Transcript Introduction to the Sphere Health Services Module

Surveillance in Humanitarian
Emergencies
Methods of Data Collection
Assessment
Survey
Surveillance
Objective
Rapid appraisal
Medium-term Continuous
appraisal
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
What factors make surveillance
especially important, in emergency
settings?
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
What Diseases or Conditions Will You
Conduct Surveillance For?
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
Health Surveillance In Emergencies
One over-riding principle
ONLY COLLECT DATA WHICH ARE
USEFUL AND CAN BE ACTED UPON
IN THE FIELD!!!
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
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
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
Mortality Surveillance
• Potential data sources for deaths?
• Limitations?
• What role could SC/US play in mortality
reporting?
Mortality Surveillance
• Potential data
sources
– Hospitals / clinics
– Community and
religious leaders
– Burial grounds
– Shroud distribution
– Body collectors
– Other sources
• Limitations
– Deaths underreported
– Exaggerated
– Concealed
– Denominator inflated
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.
What Are Some Expected Case-Fatality
Rates?
•
•
•
•
Cholera
Shigella dysentery
Typhoid
Measles
Expected Case-Fatality Rates
•
•
•
•
Cholera: 1% or lower
Shigella dysentery: 1% or lower
Typhoid: 1% or lower
Measles: 3%
Mortality Form
No. of deaths
Watery diarrhea
Bloody diarrhea
Suspected cholera
Respiratory tract disease
Measles
Malaria
Maternal death
Suspected meninigits
Other/unknown
Total by age and sex
Total <5 yrs
0-4 yrs
5+ yrs
males females males females
Total
Leading Causes of Mortality, Darfur,
Sudan, May-September 2004 (N=1,514)
Leading Causes of
Mortality in Under 5
ARI
5%
All other
58%
Leading Causes of
Mortality in Over 5
Jaundice
3% Severe
ARI
3%
Malnutr.
10%
Susp.
Malaria
24%
All other
59%
Jaundice
12%
Severe
Malnutr.
5%
Susp.
Malaria
21%
War-Related Trauma and Mortality of Refugees
Kosovo: Feb ’98 –Jul ‘99
Natural
19%
War-related
Trauma
63%
Non War-related
Trauma
37%
Chronic
51%
Unknown
22%
Infectious
3%
Other
5%
Landmine/UXO Injuries – Afghanistan
Explosive Type by Age Group
1000
54%
Number of victims
900
800
700
37%
600
500
18 yr and older
under 18 years
400
300
9%
200
100
0
Landmine
..
UXO
Other/Unknown
Morbidity Form
Diagnosis
Watery diarrhea
Bloody diarrhea
Suspected cholera
Respiratory tract disease
Measles
Malaria
Suspected meninigits
Skin disease
Sexually transmitted
infections
Trauma/accident
Other/unknown
Total by age and sex
Total <5 yrs
0-4 yrs
males
females
5+ yrs
males
females
Total
Keep case definitions simple
Disease
Definition
Measles
Fever, Rash + cough or rash or conjunctivitis
Malaria
Fever and periodic shaking, chills
Watery Diarrhea
More than 4 stools per day, but
no blood or rice-water in stool
Lower Respiratory
Infection
Fever, cough, rapid breathing
(x breaths per minute-dep. upon age)
For other examples, refer to WHO guidelines
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
Rates: Problems With Denominator
Population refugee camp: April 2001
Camp committee: 45,000
UNHCR estimate: 25,000
Census April 8:
11,500
Population refugee camp: February 2001
Camp committee:
30,000
UNHCR estimate:
23,000
Count after relocation: 20,000
Mortality Rates In Refugee Camps In Guinea, 2001
(Original Populations Estimates)
Emergency
threshholds
Mortality Rates In Refugee Camps In Guinea, 2001
(Population Estimates Revised Downward)
Case Study
Surveillance in Darfur
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
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?
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
EWARN Reporting Area
EWARN Weekly Reporting Cycle
3
Report
WHO Khartoum
Health Center in
Mossei Camp, South Darfur
2
Data
Entered
WHO States
1
Data
Gathered
Field Clinics
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
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
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
Leading Causes of
Morbidity in Over 5
Leading Causes of
Morbidity in Under 5
ARI
20%
ARI
14%
Bloody
Diarrhea
5%
Bloody
Diarrhea
5%
Injuries
4%
All other
57%
Severe
Malnutr.
3%
Susp.
Malaria
15%
All other
61%
Susp.
Malaria
16%
Outbreak Detection
• Acute Jaundice Syndrome (Hepatitis E)
• Measles
• Meningitis
• Cases of Acute Flaccid Paralysis (infection
with wild polio virus)
Measles Outbreak Darfur, MaySeptember 2005
# of Cases
EPI Curve - 2004 Measles
160
140
120
100
80
60
40
20
0
Vaccination
Campaign
May June June July July
23
6
20
4
18
Aug
1
Aug
15
Week Beginning
Aug Sept Sept
29
12
26
EPI Curve - Meningitis in Morni Camp
10
Vaccination
Starts
# of Cases
8
6
4
2
0
May June June July July Aug Aug Aug Sept Sept
23
6
20
4
18
1
15
29
12
26
Week Beginning
Acute Jaundice (Hepatitis E)
Children
Under 5
Over 5 years
of age
Cases
1,232
7,678
Deaths
7
105
0.6 %
1.4 %
Case Fatality
Rate
Attack Rate in Camps
0.7% (0.13% - 9.1%)
August 1, 2004 (Week 30)
n = 330
August 15, 2004 (Week 32)
n = 734
August 29, 2004 (Week 34)
n = 768
September 12, 2004 (Week 36)
n = 1,267
Bloody diarrhea and Acute Jaundice cases in Morni Camp, West Darfur
600
1400
500
1200
1000
400
800
300
600
200
400
100
200
0
0
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Week
AJS
Bloody diarrhea
Bloody Diarrhea cases
AJS cases
Morni
WHO: Health Risks for Communicable Diseases Following
Asian Tsunami
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: 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