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.     

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.     

Training refugees as primary health care workers: Past imperfect, future conditional

Many problems have been encountered in the planning and implementation of health care in refugee camps, and more specifically in the training of refugees as primary health care workers. A review of the published literature and a "survey" of the opinions and experiences of refugee, national and international health personnel regarding training has therefore been undertaken to provide an overview of what has been done and to make recommendations for future work.
The review highlights the need to reallocate resources away from high visibility emergency aid to development activities, such as training, that will create an infrastructure for primary health care and promote self-reliance.     

Health response to a large and rapid influx of Albanian refugees in southern Italy, 1991

Over a two-day period in March 1991, more than 23,000 Albanian refugees arrived without warning in the southern Italian port of Brindisi. A simple surveillance system was established within days of their arrival to monitor health problems that were expected to have a high frequency, were of concern to the Italian health care system because of potential spread to the local population, and were susceptible to therapeutic or preventive measures. The most commonly encountered health problems were pediculosis and scabies. Despite poor sanitary conditions, only one outbreak of gastrointestinal disease was reported. Obstetric events were common, and many resulted in adverse outcomes. Hospitalization rates were high, although in the early weeks of the emergency, many were unwarranted. This experience demonstrates the value of a simple, rapid surveillance system in prioritizing health problems and preventing rumors. In future, greater emphasis should be placed on outpatient management of simple medical problems.     

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.     

Disease Surveillance and Control After a Flood: Khartoum, Sudan, 1988

Following a flood in Khartoum, Sudan, emergency disease surveillance was implemented to monitor the health status of the population. Simple, symptom-oriented case definitions for diarrheal disease, measles, respiratory disease, malaria, and jaundice were included on the report form used to collect daily counts of outpatients in a sample of both temporary and permanent clinics located in areas of the city most affected by the flood. Data collected from major teaching hospitals allowed comparison of pre- and post-disaster levels of morbidity and mortality. In addition, special surveys collected information unobtainable from health facilities. Sentinel clinic surveillance data indicated that diarrheal disease accounted for the greatest number of clinic visits, while malaria was the second most common reason for seeking medical attention. Malaria blood smear surveys showed that the parasitemia prevalence ranged from 11% to 19% in the general population and from 21% to 46% among febrile clinic patients. Hospital admission data demonstrated an increase in morbidity from diarrhea and malaria in August 1988, when compared to previous months and August of the previous year, although it is uncertain whether this increase was due to the flood. Nutrition surveys demonstrated that 23% of young children were moderately or severely undernourished, with substantial variation by area of the city. No major outbreaks of communicable disease were detected in the 4 weeks after the flood. Disease surveillance provided data useful in identifying public health problems, setting priorities, targeting interventions and controlling rumors. Disease control measures taken by the Ministry of Health included provision of potable water, standardization of medical care, and distribution of immunizations, oral rehydration salts, and vitamin supplements to children.     

Immediate and long-term assistance following the bombing of the US Embassies in Kenya and Tanzania

On 7 August 1998 truck bombs destroyed the US Embassies in Kenya and Tanzania.(1) The response in both countries was characterised by an absence of incident command, limited pre-hospital care, a disorganised hospital response and a lack of transportation for those injured. In the next five years USD 50 million was provided by the United States Agency for International Development (USAID) to alleviate the resulting suffering, support reconstruction and strengthen disaster preparedness capacity in the two countries. These two programmes have enhanced awareness of disaster management issues, improved training capacity, built response structures and provided material resources. Their design and implementation provide lessons for future disasters in developing countries. The assistance programmes evolved very differently. In Kenya the programme largely excluded the public sector and the potential for government coordination, while the Tanzanian programme concentrated heavily on central government and regional hospital structures-largely omitting the non-governmental or civil society sector. Excluding key stakeholders raises concerns about programme sustainability and the ability to respond effectively to future emergencies.     

Using evidence to improve reproductive health quality along the Thailand-Burma border

The Mae Tao Clinic, located on the Thailand-Burma border, has provided health services for illegal migrant workers in Thailand and internally displaced people from Burma since 1989. In 2001, the clinic launched a project with the primary aim of improving reproductive health services and the secondary aim of building clinic capacity in monitoring and evaluation (M&E). This paper first presents the project's methods and key results. The team used observation of antenatal care and family-planning sessions and client exit interviews at baseline and follow-up, approximately 13 months apart, to assess performance on six elements of quality of care. Findings indicated that improving programme readiness contributed to some improvement in the quality of services, though inconsistencies in findings across the methods require further research. The paper then identifies lessons learned from introducing M&E in a resource-constrained setting. One key lesson was that a participatory approach to M&E increased people's feelings of ownership of the project and motivated staff to collect and use data for programme decision-making to improve quality.     

A general assessment of the environmental impact of refugees in Somalia with attention to the refugee agricultural programme

This paper attempts to examine the broad features of Somalia's harsh physical environment into which several hundreds of thousands of refugees, with mainly a nomadic or semi-nomadic life style and culture, dramatically descended six years ago. The thirty-six rural camps in which at least half of them live are described as is the refugee agricultural programme which is training several thousand families so that they may be "self-supporting." The four regions where the camps are located are each briefly summarized in terms of their soils, their climates, their natural vegetation, and the type of agriculture which the refugee farmers practice. A more detailed analysis is then given on the following critical environmental concerns: Vegetation and erosion on refugee farms, the growing problem of refugee livestock, the destruction of trees, and irrigation practices and salinity on refugee farms. The paper concludes with an argument to preserve Somalia's environment from careless and destructive exploitation, which is leading towards desertification, and calls for an in-depth study of the situation.     

Refugee perceptions of the quality of healthcare: findings from a participatory assessment in Ngara, Tanzania

This article describes the findings of a participatory assessment of Burundian and Rwandan refugees' perceptions of the quality of health services in camps in Ngara, Tanzania. Taking a beneficiary-centred approach, it examines a collaborative effort by several agencies to develop a generic field guide to analyse refugees' views of healthcare services. The objective was to gather information that would contribute to significant improvements in the care offered in the camps. Although the primary focus was on healthcare, several broader questions considered other general apprehensions that might influence the way refugees perceive their healthcare. Findings indicated that while refugees in Ngara were generally satisfied with the quality of healthcare provided and healthcare promotion activities, recognition of some key refugee concerns would assist healthcare providers in enhancing services. With increasing need for refugee community participation in evaluating humanitarian assistance, this assessment has relevance both in the context of Ngara and beyond.     

Evaluation of a population mobility,mortality, and birth surveillance system in South Kivu,Democratic Republic of the Congo

Prospective, community-based surveillance systems for measuring birth, death, and population movement rates may have advantages over the ‘gold-standard’ retrospective household survey in humanitarian contexts. A community-based, monthly surveillance system was established in South Kivu, Democratic Republic of the Congo, in partnership with a local implementing partner and the national ministry of health. Data were collected on the occurrence of births, deaths, arrivals, and departures over the course of one year, and a retrospective survey was conducted at the end of the period to validate the information. Discrepancies between the two approaches were resolved by a third visit to the households with discordant records. The study found that the surveillance system was superior in terms of its specificity and sensitivity in measuring crude mortality and birth rates as compared to the survey, demonstrating the method's potential to measure accurately important population-level health metrics in an insecure setting in a timely, community-acceptable manner.     

The Role of the Zairian Health Services in the Rwandan Refugee Crisis

In July 1994, a stream of Rwandan refugees entered the southern part of North Kivu Region, Zaire. The public health consequences of this crisis for the host population and health services have not been analysed up to now. The lack of human and financial resources did not prevent Zairian health structures and personnel from taking care of the many refugees settled outside the camps, following their arrival. The public health consequences of the crisis for the local population should be considered an integral part of the disaster.     

Training Community Health Workers in refugee camps: A case study from Pakistan

In October 1983 a training programme for refugee community health workers was begun as the major part of a primary health care programme for Afghan refugees in Pakistan. The programme began with a pilot period in Badaber camp, situated near to Peshawar. The general issues involved in training auxiliary health personnel were answered by the use of a "knowledge, attitudes and practices survey" and involvement of the refugees from the beginning of the programme. The development of the training programme is discussed with reference to these issues and the constraints arising from the special circumstances of the refugees, in addition to those common to most national training programmes, are reviewed.     

The management of severe malnutrition in Burundi: an NGO's perspective of the practical constraints to effective emergency and medium-term programmes

The NGO, Action contre la Faim (ACF), has been operating in Burundi since 1994, where the situation has dramatically hampered humanitarian programmes. These include poor security resulting in an inability to maintain 24-hour care for the severely malnourished and poor access to the beneficiaries, all within a politically and economically unstable context. However, ACF has been able to capitalise on lessons learnt and reflect on ways to move forward, which have included the improvement of their capacities in the treatment of severe malnutrition and the integration within broader disciplines and national structures. The protocols for the treatment of severe malnutrition currently used in Burundi have been developed as a result of the research of ACF over the past five years. Other aspects of the nutrition programme remain to be further developed. These include, for example, an improved capacity to care for severely malnourished adolescents and adults; and also a better knowledge of the beneficiaries to allow for stronger links between the provision of treatment and support for their longer-term food security.     

The Management of Severe Malnutrition in Burundi: An NGO's Perspective of the Practical Constraints to Effective Emergency and Medium-term Programmes

The NGO, Action contre la Faim (ACF), has been operating in Burundi since 1994, where the situation has dramatically hampered humanitarian programmes. These include poor security resulting in an inability to maintain 24-hour care for the severely malnourished and poor access to the beneficiaries, all within a politically and economically unstable context. However, ACF has been able to capitalise on lessons learnt and reflect on ways to move forward, which have included the improvement of their capacities in the treatment of severe malnutrition and the integration within broader disciplines and national structures.
The protocols for the treatment of severe malnutrition currently used in Burundi have been developed as a result of the research of ACF over the past five years. Other aspects of the nutrition programme remain to be further developed. These include, for example, an improved capacity to care for severely malnourished adolescents and adults; and also a better knowledge of the beneficiaries to allow for stronger links between the provision of treatment and support for their longer-term food security.     

Surveillance of the Health and Nutritional Status of Rohingya Refugees in Bangladesh

Early in 1992, Bangladesh experienced an influx of Burmese refugees, reaching a total of 263,000 by May. As the health and nutritional status of the refugee population was reportedly poor, a need was felt to collect dependable data through epidemiological surveillance, on which interventions could be based. The nutritional and health status of children was dramatically poor in all camps surveyed and a deterioration was expected in the coming monsoon. Several problem areas could be identified. Based on these findings it was possible to undertake appropriate action and to avert threatening calamities. Epidemiological surveillance is an important monitoring tool to provide reliable data on the health and nutritional status of refugee populations and to help the organizations involved to prioritize and evaluate their actions.     

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.     

Evaluation of Two Kurdish Refugee Camps in Iran, May 1991: The Value of Cluster Sampling in Producing Priorities and Policy

Following the end of the Gulf war in March 1991, Kurdish refugees from Iraq crossed the border into Western Iran. To plan public health interventions and to assist in priority setting for scarce resources, a rapid epidemiological assessment of two camps, Hafez and Kaliche, was conducted in May 1991. A 30 cluster sampling method was used to determine the demographics of the camp population, the morbidity and mortality from certain diseases, and the nutritional status of the children <5 years of age. The estimated population of the camps at the time of the survey was 28,500 and 22,500 for Hafez and Kaliche respectively; children < 5 years of age accounted for approximately 25 per cent of both camp populations. The mortality rate was highest in Hafez and estimated to be 2.5/10,000 per day (95%CI:0.3–5) for adults (> 14 years of age) and 4.9/10,000 per day (95%CI:2.4–7.4) for children. Diarrhoeal and respiratory diseases accounted for major morbidity in both camps with diarrhoea the commonest stated cause of death. Little malnutrition was found but it was greater in Hafez where 6 per cent (19/327) of the children between 1 and 5 years of age had a mid upper arm circumference (MUAC) <12 cm and eleven (5.2 per cent) of the 211 children measured for height and weight were below 80 per cent of the median (95%CI:2.6%;7.8%). The survey identified that morbidity and mortality were less severe than in the Kurdish camps on the Turkish border and provided information for camp authorities to plan appropriate relief interventions.     

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.     

Childhood Immunisation in Rural Afghanistan: The EPI Programme, 1987-91

A decade of outright war followed by civil strife and conflict has hindered the development of health care services for the population of rural Afghanistan. Despite the absence of a functional health care system and the fragmentation of the Afghan resistance, and despite widely held views to the contrary, it has proved possible to set up a technically valid and politically acceptable Expanded Programme of Immunisation (EPI). This paper discusses some of its technical and programmatic aspects and the rationale behind some of the very unusual choices made – such as the use of DPTP, the inclusion of girls 3–14 years old for TT immunisation, a vertical programme structure and a predominance of mobile and outreach strategies. The paper argues against the mindless use of global or handbook recipes. The keys to success have been strategic vision, intimate knowledge of the local context and pragmatic choices for options that are simple and effective.