Health Sector Actions in Emergencies

WHO
WESTERN PACIFIC REGIONAL OFFICE
_____________________
An Overview of Health Sector Actions

in Emergencies
3rd draft
October 2003
Emergency Health Care Page 2 of 29
Contents
1. Introduction................................................................................................................................................................. 4
2. General Planning Issues ............................................................................................................................................. 4
2.1 Assessing the impact of a hazard................................................................................................................4
2.1.1 Concepts 4
2.1.2 Information in the Assessment 5
2.1.2.1 Classification of Victims ......................................................................................................................5
2.1.2.2 Classification of Damage in Emergency Situations .............................................................................6
2.1.3 Determining Response Priorities 6
2.1.3.1 Priority Relief Needs ............................................................................................................................6
2.1.3.2 Secondary Relief Needs........................................................................................................................7
2.1.3.3 Management of Logistics, Transport and Communications .................................................................7
2.1.3.4 Epidemiological Surveillance...............................................................................................................7
2.1.3.5 Public Information and Community Participation................................................................................7
2.1.3.6 Monitoring, Evaluation and Reporting.................................................................................................7
2.1.3.7 Rehabilitation and Reconstruction........................................................................................................7
2.2 The Health Sector Role in Preparing for an Emergency Response ............................................................8
2.2.1 Co-ordination 8
2.2.2 Readiness 8
2.2.3 Warning Phase 9
2.3 The Disaster Assessment Report...............................................................................................................10
2.3.1 The First Report 10
2.3.2 Interim Report 11
2.3.3 Final Report 12
2.3.4 Consolidated Annual report 12
2.4 Demography .............................................................................................................................................12
2.5 Determining Priorities for Service Provision in Population Displacements............................................12
2.6 Vulnerability Analysis and the Health Sector ...........................................................................................13
2.6.1 Assessment of Risk 14
2.7 Tools for Health Assessments ...................................................................................................................15
2.7.1 Epidemiology 16
2.7.1.1 Mortality Rate.....................................................................................................................................17
2.7.1.2 Procedures for calculating mortality rates ..........................................................................................17
3. Specific Response Issues........................................................................................................................................... 18
3.1 Health Sector Responsibilities..................................................................................................................18
3.1.1 Disease Control 18
3.1.2 Immunisations 18
3.1.3 General Health Care 18
3.1.3.1 Estimating needs.................................................................................................................................18
3.1.4 Medical Supplies 19
3.1.4.1 Overall policy .....................................................................................................................................19
3.1.4.2 Medical Kits .......................................................................................................................................19
3.1.4.3 Donations............................................................................................................................................20
3.1.5 Vaccines 20
3.1.6 Care of the dead 21
3.1.7 Foreign Medical Teams 21
3.2 Overview of Common Health Problems ...................................................................................................21
3.2.1 Trauma 21
3.2.2 Estimating medical needs 21
3.2.2.1 Hospital Capacity Assessment............................................................................................................22
3.2.2.1.1 Hospital Treatment Capacity (htc)...................................................................................................22
3.2.2.1.2 Hospital Surgical Capacity (hsc) .....................................................................................................22
3.2.2.2 Hospital Resource Management .........................................................................................................22
3.2.3 Estimating surgical needs 23
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3.2.4 Priority Diseases 23

3.2.4.1 Measles ...............................................................................................................................................23
3.2.4.2 Acute Respiratory Infections ..............................................................................................................23
3.2.4.3 Diarrhœa .............................................................................................................................................23
3.2.4.4 Malaria................................................................................................................................................24
3.2.5 Other Diseases 24
3.2.5.1 Cholera ...............................................................................................................................................25
3.2.5.2 Diphtheria ...........................................................................................................................................25
3.2.5.3 Tetanus................................................................................................................................................25
3.2.5.4 Whooping Cough................................................................................................................................26
3.2.5.5 Intestinal Parasites ..............................................................................................................................26
3.2.5.6 Meningitis...........................................................................................................................................26
3.2.5.7 Poliomyelitis.......................................................................................................................................26
3.2.5.8 Skin Infections....................................................................................................................................27
3.2.5.9 Tuberculosis........................................................................................................................................27
3.2.5.10 Typhoid.............................................................................................................................................27
3.2.5.11 Typhus...............................................................................................................................................28
4. Summary ................................................................................................................................................................... 28
The issue of this document does not constitute a formal publication of the
World Health Organisation. It should not be reviewed, abstracted or
quoted without the permission of WHO.
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Preamble
Throughout history, natural disasters have exacted a heavy toll of death and suffering. During
the past 20 years, they have claimed about 3 million lives world-wide, have adversely affected
the lives of at least 800 million more people, and have resulted in property damage exceeding
$23 billion. The future appears to be even more frightening. Increasing population density in
flood plains, and in seismic- and hurricane-prone areas points to the probability of future catas-
trophic natural disasters with millions of casualties.1
The purpose of this paper is to give an understanding to non-health professionals of the kind of
reference information needed for assessing the condition of populations at risk of death, injury or
disease immediately before and during an emergency. It also attempts to give an understanding of
how the health sector uses this information to develop appropriate response plans which are based
not only on identifying priorities but equally importantly, on accepted international standards for
the provision of emergency health and medical relief. Although national disaster management
agencies are not responsible for detailed sectoral assessments, this reference material is useful for
their staff to:
Understand the needs, concerns and constraints that are faced by different sectors trying
to work together under difficult circumstances;
Understand the technical information provided by sectoral experts;
Evaluate the overall situation using specific information submitted by different sectors;
Determine global response priorities and allocate resources appropriately;
Anticipate potential future problems;
Inform the public and report comprehensively to government leaders.
1. Introduction
In an ideal situation, effective emergency management occurs when each administrative unit of a
country has its own functional plan for response to any hazard. This requires each district and mu-
nicipality to have its own indigenous capacity for response, through decentralised ambulance, fire-
service, police and other emergency management services. Planning for this capacity is done
within the context of a national and sub national planning process. When activated, it is supple-
mented by national resources when necessary.
However, few developing countries have the ability to plan down to the district level, nor do they
have the administrative culture of formulating procedures which delegate the necessary authority
to that level. Therefore, the focus of this module will be the first sub national level i.e. provinces
(regions, Governorates etc.) and major municipalities. It is in this context that the word “local” is
used here. As countries develop socially and economically, they will be in a better position to take
emergency management programmes to communities at the level of districts, towns and villages.
2. General Planning Issues
2.1 Assessing the impact of a hazard

2.1.1 Concepts
The aim of this paper is to outline general principles for undertaking an assessment of the impact
of a hazard on a particular population at a particular time in terms of the health sector. A detailed
discussion of assessment criteria for a variety of specific health scenarios (floods, epidemics,
1
From The Nature of Disaster: General Characteristics and Public Health Issues by Eric Noji, Centres for
Disease Control, Atlanta, USA ;
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chemical accidents etc.) can be found in the World Health Organisation publication, “Rapid As-
sessment Protocols”.
The purpose of any assessment is to give decision makers information that will allow them to
make timely and appropriate interventions to:
save lives;
minimise injury and illness;
prevent escalation or spread;
prevent secondary hazards;
inform the public.
The assessment identifies who and where are the victims, and estimates gaps between their needs
and local resources i.e. it relates the number of victims to the capacity for services to cope with
them, and it identifies future areas where risk may evolve.
One of the commonest faults with assessments is collecting too much data and/or irrelevant infor-
mation. It is important that Ministry of Health (MOH) policy defines clearly which information is
needed at the different stages of the management of an emergency. Data should be analysed to de-
fine:
the causative factors of the health problems;

the extent of the problems;
the likely trends;
constraints (geographic, political, social, logistical, organisational etc);
priorities for action;
resources and length of time needed for deployment and implementation.
Assessment is only one part of the information gathering process. The process includes:
evaluation;
monitoring;
surveillance;
reporting.
Since information will be collected by many different people from a variety of sources, it is essen-
tial that a standardised collection and analysis format is used. It is impossible to collate and inter-
pret data that has been presented in different formats using different standards and different termi-
nology. One of the most critical responsibilities of a national emergency management authority is
to standardise how data is collected and presented, and to publish forms to be used by local staff in
data collection.
2.1.2 Information in the Assessment
The assessment involves the collection of two key categories of information
Classification of the victims;

Classification of damage to infrastructure and/or interruption of services.
2.1.2.1 Classification of Victims
In order to prioritise the allocation of scarce resources in the soonest possible time, it is essential to
classify the victims. The following are considered essential to survival and are called lifelines:
water;
food;
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shelter;
energy.
Victims can be classified according to their access to lifelines. The following is used to describe
the severity of the impact on people:
affected - all those living within the administrative area involved e.g. thana, district, vil-
lage;
severely affected - those who have lost one or more of their lifelines;
critically affected - those who have lost all of their lifelines or
those who have been displaced (and therefore are totally de-
pendant on others to support them).
Therefore a report describing the impact of a hazard will describe the victims by providing the
number of:
casualties (killed, injured, sick);

affected (total, severe, critical).
In order to secure the lifelines, certain sectors have a critical role to play.
transport;
communications,
security etc.
Populations at risk are those groups of people adversely affected by a hazard (natural or man-
made), who have been placed in situations where they are at an increased risk. They are at risk
due to the disruption or loss of their normal community and social support systems that provide
the critical elements of their survival. Risk increases the longer people are displaced from their
homes.
2.1.2.2 Classification of Damage in Emergency Situations
The following are the physical elements that require assessment by the health sector after a disas-
ter:
integrity of infrastructure;
access to services;
capacity for service delivery;
essential utilities – water, energy;
capacity for distribution of essential resources to the affected area.
For each facility or service in the affected area, the assessment grades function according to a pre-
defined scale. The following is an example:
destroyed or unavailable;
more than 50% reduction in capacity;
less than 50% reduction in capacity;
undamaged.
2.1.3 Determining Response Priorities
The health sector must institute the following activities according to priorities identified in the as-
sessment:
2.1.3.1 Priority Relief Needs
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assist in search and rescue;

first aid and transport of casualties;
acute medical and surgical care;
care of the displaced and vulnerable;
security of water supply;
assist in provision of shelter, warmth and clothing.
2.1.3.2 Secondary Relief Needs
The health sector action to be undertaken includes steps to improve the capabilities of services
where deficiencies are indicated. This is accomplished by increasing stocks of materials and sup-
plies, providing auxiliary or alternative power sources with supplies of fuel, acquiring additional
repair equipment, and recruiting and briefing personnel, volunteers, retired professionals, and other
similar workers.
assist in provision of food and fuel;

assist in the provision of facilities for sanitation and personal hygiene
control of communicable disease;
control of vectors and pests;
psychological care;
disposal of dead humans and dead or injured animals.
2.1.3.3 Management of Logistics, Transport and Communications
Use of health sector resources in logistics, transport and communications should be co-ordinated
with all other sectors to maximise efficiency of the operation.
2.1.3.4 Epidemiological Surveillance

Epidemiology is a key planning tool in the health sector
morbidity – number of illnesses – priorities include trauma, diarrhœa , ARI, measles, no-
tifiable diseases;
mortality – number of dead;
laboratory support;
water quality;
nutrition;
vectors;
overall planning and decision making;
overall reporting, monitoring and evaluation.
2.1.3.5 Public Information and Community Participation
These are very important aspects of the management of all emergencies.
2.1.3.6 Monitoring, Evaluation and Reporting
It is very important that standard formats are prepared and issued by the Ministry of Health. Staff
need to be briefed on how to use the forms and given guidelines for their use and submission.
2.1.3.7 Rehabilitation and Reconstruction
As part of the overall plan, the health sector must have guidelines and mechanisms for estimating
costs for:
replacement and repair;

restocking;
and it must also:

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review the emergency plan, local policy and administrative procedures;

review overall development policy and planning review;
undertake retraining – both technical and administrative.
2.2 The Health Sector Role in Preparing for an Emergency Response

Response to emergencies has three phases:
relief;
care and maintenance;
recovery - rehabilitation and reconstruction.
Each phase has priorities, strategies and technical issues specific to that phase. There is no clear
point at which one phase ends and the next begins – it will vary according to many factors, and in
a widespread disaster, senior emergency managers can find themselves involved in all 3 at the
same time, in different parts of the affected area.
This paper will discuss issues relevant to local response activities. The responsibilities of the
health sector at Provincial level are as follows:
co-ordination;
technical planning;
resources and logistics;
training and research;
public information.
2.2.1 Co-ordination
One of the most important areas of emergency management is to participate in committees for co-
ordination. The levels at which co-ordination is needed are as follows:
within sectors;
between sectors;
with international agencies;
with community leaders and interest groups such as NGO;
between districts;
between districts and provinces;
between provinces;
In this framework, mutual support and other co-operative arrangements are initiated. Agreements
with related services, academic institutions, the military and civil defence agencies encompass the
exchange or assignment of personnel, equipment, information and supplies of the various co-
operating groups. The co-ordination of reconnaissance and assessment, taking inventories, stan-
dardising stock lists, training and so forth also are covered in the agreements. Responsibilities
should be defined and assigned, and legal limitations of co-operation should be considered.
2.2.2 Readiness
It is important to maintain an updated file of essential information. This information should be
organised so that each administrative sub unit of the Province has its own file. This information
includes:
any existing national, provincial or district emergency profiles;

vulnerability analyses;
inventory of resources and deficits;
maps;
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directory of staff and experts;

emergency materials and supplies;
logistics arrangements for emergencies;
standing orders and administrative guidelines;
public awareness of local emergency issues.
Setting priority issues in response to an emergency depends on several factors:
the level of readiness in the country and its districts;

the estimated shortfall in essential resources;
the type of hazard, its potential impact and its expected duration;
the level of vulnerability of the affected community.
2.2.3 Warning Phase
The concerns of the warning period are allocating personnel, assessing plant and equipment avail-
ability, community action liaison, securing transport and communications and disseminating public
information. Procedures must be provided for the following activities:
reconnaissance;
assessment of damage and needs;
determination of priorities;
monitoring and reporting.
The longer the period of warning, the greater the number of emergency readiness measures that
can be accomplished. Emergency readiness measures include the following:
meeting of co-ordination bodies;

alerting and assigning personnel;
briefing (and possibly some abbreviated training);
disseminating information to the public;
increasing the protection of personnel;
increasing the protection of structures and equipment;
reviewing emergency plans and procedures.
Depending on the threat, the following information will be needed:
which areas are susceptible;

what population will be affected;
what type of houses are involved;
what critical infrastructure (warehouses, hospitals, roads and bridges etc.) will be af-
fected;
what communications (including transport) will be affected;
how public transport (including animal transport) will be affected;
how sources fuel will be affected;
how food markets and food distribution systems will be affected;
how utilities will be affected;
what health facilities will be affected;
what health staff will be affected;
how factories and places which use or store dangerous substances will be affected;
how previously designated emergency shelter areas (schools, railway yards and sta-
tions, stadiums, parks, high areas for floods, protected areas for wind and storms) will
be affected;
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update information on businesses which stock or make materials essential for relief
(boats, plastic sheeting, rope, tents etc.);
In this phase, the Co-ordinator will call a meeting of the emergency management committee and
ensure that each person knows their duty and has to hand the information that she needs. Shortfalls
in essential staff and resources are estimated, arrangements made to address those shortfalls and
the contingency plans reviewed for each sector.
When the Co-ordinator is satisfied that her staff are properly prepared, she will brief her superiors
on the level of readiness and her estimate of needs. She must be prepared with information for hers
superiors so that neighbouring districts can be requested to be ready to assist. She would also pro-
vide information that would help make a decision to request international assistance. Should it be
decided that evacuation of certain population groups might become necessary, it is the duty of the
MOH to ensure that basic services for health care, water and sanitation are available and able to
cope with the expected load. If a good response plan has been activated, the site for emergency
shelter will have been already selected and would only require final preparation during the warn-
ing phase.
The site should be checked with those responsible for shelter for health factors in the accommoda-
tion, the proposed feeding plan, personal hygiene arrangements, water supply, sanitation, the dis-
posal of wastes and vector control. The special needs of mental hospitals, prisons, orphanages and
other vulnerable institutions should be checked. The latest information is needed on population
density, health and demographic profiles, hazard map, risk map, resources map including staff
residences, access road maps and routine maintenance activities which affect the condition of, and
availability of, key resources. Information also needs to flow to the public, from the public, to
higher authorities, to staff, to liaison staff, the media, to other agencies.
The costs in human suffering in a disaster can be reduced by local government measures which
ensure that important community resources such as bus stations, produce markets and trucking
centres are sited in areas which are protected from hazards and are not the cause traffic congestion
or bottlenecks which will block emergency response vehicles. Vulnerability can be unnecessarily
increased by inadequate consideration given to the needs of animals and their environments. Fi-
nally, private agents or bodies which can augment local capabilities during emergencies should be
identified, and a list of local consultants or institutions which can be called upon in emergencies
should be compiled. All of these measures should be repeated at least once a year.
2.3 The Disaster Assessment Report

The report fulfils several functions – it is a request for assistance, it provides information to deci-
sion makers, it contributes to future training exercises, it is an input to any policy review that make
take place and it contributes to maintaining databases and statistics.
In addition to determining the format and the data to be collected, policy makers need to determine
in advance:
who files the report district, province, department;

how often within 4 hours then daily;
when is it required all events with >10 casualties;
where does it go province and centre;
who consolidates the information special report, annual report.
2.3.1 The First Report

Responsible: District Medical Officer;
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Classification Mandatory for all events with more than 10 casualties (killed and in-
jured);
Send To Provincial Medical Officer and MOH.
1. What happened:
event, date, time, area involved, total population, number and severity of affected,
casualties.
2. What is the caseload:
acute medical (injured) - first aid only, hospital outpatient only, inpatient;
public health (affected);
disability;
social (total population).
3. What resources are available:
Level of functioning of pre-existing capacity of services and infrastructure: ( e.g. 100%, <50%,
>50%, 0%)
access;
structures;
water supply;
energy supply;
personnel;
equipment;
medical supplies;
laboratory and blood bank;
x ray;
hospital beds;
specialist care - spinal unit, burns unit, intensive care;
transport;
communications.
4. What resources are needed
Specify type, quantity and time period:
personnel;
equipment;
medical supplies;
health care delivery buildings;
laboratory and blood bank;
x ray;
hospital beds;
specialist care - spinal unit, burns unit, intensive care;
transport;
communications;
electricity;
water;
Attach district emergency profile (mandatory reporting every 6 months)
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2.3.2 Interim Report

As above, filed every 24 hours at the same time each day by the DMO.
2.3.3 Final Report
Filed by the Provincial Medical Officer:
1. What happened?
2. How was it managed?
3. What were the lessons learned?
2.3.4 Consolidated Annual report

1. What are the trends?
2. How are lessons learned being implemented?
2.4 Demography
In the absence of a proper census of a population receiving relief, planning for all aspects of emer-
gency care can be based on an internationally accepted understanding of a typical population. This
is composed of:
51% are female;

34.6% are under 15 years of age;
12.4% are under 5 years of age;
4.0% are under 1 year old;
0.4% are under one month;
26.2% are females 15-44 years of age;
2.4% are pregnant females;
2.6% are lactating mothers;
2.5% are females aged 15 (need tetanus booster);
7.2% are over 60 years of age.
2.5 Determining Priorities for Service Provision in Population Displacements

The following matrix can be used to help prioritise response activities in an emergency as-
sociated with displacement of a large population. It describes the needs of victims (not agencies)
for the various stages in an emergency in those cases where there has been significant population
displacement in a developing country. The time frame indicates the maximum time it should take
to have the basic elements of a particular service in place. In a more developed country, the time
frame will probably be shorter and may contain different emphases, but the needs will be basically
the same.
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Stage Time- Services Health Sector Priorities

frame
Immediate first 24 • search and rescue; • triage;
hours • first aid;
• shelter;
• acute medical and surgical services;
• food;
• water;
• public information;
Short-term one week • security; • epidemiological surveillance;
• care of the dead;
• environmental health ser- • general curative care services;
vices such as personal hy- • control of diarrhœa and acute respiratory
giene, sanitation, waste dis- diseases;
posal, etc.; • nutritional surveillance;
• energy (fuel, heating, light); • (providing measles vaccination and Vitamin
A supplements is often a priority in this
phase);
Medium one month • protection (legal and physi- • restoration of preventative health care ser-
term cal); vices such as EPI, MCH, etc.;
• restoration of priority disease control
• transport; programmemes such as TB, malaria etc.;
• communications; • (re) establishment of a health information
system;
Long term Three • education; • rehabilitation;
months • training;
• agriculture; • health information and health education
• employment; programmemes;
• social services;
• environmental protection.
This chart can be completed by an agency for each emergency. Once the needs have been defined
for the victims, the same process needs to be carried out using the same matrix to define the needs
of the agency if it is to provide that service efficiently an effectively.
2.6 Vulnerability Analysis and the Health Sector

Vulnerability is normally understood in terms of social indicators (age, sex, income). However, the
health sector has much to offer in determining vulnerability. In doing so, the health sector uses in-
formation that it already collects, plus certain key social indicators, to identify those within a given
community who are especially vulnerable to hazards. This allows Emergency Preparedness and
Response Programmes to target these groups in non-emergency times, so as to address the factors
which make them vulnerable. In an emergency, the information can be used to direct relief actions
to these pre-identified groups on a priority basis.
Countries are often called vulnerable. This is a misleading use of the word, since it is impossible to
assess the vulnerability of a whole country in anything other than theoretical terms. For practical
purposes, the label “vulnerable” is best applied to particular groups within certain communities.
Both development and emergency response occur at community level, so planners and emergency
managers need information at that level.
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In the emergency management context, vulnerability can be defined as:
factors (of the community) that increase the chances of that community being unable to
cope during an emergency; e.g. the level of underdevelopment of the community; i.e. it
is one of the factors which determine that a hazard will become a disaster.
2.6.1 Assessment of Risk
Not all hazards create an emergency and not all those exposed to a hazard will be a casualty or
even affected2. What determines when or if an emergency occurs and who or what is damaged
when a hazard meets a community is not simply luck or fate – outcome is to a great extent deter-
mined by a complex set of factors which collectively generate what we call risk and unlike luck or
fate, we now have tools which allow us to estimate levels of risk quite accurately. Factors which
are reliably associated with a known outcome are called determinants. There are certain determi-
nants of hazard and community that we can identify in order to indicate a relative level of risk and
we can then undertake measures to reduce risk. We can then go back and reassess risk, to deter-
mine if our actions have actually influenced the risk.
In the emergency management context, a risk assessment is:
the quantitative study of the determinants of hazard related events in communities.3
In assessing risk, there are two major sets of determinants:
Susceptibility - called a locator – it describes the probability of exposure to a particular

hazard. It is a general statement of risk for a community and is used to locate areas
where further assessment is needed, such as for vulnerable groups. For instance, the
first step in undertaking a study of the effects of flooding would be to identify commu-
nities that are susceptible to flooding – it would be a waste of time and resources to
carry out research in areas when flooding doesn’t happen.
Vulnerability – called an identifier – this identifies groups within susceptible communi-
ties that have certain characteristics which increase their probability of a negative out-
come in comparison with other members of the community.
In general terms, a risk assessment of a community should define the following visible outputs.
Each of the elements can be given either a quantitative or qualitative value. Once the elements of
risk have been defined, the impact of prevention, mitigation and preparedness can then be assessed
as having, or not having, reduced vulnerability over time.
• the risk of death;

• the risk of injury (mental and physical);
• the risk of disease (mental and physical);
• the risk of secondary hazards (fire, disease etc.);
• the risk of contamination;
• the risk of displacement;
• the risk of loss of property;
• the risk of loss of income;
• the risk of breakdown in security;
• the risk of damage to infrastructure;
2
This analysis parallels the exposure–infection-disease-death or survival model in the biology of communica-
ble diseases. It can be illustrated with the “glasses of water” exercise.
3
See the definition of epidemiology.
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November 2009
• the risk of breakdown in essential services.
In this context, it can be seen that a risk assessment for hazards and disasters can only be meaning-
ful when it is applied to communities. It cannot be easily applied to a whole country. For the health
sector specifically, vulnerable groups are people who are a) members of a community which is
susceptible to a hazard and b) at special risk because of their health status.
To find these groups, it is essential to work in terms of communities. For practical purposes, a
community is defined as everyone living within a small, legally defined administrative area, such
as a thana, a district or a municipality. Larger units such as states or provinces are too heterogene-
ous and diverse to allow practical application of the information that is collected. Once the admin-
istrative level has been decided, a list is drawn up of all those communities, with population data
and the emergency management information that is needed. In emergency preparedness pro-
grammes, the next step is to determine the level of ambition that is to be the goal of any interven-
tion. This is dependant on the available resources and the operational constraints. You may chose
to identify and work with the bottom 10% of the vulnerable districts in one state only or in the
whole country, or, with a higher level of ambition, you may chose the bottom 20%.
Once the level of ambition is decided, the districts which fall within that level are identified for
each of the nine key health indicators e.g. the bottom 10%. The objective is to find out the districts
with the worst coverage. A second list is then drawn up identifying districts that are susceptible to
hazards, based on known risks (a chemical factory) or historical data (previous floods). Again a
level of ambition is decided e.g. to work with districts whose annual risk is greater than 90%. This
information is then correlated with the first list and those districts which have both a high suscep-
tibility to the hazard and where people are vulnerable because of poor health indicators are the
high risk group. They are then targeted by development programmes in order to raise coverage or
improve access to services.
Since the constituents of the vulnerable groups is fluid and hazards evolve over time, the process
needs to be carried out on a regular basis to identify communities in need. Upper limits for inter-
ventions should also be set i.e. if a point is reached whereby all communities in the country have
measles coverage above 90%, then measles coverage could be dropped from the surveillance pro-
gramme. In an emergency, these lists also provide up to date information to emergency managers,
so that affected districts can receive timely and appropriate health interventions.
2.7 Tools for Health Assessments

The aim of the health assessment is to determine mortality and morbidity rates, health needs and to
establish response recommendations and priorities. The principle tool used by health workers in
collecting information is epidemiology.
Factors contributing to health, or lack of it, in a displaced population must be determined by estab-
lishing the pattern of disease, the effect of cultural and social influences on the health of the popu-
lation, and the effectiveness4 of the existing health services. The key to an effective assessment and
surveillance programme is good information. Information can be collected by direct observation or
from secondary sources, such as reports from health workers. Sample surveys reveal symptoms
and disease patterns and indicate their distribution within a community. Ideally in a disaster, mass
screening on arrival at an evacuation area should always be done as it is the most reliable method
of collecting data but it is not always possible as immediate relief of suffering is the first priority.
4
Range of services, coverage, penetration, caseload, follow-up, referrals, active/passive case-finding, promo-
tion/education, etc.
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November 2009
For refugees, mass screening sometimes can be conducted at a camp during the registration proc-
ess, but it is more often done once the emergency phase is under control.
A centrally co-ordinated surveillance system must be established quickly to identity problems in

time for preventative action. For example, the incidence of diarrhœa may be an important indicator
of environmental problems. To be fully effective, surveillance requires rapid access to laboratory
services. Very simple lab services at the community level are usually adequate but good referral
and quality control systems for both patient care and specimens is an essential component of any
prevention, treatment and surveillance network.
Community reporting is an essential tool for the monitoring of disease patterns and planning of
services. National health authorities may require specified 'notifiable' communicable diseases to be
reported at once. Individual record cards are used for recording immunisations and the treatment of
illnesses. These cards should be kept by the displaced person, and in the case of young children, by
the mother.
2.7.1 Epidemiology
Epidemiology is:
the quantitative study of the determinants of health related events in human populations.
Epidemiology is a specialised form of statistics. Epidemiologists are public health professionals

who usually work for Government departments or academic institutions. They are normally con-
cerned with routine monitoring the health status of populations and advising policy makers on cur-
rent trends. In emergencies the same statistical tools can be used to investigate the effects of the
event on the health of a population. As such, the role of the epidemiologist is to present informa-
tion in a form that decision makers can use to address the situation.
The role of the epidemiologist in emergency management is to:
Identify vulnerable groups in advance;

Predict the health impact of known hazards on known populations;
Assess the needs of an affected population;
Match available resources to immediate needs;
Prevent further adverse health effects;
Evaluate a relief effort;
Contribute to future emergency planning.
To be able to function, an epidemiologist has few needs. She does need, however, rigid application
of definitions, as information cannot be collected from multiple sites and multiple sources unless
everyone involved has exactly the same understanding of the key terms involved. In health there
are fixed epidemiological definitions of most conditions (e.g. child, measles, hospital, policy)
called the case-definition. However, there are no universally accepted definitions of many terms,
such as emergency or disaster. This is not a major constraint to epidemiologists working in a spe-
cific emergency, but the lack of standard terminology makes wider trend analysis, especially when
comparing the impact of similar events on different populations, almost a worthless exercise. Simi-
lar problems occur with definitions of other common emergency-related words such as affected,
casualty, damaged, displaced, vulnerable, etc.
A common fault in reporting of emergencies is to use raw data for analysis e.g. reporting that an
earthquake killed 1,234 people. This is meaningless as well as useless to anyone except journalists.
To be practical and meaningful, data needs to be expressed in two main forms, called indicators:
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November 2009
Rates – the number of cases per unit of population – this tells you what is happening
now and how big (or how serious) the problem is e.g. in a cyclone, a district with 2500
killed at a rate of 250/1000 is more in need that one with 5000 killed at a rate of
50/1000;
Trends – this compares one rate with another over a period of time – it tells you what
has happened up to now, how your interventions are doing, what might happen in the
near future or how this emergency compares with other similar events e.g. in the 5
years since our project started, floods have injured an average of 19/1000 in District X
but in the ten years prior to our project, an average of 123/1000 people were killed each
year in the same population; therefore we can say our interventions have been success-
ful.
Some other terms are very important in epidemiology. These are:
Incidence – this is a rate which tells the number of new cases of a disease in a given pe-
riod of time;
Prevalence – this is a rate which tells the number of existing cases of a disease present
in a community at any given time;
Endemic – this describes diseases which are always present in a community; they may
be constantly present (holo-endemic), with seasonal or periodic fluctuations. They can
cause large numbers of cases each year e.g. malaria (hyper-endemic) or very few e.g.
rabies (hypo-endemic).
Epidemic – this describes the appearance of diseases which are not usually present in a
community as well as any unusual increase in the incidence of an endemic diseases
(malaria can be endemic and also cause epidemics). Epidemics are public health emer-
gencies because they affect large numbers of people in a short period and thus can
quickly overwhelm health systems or because they have very serious social and eco-
nomic consequences if not contained. Not all infectious agents cause epidemics - cer-
tain micro-organisms are classified as causes of diseases of epidemic potential, and
each of them has different thresholds for being declared epidemics.
Outbreak – this describes an increased number of cases of an infectious disease of suf-
ficient magnitude to cause concern, but not enough to create an emergency.
2.7.1.1 Mortality Rate
The Mortality Rate (death rate) is the single most important indicator of serious stress (e.g. ill-
ness, malnutrition) in a displaced population. Knowing the causes of death is crucial since it
helps set priorities for appropriate relief and prevention interventions.
In a displaced population served by well-run relief efforts, overall mortality rates should not ex-
ceed 1.5 times those of the host population. In general, even initially high mortality rates should
fall to or below 1.0 per 10,000 per day within 4-6 weeks of beginning a basic support programme
that provides sufficient food, water, immunisation, simple health care, and other immediate needs.
Mortality Rates exceeding 2.0 per 10,000 population per day indicate a very serious situation and
immediate action needs to be taken. Death rates should be calculated over an extended period,
ranging from one week to a month. Since it may be difficult to determine the total population, a
sample size of 20-30 families is recommended.
2.7.1.2 Procedures for calculating mortality rates
Mortality Rate = Deaths/10,000/day = Number of deaths x 10,000/Number of days x Population
For example: if 21 deaths have occurred over a 7-day period in a displaced population of 5,000
people, the mortality rate would be calculated as follows:
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November 2009
Mortality Rate = 21x10,000/7 x 5000 = 210,000/35,000 = 6

which is expressed as 6 deaths per 10,000 per day
To convert to the number of deaths per 1,000, which is the preferred method of public health per-
sonnel and epidemiologists, divide the rate above by 10 (0.6 deaths per 1000 per day).
A mortality rate greater than 1.0/10000/day is considered a medical emergency. The “normal”
death rate in a developing country is about 0.5/10,000/day.
3. Specific Response Issues
3.1 Health Sector Responsibilities

3.1.1 Disease Control
The risk to an individual of both contracting and transmitting a communicable (infectious) dis-
eases is increased by overcrowding, poor environmental conditions, and the often poor initial state
of health of the population. The infectious organism however, must first be present to spread.
Measures to improve environmental health conditions are, therefore, very important. These meas-
ures include providing enough safe water, washing facilities and soap, proper disposal of excreta
and garbage, controlling rodents and vectors of disease, as well as informing and educating the
population on general public health issues.
3.1.2 Immunisations
The only immunisation required during the early weeks of an emergency is for young children
against measles (all children between six months and 15 years of age). This is a high priority even
when resources are scarce, and all children should receive the vaccine even if they have had it be-
fore. If significant malnutrition is present, it is absolutely essential to implement a vaccination
programme as soon as possible. All other necessary immunisations e.g. Diphtheria-Tetanus-
Pertussis (DTP), Tetanus (TT) Polio (OPV) and Tuberculosis (BCG) should be given later, once facili-
ties allow, and to the extent possible within the framework of the existing Expanded Programme of
Immunisation (EPI) of the (host) government.
The chart below illustrates immunisable diseases that might be present during a displaced person
emergency situation, the relative value of an immunisation programme for each disease, and the
age group target for each type of immunisation programme.
DISEASE NAME OF VACCINE PRIORITY IN AN EMERGENCY TARGET AGE GROUP
Measles Measles ++++ Under 15 years

Polio OPV ++ Under 5 years
Diphtheria DPT ++ Under 5 years
Pertussis DPT ++ Under 5 years
Tetanus DPT ++ Under 5 years
Tetanus TT ++ Females over 15 years
Tuberculosis BCG + Under 5 years
Cholera Cholera 0 No vaccination needed
Typhoid Typhoid 0 Vaccination arely needed
Meningococcus Meningococcal Use only in outbreaks Children 2-15 years
3.1.3 General Health Care

Displaced people must be given an opportunity to share in the responsibility for their own health.
This has been shown many times to have a positive effect on the morale and overall mental state of
people confined in restricted circumstances. Services should be operated with rather than for the
displaced people. Strong emphasis should be placed on the training and/or upgrading of the medi-
cal skills of selected displaced people, particularly in their former roles within the community (e.g.
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November 2009
traditional healers and midwives). As a general principle, the order of preference for selecting
health personnel, in co-operation with the national services, is displaced people first, experienced
nationals or residents next, and finally, outsiders. Most emergencies will require some combination
of these sources. An important consideration may be the government's attitude toward foreign
medical personnel, including the recognition of qualifications and authority to practice medicine.
3.1.3.1 Estimating needs
The first level of health care for displaced people is the community health worker (CHW), who is
responsible for a small section of the population and works among them to provide outreach ser-
vices such as home visits, case finding, referrals and follow up. She is also responsible for basic
community-wide preventive measures, including public health information, promotion and educa-
tion. The CHW should be a displaced person with appropriate training, who can identify health and
nutritional problems and refer patients to a clinic if simple on-the-spot treatment is not possible.
She also should be able to explain in appropriate cultural terms general public health and adminis-
trative interventions which need the assistance and co-operation of the community, such as mass
vaccinations and undertaking surveys.
As a general rule, one CHW can serve 50-100 families. A clinic should be established for every 5-
10,000 displaced people. The clinic should be staffed by one nurse and 2-3 displaced people or na-
tional health workers. The next level would be a health centre for each displaced person settle-
ment. The centre should have a limited number of beds for overnight stays at a ratio of approxi-
mately one bed per 5,000 displaced people. The health centre should be staffed by two doctors,
and 8-10 nurses per 20,000 displaced people. One doctor should work in the centre while the other
covers clinic level activities. A district hospital normally can serve a maximum base population of
200,000 people.
It can be estimated that 1% of a displaced population will see a health worker each day, 1% of
those examined will need hospitalisation and 1 hospital bed is needed for every 1000 people. It is
also known that the average consultation in a clinic takes 7 minutes, a CHW can see about 30 peo-
ple per day, a nurse 50 people and a doctor 40 people. With these guidelines, it is easy to estimate
facility, staffing and material needs for any given population.
There may also be a regional/district hospital with staff assisted by doctors and nurses from the
emergency organisation that handles complicated maternity cases and surgical emergencies on re-
ferral from the settlement.
If possible, establishing special hospitals for displaced people should be avoided. They are skilled-
labour intensive, provide only curative services, rarely continue to function once outside support is
withdrawn and are inappropriate for long-term needs. Once established they are extremely difficult
to close. Such hospitals, therefore, should only be provided if a clear and continuing need exists
that cannot be met by existing or strengthened national hospitals.
"Portable field hospitals" have several disadvantages including: the complicated logistics of trans-
porting and set up, high cost and inappropriate systems and equipment that are overly sensitive and
dependent on electricity. Field hospitals are rarely satisfactory for meeting continuing needs. They
may, however, be very useful for meeting acute needs (in earthquakes or civil conflict) where inju-
ries requiring surgical intervention are the major problem.
3.1.4 Medical Supplies
3.1.4.1 Overall policy
The World Health Organisation (WHO) has developed an standard list of essential drugs and medi-
cal supplies for use in an emergency. They recommend that all Ministries of Health formally adopt
this list as policy and set up supply management systems whereby these items can be made avail-
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November 2009
able rapidly and efficiently in times of emergency. The best way to do this is to ensure that these
items are held in buffer stocks at key points around the country. Buffer stocking ensures that items
with expiry dates are rotated that essential relief supplies are as close as possible to where they
may be needed and that they are integrated into a logistics system that already exists (as opposed
to setting up special systems during a crisis).
3.1.4.2 Medical Kits
Also developed by WHO is a kit for sending these basic health relief items to international disasters.
Its contents are calculated to meet the common medical needs of a population of 10,000 persons
for three months. It is packaged as the New Emergency Health Kit, a standard that has been
adopted by all reputable international relief organisations and many national authorities as a reli-
able, appropriate, inexpensive, and quickly available source of essential drugs and health equip-
ment needed urgently in an emergency situation. The Kit consists of two different units of drugs
and medical supplies: the Basic Unit (10 units per kit) and the Supplementary Unit (1 unit per kit).
The 10 Basic Units contain drugs, medical supplies and some essential equipment for use by pri-
mary health care workers with limited training. Each Basic Unit is designed for a population of
1000 for 3 months, weighs 45 kg and has a volume of 0.2 cubic metres. It contains twelve drugs,
none of which are injectable. Simple guidelines are included to help the training of personnel in
the proper use of the drugs.
The Supplementary Unit is designed for a population of 1000 for 3 months, weighs 410 kg and is 2
cubic meters in volume. It contains drugs and medical supplies to be used only by professional
health workers and doctors. It does not contain any drugs or supplies from the basic units and
therefore can only be used as a supplement to the Basic Unit Kit. The full Emergency Health Kit
includes 10 Basic Units and one Supplementary Unit, weighs approximately 860 kg and is 4 m3 in
volume. An entire kit could be strapped into the back of a pickup. In an emergency, the kit can be
requested through any WHO office and it will be delivered within 3-4 days. The cost of a complete
kit in 1998 was about $5,000 excluding freight costs.
3.1.4.3 Donations
Emergency medical supplies and medical equipment should draw on in-country resources and dis-
tribution channels to the greatest extent possible. Provided local purchase is possible and not un-
usually expensive, cash contributions are the best way to meeting immediate needs.
Unsolicited donations of drugs may present a problem, as their quantity and quality may vary
greatly and they rarely arrive in time to meet urgent needs. In general, drug donations should be
refused as they may consist of small quantities of mixed drugs, free samples, expired medicines,
inappropriate vaccines and drugs identified only by brand names or in a foreign language. The cost
of transporting, storing, sorting and distributing them is born by the recipient, and the workload
involved diverts already overworked staff from more pressing needs.
If needed, medical supply donations should be specifically requested on an item by item basis.
They are best used to supplement stocks in central warehouses to replace what has already been
sent to the field or to send to unaffected areas if their routine supplies have been diverted to the
disaster area.
3.1.5 Vaccines
Mass vaccination campaigns are rarely required after a disaster. The priority is always to restore
normal services. However, in situations where people have been displaced and have become refu-
gees, measles vaccination of children under 5 may be a priority. Vaccinations for cholera and ty-
phoid are NEVER required.
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November 2009
It should be noted that most vaccines require refrigeration and careful handling to remain effective.
Without a Cold Chain, the refrigerated transportation system for vaccines from manufacturer to
individual, the immunisation programme will be ineffective. Storage facilities located at the central
(capital city) and regional level should have temperature alarms and backup (emergency) genera-
tors.
3.1.6 Care of the dead
The collection, identification and disposal of dead bodies is not normally a health sector responsi-
bility, but it is worth mentioning here as there are many issues that concern the public related to
health and dead bodies.
It is a common misconception, always propagated enthusiastically by the media after a disaster,

that dead bodies are a source of epidemics. In fact epidemics are very rare after disasters, and they
are never caused by dead bodies. When they have occurred, it has been due to inadequate attention
being paid to ensuring that survivors have access to clear water and sanitation.
Care of the dead is a very important aspect of emergency management, but not for public health
reasons. We have social and cultural obligations to ensure that the dead are treated with respect
and disposed of according to the rites and traditions of their culture. Mass burials, spraying anti-
septics at disaster sites and use of lime powder on bodies are not public health requirements and
serve not only to further distress already traumatised survivors but also to waste the time of emer-
gency staff, who would be much better employed in taking care of the living.
3.1.7 Foreign Medical Teams
Occasionally, a country’s health care system can be so overwhelmed as to necessitate the govern-
ment requesting foreign personnel to assist. This decision should not be taken lightly – foreigners
unfamiliar with local customs, language, living conditions and medical culture can be more of a
problem than a help. If requested, they should be assigned to medical and health facilities away
from the disaster area, to replace local staff temporarily reassigned to the relief operation.
3.2 Overview of Common Health Problems

Health is defined by the World Health Organisation in terms of well-being rather than illness. This
definition includes aspects of psychological trauma that are particularly relevant to emergency
management.
The following provides information on diseases common to emergency situations where a large
number of people have been displaced. It includes information on the symptoms, transmission, and
possible curative and/or preventative measures that can be introduced for these diseases.
An important point to note is that among the all diseases discussed in this section, 80-90% of all
deaths in displaced populations are caused by the following five conditions:
Malnutrition;
Measles;
Acute respiratory infections;
Diarrhœa;
Malaria.
All of these conditions are already common in areas prone to hazards and are exacerbated when a
disaster occurs. The presence of one makes the risk of contracting any of the others higher so that
the effects are compounded rapidly.
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November 2009
3.2.1 Trauma
3.2.2 Estimating medical needs
The flowing data is from the CRED disaster database for the period 1990-2000. All that is needed is
to know the population of the affected area to make an initial estimates of likely medical, surgical,
water and food needs in a given population. Actual needs can be assessed and addressed as infor-
mation starts to flow.
% affected % affected population

Hazard population killed injured injured: killed
Transport mass accident 49.6% 23.6% 0.47
Tsunami/storm urge 4.42% 1.14% 0.26
Earthquake 0.51% 1.68% 3.28
Slides (mud, land, snow) 0.45% 0.11% 0.23
Tropical storms 0.09% 0.13% 1.37
All storms (+snow, wind) 0.08% 0.13% 1.71
Volcano 0.04% 0.02% 0.47
Forest fires 0.02% 0.02% 1.41
Flood 0.01% 0.06% 8.36
Epidemic 0.68% n/a n/a
Drought 0.001% n/a n/a
3.2.2.1 Hospital Capacity Assessment

For hospitals that already exist, there are empirical guidelines for assessing the capacity of a hospi-
tal to absorb a large number of casualties. It is important for hospitals to recognise their limits so
as to avoid becoming overloaded.
These figures are guidelines only. Each hospital must prepare its own emergency plan and estab-
lish its own capacity assessment criteria that correctly reflect its own situation. It is important to
reassess capacity each year, based on actual experience and also because new resources and facili-
ties may have been added.
3.2.2.1.1 Hospital Treatment Capacity (HTC)

In general, the maximum capacity of a hospital to absorb seriously injured (triage red) casualties
can be calculated at 3% of the number of beds e.g. a 500 bed hospital can handle a maximum of 15
serious patients per hour, including time for assessment, urgent radiology and clinical investiga-
tions, diagnosis, initial treatment and transfer to surgery, a ward or another hospital. If the HTC is
exceeded, the management of seriously ill patients will be unacceptably delayed and morbidity and
mortality will increase.
Those despatching casualties to a hospital from an incident should be aware of the capacities of all
the hospitals that are receiving injured people. All hospitals should have backup arrangements so
that when they have filled all their beds, another hospital can take over.
Patients with special needs (burns, spinal injuries, etc.) should be sent to a specialist unit as soon
as possible after stabilisation.
3.2.2.1.2 Hospital Surgical Capacity (HSC)

Surgical capacity is an estimate of how many operations the hospital can perform over a 12 hour
period.
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HSC = number of operating rooms x 7 x 0.255 for a 12 hour period.
This allows for change over time, re-supplying and re-equipping and staff rotation.
3.2.2.2 Hospital Resource Management
WHO provides guidelines on how to calculate amounts of renewable resources that will be needed in
an emergency6. For equipping and supplying field hospitals and other temporary medical facilities,
ICRC have excellent guidelines.
3.2.3 Estimating surgical needs

The following is taught by military medical specialists working in disasters with significant num-
bers of trauma cases:
60% of injured don’t need surgical treatment in a hospital – they need simple first aid
or primary medical care;
25% of injured will die regardless of treatment (95% die before they reach hospital);
15% of injured will die or survive depending on the treatment they receive.
3.2.4 Priority Diseases

3.2.4.1 Measles
Measles is the number two killer of children under 5 after a disaster. It is a highly contagious viral
infection spread by coughing. It is characterised initially by fever, cough, running nose and red
eyes, This is followed after 3-7 days by a dusty red, blotchy rash which begins on the face and then
extends over the rest of the body and lasts for 4-6 days. Measles is a disease that can result in very
high mortality, especially in an undernourished population. The incubation period is about 10 days
from exposure to disease to onset of first symptom.
The infected individual can re-infect others from the first appearance of symptoms, until four days
after the appearance of a rash. However, once a person has had measles, she will develop a lifelong
immunity. Measles vaccine should be given before an outbreak occurs, ideally as soon as the dis-
placed persons can be assisted. If significant malnutrition is present, it is absolutely essential to
implement a measles vaccination programme as soon as possible. If vaccine supplies are limited,
the top priority is to vaccinate all malnourished and hospitalised children. Vitamin A given at the
time of vaccination will enhance the protection of the child.
Since measles is such a highly contagious disease, it is likely that most susceptible individuals
have been exposed, and are already incubating the disease by the time several cases have been re-
ported. It is important not to waste vaccine and manpower trying to stop the spread of measles in a
camp where the disease is already established because it takes approximately one week after vac-
cination for a child to develop immunity to measles. The attention should instead be focused on
populations where measles has not yet appeared, especially villages immediately surrounding the
infected area.
3.2.4.2 Acute Respiratory Infections
Acute Respiratory Infection (ARI ) is a spectrum of diseases ranging from bronchitis to pneumonia
that is caused by a variety of viruses and bacteria. It is marked by rapid breathing, cough and often
fever. It may be mild or may progress rapidly to death, especially among malnourished children.
5
the average operating room performs 7 procedures per 12 hour period over the whole year. But many seri-
ously injured patients requiring surgery at the same time reduces the efficiency of an operating theatre to 25%
of normal.
6
The New Emergency Health kit;
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November 2009
ARI is more likely when there is cold, rain, inadequate blankets and clothing, poor ventilation and
over-crowding. The best preventative strategy is to provide adequate space, shelter, clothing blan-
kets and ventilation. For severe cases, the treatment is antibiotics.
3.2.4.3 Diarrhœa
Diarrhœa is the most common fatal childhood diseases world-wide. Malnourished children are par-
ticularly prone to diarrhœa and its complications of dehydration and shock. If untreated, it is fre-
quently fatal. Diarrhœa is transmitted through contaminated food and water. There are many dis-
eases that cause diarrhœa – most are caused by viruses (which is why antibiotics are useless) but
some are caused by bacteria (cholera, typhoid and shigella), and protozoa (giardia and amœba).
Dysentery is a form of diarrhœa caused by amœba or shigella where blood is lost as well as fluid.
Antibiotics rarely affect the course of childhood diarrhœa. Diarrhœa generally is self-limited and if
fluids and electrolytes (water, salt, bicarbonate, potassium, etc.) can be replaced by mouth, the ill-
ness will run its course and the patient will survive . Treatment can be done at home with packets
containing the proper mixture of electrolytes (Oral Rehydration Salts - ORS).
If diarrhœa, other than cholera or typhoid, is suspected to be a major problem, the following
measures should be taken by the health authorities or other responsible specialised agencies:
Confirm the problem by reviewing morbidity and mortality data. Additional informa-
tion, such as location of patients, the length of time in the camp and the source of fam-
ily water supplies can help pinpoint the source of infection.
Check the adequacy and purity of water supply to determine if there is any actual or po-
tential contamination of water supplies by human fæces.
Stress the importance of oral rehydration therapy (ORS);
Intravenous fluids are rarely needed.
3.2.4.4 Malaria
Malaria is caused by a parasite called Plasmodium that lives in the saliva of Anopheles mosqui-
toes. Plasmodium invades human blood cells to complete its life cycle. There are four types of
Plasmodium, but Vivax and Falciparum are the most common. Vivax is generally not a life-
threatening disease, but Falciparum can be rapidly fatal and requires prompt treatment. The usual
symptoms of malaria are fever, chills, headache and sweats that can progress to kidney and liver
failure, shock and even coma. Fever and delirium, disorientation or coma should be assumed to
be malaria and treated promptly in an area known to have Falciparum malaria.
If malaria is suspected, the following measures should be taken by the health authorities or other
responsible specialised agencies:
Confirm the diagnosis. If laboratory confirmation is not available it can be assumed that
recurrent fever, chills and headache in a known malaria area is malaria until proven
otherwise.
Assess the risk of disease. The major threat to health arises in non-immune populations
who may be forced to flee from a setting where malaria is not a problem (especially in
urban areas) to jungle, swamps or other areas where malaria transmission is occurring.
Assess prevalence and seventy:
Analyse laboratory data, if available, to determine number of confirmed cases by
type (Vivax or Falciparum);
Check morbidity and mortality records;
Institute control measures:
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November 2009
If it can be assumed that malaria may be or might become a problem (during the
malaria season), mosquito spraying, or other appropriate control measures in the
concerned areas, and close surveillance for possible malaria, should be instituted.
If malaria is already a major problem, mosquito control becomes more urgent.
Consideration should also be given to prophylaxis of the entire population with
anti-malarial drugs (if this is possible) until mosquito control programmes can be
instituted.
3.2.5 Other Diseases

The following diseases may also cause problems in an emergency:
Cholera;
Diphtheria;
Tetanus;
Whooping cough;
Intestinal parasites;
Meningitis;
Polio;
Skin infections;
Tuberculosis;
Typhoid.
3.2.5.1 Cholera
Cholera is an acute intestinal disease characterised by sudden onset of profuse watery diarrhœa
with occasional vomiting. It is caused by a bacteria (Vibrio Cholera) that releases a toxin into the
intestines. Transmission occurs through ingestion of water contaminated with fæces. To a lesser
extent, food contaminated by water, soiled hands, and even flies can spread the disease. Person-to-
person spread generally does not occur. The incubation period for cholera is usually 2-3 days, but
can be from a few hours to as long as 5 days. Patients generally carry the cholera bacteria in their
stools only while they are having diarrhœa and for a few days after recovery. Although long-term
carrier states have been described, incidence is quite rare.
Not everyone who is exposed gets cholera as a very high dose of bacteria is needed to become ill.
Only about 10% of those exposed will get ill and of those, about 1% will die. Therefore, most in-
fected individuals will have mild diarrhœa or even no symptoms at all and only in some cases will
diarrhœa be so severe as to lead to dehydration and even death. The recommended treatment is re-
hydration with ORS by mouth.
A cholera vaccine is available but current vaccines provide protection in only about 50% of cases
and protection lasts only a few months. WHO does not recommend mass vaccination during epi-
demics, as initial immunisation requires two doses of vaccine given 4 weeks apart, which is too
long to be of use in an acute situation. It cholera is suspected, the following measures should be
taken by the health authorities or other concerned agencies:
1. Report suspected cases to national public health authorities;

2. Confirm the diagnosis by culturing stool samples from suspected cases. Regional
public health laboratories or a hospital lab in the capital city should be able to help
confirm this diagnosis by testing the samples;
3. Check the hygiene loop to be sure water is safe and is protected from sewage con-
tamination (the source of the infection in most cases);
4. Vaccine does not prevent the spread of cholera!
3.2.5.2 Diphtheria
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November 2009
Diphtheria is generally not a problem in tropical countries. It is usually characterised by a patch or

patches of a greyish membrane in the throat. It is caused by a bacteria (Clostridium diphtheriæ)
that releases a toxin in the throat. Diphtheria can be easily prevented by DTP vaccination.
3.2.5.3 Tetanus
Tetanus is a severe infection caused by a bacteria (Clostridium tetani) that releases a toxin in a
wound. It is characterised by painful muscular contractions, especially of the jaw and neck mus-
cles. In developing countries, this disease is almost always fatal. Tetanus is transmitted through
spores introduced into the body during injury, usually a puncture wound contaminated with soil or
fæces, but also through burns and trivial wounds. Neonatal (infant) tetanus continues to occur in
large numbers in developing countries because of unsterile cutting of the umbilical cord or tradi-
tional practices such as covering the cord stump with unsterile items (e.g. cow dung). Tetanus can-
not be transmitted person-to-person. The incubation period is about 10 days.
Tetanus can be effectively prevented by mass vaccination of infants, adolescent girls and pregnant
women.
3.2.5.4 Whooping Cough

Whooping Cough is a bacterial disease (Bordetella Pertussis) common in children throughout the
world. It begins with a runny nose and an irritating cough. The cough gradually becomes worse
over 1-2 weeks and lasts for 1-2 months. Whooping Cough can be a severe disease and fatal, espe-
cially in non-immunised malnourished children less than one year of age. Diphtheria and Whoop-
ing Cough are transmitted through the air from respiratory secretions of infected patients. The in-
cubation period for both can last from 7-10 days. The period of communicability is the first three
weeks of illness. DTP (Diphtheria-Tetanus-Pertussis) vaccine is available and highly protective
against these three diseases. The vaccine must be given in three separate injections at least four
weeks apart.
3.2.5.5 Intestinal Parasites
Intestinal parasites are extremely common in developing countries. A majority of the population
can be infected with one or more parasites, of which the most common are usually Ankylostoma,
Ascaris, Giardia, and Trichuris. Many of those infected will appear perfectly healthy, but fever,
anæmia, abdominal pain, vomiting and exacerbation of malnutrition can occur with heavy infesta-
tions. These parasites are transmitted when walking barefoot on soil contaminated by fæces or by
eating food with unwashed hands. Intestinal parasitic infections should assume a very low priority
in the emergency phase.
3.2.5.6 Meningitis
Meningitis is a disease caused by a by a variety of viruses, bacteria and parasites, including ma-
laria. It is characterised by fever, stiff neck and headaches. If left untreated, it can progress rapidly
to coma, and death in up to 50% of those infected. Some types of meningitis are highly contagious,
especially those due to certain bacteria (Meningococcus and Haemophilus) and are spread by
coughing and sneezing. An outbreak of meningococcus is a public health emergency as it causes
high levels of morbidity and mortality. Ascertaining the specific cause of meningitis is often very
important since, with meningococcal meningitis, it may be appropriate to treat, or perhaps vacci-
nate, high risk groups with an antibiotic.
3.2.5.7 Poliomyelitis
Polio is not normally a problem in an emergency although it may appear as a consequence of poor
hygiene in temporary camps. It is an acute infection caused by a virus (Poliomyelitis) and is char-
acterised by fever, malaise, headache, nausea and vomiting, and stiffness of the neck and back,. A
small proportion of those infected will develop paralysis, usually of one leg. Polio can range in
____________________________________________________________________________________________________________________
November 2009
severity from an infection without any symptoms to meningitis to paralytic disease and even death
due to paralysis of the muscles of respiration.
The paralysis of polio is typically asymmetrical (i.e. involving only one leg or one arm). In dis-
placed persons situations, the diagnosis is generally made on symptoms alone, since laboratory
diagnosis involves the difficult task of isolating the virus from fæces or saliva. Polio is spread by
close contact with infected individuals, and rarely by food or water. In developing countries, older
children and adults are usually immune to polio, having had contact with the virus during child-
hood. The incubation period for polio is from 3-21 days, but commonly 7-12 days. Even a few
cases of paralytic polio indicate an epidemic and should be treated by a mass childhood vaccina-
tion campaign with oral polio vaccine. Oral polio vaccine is safe, inexpensive, has few side effects
and is easy to administer.
WHO and UNICEF are currently operating a world-wide campaign against polio and expect to eradi-
cate it early in this century.
3.2.5.8 Skin Infections
Skin infections are generally a low priority in the emergency phase of the relief operation; but
since these infections may be an indication of deficiencies in the supply of soap and water, and of
overcrowding, they should be investigated.
Scabies is a common skin infection in displaced person, especially for those living in
crowded conditions with inadequate water supplies for washing. Scabies is caused by a
mite and is characterised by intense itching and small sores caused by the mite burrow-
ing under the skin;
Impetigo (bacterial infection of the skin) is a highly contagious skin infection common
in displaced people.
3.2.5.9 Tuberculosis
Tuberculosis (TB) is usually not an illness that needs to be considered in the first few weeks of a
displaced person emergency. The disease is caused by a bacteria (Mycobacterium tuberculosis)
spread by coughing. It can take years to develop after exposure. It is a chronic, progressively de-
bilitating disease most commonly involving the lungs and is characterised by fever, cough with
sputum production and weight loss. TB is usually not a rapid fatal disease except in AIDS patients
and very young children who can die of disseminated TB or TB meningitis.
Although TB may not be a first priority in an emergency, it should not be forgotten. Crowded
camps provide a fertile ground for transmission of the disease. If TB is suspected, the following
measures should be taken by the health authorities or agency concerned:
1. Attempt to confirm the diagnosis. TB can be easily diagnosed by a laboratory tech-

nician if a microscope is available. If laboratory confirmation is not available,
assume that fever and cough that persists for more than three weeks is TB until
proven otherwise.
3. If sputum smears can be done, examine laboratory records to determine the total
number of smears examined and the number found to be positive for TB.
4. Check morbidity and mortality records to assess the number of deaths attributable
to TB, Check also the number of patients reporting to the hospital, or clinic,
with fever and chronic cough.
5. If TB is a major problem, a treatment and control programme should be instituted by
the moh or an experienced agency and case finding should begin.
6. Consideration should be given to starting a BCG vaccination programme. Since
young children are at high risk of developing severe and rapidly progressive
____________________________________________________________________________________________________________________
November 2009
cases, BCG vaccine should be targeted at the young, especially children under
one year of age.
WHO has developed a very successful treatment regime for TB called DOTS, which can deliver up to
90% cure. If TB is a problem in an emergency situation, the local WHO office can provide valuable
assistance.
3.2.5.10 Typhoid
Typhoid is caused by a bacteria (Salmonella typhi). It is characterised by fever, headache, malaise
and, occasionally, a mild rash on the trunk. Constipation occurs more commonly than diarrhœa.
Typhoid is spread by food or water, contaminated by fæces or urine from a patient or carrier of the
disease. Flies can also transmit the disease. The incubation period is 1-3 weeks.
Usually the typhoid bacteria is excreted in the stool while the patient is sick. About 70% of pa-
tients will excrete bacteria for three months, and 2-5% become permanent carriers. As with cholera
vaccine, typhoid immunisation is not recommended in displaced person situations or following
natural disasters. The vaccine requires two doses one month apart to be effective.
In an outbreak situation, vaccination programmes can be harmful since they divert scarce re-
sources and attention that should be directed to ensuring safe food and water supplies. If a typhoid
outbreak is suspected, the following measures should be taken by the health authorities.
Confirm the diagnosis;

Ensure the water supply is safe and protected from contamination.
3.2.5.11 Typhus
Typhus is a disease caused by a bacteria that is spread by ticks and lice and it is characterised by
fever and a rash. It is commoner in cold climates where people live in overcrowded conditions
where they are unable to wash properly or change their clothes regularly. Treatment is with antibi-
otics and prevention is by improving the living conditions of the population.
4. Summary
Major emergencies, which arise when hazards interact with communities, and which are com-
prised of mass casualty events, disasters and complex emergencies, are a threat to public health,
public safety, security and human development. It is essential that, if lives, property and the envi-
ronment are to be protected, an organised approach is taken to the management of major emergen-
cies. This is done through developing Hazard Mitigation and Prevention, Emergency Preparedness
and Vulnerability Reduction Programmes, each of which address different aspects of risk.
The management of risk in communities should be a fundamental component of any human devel-
opment programme if it is to be sustainable, in that risk management addresses factors which im-
pede or retard development. The health sector is a key partner in the management of community
risk because so many of the effects of a hazard have a direct impact on health and because many of
the causes of vulnerability can be addressed through health sector development programmes. The
health sector was the first to take an organised approach to emergency management and has given
the emergency management community many of the concepts and tools that they use.
Emergency management capability is a basic need in any community but it often a neglected com-
ponent of public health systems. If health is to achieve its full expression7, policy makers need to
7
not just absence of disease but the attainment of well-being (WHO)
____________________________________________________________________________________________________________________
November 2009
encourage and empower local health staff to play an active role in community initiatives to reduce
risk and protect development.
____________________________________________________________________________________________________________________
November 2009

Health Sector Actions in Emergencies

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Health Sector Actions in Emergencies

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WHO

WESTERN PACIFIC REGIONAL OFFICE

An Overview of Health Sector Actions

3.2.4 Priority Diseases 23

2. General Planning Issues

2.1 Assessing the impact of a hazard

the causative factors of the health problems;

Classification of the victims;

casualties (killed, injured, sick);

assist in search and rescue;

assist in provision of food and fuel;

2.1.3.4 Epidemiological Surveillance

replacement and repair;

and it must also:

review the emergency plan, local policy and administrative procedures;

2.2 The Health Sector Role in Preparing for an Emergency Response

any existing national, provincial or district emergency profiles;

directory of staff and experts;

Setting priority issues in response to an emergency depends on several factors:

the level of readiness in the country and its districts;

meeting of co-ordination bodies;

Depending on the threat, the following information will be needed:

which areas are susceptible;

2.3 The Disaster Assessment Report

who files the report district, province, department;

2.3.1 The First Report

2. What is the caseload:

3. What resources are available:

4. What resources are needed

Specify type, quantity and time period:

Attach district emergency profile (mandatory reporting every 6 months)

2.3.2 Interim Report

2.3.4 Consolidated Annual report

51% are female;

2.5 Determining Priorities for Service Provision in Population Displacements

Stage Time- Services Health Sector Priorities

2.6 Vulnerability Analysis and the Health Sector

In the emergency management context, vulnerability can be defined as:

In the emergency management context, a risk assessment is:

the quantitative study of the determinants of hazard related events in communities.3

In assessing risk, there are two major sets of determinants:

Susceptibility - called a locator – it describes the probability of exposure to a particular

• the risk of death;

• the risk of breakdown in essential services.

2.7 Tools for Health Assessments

A centrally co-ordinated surveillance system must be established quickly to identity problems in

Epidemiology is a specialised form of statistics. Epidemiologists are public health professionals

The role of the epidemiologist in emergency management is to:

Identify vulnerable groups in advance;

Some other terms are very important in epidemiology. These are:

Mortality Rate = 21x10,000/7 x 5000 = 210,000/35,000 = 6

3. Specific Response Issues

3.1 Health Sector Responsibilities

DISEASE NAME OF VACCINE PRIORITY IN AN EMERGENCY TARGET AGE GROUP

Measles Measles ++++ Under 15 years

3.1.3 General Health Care

It is a common misconception, always propagated enthusiastically by the media after a disaster,

3.2 Overview of Common Health Problems

% affected % affected population

3.2.2.1 Hospital Capacity Assessment

3.2.2.1.1 Hospital Treatment Capacity (HTC)

3.2.2.1.2 Hospital Surgical Capacity (HSC)

HSC = number of operating rooms x 7 x 0.255 for a 12 hour period.