1. (Health & Nutrition Specialist)
Public Health Effects of & Public Health Efforts made for the Pakistan Floods
Dr. Abdul Jamil
(Health & Nutrition Specialist)
UNICEF Peshawar
March 8, 2012
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil] 1

2. Background
Pakistan Floods of August 2010 were unprecedented & devastating that affected 20 million people in 78 districts
Killed 1800 individuals, destroyed 2 million homes & 514 health facilities
Prior to this crises the country already had about 4 million IDPs & Refuges in KP.
Health indicators were dismal before the flood, MMR=203 [ ] and U5MR 89.
Most of the flooded populations comprise the lowest socioeconomic quintiles that were already facing neglect. This crisis worsened their plight
Emergencies such as floods are usually characterized by situations in which large populations are in need of urgent humanitarian relief. Such emergencies usually results in large scale displacements of population, that needs temporary resettlement in camps.
Resettlement in camps may entail high population densities, inadequate shelter, poor water supplies and sanitation, and a lack of even basic health care. In these situations, there is an increased threat of communicable disease and a high risk of epidemics.
Communicable diseases are a major cause of mortality and morbidity in emergencies, and particularly in complex emergencies, where collapsing health services and disease control programmes, poor access to health care, malnutrition, interrupted supplies and logistics, and poor coordination among the various agencies providing health care often coexist. The main causes of morbidity and mortality in emergencies are diarrheal diseases, acute respiratory infections, measles and, in areas where it is endemic, malaria. Other communicable diseases, such as epidemic meningococcal disease, tuberculosis, relapsing fever and typhus, have also caused large epidemics among emergency-affected populations. Malnutrition and trauma are the two main additional causes of illness and death.
Ensuring adequate shelter, water, sanitation and food and providing basic health care are the most effective means of protecting the health of those affected by emergencies. A systematic approach to the control of communicable diseases is a key component of humanitarian response, and is crucial to protect the health of affected populations. This requires co-operation among agencies working at local, national and international levels, and collaboration among all sectors involved in the emergency response – health, food and nutrition, shelter, water and sanitation.
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

3. Damages of Floods in KP 1 Total population (million) 25.23 2
Total affected population (million)
4.366 3
Total affected districts (#) 10 4
Total Affected Households (#)
545,739 5
Total affected villages (#)
581 6
Total Dead (#)
1,011 7
Population Displaced
890,256 8
Population Inaccessible
660,000 9
Houses damaged-CD (#)
105,214
Houses damaged-PD (#)
68,079 11
Shops damaged (#)
500 12
Roads damaged (#)
283 13
Bridges damaged (#)
278 14
Educational Facilities damaged (#)
522 15
Health Facilities damaged (#)
133 16
Livestock (Losses) (#)
8,325 17
Crops (Losses) (# Acres)
466,451 18
WSS Damaged (#)
908
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

4. Effects of Natural Disasters [Historical]
During the past two decades, natural disasters have killed millions of people, adversely affecting the lives of at least one billion more people and resulting in substantial economic damage.
Developing countries are disproportionately affected because of their lack of resources, infrastructure & disaster preparedness systems.
The potential impact of communicable diseases is often presumed to be very high in the chaos that follows natural disasters. Increases in endemic diseases and the risk of outbreaks, however, are dependent upon many factors that needs to be systematically evaluated with a comprehensive risk assessment. This allows the prioritization of interventions to reduce the impact of communicable diseases post-disaster.
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

5. Public Health Effects of Floods [Risk Factors]
Large scale displacements/ movements resulting overcrowding in camps or host areas.
[burden on host infrastructure]
Inadequate shelter [Infrastructure damage]
Disruption of services
HR displacements (LHWs), Effects on moral of staff
Communication disruption leading to issues of supplies, referrals & monitoring
Contamination of water & disruption of sanitation & hygiene practices
Protection is cross cutting [Kidnapping, missing/lost children & women]
Overcrowding results in (1) high population density, which in turn leads to Greater opportunity for contact ("c") between infectious and susceptible people = higher transmission (2) Large concentration of population; Once an epidemic starts, it spreads faster = higher transmission
Providing sufficient residential space and avoiding very large camps are high impact public health interventions
Airborne droplet diseases; (1) Measles, meningitis, ARI, TB (2) Vaccine-preventable diseases: greater requirements for vaccination!
Faecal-oral diseases (1) Diarrhoeal diseases including shigella and cholera
Public health message: don't force people into camps
Inadequate Shelter: Exposure to the elements [Hypothermia, Dehydration], Indoor smoke ARI [higher disease progression]
Exposure to vectors [Preventive tools less feasible]
Poor water, sanitation and hygiene, Exclusively affect “c” = higher transmission rate
Faecal-oral diseases, Vector-borne disease [Stagnant water]
High exposure to and/or proliferation of Vectors [People displaced into a large overcrowded camp, expect an epidemic of malaria]
[Massive flooding in an area of possible dengue transmission, high transmission can be stop by giving out Bednets as soon as possible to stop the
Epidemic]
Sudden exposure to transmission of previously unexposed people? (esp. malaria, if displaced move to transmission area)
When would an outbreak start? Depends on [latency period in vectors + latency period in humans]
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

6. Public Health Effects of Floods [Risk Factors]
High exposure to and/or proliferation of vectors
Incidents [snake bites, skin diseases, ARI, diarrhea]
Insufficient nutrient intake [food availability & quality]
disruption of family and cooking services [issues in BF, CF, BMS]
Insufficient vaccination coverage
Lack of and/or delay in treatment
These effects are intense in absence of contingency plans, trained/skilled HR, prepositioned supplies
Insufficient nutrient intake
Malnutrition = lower immunity
Higher "c", "p" and probably "d" of most infectious diseases = higher R = higher transmission
Higher probability that infection progresses to disease
Higher CFR
Nutritional crises can precipitate epidemics
Lower immunity means lower vaccine efficacy, higher susceptibility = greater transmission
Epidemics can precipitate nutritional crises e.g. if measles attack rate = 20%, you could expect that something like 10% more children will become acutely malnourished
Insufficient vaccination coverage
Most vaccines reduce "c", others "p“. Some prevent not only transmission, but also progression to disease and death
In order to protect the entire community (i.e. avert an outbreak), we must reach the herd immunity threshold coverage
We can't rely on routine EPI to do this (it would take too long): need mass vaccination campaigns!
However, we should move to re-establish EPI services in the post-emergency phase
Sudden mass displacement into camps:
The herd immunity threshold changes as a function of the settlement pattern [In camps it is higher, due to overcrowding!!!]
i.e. a coverage of 85% for measles might be sufficient in a village, but, as soon as people move to a camp, it is no longer enough: % is needed
This risk is immediate (days after displacement)
Must do preventive measles mass vaccination campaign as soon as camp is established (children 6-59m, or up to 14y old)
Protracted "entrapment" crises: Vaccination coverage decreases gradually due to disruption in EPI health services
Unvaccinated newborns are constantly being added to the susceptible pool: eventually, coverage dips below the herd immunity threshold, and outbreaks start to occur. This risk manifests itself over months
Lack of and/or delay in treatment: Main effect: increase in CFR; For most infectious diseases, exponential increase in CFR as a function of delay in treatment
Two parameters: [Coverage of treatment, Effectiveness of treatment],
Possible effect: increase in transmission rate [Higher “d”] However, impact on transmission dependent on coverage and proportion of asymptomatic cases
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

7. Different Risk Factors = Different Effects
Increased Transmission
Increased progression to disease
Increase case-fatality (CFR)
Increased malnutrition
Nearly all diseases
Displacement into overcrowded camps
Air-droplet diseases
Diarrhea, dysentery, worm infestation, Tuberculosis, ARI
Diarrhea
Poor shelter
Vector-borne diseases
Malaria, Dengue
Malaria
Insufficient vaccination coverage
Vaccine preventable diseases
Measles
Poor water, sanitation and hygiene condition
Faecal-oral diseases
Dysentery
Vector proliferation and/or increased human-vector contact
Dengue
Lack of and/or delay in treatment
Maternal diseases
APH
PPH
Pregnancy related (Maternal deaths)
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

8. Which Epidemic disease should we expect and when?
Risk Factor
Main epidemic disease of concern
Timing after onset of risk factor
Flooding
Intense rainy season
Temperature abnormalities
Malaria
Dengue
Rift Valley Fever
At least 1 month
Movement of people from non-endemic into disease-endemic region
Dry season
Meningitis
About 2 weeks
Overcrowding
Measles, Meningitis
As little as 2 weeks
Insufficient water
Contaminated water
Very poor sanitation
Cholera
Shigella (bloody dysentery)
Rotavirus
Poor nutritional intake
Measles, cholera, Rota virus
Starting about 1-2 months
Interruption of routine vaccination activities
Measles
A few months
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

9. Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

10. Insufficient Food intake
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

11. Undernutrition and Child Mortality
Nearly 9 million children under five died in 2009, more than 2/3 of them during the first year of life, Millions more survived only to face diminished lives unable to develop to their full potential
Five diseases-pneumonia, diarrhoea, malaria, measles and AIDS – together account for half of all deaths of children under 5 years old. Undernutrition is a contributing cause of more than one third of these deaths.
The single largest common denominator in global child deaths is malnutrition
Severe wasting is an important cause of these deaths
Proportion associated with acute malnutrition often grows dramatically in emergency contexts
Malnutrition 54%
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

12. Different risk factors = different effects
From the previous slide we can immediately see that:
Malnutrition is a critical modulator of all infectious disease dynamics
Living in overcrowded camps affects the risk of the two most important routes of transmission [air-droplet, faecal-oral]
Lack of treatment can undo gains in prevention
Worst scenario = gradually declining vaccination coverage + sudden mass displacement into camps + nutritional crisis + no health services
i.e. the first 3-4 weeks of many emergencies!
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

13. Priority measure to reduce the impact of communicable diseases
Ensuring Safe water and sanitation
Site planning and provision of adequate shelter
Provision of adequate food
Primary healthcare services and nutrition
Establishment of surveillance/early warning system to ensure rapid control
Immunization [Especially Mass measles vaccination]
Prevention of Malaria and Dengue
Safe water, sanitation, site planning
Ensuring uninterrupted provision of safe drinking-water is the most important preventive measure to be implemented following a natural disaster. Chlorine is widely available, inexpensive, easily used and effective against nearly all waterborne pathogens.
Access to primary care is critical to prevention, early diagnosis and treatment of a wide
range of diseases, as well as providing an entry point for secondary and tertiary care. The
immediate impact of communicable diseases can be mitigated with the following
interventions:
• Ensure early diagnosis and treatment of diarrheal diseases and ARI, particularly in those aged <5 years.
• Ensure early diagnosis and treatment for malaria in endemic areas (within 24 hours of onset of fever, using artemisinin-based combination therapy ACT for falciparum malaria).
• Ensure the availability and application of treatment protocols for the main communicable disease threats.
• Ensure proper wound cleaning and care. Tetanus toxoid with or without tetanus immunoglobulin, as appropriate, should accompany wound treatment post disaster.
• Ensure availability of drugs included in the interagency emergency health kit, e.g. oral rehydration salts for management of diarrhoeal diseases, antibiotics for ARI.
• Distribute health education messages, including:
− encouraging good hygienic practices;
− promoting safe food preparation techniques;
− ensuring boiling or chlorination of water;
− encouraging early treatment seeking behavior in case of fever;
− encouraging use of insecticide-treated mosquito nets as a personal
− protection measure in malaria-endemic areas.
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

14. Public Health Efforts made------
Immediate Relief Work mainly carried out by Govt., Army, UN Agencies, bilateral donors, I/NGOs. In addition civil society, volunteers & independent teams provided support.
It included:
Evacuation, IRA/McRAM
Shelter Arrangements
Camps, communities, institutions
Cooked, Ready to use Foods, Water supply, Sanitation
Health [Immunization, PHC, MCH]------Mobile & Static
Nutrition [Supp. & Therapeutic Foods, Monitoring BMS, Estab of BF corners, Hygiene promotion]
Cluster Formation/Revivals
Health, Nutrition, Shelter, WASH, Education, Protection, Agriculture
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

15. --------Public Health Efforts made
Capacity Building of humanitarian community and Govt.
Resource Mobilization
Flash Appeals, Humanitarian Response Appeals
Information Management [3 Ws Matrix, Pooling of Resources, Avoiding Duplication]
Surveillance and assessments [DEWS, NIS, FANS]
Recovery-Reconstruction----[PDMA].
The threat was converted into opportunities
What was gained, this turned to be an opportunity for CB, self assessment and better planning
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

16. Public Health Efforts made [KP]
Around 5,000 healthcare providers and field workers were trained in emergency health and nutrition interventions [Better and coordinated Response]
Around 4 million children 5-13 years were vaccinated against measles [No measles outbreak]
Routine Immunization services were strengthened; providing routine immunization services to around 0.5 million children
Millions+++ free consultations were provided to flood affectees for PHC services [No major outbreaks of diarrhea, ARI and other diseases]
Over one million women were provided maternal health [ANC/PNC] services and >5,000 safe deliveries conducted [decreased maternal deaths]
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

17. Public Health Efforts made [KP]
Around 2 million children and 1 million women were assessed for acute malnutrition. Malnutrition level between %.
> half a million acute malnourished children and mothers were treated through CMAM protocols
>2 million mothers/caretakers were reached with messages on appropriate health, nutrition and hygiene messages.
>1 million children dewormed, >1 million children and women were provided mm supplements.
[Cure rate>90%, death rate<1%, default rate<10%]
Millions+++ were provided safe drinking water and sanitation services
Millions+++ were provided food and non food [hygiene] packages
CFR = Case Fatality Ratio
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

18. Conclusion
Infectious diseases do not exhibit unexpected properties in crises, but crises exacerbate existing or bring about new risk factors
Higher transmission rate, probability of progression to disease and/or CFR
Excess morbidity and mortality
Think of which processes a risk factor or intervention affect:
Transmission?
Progression to disease?
CFR?
Humanitarian relief in the health sector aims to reduce excess morbidity and mortality by reducing CFR
CFR = Case Fatality Ratio
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil]

19. THANKS
Public Health Effects of & Public Health Efforts made for the Pakistan Floods [Dr. Abdul Jamil] 19