Surveillance in Humanitarian Emergencies

1
Surveillance in Humanitarian Emergencies
2
Methods of Data Collection
3
What factors make surveillance especially
important, in emergency settings?
4
Why Is Surveillance Especially Important In
Emergencies?

• Host
• Morbidity and mortality are higher among
  malnourished persons
• New arrivals may have no natural immunity
• Organism
• Crowding can mean higher infective dose
• Displacement may result in exposure to new
  pathogens
• Environment
• Lack of clean water and poor sanitation are
  favorable to spreading disease
• Poor access to care can increase case fatality
  ratios

5
What Diseases or Conditions Will You Conduct
Surveillance For?
6
Types of Data Dollected in Surveillance Systems
in Emergencies

• Mortality
• Morbidity
• diseases of public health importance
• diseases of epidemic potential
• Nutritional Status
• Program Indicators
• Indicators of the quality of the system itself

7
Health Surveillance In Emergencies

• One over-riding principle
• ONLY COLLECT DATA WHICH ARE
• USEFUL AND CAN BE ACTED UPON
• IN THE FIELD!!!

8
Who Conducts Surveillance in Emergencies?

• WHO has overall responsibility for surveillance
• UNHCR often manages surveillance in refugee camp
  situations
• But
• Implementing partners (usually NGOs) actually
  carry it out

9
Objectives Of A Surveillance System

• To determine main health problems requiring
  intervention
• To follow trends in health status in order to
  revise health priorities
• To target resources to area of greatest need
• To detect and respond rapidly to epidemics
• To evaluate program effectiveness
• Coverage
• Quality of care
• Impact

10
Principles Of Health Surveillance In Emergencies

• Include all facilities and health partners
• Use simple standardized case definitions
• Use a simple standardized data collection form
• Collect data regularly (daily, weekly, or
  monthly)
• If possible, augment clinic-based surveillance
  with community-based surveillance
• Analyze data and provide timely feedback

11
(No Transcript)
12
(No Transcript)
13
Mortality Surveillance

• Potential data sources for deaths?
• Limitations?
• What role could SC/US play in mortality reporting?

14
Mortality Surveillance

• Potential data sources
• Hospitals / clinics
• Community and religious leaders
• Burial grounds
• Shroud distribution
• Body collectors
• Other sources

• Limitations
• Deaths under-reported
• Exaggerated
• Concealed
• Denominator inflated

15
Surveillance EmergenciesMortality

• Important indicators in emergencies
• Reported number of deaths
• Mortality rates - CMR, U5MR
• Age/Sex specific mortality rates
• Cause specific mortality rates
• Case fatality rates - measles, cholera etc.

16
What Are Some Expected Case-Fatality Rates?

• Cholera
• Shigella dysentery
• Typhoid
• Measles

17
Expected Case-Fatality Rates

• Cholera 1 or lower
• Shigella dysentery 1 or lower
• Typhoid 1 or lower
• Measles 3

18
Mortality Form
19
Leading Causes of Mortality, Darfur, Sudan,
May-September 2004 (N1,514)
20
War-Related Trauma and Mortality of Refugees
Kosovo Feb 98 Jul 99
21
Landmine/UXO Injuries AfghanistanExplosive
Type by Age Group
54
37
9
..
22
Morbidity Form
23
Keep case definitions simple
Disease
Definition
Fever, Rash cough or rash or conjunctivitis
Measles
Malaria
Fever and periodic shaking, chills
More than 4 stools per day, but no blood or
rice-water in stool
Watery Diarrhea
Lower Respiratory Infection
Fever, cough, rapid breathing (x breaths per
minute-dep. upon age)
For other examples, refer to WHO guidelines
24
Surveillance in Emergencies Morbidity

• Record ONLY ONE diagnosis per patient
• choose most important
• Take new (incident) cases not repeat cases
• record and register if case is new or repeat
• In post emergency phase, consider including lab
  diagnosis as part of case-definition to improve
  sensitivity of clinical diagnosis

25
Rates Problems With Denominator
26
Population refugee camp April 2001 Camp
committee 45,000 UNHCR estimate 25,000 Census
April 8 11,500
27
Population refugee camp February 2001 Camp
committee 30,000 UNHCR estimate 23,000 Count
after relocation 20,000
28
Mortality Rates In Refugee Camps In Guinea, 2001
(Original Populations Estimates)
Emergency threshholds
29
Mortality Rates In Refugee Camps In Guinea, 2001
(Population Estimates Revised Downward)
30
Case Study

• Surveillance in Darfur

31
Date
26 Jul 2004
Source
World Food Programme


32
Early Warning and Response Network (EWARN) -
Darfur

• Established in May 2004 by WHO and Sudanese MoH
  aiming
• To ensure timely detection, response and control
  of outbreaks among IDPs in Darfur region
• To monitor trends of communicable diseases in
  order to take appropriate public health actions
• To estimate workload of different health units
  involved in the system in order to rationalize
  resource allocation
• Thanks to Ondrej Mach, M.D., CDC

33
Darfur Surveillance

• What kind of system would you set up?
• Would you collect surveillance data from every
  location?
• What conditions would you include?
• Would you use this system to collect mortality
  data?

34
Stakeholders in EWARN

• MoH (Federal and Local)
• Coordination
• Data collection and data entry
• WHO
• Coordination
• Data entry and analysis
• Presentation and dissemination of results
• NGOs
• Data collection
• Communications
• Logistics

35
EWARN Reporting Area
36
EWARN Weekly Reporting Cycle
3
1
Report WHO Khartoum
Data Gathered Field Clinics
2
Data Entered WHO States
Health Center in Mossei Camp, South Darfur
37
Health Events Under Surveillance

• 10 communicable diseases/syndromes
• Acute Watery Diarrhea
• Bloody Diarrhea
• AFP
• ARI
• Neonatal Tetanus
• Malaria
• Suspected measles
• Suspected meningitis
• Acute Jaundice syndrome
• Acute unknown fever

• Severe malnutrition
• Injuries
• Other

38
Reporting

• There are 56 reporting units (health facilities)
  in the three states
• Four indicators are collected for each Event
• Count of new cases diagnosed
• Under 5 years of age
• Above 5 years of age
• Count of deaths in the week caused by event
• Under 5 years of age
• Above 5 years of age

39
Reporting Cycle

• Reporting is weekly
• Data is sent from reporting units to state
  capitals
• Data is entered in state capitals and forwarded
  to WHO office in Khartoum and the Federal MoH
• Epi Info 6 with EPI Data are used for data
  processing
• MMWB is prepared and distributed every Sunday

40
(No Transcript)
41
Outbreak Detection

• Acute Jaundice Syndrome (Hepatitis E)
• Measles
• Meningitis
• Cases of Acute Flaccid Paralysis (infection with
  wild polio virus)

42
Measles Outbreak Darfur, May-September 2005
Vaccination Campaign
43
Vaccination Starts
44
Acute Jaundice (Hepatitis E)
45
August 1, 2004 (Week 30)n 330
46
August 15, 2004 (Week 32)n 734
47
August 29, 2004 (Week 34)n 768
48
September 12, 2004 (Week 36)n 1,267
49
Bloody diarrhea and Acute Jaundice cases in Morni
Camp, West Darfur
50
WHO Health Risks for Communicable Diseases
Following Asian Tsunami
Diseases linked to overcrowding All
diarrhoeas Acute respiratory tract
infection Hepatitis A, E Influenza Meningitis Meas
les Tuberculosis Vector borne diseases
Dengue Malaria Scrub Typhus Lymphatic
Filariasis Japanese encephalitis Zoonosis
present Leptospirosis Anthrax RabiesTrichinosis
Melioidosis Brucellosis Nipah virus

• Epidemic prone diseases
• Cholera
• Shigellosis
• Typhoid fever
• Acute Lower Respiratory Inf
• Hepatitis A, E
• Measles
• Meningitis
• Influenza
• Diseases with increased risk due to flooding
• Tetanus in adults
• Leptospirosis (rats)
• Dengue
• Malaria

51
WHO Suggested Health Events For EWAR
Acute watery diarrhoea (suspect cholera) Acute
diarrhoea Acute bloody diarrhoea Acute Jaundice
syndrome Suspected meningitis Acute Lower
Respiratory Infection Suspected measles Fever
of unknown origins Suspected malaria Acute
hemorrhagic fever Unknown diseases occurring in a
cluster