1. Surveillance in Humanitarian Emergencies

2. Methods of Data Collection AssessmentSurveySurveillance Objective Rapid appraisal Medium-term appraisal Continuous appraisal Data Type Qualitative/ Cross sectional snapshot Quantitative/ Cross sectional snapshot Quantitative/ Longitudinal trends Method Observational / Secondary source Sample with survey instrument Periodic, standardized data collection

3. What factors make surveillance especially important, in emergency settings?

4. Why Is Surveillance Especially Important In Emergencies? Host –Morbidity and mortality are higher among malnourished persons –New arrivals may have no natural immunity Organism –Crowding can mean higher infective dose –Displacement may result in exposure to new pathogens Environment –Lack of clean water and poor sanitation are favorable to spreading disease –Poor access to care can increase case fatality ratios

5. What Diseases or Conditions Will You Conduct Surveillance For?

6. Types of Data Dollected in Surveillance Systems in Emergencies Mortality Morbidity –diseases of public health importance –diseases of epidemic potential Nutritional Status Program Indicators Indicators of the quality of the system itself

7. Health Surveillance In Emergencies One over-riding principle ONLY COLLECT DATA WHICH ARE ONLY COLLECT DATA WHICH ARE USEFUL AND CAN BE ACTED UPON IN THE FIELD!!!

8. Who Conducts Surveillance in Emergencies? WHO has overall responsibility for surveillance UNHCR often manages surveillance in refugee camp situations But Implementing partners (usually NGOs) actually carry it out

9. Objectives Of A Surveillance System To determine main health problems requiring intervention To follow trends in health status in order to revise health priorities To target resources to area of greatest need To detect and respond rapidly to epidemics To evaluate program effectiveness –Coverage –Quality of care –Impact

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

13. Mortality Surveillance Potential data sources for deaths? Limitations? What role could SC/US play in mortality reporting?

14. Mortality Surveillance Potential data sources –Hospitals / clinics –Community and religious leaders –Burial grounds –Shroud distribution –Body collectors –Other sources Limitations –Deaths under- reported –Exaggerated –Concealed –Denominator inflated

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

16. What Are Some Expected Case-Fatality Rates? Cholera Shigella dysentery Typhoid Measles

17. Expected Case-Fatality Rates Cholera: 1% or lower Shigella dysentery: 1% or lower Typhoid: 1% or lower Measles: 3%

18. Mortality Form

19. Leading Causes of Mortality, Darfur, Sudan, May-September 2004 (N=1,514)

20. War-Related Trauma and Mortality of Refugees Kosovo: Feb ’98 –Jul ‘99

21. .. 37% 54% 9% Landmine/UXO Injuries – Afghanistan Explosive Type by Age Group

22. Morbidity Form

23. Keep case definitions simple DiseaseDefinition Measles Malaria Watery Diarrhea Lower Respiratory Infection For other examples, refer to WHO guidelines Fever, Rash + cough or rash or conjunctivitis Fever and periodic shaking, chills More than 4 stools per day, but no blood or rice-water in stool Fever, cough, rapid breathing (x breaths per minute-dep. upon age)

24. Surveillance in Emergencies: Morbidity Record ONLY ONE diagnosis per patient  choose most ‘important’ Take new (incident) cases not repeat cases  record and register if case is new or repeat In post emergency phase, consider including lab diagnosis as part of case-definition to improve sensitivity of clinical diagnosis

25. Rates: Problems With Denominator

26. Population refugee camp: April 2001 Camp committee:45,000 UNHCR estimate:25,000 Census April 8:11,500

27. Population refugee camp: February 2001 Camp committee:30,000 UNHCR estimate:23,000 Count after relocation:20,000

28. Mortality Rates In Refugee Camps In Guinea, 2001 (Original Populations Estimates) Emergency threshholds

29. Mortality Rates In Refugee Camps In Guinea, 2001 (Population Estimates Revised Downward)

30. Case Study Surveillance in Darfur

31. Date :26 Jul 2004Source :World Food Programme

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

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

34. Stakeholders in EWARN MoH (Federal and Local) –Coordination –Data collection and data entry WHO –Coordination –Data entry and analysis –Presentation and dissemination of results NGOs –Data collection –Communications –Logistics

35. EWARN Reporting Area

36. EWARN Weekly Reporting Cycle Health Center in Mossei Camp, South Darfur Data Gathered Field Clinics 1 Data Entered WHO States 2 Report WHO Khartoum 3

37. Health Events Under Surveillance 10 communicable diseases/syndromes –Acute Watery Diarrhea –Bloody Diarrhea –AFP –ARI –Neonatal Tetanus –Malaria –Suspected measles –Suspected meningitis –Acute Jaundice syndrome –Acute unknown fever Severe malnutrition Injuries Other

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

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

41. Outbreak Detection Acute Jaundice Syndrome (Hepatitis E) Measles Meningitis Cases of Acute Flaccid Paralysis (infection with wild polio virus)

42. Measles Outbreak Darfur, May- September 2005 Vaccination Campaign

43. Vaccination Starts

44. Acute Jaundice (Hepatitis E) Children Under 5 Over 5 years of age Cases 1,2327,678 Deaths 7105 Case Fatality Rate 0.6 %1.4 % Attack Rate in Camps 0.7% (0.13% - 9.1%)

45. August 1, 2004 (Week 30) n = 330

46. August 15, 2004 (Week 32) n = 734

47. August 29, 2004 (Week 34) n = 768

48. September 12, 2004 (Week 36) n = 1,267

49. Bloody diarrhea and Acute Jaundice cases in Morni Camp, West Darfur

50. Epidemic prone diseases: Cholera Shigellosis Typhoid fever Acute Lower Respiratory Inf Hepatitis A, E Measles Meningitis Influenza Diseases with increased risk due to flooding: Tetanus in adults Leptospirosis (rats) Dengue Malaria Diseases linked to overcrowding: All diarrhoeas Acute respiratory tract infection Hepatitis A, E Influenza Meningitis Measles Tuberculosis Vector borne diseases: Dengue Malaria Scrub Typhus Lymphatic Filariasis Japanese encephalitis Zoonosis present: Leptospirosis Anthrax RabiesTrichinosis Melioidosis Brucellosis Nipah virus WHO: Health Risks for Communicable Diseases Following Asian Tsunami

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