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.     

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.     

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.     

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.     

Some epidemiologic features of disasters in guatemala

Epidemiological procedures can be organised under disaster conditions by means of a simple surveillance system and with few personnel.
In the aftermath of the 4 February 1976 earthquake in Guatemala, an information system was organized by which the requisite information for decision-making was obtained with adequate speed and promptness.
The initial epidemiologic informution was based on reports collected during the early days on symptoms observed at hospitals and health centers and in localities and villages in the stricken area.
At a second, post-emergency stage a more elaborate surveillance system was instituted to provide guidance in the investigntwn of outbreaks, evaluate the health activities and establish basic criteria for preventive and control measures.     

Cross-sectional survey methods to assess retrospectively mortality in humanitarian emergencies

Since the rates and causes of mortality are critical indicators of the overall health of a population, it is important to evaluate mortality even where no complete vital statistics reporting exists. Such settings include humanitarian emergencies. Experience in cross-sectional survey methods to assess retrospectively crude, age-specific, and maternal mortality in stable settings has been gained over the past 40 years, and methods appropriate to humanitarian emergencies have been developed. In humanitarian emergencies, crude and age-specific mortality can be gauged using methods based on the enumeration of individuals resident in randomly selected households—frequently referred to as a household census. Under-five mortality can also be assessed through a modified prior birth history method in which a representative sample of reproductive-aged women are questioned about dates of child births and deaths. Maternal mortality can be appraised via the initial identification of maternal deaths in the study population and a subsequent investigation to determine the cause of each death.     

A retrospective statistical review of deaths owing to migration through the southeasternmost land borders of the European Union,Greece 2000–14

The land borders of Evros, Greece, have been a common entry point for undocumented migrants on their way to Europe through Turkey. Adverse conditions, however, have resulted in many human casualties over the years. On the Greek side, 334 cadavers were retrieved between 2000 and 2014. This study provides a detailed forensic account of the humanitarian disaster in Evros to create an official scientific record of the situation. It showcases the gravity of the global issue of migration relating to health and mortality, and encourages communication and continual improvement of the approach and patterns of practices surrounding the subject. A retrospective statistical research review was conducted of border‐related fatalities between 2000 and 2014, assessing the age and gender of victims, the cause of death, the location of bodies, identification rates, and country of origin. Age ranged generally from 24 to 29 years, but infants and children were among the deceased.     

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.     

Mortality,violence and lack of access to healthcare in the Democratic Republic of Congo

The people of the Democratic Republic of Congo for decades have been living in a situation of chronic crisis. Violence, population displacement and the destruction of infrastructure and health services have devastated the health of the population. In 2001, Médicins Sans Frontières conducted a survey in five areas of western and central DRC to assess mortality, access to health-care, vaccination coverage and exposure to violence. High mortality rates were found in front-line zones, mainly due to malnutrition and infectious diseases. In Basankusu approximately 10 per cent of the total population and 25 per cent of the under-five population had perished in the year before the survey. Humanitarian needs remain acute across the country, particularly near the front line. Infectious-disease control and treatment are a priority, as is increasing access to health-care. Humanitarian assistance must be increased considerably, especially in rural areas and zones that have been affected directly by conflict.     

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.     

Social vulnerability and pneumonic plague: revisiting the 1994 outbreak in Surat,India

The 1994 outbreak of pneumonic plague in Surat, India is revisited and analyzed using the pressure and release (PAR) model. Overviews of the outbreak, of India's experience with plague, and of the disease are provided and the PAR model is used to trace the production of vulnerability via root causes, dynamic pressures, and unsafe conditions and to explain the why, when, and where of the epidemic. The emergence of plague in Surat was an unfortunate amalgam of prior hazard events and of factors generating vulnerability. Root causes include the country's colonial legacy and a complex and pervasive social hierarchy promoting caste and class interests over the common good. Dynamic pressures include: a curative-focused healthcare system; a weak civil society; misplaced spending priorities; and public and private corruption that deprived public health programs of needed funds and which compelled workers to live and labor in unhealthy environments. Unhealthy public, residential and workplace environments; fragile economic conditions; and a lack of surveillance and preparation are immediately linked to the outbreak and to the transmission of pneumonic plague.     

Health Assessment of the 1985 Flood Disaster in Puerto Rico

In Puerto Rico, during October 1985, tropical storm Isabel caused widespread flooding, landslides, and collapsing of bridges. A maximum of 180 persons died, including an estimated 127 at a landslide where the majority (78%) of deaths resulted from traumatic injury. Approximately 3,000 homes were damaged with 4,400 persons temporarily displaced into 44 shelters. A shelter surveillance system was established to monitor 19 acute and chronic conditions in 28 shelters during a 5-week period. Trend analysis trends of selected reportable communicable diseases in the general community revealed no changes attributable to the disaster in the 12 most severely affected municipalities. In these municipalities, the number of persons using the scheduled outpatient clinics after the disaster decreased significantly, but the mean daily number of emergency room visits did not show significant change. Analysis of surveillance data showed that no infectious disease outbreaks had occurred in the shelters. The post-impact health consequences resulting from this widespread flooding were minimal. Even so, disease surveillance remains essential for efficacious resource allocation and prevention strategies.     

Earthquake drills and simulations in community-based training and preparedness programmes

The San Francisco, California, bay area is subject to continuous seismic risk. One particular response has been the development of community-based training programmes designed to teach residents basic emergency response skills. Citizens are taught emergency medical techniques, search and rescue, fire suppression and other fundamental response skills. Current estimates in the Bay Area place the number of programmes at more than 100. Many programmes now include an annual community drill to reinforce the training and to evaluate the programme. The study described here is based on an evaluation of an effort initiated by BayNET (Bay Area Neighborhood Emergency Training), a voluntary association of communities with community-based disaster preparedness programmes. In April 1996, BayNET asked all of its members to hold a community earthquake drill. After the drill, a mail survey was conducted of all programme managers. The survey examined the structure and administration of the programmes, training efforts and other related components. This paper describes the typology of drill formats that communities used, the role of the simulation in the city's preparedness efforts, the qualitative costs and benefits, as well as an assessment of the drill based on survey respondents.     

Risk factors for mortality during the 2002 landslides in Chuuk, Federated States of Micronesia

This study examines health effects resulting from landslides in Chuuk during Tropical Storm Chata'an in July 2002, and suggests strategies to prevent future mortality. In August 2002, we conducted a cross-sectional survey to identify risk factors for mortality during landslides, which included 52 survivors and 40 surrogates for 43 decedents to identify risk factors for death. Findings suggest that 1) females had a higher mortality rate from this event than males, and 2) children aged 5–14 years had a 10-fold increase in mortality when compared with annual mortality rates from all causes. Awareness of landslides occurring elsewhere and knowledge of natural warning signs were significantly associated with lower risks of death; being outside during landslides was not associated with reduced mortality. In Chuuk, improving communication systems during tropical storms and increasing knowledge of natural warnings can reduce the risk for mortality during landslides.     

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.     

Health implications of the Tumaco earthquake, Colombia, 1979

A retrospective study of the effects of the Tumaco earthquake of 1979 shows a smaller number of deaths and injuries than in earthquakes of similar magnitude that have occurred elsewhere, which is probably related to the type of building. Most of the deaths were caused by a tsunami. Proportionally the mortality was higher in the 0 to 4 age group. Among the injured, most of the lesions were minor. Morbidity was higher in the over 45 years age group, and lower among the "under-fives." There was an evident need for a simple "disaster medical record card." Coordination among the different relief agencies could have been better.     

Taking stock of community-based flood risk management in Malawi: different stakeholders,different perspectives

Current flood risk strategies in Malawi are characterized by community-based flood risk management (CB-FRM), even though studies explicitly documenting evidence of successful CB-FRM remain limited. This paper investigates the realities and challenges of CB-FRM as seen through a lens of different stakeholders. In order to capture the experiences of CB-FRM, a predominantly qualitative research framework was developed. In 2016, 11 focus group discussions with stakeholder groups (local communities, local government and non-governmental organisations) were held. Additionally, informal discussions, field visits, a short survey and an extensive desk study were undertaken. The findings were analysed according to the major themes that emerged related to the realities and challenges of specific stakeholder groups. Although response and relief still remain prominent components of CB-FRM in Malawi, a number of mitigation and preparedness activities is observed. However, a lack of in-country resources, relief-oriented aid approaches and an ‘aid dependency’ syndrome represent obstacles. Different stakeholder groups share similar challenges in terms of financing, participation, decentralised governance and project management. Lack of project sustainability and localised ownership also emerged as major challenges. The identified challenges shed light on the frontiers and directions in which improvements are needed, thus offering a valuable contribution to the existing knowledgebase.     

Reproductive health in Afghanistan: results of a knowledge, attitudes and practices survey among Afghan women in Kabul

A reproductive-health knowledge, attitudes and practices (KAP) survey was carried out among 468 Afghan women of reproductive age. A convenience sample of women was selected from attendees in the outpatient departments of four health facilities in Kabul. Seventy-nine per cent of respondents had attended at least one antenatal consultation during their last pregnancy. Two-thirds (67 per cent) delivered their first child between 13 and 19 years. The Caesarean-section rate was low (1.6 per cent). Two-thirds (67 per cent) of deliveries occurred in the home. The contraceptive prevalence rate was 23 per cent (16 per cent modern and 7 per cent natural methods). Twenty-four per cent had knowledge of any STIs, although most of these women did not know correctly how to prevent them. Most of the women (93 per cent) needed authorization from their husband or a male relative before seeking professional health-care. In multivariate analysis, women's schooling was significantly associated with antenatal-care attendance (AOR 4.78), institutional delivery (AOR 2.29), skilled attendance at birth (AOR 2.07) and use of family planning (AOR 4.59). Reproductive-health indicators were noted to be poor even among these women living in Kabul, a group often considered to be the most privileged. To meet the reproductive-health needs of Afghan women, the socio-cultural aspects of their situation--especially their decision-making abilities -- will need to be addressed. A long-standing commitment from agencies and donors is required, in which the education of women should be placed as a cornerstone of the reconstruction process of Afghanistan.     

Evaluative research in a refugee cAMP: the effectiveness of community health workers in khao I dang holding center, Thailand

An evaluation of Khmer refugee public health services found a strong cultural preference for older females as Community Health Workers (CHWs), in contrast to the young males employed. Class conflicts were identified between educated, upper-class CHWs and the uneducated camp majority. Poor community acceptance of the CHWs impaired their effectiveness, and was attributed to age, sex and socioeconomic barriers. Based on these evaluation findings, the refugee health program was restructured to include a preponderance of female workers. A repeat survey demonstrated enhanced program effectiveness following this change.
Selection of refugee health workers should be based on intrinsic community roles, taking age, sex, socioeconomic and other group distinctions into account. Additional research is needed on the adaptation of community health principles to the refugee context.     

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.