiving food aid within five days of the cyclone.
The major health effect of this cyclone was acute deaths due to drowning. Preventing deaths during future cyclones will require increasing accessible shelter.     

The Accuracy of Mortality Reporting in Displaced Persons Camps During the Post-emergency Phase

For humanitarian organisations, accurate data are essential to identify emerging health problems and determine programme needs. We visited 45 post-emergency phase displaced persons camps and collected three months' mortality data which we compared with organisations' routine mortality reports. Organisations reported 612 deaths and we identified 741 deaths, for a mortality-reporting ratio, defined as the number of organisation-reported deaths divided by the number of investigator-identified deaths, of 83 per cent. For the majority of camps which under-reported deaths, mortality reporting ratios were significantly higher for women than men, and for camps with central mortality registers rather than those without. In the few camps which over-reported deaths, these occurred primarily among children younger than five years of age, probably due to the inclusion of abortions and stillbirths. Despite the overall under-reporting of deaths by humanitarian organisations, the existing health information systems appear to estimate mortality rates adequately in these post-emergency camps. However, organisations should improve the precision and completeness with which they report the characteristics of deaths in order to provide valuable data to target their programmes at the most vulnerable people.     

Tsunami mortality and displacement in Aceh province, Indonesia

A survey of 388 Indonesian households displaced by the December 2004 tsunami was conducted in Aceh province in February 2005. Of tsunami-displaced households in Aceh Barat and Nagan Raya districts, 61.8 per cent reported one or more family members as dead or missing due to the tsunami, with an overall mortality rate of 13.9 per cent (95% confidence interval (CI): 12.4-15.4). Risk of death was greatest in the youngest and oldest age groups, and among females. Overall, 36 per cent of tsunami-displaced households indicated an intention to return to their original community within three months, and displaced households residing in host communities were 2.2 (95% CI: 1.2-2.8) times more likely to state an intention to return to their original villages or another community as those residing in camps. The tsunami recovery effort should focus on strategies that facilitate either prompt return or permanent, voluntary relocation for those displaced.     

Risk of flood-related mortality in Nepal

In July 1993, severe flooding devastated Sarlahi district in Nepal. The next month, a follow-up study of a large population cohort was undertaken. The study is unique in that a prospective research database was used to verify residency prior to the flood and to confirm vital status afterwards. It evaluated 41,501 children aged between two and nine years and adults aged 15-70 in 7,252 households. Flood-related fatality rates were 13.3 per 1,000 for girls and 9.4 per 1,000 for boys, 6.1 per 1,000 for women and 4.1 per 1,000 for men. Flood-related fatality rates for children were six times higher than mortality rates in the same villages a year before the flood (relative risk (RR) = 5.9, 95 per cent confidence interval (CI) 5.0-6.8). Flood-related fatality was associated with low socio-economic status preflood (RR = 6.4, 95 per cent CI 2.7-20.0), and having a house constructed of thatch (RR = 5.1, 95 per cent CI 1.7-24.5).     

Practical experience with the management of a cholera outbreak in a refugee cAMP in eastern Sudan, 1985

From May to November 1985 most refugee camps in Eastern Sudan were affected by cholera. This article summarizes the experience from the refugee camp Wad Sherife with the emphasis on the practical aspects of management of cholera in a refugee context. Paramedical personnel from the refugee community were used to a great extent both in curative and preventive measures. The home visitors played an important role in the early detection of the cases and in trying to prevent the spread of cholera in the camp. A total of 1793 cases were admitted during a three month period. The results show a case fatality rate of 1.8%. A significantly higher number of women were affected in the age group 15–44. As seen in other refugee camps in Eastern Sudan, there was a relatively high intravenous fluid consumption with an average of about 6 litres in adults.     

Rapid Assessment of Population Size by Area Sampling in Disaster Situations

In the initial phase of a complex emergency, an immediate population size assessment method, based on area sampling, is vital to provide relief workers with a rapid population estimate in refugee camps. In the past decade, the method has been progressively improved; six examples are presented in this paper and questions raised about its statistical validity as well as important issues for further research. There are two stages. The first is to map the camp by registering all of its co-ordinates. In the second stage, the total camp population is estimated by counting the population living in a limited number of square blocks of known surface area, and by extrapolating average population calculated per block to the total camp surface. In six camps selected in Asia and Africa, between 1992 and 1994, population figures were estimated within one to two days. After measuring all external limits, surfaces were calculated and ranged between 121,300 and 2,770,000 square metres. In five camps, the mean average population per square was obtained using blocks 25 by 25 meters (625 m2), and for another camp with blocks 100 by 100 m2. In three camps, different population density zones were defined. Total camp populations obtained were 16,800 to 113,600. Although this method is a valuable public health tool in emergency situations, it has several limitations. Issues related to population density and number and size of blocks to be selected require further research for the method to be better validated.     

Mortality and morbidity in refugee camps in eastern Sudan: 1985-90

Civil war has disrupted life in Ethiopia since the 1960s and many people have sought refuge in Eastern Sudan, particularly during the famine emergency of 1984–85. UNHCR has provided the main financial support for the refugee programme, but began scaling down operations in 1990. Nearly 300,000 refugees still live in camps and benefit from food and health programmes. Health services are co-ordinated by the Sudanese Refugee Health Unit which operates a centralised health and nutrition surveillance system with the co-operation of the NGOs responsible for health care in the camps. A revision of the monthly reporting system and the establishment of a computer database in 1990 provided an opportunity to review the situation in the camps over the five years since the emergency. Child death rates for example, appear to have been reduced to levels below those expected in rural Africa. Patterns of mortality, morbidity, and nutritional status are outlined here and point to the general effectiveness of the health care programme. The surveillance system can, however, be used to identify those camps which have persistent problems, while monthly comparisons with the situation in previous years can provide early warning of deteriorating conditions.     

Emotional,physical, and social needs among 0–5‐year‐old children displaced by the 2010 Chilean earthquake: associated characteristics and exposures

An 8.8‐magnitude earthquake occurred off the coast of Chile on 27 February 2010, displacing nearly 2,000 children aged less than five years to emergency housing camps. Nine months later, this study assessed the needs of 140 displaced 0–5‐year‐old children in six domains: caregiver stability and protection; health; housing; nutrition; psychosocial situation; and stimulation. Multivariate regression was applied to examine the degree to which emotional, physical, and social needs were associated with baseline characteristics and exposure to the earthquake, to stressful events, and to ongoing risks in the proximal post‐earthquake context. In each domain, 20 per cent or fewer children had unmet needs. Of all children in the sample, 20 per cent had unmet needs in multiple domains. Children's emotional, physical, and social needs were associated with ongoing exposures amenable to intervention, more than with baseline characteristics or epicentre proximity. Relief efforts should address multiple interrelated domains of child well‐being and ongoing risks in post‐disaster settings.     

Severe drought and the vitamin A status of rural pre-school children in India

A community-based cross-sectional study was carried out in six drought-affected areas of India in 2003 to assess the impact of drought on the vitamin A status of 3,657 rural pre-school children. The prevalence of Bitot's spots was found to be significantly (p < 0.01) higher (1.8 per cent) during drought (odds ratio (OR) = 2.0; 95 per cent confidence interval: 1.6 -2.7). The dietary intake of vitamin A was lower during drought and in 81 per cent of households it was less than 50 per cent of the recommended rate. Severe drought has an adverse impact on the vitamin A status of rural pre-school children, particularly those with illiterate mothers and belonging to an older age group (p < 0.01). Communities need to be sensitised, therefore, to vitamin A deficiency through health and nutrition education, and there needs to be wider coverage of vitamin A supplementation, particularly among children in drought-affected and drought-prone areas.     

Needs assessment of the displaced population following the August 1999 earthquake in Turkey

In August 1999 a major earthquake struck north-western Turkey. An assessment followed to identify the immediate needs of the displaced population. A random cluster sample of displaced families living in temporary shelter outside of organised relief camps was designed. Representatives of 230 households from the four communities worse affected by the earthquake were interviewed. Most families lived in makeshift shelters (84 per cent), used bottled water (91 per cent), obtained food from relief organisations (61 per cent), had access to latrines (90 per cent), had a member on routine medication (53 per cent) and obtained information by word of mouth (81 per cent). Many respondents reported having family members who were over the age of 65 (32 per cent) or under age three (20 per cent), who were pregnant (6 per cent), or who had been ill since the earthquake (64 per cent). The greatest immediate need reported by most families was shelter requirements (37 per cent), followed by food (23 per cent) and hygiene requirements (19 per cent). Ten days after the earthquake, basic environmental health needs of food, shelter and hygiene still predominated in this displaced population. Significant portions may have special needs due to age or illness.     

Epidemiology of tornado destruction in rural northern Bangladesh: risk factors for death and injury

The epidemiology of tornado-related disasters in the developing world is poorly understood. An August 2005 post-tornado cohort study in rural Bangladesh identified elevated levels of death and injury among the elderly (≥ 60 years of age) (adjusted odds ratio (AOR) = 8.9 (95 per cent confidence interval (CI): 3.9-20.2) and AOR = 1.6 (95 per cent CI: 1.4-1.8), respectively), as compared to 15-24 year-olds, and among those outdoors versus indoors during the tornado (AOR = 10.4 (95 per cent CI: 5.5-19.9) and AOR = 6.6 (95 per cent CI: 5.8-7.5), respectively). Females were 1.24 times (95 per cent CI: 1.15-1.33) more likely to be injured than males. Elevated risk of injury was significantly associated with structural damage to the house and tin construction materials. Seeking treatment was protective against death among the injured, odds ratio = 0.08 (95 per cent CI: 0.03-0.21). Further research is needed to develop injury prevention strategies and to address disparities in risk between age groups and between men and women.     

Operation Child-ID: reunifying children with their legal guardians after Hurricane Katrina

Children constitute a vulnerable population and special considerations are necessary in order to provide proper care for them during disasters. After disasters such as Hurricane Katrina, the rapid identification and protection of separated children and their reunification with legal guardians is necessary in order to minimise secondary injuries (i.e. physical and sexual abuse, neglect and abduction). At Camp Gruber, an Oklahoma shelter for Louisianans displaced by Hurricane Katrina, a survey tool was used to identify children separated from their guardians. Of the 254 children at the camp, 36 (14.2 per cent) were separated from their legal guardians. Answering 'no' to the question of whether the accompanying adult was the guardian of the child prior to Hurricane Katrina was a strong predictor (27.8 per cent versus 3.2 per cent) of being listed as 'missing' by the National Center for Missing and Exploited Children (NCMEC). All the children at Camp Gruber who were listed as 'missing' by the NCMEC were subsequently reunited with their guardians.     

Psychological consequences among adults following the 1999 earthquake in Athens, Greece

One year after the 7 September 1999 earthquake in Athens, Greece, we investigated the psychological consequences among 305 individuals (71 per cent female) residing in the settlements of Ano Liosia Municipality. Adaptability was difficult (63 per cent) due to limited space (50 per cent). Insecurity feelings were predictive of difficult adaptability (chi2= 29.8, p<0.0001) and were common (63 per cent) among married subjects, independent of age (chi2= 5.0, odds ratio (OR): 0.49, 95 per cent confidence interval (CI): 0.26-0.90). Eighty per cent expressed stress feelings, mainly nervousness/tension (60 per cent). Adaptability (chi2= 5.3, OR: 0.5, 95 per cent CI: 0.27-0.9), age (chi2= 6.5, OR: 1.03, 95 per cent CI: 1.01-1.06), and female gender (chi2= 4.7, OR: 0.48, 95 per cent CI: 0.25-0.90) were independent predictors of stress feelings. The majority (55 percent) developed sleep disorders, chiefly insomnia (60 percent). Adaptability problems were the only predictor of sleep disorders (chi2= 6.4, OR: 0.5, 95 per cent CI: 0.33-0.87). Psychiatric medication use increased after the earthquake.     

Setting up an early warning system for epidemic-prone diseases in Darfur: a participative approach

In April-May 2004, the World Health Organization (WHO) implemented, with local authorities, United Nations (UN) agencies and non-governmental organisations (NGOs), an early warning system (EWS) in Darfur, West Sudan, for internally displaced persons (IDPs). The number of consultations and deaths per week for 12 health events is recorded for two age groups (less than five years and five years and above). Thresholds are used to detect potential outbreaks. Ten weeks after the introduction of the system, NGOs were covering 54 camps, and 924,281 people (IDPs and the host population). Of these 54 camps, 41 (76%) were reporting regularly under the EWS. Between 22 May and 30 July, 179,795 consultations were reported: 18.7% for acute respiratory infections; 15% for malaria; 8.4% for bloody diarrhoea; and 1% for severe acute malnutrition. The EWS is useful for detecting outbreaks and monitoring the number of consultations required to trigger actions, but not for estimating mortality.     

Economic evaluation of measles catch-up and follow-up campaigns in Afghanistan in 2002 and 2003

This paper assesses the cost-effectiveness of, and the return on the investment in, the 2002 catch-up and the 2003 follow-up measles campaigns in Afghanistan from the perspective of the donor. The catch-up campaign targeted nearly 12 million children aged between six months and 12 years, while the follow-up campaign targeted over five million children aged between 9 and 59 months. Both campaigns successfully vaccinated approximately 96 per cent of the respective target populations, and are expected to avert an estimated 301,000 measles deaths over the next 10 years. The average cost per dose of measles vaccine delivered was USD 0.40. The cost per death prevented is USD 23.6, assuming a case fatality rate of 10 per cent and a discount rate of three per cent. With more than 42,000 measles deaths avoided for every one million US dollars spent, the campaigns are an excellent public health investment for precluding childhood mortality in a country affected by a complex emergency.     

Post-Emergency Epidemiological Surveillance in Iraqi-Kurdish Refugee Camps in Iran

In 1991 a computerized, comprehensive epidemiological surveillance system was developed to monitor health trends in approximately 25,000 acutely displaced Kurds in Nowsood and Saryas refugee camps, Bakhtaran region, Northwestern Iran. In addition, community-based surveys offered information unobtainable from health facilities. Weekly population movements, attack rates, point-prevalence estimates, and case fatality ratios were calculated, and the data were analysed and compared. The overall crude mortality rate (CMR) in the camps under study was still 9 times higher than the reported CMR for Iraq. Health problems with very low rates (less than 1.0/ 1,000 population/week) included the triad of measles, meningitis and tetanus. However, morbidity for the most common conditions (acute respiratory infections, diarrhoea, skin infections, eye diseases and, finally, typhoid fever) was shown to increase at the end of the intervention, highlighting that the pressure of repatriation on refugees made them progressively worse. This article concludes that epidemiological surveillance systems should be implemented during mass-migrations in developing countries also in post-emergency settings. Furthermore, surveillance appears to be indispensable in order for the international agencies to keep abreast of events and to safeguard human rights when international attention subsides.     

Changes in HIV/AIDS/STI knowledge, attitudes and practices among commercial sex workers and military forces in Port Loko, Sierra Leone

Sierra Leone suffered from 11 years of civil war (1991-2002) resulting in tens of thousands of deaths and mutilations together with massive population displacement. In 2001, ARC International, Sierra Leone conducted a baseline survey of 201 commercial sex workers (CSWs) and 202 military respondents on the knowledge, attitudes and practices surrounding HIV/AIDS and STIs in Port Loko, Sierra Leone. In 2003, a comparable post-intervention survey of 202 CSWs and 205 military respondents was performed. Comparison of baseline and post-intervention results showed that HIV/AIDS knowledge increased among both groups, with those able to name three effective means of avoiding AIDS increasing from 5 per cent to 70 per cent among CSWs, and 11 to 75 per cent among the military. Reported condom use during last sex increased among CSWs from 38 to 68 per cent and among military from 39 to 68 per cent. These results demonstrate that, despite the challenges inherent in a post-conflict country, good-quality AIDS-prevention programmes can be effective.