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Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues

MMWR - Vol. 41, No. RR-13

Publication date: 07/24/1992

Table of Contents

ARTICLE

SUGGESTED CITATION

AUTHORS

GLOSSARY

PREFACE

FOREWORD

INTRODUCTION

BACKGROUND
Classification of Disasters

FAMINE-AFFECTED POPULATIONS
Definition and Causes
Detection of Famine

REPORTS
Mortality
Cause-specific mortality
Nutritional Diseases
Protein-energy malnutrition
Micronutrient deficiency diseases
Vitamin A deficiency
Vitamin C deficiency (scurvy)
Niacin deficiency
Anemia
Other micronutrient deficiencies
Communicable Diseases
Measles
Diarrheal diseases
Cholera
Acute respiratory infections
Tuberculosis (TB)
Malaria
Hepatitis
Meningitis
Other Health Issues
Injuries
Maternal health
Sexually transmitted diseases and HIV

REFERENCES

RECOMMENDATIONS
Response Preparedness
Maternal and Child Health Care
Program-Specific Recommendations
Rapid Health Assessment
Preparations
Field assessment
Background health information
Nutritional status
Mortality rates
Environmental conditions
Resources available
Health Information System
Data collection
Analysis and interpretation
Control measures
Assessment
Reference
Nutrition
Rations
References
Vaccine-Preventable Diseases
Overview
Measles
Diphtheria-tetanus-pertussis
Poliomyelitis
Tuberculosis
Neonatal tetanus
Meningococcal meningitis
Typhoid and cholera
Diarrheal Diseases
Prevention
Case management
Management of the dehydrated patient
Surveillance for Diarrheal Diseases
Cholera
Dysentery
Shigellosis
Amebiasis and giardiasis
References
Malaria
Control of Transmission
Case Management
Chemoprophylaxis
Severe malaria
Anemia
Renal failure
Tuberculosis
Control of transmission
Prevention
Epidemic Investigations
Purpose
Preparations
Conducting the investigation

POINT OF CONTACT FOR THIS DOCUMENT:

Tables
Refugees And Aslyum Seekers By Geographic Region, July 1991
Monthly Crude Mortality Rates, 1978-1991
Monthly Crude Mortality Rates, 1982-1990
Monthly Crude Mortality Rates, 1984-1985
Prevalence of acute undernutrition, Refugee Populations
Prevalence Of Acute Undernutrition, Famine-affected Populations
Prevalence Of Acute Undernutrition, Displaced Populations
Micronutrient Deficiency Disease Outbreaks in Refugee Camps

Figures
Countries With Major Refugee Populations
Countries With Major Internally Displaced Populations
Crude Mortality Rates For Persons In Refugee Camps
Major Causes Of Death In Refugee Populations
Major Causes Of Death In All Ages
Major Reported Causes Of Death In Children
Mortality Rates In 41 Refugee Camp Populations
PEM Prevalence In Children
Measles Mortality In Wad Kowli Refugee Camp
Proportion Of Outpatients With Diarrhea
Cholera Cases And Deaths In Gannet
Cholera Cases Reported in Nyamithutu Camp
Hepatitis Cases Reported Among All Age Groups

ARTICLE

U.S. Department of Health and Human Services
Public Health Service
Centers for Disease Control
Atlanta, Georgia 30333

The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333.

SUGGESTED CITATION

Centers for Disease Control. Famine-Affected, refugee, and displaced populations: recommendations for public health issues. MMWR 1992;41(No. RR-13);(inclusive page numbers).

Centers for Disease Control
William L. Roper, M.D., M.P.H., Director

The material in this report was prepared for publication by: International Health Program Office
Joe H. Davis, M.D., Director
Division of Technical Services

Andrew A. Vernon, M.D., Director
Division of International Liaison

Robert J. Baldwin, Director

The production of this report as an MMWR serial publication was coordinated in:
Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc., Director
Richard A. Goodman, M.D., M.P.H., Editor, MMWR Series

Scientific Information and Communications Program
Public Health Publications Branch
Suzanne M. Hewitt, Chief
Sharon D. Hoskins, Project Editor
Morie E. Miller, Editorial Assistant

Information Resources Management Branch
Sandra L. Ford, Visual Information Specialist

Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

Copies can be purchased from Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402-9325. Telephone (202)783-3238.

AUTHORS

The following CDC staff members served as authors for this publication: Mike J. Toole, M.D., DTM&H *
Technical Support Division
International Health Program Office
* Diploma in Tropical Medicine & Hygiene.

Rita M. Malkki, M.P.H.
Technical Support Division
International Health Program Office

The experts listed below contributed to the preparation of this publication: Paul A. Blake, M.D., M.P.H.
Enteric Diseases Branch
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases

Lisa A. Lee, V.M.D., M.P.H.
Technical Support Division
International Health Program Office

Eric E. Mast, M.D., M.P.H.
Hepatitis Branch
Division of Viral and Rickettsial Diseases
National Center for Infectious Diseases

Phillip I. Nieburg, M.D., M.P.H.
International Activity
Division of HIV/AIDS
National Center for Infectious Diseases

Dixie E. Snider, Jr., M.D. M.P.H.
Assistant Director for Science
National Center for Prevention Services

Richard W. Steketee, M.D., M.P.H.
Malaria Branch
Malaria Epidemiology and Control Activity
National Center for Infectious Diseases

Roland W. Sutter, M.D., M.P.H.&TM
Division of Immunization
National Center for Prevention Services

Ronald J. Waldman, M.D., M.P.H.

Strengthening of Epidemiological and Statistical Services Unit Health Situation and Trend Assessment Division
World Health Organization

Ray Yip, M.D., M.P.H.
Division of Nutrition

National Center for Chronic Disease Prevention and Health Promotion Special contributions were made by:

Molly (Mary Susan) Bardsley
Research Assistant
Emory University School of Public Health

GLOSSARY

AFB     Acid-Fast Bacilli
ALRI    Acute Lower Respiratory Infection
ARDS    Adult Respiratory Distress Syndrome
ARIs    Acute Respiratory Infections
BCG     Bacille Calmette-Guerin
CFR     Case-Fatality Ratio
CMR     Crude Mortality Rate
CNS     Central Nervous System
CSB     Corn-soya Blend
CSF     Cerebral Spinal Fluid
CSM     Corn-soya Milk
DPT     Diphtheria-Pertussis-Tetanus
DSM     Dry Skim Milk
E-Z     Edmonston-Zagreb Vaccine
EIS     Epidemic Intelligence Service
EPI     Expanded Programs on Immunization
G-6-PD  Glucose-6-Phosphate Dehydrogenase
Hb      Hemogolobin
HEM     High Energy Milk
HIS     Health Information System
HIV     Human Immunodeficiency Virus
IU      International Units
Kcal    Kilocalories
MCH     Maternal and Child Health
MOH     Ministry of Health
MSF     Medecins Sans Frontieres
MUAC    Mid-Upper Arm Circumference
NGO     Nongovernmental Organization
OPV     Oral Polio Vaccine
ORS     Oral Rehydration Solution
ORT     Oral Rehydration Therapy
PAHO    Pan American Health Organization
PEM     Protein Energy Malnutrition
PHC     Primary Health Care
PVO     Private Voluntary Organization
SFP     Supplementary Feeding Program
SMX     Sulfamethoxazole
SP      Sulfadoxine-Pyrimethamine
STD     Sexually Transmitted Disease
TB      Tuberculosis
TFP     Therapeutic Feeding Program
TMP     Trimethoprim
TT      Tetanus Toxoid
UNHCR   United Nations High Commissioner for Refugees

UNICEF United Nations International Children's Emergency Fund USAID United States Agency for International Development

WFH     Weight-For-Height
WHO     World Health Organization
WSB     Wheat-soya Blend

PREFACE

Preparing for the health problems experienced by large populations displaced by natural or man-made disasters is among the greatest challenges facing public health officials in the world today. The diversity of problems experienced in long- and short-term refugee situations demands a diversity of approaches in disease surveillance, control, and prevention. The Centers for Disease Control's experience over the past decade has allowed us to evolve approaches which allow for timely and accurate surveillance data to be generated even in extremely adverse conditions. The resulting prevention activities are well focused on the most important public health problems.

These reports and guidelines have been developed by a number of CDC professionals working with international organizations and public health agencies, such as, the Pan American Health Organization, the United Nations High Commissioner for Refugees, the United States Agency for International Development, and the private voluntary organization's of refugee situations. These reports and guidelines reflect our belief that appropriate, cost-effective disease prevention technology can be rapidly applied in most situations that will impact positively the lives of the affected populations. The recommendations underscore our organizational interest and commitment to a global health agenda that will improve the health status of people worldwide. International disaster preparedness and refugee activities are collaborative efforts. CDC efforts are performed jointly with many other governmental, nongovernmental, and international organizations. It is my hope that public health professionals involved in dealing with these issues will find this information useful in their planning, training, and emergency preparedness efforts.

William L. Roper, M.D., M.P.H., Director
Centers for Disease Control

FOREWORD

In the past decade, public health emergencies have occured with great frequency -- and the number of people affected has captured the attention of the world. Many of these emergencies involved some degree of forced population migration, and almost all have been associated with severe food shortages. Natural disasters, such as droughts and floods, have been partially responsible, but the most common causes of these emergencies have been war and civil strife. Since 1984, the number of refugees dependent for their survival on international assistance has more than doubled to a current estimate of approximately 17 million persons -- almost all in developing countries. Kurdish refugees fleeing Iraq captured the world's attention briefly in early 1991, but the desperate plight of many others -- especially the 5 million refugees in Africa -- receives scant attention from the world media. Even more obscure are the estimated 16-20 million displaced persons who are trapped within their countries by civil wars and are unable to cross borders to seek help from the international community. This situation represents an unprecedented challenge to the international public health community.

CDC has had a long-standing institutional commitment to the problem of famine-affected, refugee, and displaced populations for many years. During the Nigerian Civil War in the 1960s, 20 Epidemic Intelligence Service officers helped maintain public health programs for millions of displaced civilians, who were deprived of their basic needs by that war. Since then, CDC has provided technical assistance to relief agencies working in most of the world's major refugee emergency communities including those in, for example, Ethiopia, Kenya, Malawi, Pakistan, Somalia, Sudan, Thailand, Turkey, and West Africa. CDC, United Nations agencies, countries of asylum, and private voluntary organizations (PVOs) have attempted to adapt traditional epidemiologic techniques and public health programs to the realities of refugee camps and scattered, famine-affected communities. As a result, a considerable body of knowledge and experience has accumulated and has been documented in various issues of the MMWR. This report represents a compilation of this knowledge for dissemination and for providing guidance on certain technical subjects for those involved in future relief programs.

By necessity, this document is unable to cover all aspects of emergency relief. The recommendations provided here will not be effective unless they are supported by adequate preparedness planning, coordination, communications, logistics, personnel management, and relief worker training. Even more critical is ensuring access by relief workers to internally displaced populations -- many needy communities are caught in areas of contested sovereignty. Unless the international community can devise ways of providing assistance to communities in these circumstances, it will be impossible to implement these basic public health programs. Finally, the situation of refugees and displaced persons is a timely reminder of the clear interface between public health and social justice. The most effective measure to prevent the high mortality experienced by these populations would be to eliminate the causes of the violence and conflict from which they fled.

Joe H. Davis, M.D.
Associate Director for International Health
Director International Health Program Office
Centers for Disease Control

Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues

INTRODUCTION

During the past three decades, the most common emergencies affecting the health of large populations in developing countries have involved famine and forced migrations. The public health consequences of mass population displacement have been extensively documented. On some occasions, these migrations have resulted in extremely high rates of mortality, morbidity, and malnutrition. The most severe consequences of population displacement have occurred during the acute emergency phase, when relief efforts are in the early stage. During this phase, deaths -- in some cases -- were 60 times the crude mortality rate (CMR) among non-refugee populations in the country of origin (1). Although the quality of international disaster response efforts has steadily improved, the human cost of forced migration remains high.

Since the early 1960s, most emergencies involving refugees and displaced persons have taken place in less developed countries where local resources have been insufficient for providing prompt and adequate assistance. The international community's response to the health needs of these populations has been at times inappropriate, relying on teams of foreign medical personnel with little or no training. Hospitals, clinics, and feeding centers have been set up without assessment of preliminary needs, and essential prevention programs have been neglected. More recent relief programs, however, emphasize a primary health care (PHC) approach, focusing on preventive programs such as immunization and oral rehydration therapy (ORT), promoting involvement by the refugee community in the provision of health services, and stressing more effective coordination and information gathering. The PHC approach offers long-term advantages, not only for the directly affected population, but also for the country hosting the refugees. A PHC strategy is sustainable and strengthens the national health development program.

BACKGROUND

Classification of Disasters

One way of describing the evolution of disasters is in terms of a "trigger event" leading to "primary effects" and "secondary effects" on vulnerable groups in the population (2). In the case of a rapid-onset natural disaster like an earthquake, the primary effects, deaths and injuries, may be high, but there are few secondary effects. In the case of slow-onset natural disasters like drought and manmade disasters, like war and civil strife, the secondary effects (i.e., decreased food availability, environmental damage, and population displacement) may lead to a higher delayed death toll than that of the initial event. Although population displacement may result from a number of different types of disasters -- manmade and natural -- the two most common recent trigger events have been food deficits and war. In many parts of the world where food shortages have become common, war and civil strife are major causative factors. Consequently, war, food deficits, famine, and population displacement have been inextricably linked risk factors for increased mortality in certain large populations in Africa, Asia, Latin America, and the Middle East.

(Figure 1) Countries with major refugee populations (Table 1) Refugees and asylumseekers by geographic region, July 1991 (Figure 2) Countries with major displaced populations, estimated global total: 16- 20 million

The purpose of this report is to describe the public health consequences of famine and population displacement in developing countries and to present the most current recommendations on public health programs of major importance. Refugee and Displaced Populations

The 1951 United Nations Convention defines a refugee as "Any person who owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable, or owing to fear is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable, or having such fear is unwilling to return to it" (3). In 1969, the Organization of African Unity expanded this definition to include persons fleeing from war, civil disturbance, and violence of any kind (4).

These definitions, however, exclude persons who leave their country of origin to seek economic betterment, as well as persons or groups who may flee their homes for the above or other reasons, yet remain within the borders of their own country. There are few, if any, international regulations covering these internally displaced populations, yet it is estimated that more than half of all displaced persons worldwide are living within the borders of their home country (5).

FAMINE-AFFECTED POPULATIONS

Definition and Causes

Famine has been defined as "a condition of populations in which a substantial increase in deaths is associated with inadequate food consumption" (6). Famine does not necessarily arise solely from problems of food production. Natural disasters (e.g., drought or crop infestations) may act as triggers, but lack of sufficient food for consumption may be due to economic collapse and loss of purchasing power in some sections of the population, (i.e., the Indian famine of 1972). In early 1992, efforts to assess the impact of sudden economic changes in the republics of the former Soviet Union have focused on income and food price indicators. In Russia, elderly pensioners were identified as a vulnerable group among whom the income-to-food cost ratio was estimated to be 1:2 in mid-January (7). Other causes of famine have included disruption of food production and marketing by armed conflict (i.e., Biafra in 1968, Sudan in 1988, and Somalia in 1991) and widespread civil disturbances (i.e., Zaire in 1991).

Famine is usually caused by the amplification of a pre-existing condition characterized by widespread poverty, intractable debt, underemployment, and high malnutrition prevalence. Under these conditions, a large percentage of the population may routinely experience starvation. When additional burdens related to the production or availability of food arise, generalized starvation occurs rapidly. In recent years, frequent crop failures in Ethiopia, Somalia, Sudan, and the Sahelian countries of Africa have been attributed to progressive deterioration of the environment, including deforestation, desertification, and poor agricultural practices.

Populations experiencing famine may or may not displace themselves in order to improve food availability. Initially, male family members may migrate to cities or neighboring countries to seek employment. During a full-scale famine, whole families and villages may flee to other regions or countries in a desperate search for food. In most of the major population displacements of the past 20 years, however, people have been forced to flee because of fear for their physical security caused by war or civil strife. Famine in the absence of violence has generated few of the world's refugees.

Detection of Famine

Famines are often assessed and reported in terms of cases, rates, or degrees of malnutrition, or numbers of deaths from malnutrition. These parameters have been classified as "trailing" indicators and are not useful for early famine detection and the initiation of prevention or mitigation measures. More important in the early detection of famine are "leading" and "intermediate" indicators that reflect changes in the economic, social, and environmental factors that influence the evolution of food shortages and famine.

The leading and intermediate indicators will be useful if they trigger early interventions aimed at ensuring adequate food supplies for the population and at maintaining the purchasing power of vulnerable groups. These measures have included temporary government subsidies for food crops, "food-for-work" programs; government-run, fixed-price food shops; rural employment schemes; the distribution of drought-resistant seeds; and the release of food reserves.

Effective early warning systems might help avert major population movements, thereby allowing local government and international and private voluntary organizations (PVOs) to provide assistance in situ without major disruption in traditional social structures and lifestyle patterns. Affected communities can be surveyed, needy households identified, food and other relief supplies distributed, and major epidemics averted with greater ease and effectiveness in a stable population than in a temporary refugee settlement. National early warning systems have proved effective in preventing famine during the past decade in India and Botswana (8). When populations are forced to migrate en masse, they usually end up in camps or urban slums characterized by overcrowding, poor sanitation, substandard housing, and limited access to health services. These conditions hamper the effective and equitable distribution of relief supplies and promote the transmission of communicable diseases.

REPORTS

The most direct and obvious results of famine are severe undernutrition and death. While longitudinal studies have demonstrated that undernourished persons -- particularly children -- are at higher risk of mortality, the immediate cause of death is usually a communicable disease. Malnutrition causes an increased case-fatality ratio (CFR) in the most common childhood communicable diseases (i.e., measles, diarrheal disease, malaria, and acute respiratory infections (ARIs)). Those at highest risk of mortality during nonfamine times -- namely, the poor, the elderly, women, and young children -- are the same groups most at risk for the morbidity and mortality caused by famine. In addition, the movement of populations into crowded and unsanitary camps, the violence associated with forced migrations, and the negative psychological effects of fear, uncertainty, and dependency contribute to the health problems experienced by displaced persons.

Mortality

Mortality rates are the most specific indicators of the health status of emergency-affected populations. Mortality rates have been estimated retrospectively from hospital and burial records, or from community-based surveys, and prospectively from 24-hour burial site surveillance. Among the many problems encountered in estimating mortality under emergency conditions are recall bias in surveys, families' failure to report perinatal deaths, inaccurate denominators (overall population size, births, age-specific populations), and lack of standard reporting procedures. In general, bias tends to underestimate mortality rates, since deaths are usually underreported or undercounted, and population size is often exaggerated. Most reports of famine-related mortality have come from populations that have experienced considerable displacement. It is possible that mortality rates are lower in those populations that remain in their original villages and homes. A comparison of mortality in displaced vs. nondisplaced, famine-affected populations is problematic because displacement itself may reflect a more serious baseline situation. Nonetheless, comparisons between displaced and nondisplaced populations during famine on one hand, and between refugees and local, host country populations on the other hand, show that in nearly all cases the displaced and refugee populations experience a markedly higher CMR.

The CMRs reported in various refugee, internally displaced, and famine-affected (but nondisplaced) populations, respectively, during the emergency phase of relief operations in the past 15 years are listed in ( Table 2), (Table 3), and (Table 4). These rates are compared with baseline CMRs reported for nonfamine-affected and nondisplaced populations, or, in the case of refugees, with CMRs in their country of origin. CMRs in these tables are expressed as deaths per 1,000 per month to reflect the short reporting periods; comparison rates have been extrapolated from annual CMRs published by the United Nations Children's Fund (UNICEF) (13). Although CMRs reported in refugee emergencies have not been adjusted for age and sex, it is unlikely that demographic differences between refugee and non-refugee populations account for the excess mortality found among many of the latter.

Monthly CMRs recorded immediately after the initial influx of Cambodian refugees into Thailand (1979), Ethiopian refugees into Somalia (1980), and Ethiopian refugees into eastern Sudan (1985) were 8.1 to 15.2 times the expected rates. The early death rate among Kurdish refugees in Turkey in April 1991 was 18 times the baseline rates in both Iraq and Turkey. In contrast, among Mozambican refugees in Malawi in 1987, camp-based CMRs were one-third lower than the national CMR reported for Mozambique. A movement of 50,000 refugees from Burundi into Rwanda in 1988 also resulted in minimal mortality once asylum had been attained. The rate of improvement in camp populations has varied considerably. For example, mortality rates decreased rapidly in Cambodian refugee camps in Thailand in 1979-1980 and in the Kurdish camps of Turkey in 1991, but only slow improvement occurred during the initial 8 months in Somalia (1980) and in Sudan (1985). In eastern Ethiopia in 1988-1989, initially low mortality rates among Somali refugees increased after 6 months, reaching a peak at 9 months (Figure 3). Overall, less than 1% of Cambodian refugees in Thai camps died during the first 12 months; 9% of refugees in eastern Sudan died during the same period of time (1).

Political and security factors often obstruct the accurate documentation of death rates among internally displaced populations; however, a few situations have been well documented. In Mozambique (1983), Ethiopia (1984-1985), and Sudan (1988), CMRs estimated by surveillance or population-based surveys of internally displaced persons ranged between 4 and 70 times the death rates in nondisplaced populations in the same country. In the Korem area of Ethiopia, CMRs recorded among camp populations displaced by famine in 1985 were 7-10 times those of settled villagers in a similar highland zone affected by the famine. In Monrovia, the capital of Liberia, the death rate among civilians displaced during the 1990 civil war was 7 times the pre-war death rate (Holland MSF, unpublished data, January 1991).

As in stable populations in developing countries, age-specific death rates in displaced and refugee populations are highest in children less than 5 years of age. A mortality survey of Kurdish refugees at the Turkey-Iraq border during 1991 revealed that 63% of all deaths occurred among children less than 5 years of age, who comprised approximately 18% of the population (11). Although absolute death rates are highest in infants less than 1 year of age, the relative increase in mortality during emergencies may be highest in children 1-12 years of age (1).

Cause-specific mortality

The major reported causes of death in refugee and displaced populations have been those same diseases that cause high death rates in nondisplaced populations in developing countries: malnutrition, diarrheal diseases, measles, ARIs, and malaria. These diseases consistently account for 60%-95% of all reported causes of death in these populations (Figure 4), ( Figure 5), and (Figure 6). Specific reports on these and other communicable diseases are presented in a later section. In those situations where malnutrition was not classified as an immediate cause of death (i.e., Sudan and Somalia), it was a major underlying factor accounting for the high CFRs from communicable diseases. This synergism between high malnutrition prevalence and increased incidence of communicable diseases explains much of the excess mortality seen in refugee and displaced populations.

A study of 42 refugee populations completed in 1989 examined acute protein energy malnutrition (PEM) prevalence and crude unadjusted monthly mortality rates, gathered from 1984-1988. Analysis of the data showed a strong positive association between PEM prevalence and CMRs. Populations with PEM prevalence rates of less than 5% had a mean CMR of 0.9/1,000/month. Refugee populations with PEM prevalences of greater than or equal to 40%, however, experienced a mean CMR of 37/1,000/month with a range of 4/1,000/month to 177/1,000/month ( Figure 7). The rate ratio between the lowest and highest CMR values was 40.7 (14).

The close correlation between malnutrition prevalence and crude mortality during a relief operation for Somali refugees in eastern Ethiopia in 1988-1989 is clearly demonstrated in (Figure 8. Malnutrition prevalence was estimated by serial, cross-sectional, cluster sample surveys of children less than 5 years of age, and monthly death rates were estimated retrospectively by a population-based survey in August 1989. During the period of high malnutrition prevalence and high mortality (March-May 1989), food rations provided an average of approximately 1,400 kilocalories (kcal)/person/day instead of the recommended minimum of 1,900 kcal/person/day (9). Likewise, in eastern Sudan in 1985, inadequate amounts of food (1,360-1,870 kcal/person/day) were distributed to Ethiopian refugees during the first 5 months after their arrival in the camps. Malnutrition rates, as well as mortality rates, remained high during this period (Figure 3) ( Table 5). In addition, a severe measles outbreak in the Sudanese camps added to the high mortality (21).

Nutritional Diseases

Protein-energy malnutrition

PEM can refer to either acute or chronic undernutrition. Because children less than 5 years of age are among the most acutely affected by undernutrition, assessment of this age group by anthropometry is usually done to determine PEM prevalence in a population (see "Indicators of Acute Undernutrition"). In general, acute undernutrition results in wasting and is assessed by an index of weight-for-height (WFH); however, edema of the extremities may be associated with acute undernutrition in which case, a clinical assessment is necessary. Chronic undernutrition produces stunting and typically results in a diminished height-for-age index.

The prevalence of moderate to severe acute undernutrition in a random sample of children less than 5 years of age is generally a reliable indicator of this condition in a population. Since weight is more sensitive to sudden changes in food availability than height, nutritional assessments during emergencies focus on measuring WFH. Also, WFH is a more appropriate measurement for ongoing monitoring of the effectiveness of feeding programs. As a screening measurement, the mid-upper arm circumference (MUAC) may also be used to assess acute undernutrition, although there is not complete agreement on which cutoff values should be used as indicators. Nutritional assessment methods are fully described in the Rapid Nutrition Assessment Manual. *

* Available from the International Health Program Office (IHPO), CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.

Anthropometric indices such as WFH and height-for-age are interpreted by comparison with a "reference population". Index values are assigned a "Z-score" based on the number of standard deviations above or below the median value in the reference population. Currently, the World Health Organization (WHO) recommends the use of the CDC/NCHS reference population for nutritional assessments in all countries (22). Before the mid-1980's, anthropometric data was reported as a percentage of the median of the reference population value. Current international guidelines, however, recommend the use of Z-scores to report nutritional assessment data. Tables in this report define acute undernutrition on the basis of percentage median in order to allow comparisons of recent data with data from surveys performed before the mid-1980s.

In a well-nourished population in which WFH values are distributed normally (i.e., the reference population), approximately 3% of children less than 5 years of age will have WFH Z-scores of less than -2. For less developed countries with lower "normal" nutritional intake levels, 5% of the children may have a Z-score less than -2 when compared with the reference population median, particularly at certain times of the year. Relief organizations agree that a nutritional emergency exists if greater than 8% of the children sampled have a Z-score less than -2. An excess of even 1% of children with Z-scores less than -3 indicates a need for immediate action. Acute PEM prevalence rates have been high in recent famine-affected populations, especially in Africa (Table 6).

In addition, acute undernutrition prevalence rates have been elevated in many displaced and refugee populations during the past 12 years, ranging as high as 50% in eastern Sudan in 1985 (Table 5) and (Table 7). PEM rates have decreased rapidly in situations where effective emergency relief operations have been mounted promptly, i.e., Thailand (1979) and Pakistan (1980). However, in other emergencies, such as in Somalia (1980) and Sudan (1985), PEM rates have remained high (greater than 20%) for 6-8 months. Of even greater concern is the observation that acute undernutrition rates among Somali refugees in Ethiopia (1988-1989) actually increased 6 months after a relief program was launched. Although most high acute undernutrition prevalence has been associated with inadequate food rations, it appears that malnutrition developed among Kurdish children 1-2 years of age in Turkey within a period of 1-2 months, primarily because of the high incidence of diarrheal diseases in the camps (10). Among internally displaced civilian populations, high PEM prevalence has been associated with the intentional use of food as a weapon by competing military forces (30).

The use of serial anthropometry surveys as monitoring tools has certain limitations when mortality rates are high. For example, an analysis of anthropometric data from two cross-sectional surveys in a refugee camp in Sudan in 1985 initially implied a relatively stable nutritional situation. In January, the prevalence of acute malnutrition in children less than 5 years of age was 26.3%; in March, the rate was 28.4%. During these two months, almost 13% of the children in the camp died, mainly from measles and diarrheal diseases. In this instance, the elevated child mortality rate masked diminished nutritional status in the population. Many malnourished children in the first survey, who had died, were "replaced" in the second survey sample by surviving children whose nutritional status had meanwhile deteriorated (31). Thus, anthropometry data need to be interpreted in the context of concurrent mortality rates.

Micronutrient deficiency diseases

In addition to PEM, micronutrient deficiencies play a key role in nutrition-related morbidity and mortality. The importance of micronutrient deficiencies in famine-affected and displaced populations has recently been extensively documented. In addition to deficiencies of vitamin A and iron, conditions widely recognized as important childhood problems in developing countries (i.e., epidemics of scurvy and pellagra) have also been reported in refugee populations during the past decade (Table 8).

Vitamin A deficiency

The most common deficiency syndrome in emergency affected populations is caused by lack of vitamin A. Ocular signs of vitamin A deficiency -- known as xerophthalmia -- include night blindness and Bitot's spots in the earlier stages. Xerophthalmia progresses to corneal xerosis, ulceration and scarring, and eventually blindness. Signs of xerophthalmia were detected in 7% of children surveyed in one region of Somalia during the drought of 1986-1987 (27); 2.1% in drought-affected Niger in 1985 (24); 4.3% among Kampuchean refugees in Thailand (36); and 2.7% in a region of Mauritania in 1984 (23). Recent data suggest that vitamin A deficiency is linked with high childhood mortality (37-38).

Famine-affected and displaced populations often have low levels of dietary vitamin A intake before experiencing famine or displacement, and therefore, may have very low vitamin A reserves. Furthermore, the typical rations provided in large-scale relief operations lack vitamin A, putting these populations at high risk. In addition, some communicable diseases that are highly incident in refugee camps -- measles and diarrheal diseases -- rapidly deplete vitamin A stores. Depleted vitamin A stores need to be adequately replenished during recovery from these diseases to prevent the deficiency from becoming clinically important.

Vitamin C deficiency (scurvy)

Although scurvy has been reported rarely in stable populations in developing countries, many outbreaks have occurred in displaced and famine-affected populations in recent years, primarily because of inadequate vitamin C in rations. In 1981-1982, an outbreak of more than 2,000 cases of scurvy occurred in the refugee camps of the Gedo region of Somalia. These Ethiopian refugees had traditionally obtained sufficient dietary vitamin C from camel's milk. Once in refugee camps they subsisted on a ration devoid of vitamin C. The outbreak was precipitated when local markets, where refugees had exchanged rations for fresh fruit and vegetables, were suddenly closed (39).

Active surveillance for scurvy among Ethiopian refugees in Somalia and Sudan in 1987 revealed cumulative incidence rates of up to 19.8% in some camps, with initial onset reported between 3-10 months after the arrival of the refugees (32). Cross-sectional surveys performed in 1986-1987 reported point prevalence rates as high as 45% among females and 36% among males; prevalence increased with age. The prevalence of scurvy was associated with the period of residence in camps, and the time exposed to rations lacking in vitamin C. In 1989, a population survey of children less than 5 years of age in Hartisheik camp in eastern Ethiopia in 1989 found the prevalence of clinical scurvy to be 2% (19). The international community has not developed an adequate strategy to prevent scurvy in refugee camps at the Horn of Africa, as demonstrated by an outbreak that took place among adult males (former Ethiopian soldiers) in a camp in eastern Sudan during 1991 (Bhatia R, personal communication, October 1991).

Niacin deficiency

Pellagra is the condition resulting from a severe deficiency of biologically available niacin in the diet. Once common in the southeastern United States, Italy, and Spain, pellagra now occurs mainly in maize- or sorghum-consuming populations in southern Africa, North Africa, and India. An outbreak of pellagra occurred in Malawi among Mozambican refugees between July and October 1989. Eleven camps reported a total of 1,169 patients; 20% of the patients were children less than 5 years of age (40). The French agency Medecins Sans Frontieres (MSF) instituted active surveillance at the time. Another outbreak occurred between February and October 1990 with 17,878 cases reported among 285,942 refugees in the same 11 sites (attack rate of 6.3%). More than 18,000 cases of deficiency were reported from all districts hosting approximately 900,000 refugees in southern Malawi, for an overall attack rate of 2.0% (35). Food rations contained an average of 4.9 mg of available niacin/person/day; the Food and Agriculture Organization (FAO)/WHO recommendations for daily niacin intake range from 5.4 mg for infants to 20.3 mg for adults. This outbreak occurred when relief efforts failed to include an adequate supply of groundnuts (peanuts), the major source of niacin in refugee rations. The lack of variety in basic relief rations is a major risk factor for pellagra and other micronutrient deficiency syndromes. Treatment of maize flour with lime (which converts niacin to a biologically available form of niacin) and the inclusion of beans, groundnuts, or fortified cereals in daily rations increase the total intake of available niacin and will prevent the development of pellagra (35).

Anemia

The high prevalence of anemia in refugee and displaced populations has been noted in few publications to date, but unpublished data from CDC assessments suggest that it may be a serious problem in some areas. In 1990, a survey of Palestinian refugees in Syria, Jordan, and the West Bank revealed that the prevalence of anemia among infants and young children was between 50% and 70%. Anemia among both nonpregnant and pregnant women was shown to be 25%-50%, whereas a low anemia prevalence rate was found among the male population. (In this study anemia was defined as a hemoglobin concentration of less than 11 g/dL among children and less than 12 g/dL among nonpregnant women. Pregnant women were considered to be anemic if their hemoglobin concentration was less than 11.5 g/dL during either the first or third trimester, or less than 11.0 g/dL during the second trimester.) These findings suggest that iron deficiency, which preferentially affects women and children, was the primary cause of anemia in this population.

A 1987 study among refugees in Somalia demonstrated an anemia prevalence rate of 44%-71% among pregnant women, with that proportion being even greater if only women in the third trimester of pregnancy were considered. The cutoff point for hemoglobin concentration in this study was 10 g/dL; with the WHO cutoff of 11 g/dL, the prevalence would have been greater. Among children 9-36 months of age, 59%-90% were below the 10 g/dL cutoff. The inadequacy of the general ration was identified as the major factor causing iron deficiency anemia in this population. In a 1990 study, the prevalence rate of anemia was 13% among children less than 5 years of age in an Ethiopian camp for Somali refugees (Save the Children Fund UK, unpublished data). In addition to dietary iron deficiency, the high incidence of malaria in many refugee populations probably contributes to the high prevalence of anemia in children. This high prevalence of anemia found in some refugee populations may not be significantly greater than that found in local, non-refugee populations, since the latter group has been poorly documented. Nevertheless, anemia may be an additional important preventable risk factor for high mortality in refugee populations. The high prevalence of anemia is often correlated with a subset of the population with severe anemia (hemoglobin (Hb) less than 5 g). Severe anemia in itself can be a major cause of mortality for young children and pregnant women during the peripartum period.

Other micronutrient deficiencies

Beriberi (thiamine deficiency) has been reported from several refugee populations that subsist on rice-based food rations (Thailand, 1980; Guinea, 1990). Data regarding iodine deficiency in displaced populations are difficult to find, anecdotal evidence suggests that iodine deficiency, as evidenced by the presence of goiter, has been a problem in at least some camps in Pakistan and Ethiopia (CDC. Toole M, trip report, 1991).

Communicable Diseases

Measles, diarrheal diseases, ARIs, and in some cases, malaria are the primary causes of morbidity and mortality among refugee and displaced populations (1,16,41). (Figure 4), (Figure 5), and (Figure 6) illustrate patterns of mortality typical among those found in refugee camps. Other communicable diseases, i.e., meningococcal meningitis, hepatitis, typhoid fever, and relapsing fever have also been observed among refugee populations; however, the contribution of these illnesses to the overall burden of disease among refugees has been relatively small.

Densely populated camps with poor sanitation, inadequate clean water supplies, and low-quality housing all contribute to the rapid spread of disease in refugee settings. In addition, the interaction between malnutrition and infection in these populations, particularly among young children, has contributed to the high rates of morbidity and mortality from communicable diseases. Available and affordable technology could prevent much of this morbidity and mortality either through primary prevention (e.g., immunization, adequate planning, and sanitation) or through appropriate case management (e.g., treatment of dehydration caused by diarrhea with oral rehydration salts and continued feeding).

Measles

Outbreaks of measles within refugee camps have been common and have caused many deaths. Low levels of immunization coverage, coupled with high rates of undernutrition and vitamin A deficiency, have played a critical role in the spread of measles and the subsequent mortality within some refugee camps. Measles has been one of the leading causes of death among children in refugee camps. In addition, measles has contributed to high malnutrition rates among those who have survived the initial illness. Measles infection may lead to or exacerbate vitamin A deficiency, compromising immunity and leaving the patient susceptible to xerophthalmia, blindness, and premature death (42). In early 1985, the crude, measles-specific death rate in one eastern Sudan camp reached 13/1,000/month; among children less than 5 years of age, the measles-specific death rate was 30/1,000/month. Over 2,000 measles deaths were reported in this camp from February through May 1985. (Figure 9) illustrates the proportion of all deaths that were due to measles in this camp during the course of the outbreak (16). The CFR was reported to be 33% during this outbreak; however, mild cases may have been underreported. Large numbers of measles deaths have been reported in camps in Somalia, Bangladesh, Sudan, and Ethiopia (1). Mass immunization campaigns were effective in reducing the measles morbidity and mortality rates in camps in both Somalia and Thailand (16). Measles outbreaks probably did not occur during certain other major refugee emergencies (e.g., Somalis in Ethiopia in 1989; Iraqis in Turkey in 1991), because immunization coverage rates were already high in those refugee populations before their flight (9,10).

Diarrheal diseases

Diarrheal diseases are a major cause of morbidity and mortality among refugee and displaced populations, primarily because of the inadequacy of the water supply (both in terms of quality and quantity), and the insufficient and poorly maintained sanitation facilities. In eastern Sudan in 1985, between 25%-50% of all deaths in four major camps were attributed to diarrheal diseases. In Somalia (1980), Malawi (1988), and Ethiopia (1989), between 28%-40% of all deaths in refugee camps were attributed to diarrhea (1). Between March and October 1991, 35% of deaths among Somali refugees in the Liboi camp in Kenya were caused by diarrhea. Among Central American refugees in Honduras, diarrheal diseases were responsible for 22.3% of mortality among children less than 5 years of age during a 3-year period (43). In April 1991, in camps for Iraqi refugees on the Turkish border, approximately 70% of all patients arriving at clinics had diarrhea (10). Of these, approximately 25% complained of bloody diarrhea during the first 2 weeks of April. (Figure 10 ) shows the gradual decline in diarrheal disease among clinic outpatients at a Kurdish refugee camp in Turkey.

Improvements in camp sanitation and water supply were probably responsible for this trend. Although the etiologies of diarrheal illness during refugee emergencies have not been well documented, the responsible pathogens are most likely to be the same agents that cause diarrhea in non-refugee populations in developing countries. In one study in a camp for famine victims in Ethiopia, of 200 patients with diarrhea, 15.6% had positive cultures for Escherichia coli (pathogenicity not specified by authors), 3.5% for Shigella spp., and 2% for Salmonella spp. (44).

Cholera

Outbreaks of cholera have occurred in several refugee populations, although overall, other diarrheal diseases have probably caused many more deaths than cholera. In addition to the morbidity and mortality directly caused by cholera, epidemics of this severe disease cause serious disruption to camp health services. Outbreaks of cholera have been reported in refugee camps in Thailand (16,45), Sudan (46), Ethiopia (11-12), Malawi (47), Somalia (48), and Turkey (10). The Somali Refugee Health Unit reported 6,560 cases of cholera and 1,069 cholera deaths in 1985. During the course of the epidemic, one camp (Gannet) experienced a CFR of 25%. The CFR in the remaining camps was 2.9%, with some areas reporting a CFR of less than 1% (Figure 11) (48). During the same year, two adjacent refugee camps in the Sudan reported a total of 1,175 cases of cholera with 51 deaths (CFR = 4%) over the course of a 2-week epidemic (46). Mozambican refugees in Malawi have been especially vulnerable to cholera; 20 separate outbreaks have been reported in Malawian camps since 1988 (49). Outbreak investigations have identified polluted water sources, shared water containers and cooking pots, lack of soap, failure to reheat leftover food, and possibly contaminated food (dried fish) as important risk factors for infection. Nearly 2,000 cases were reported among 80,000 refugees in one camp (Nyamithutu) during a 4-month period in 1990 ( Figure 12). Among 26,165 new arrivals during this period, 1,651 cases were reported for an attack rate of 6.3% in this group. The variation in CFRs between camps reflects the different levels of organizational preparedness, health worker training and experience, and available resources. One group of relief workers speculated that high CFRs in some Malawian camps may be associated with concurrent niacin deficiency, although their hypothesis has not yet been proven (Moren A, personal communication).

Acute respiratory infections

ARIs are among the leading causes of death among refugee populations. In Thailand (1979), Somalia (1980), Sudan (1985), and Honduras (1984-1987), ARIs were cited among the three main causes of mortality in refugee camps, particularly among children (16,43). Among children less than 5 years of age in refugee camps in Honduras, respiratory infections were responsible for slightly greater than 1 of every 5 deaths during a 3-year period (43).

Tuberculosis (TB)

TB is well recognized as a health problem among refugee populations. The crowded living conditions and underlying poor nutritional status of refugee populations may foster the spread of the disease. Although not a leading cause of mortality during the emergency phase, TB often emerges as a critical problem once measles and diarrheal diseases have been adequately controlled. For example, 26% of adult deaths among refugees in Somalia in 1985 were attributed to TB (16). During this time, TB was the third leading cause of death, and the leading cause among adults (48). In eastern Sudan, between 38% and 50% of all deaths in two camps were caused by TB during the 9 to 10 months period after the camps opened (16). TB has been cited as a major health problem among Afghan refugees in Pakistan (CDC. Serdula M, trip report). Although it may be theoretically easier to ensure patient compliance with protracted chemotherapy in the confined space of a refugee camp, the personnel needed to supervise treatment may not be available. In addition, the uncertain duration of stay, frequent changes of camp locations, and poor camp organization may hinder TB treatment programs.

Malaria

Malaria is a major health problem in many areas that host large refugee populations, including Somalia, Sudan, Ethiopia, Thailand, Guinea, Cote d'Ivoire, Malawi, Pakistan, and Kenya. Malnutrition and anemia, conditions that are common among refugees, may be directly related to recurrent or persistent malaria infection or may compound the effects of malaria and lead to high mortality. Malaria is the leading cause of morbidity among adult refugees in Malawi and in 1990 caused 18% of all deaths and 25% of deaths among children less than 5 years of age (CDC, unpublished data). Malaria is of particular concern when the displaced population has traveled through, or into, an area of higher endemicity than its region of origin (1). During the period 1979- 1980, Khmer refugees traveled from the central valley of Kampuchea, where malaria transmission is very low, into Thailand. Those refugees who arrived at the Sakaeo camp traveled through mountain regions where malaria is highly endemic year round, while refugees who arrived at Khao I-Dang camp had traveled a route that remained within the areas of low malaria transmission. As a result of the differences in exposure during transit, the initial malaria prevalence rate at Sakaeo was 39% compared with a 4% prevalence rate at Khao I-Dang. During this time, malaria was a major cause of death at Sakaeo (50). Similarly, Ethiopian refugees from the highland areas of Tigray province arrived in eastern Sudan in 1985 with decreased immunity against the malaria that is seasonally endemic in that region of Sudan. Not surprisingly, malaria was an important cause of death among these refugees. Farther north, in the Kassala region of eastern Sudan, a major outbreak of malaria occurred among refugees from Eritrea following extensive flooding in the area in September 1988. In contrast to the Tigrayan refugees, the Eritreans were largely from lowland areas and had been previously exposed to malaria. The severity of this outbreak may have been due to the emergence of chloroquine resistant Plasmodium falciparum malaria in eastern Sudan at that time, and the subsequent widespread failure of first-line treatment regimens (Toussie S, personal communication, 1989).

Afghan refugees living in the North-West Frontier Province of Pakistan have a higher incidence of clinical malaria than that observed among the local population. A comparison of the epidemiologic trends of malaria between the refugees and the local population over a period of several years demonstrated that the increased rate of malaria illness among refugees was a result of having resettled in an area of higher transmission than that from which they had fled. Because of their limited exposure history, the Afghan refugees had lower levels of immunity to malaria illness than did the local population (51). Few deaths associated with malaria have been reported in this population because the majority of cases have been associated with Plasmodium vivax, a milder form of malaria than that caused by Plasmodium falciparum, the form that is more commonly reported in African camps.

Hepatitis

Hepatitis has not been among the most common diseases reported in refugee and displaced populations worldwide, however, since 1985 it has emerged as a serious problem in camps at the Horn of Africa, where access to adequate supplies of clean water has been severely limited. In Somalia during the period 1985-1986, an outbreak of greater than 2,000 cases occurred in two refugee camps, with an overall attack rate of 8% among adults. Of 87 hepatitis deaths, 46% were among pregnant women. The overall CFR was 4%, the CFR in second- and third-trimester pregnant women was 17%. By a process of exclusion, the outbreak was attributed to enterically transmitted non-A, non-B hepatitis (now known as hepatitis E) (52). (Figure 13) depicts an outbreak of hepatitis that occurred in the Hartisheik refugee camp in Ethiopia between 1989 and 1990.

During an 18-month period, greater than 6,000 cases were reported. Between March and October of 1991, a major outbreak of hepatitis occurred among Somali refugees living in Kenya's Liboi camp; a total of 1,700 cases were reported, yielding an attack rate of 6.3%. The overall CFR was 3.7% and in pregnant women the CFR was 14%. Hepatitis was responsible for one of every five deaths in the camp during that time period. The hepatitis E virus was identified in stool and serum specimens from ill patients. The Ethiopian and Kenyan outbreaks were associated with inadequate water supply. In both camps, refugees had access to an average of only 1-3 liters of clean water/person/day (the United Nations High Commissioner for Refugees (UNHCR) recommends a minimum of 15 liters/person/day) (53).

Meningitis

Overcrowding and limited access to medical care are contributing factors in outbreaks of meningococcal meningitis among refugee populations. Also, many large refugee populations are found in what is termed the "meningitis belt" of sub-Saharan Africa. Although children less than 5 years of age are at greatest risk for meningitis, meningococcal meningitis also occurs among older children and adults, particularly in densely populated settings i.e., refugee camps (54). During an outbreak of group A meningococcal disease at the Sakaeo refugee camp in Thailand in 1980, children less than 5 years of age experienced a CFR of 50%. The overall CFR during that outbreak was just over 28% (55). Outbreaks of meningococcal meningitis have also been reported among Ethiopian refugees in eastern Sudan (1985) and among displaced Sudanese in Khartoum and southern Sudan during 1988 (56).

Other Health Issues

Although these reports focus on the major causes of morbidity and mortality during the emergency phase of refugee displacements, other health problems warrant the attention of public health practitioners in these settings.

Injuries

Thus far, injuries related to armed conflict and psychological problems relating to war, persecution, and the flight of the refugee have been poorly quantified. In a recent report on Iraqi refugees on the Turkish border, 8% of the deaths during a 2-month period were attributed to trauma. Sixty percent of these trauma-related deaths were attributable to shootings by armed soldiers (CDC. Toole M, trip report, September 1991). Anecdotal reports support the existence of high rates of physical disabilities caused by war injuries in some refugee camps, such as those for Afghan refugees in Pakistan, Cambodian refugees in Thailand, and Mozambican refugees in Malawi.

Maternal health

The problem of morbidity and mortality related to pregnancy and childbirth has been inadequately documented, although earlier sections of this report described high anemia rates and high hepatitis-specific mortality rates among pregnant women (52). Also, studies of scurvy and pellagra among refugees in Africa have consistently revealed higher incidence rates in women than in men, and a study in Somalia showed that pregnancy was a risk factor for the development of clinical scurvy (32,35).

Sexually transmitted diseases and HIV

Few published reports have referred to sexually transmitted diseases (STD) in refugee populations. However, there is no evidence that the incidence of STDs in camps is any higher (or lower) than in non-refugee communities. Similarly, practically no data exist on the prevalence of HIV infection, nor on rates of transmission in these populations. Many of the large displaced and refugee populations of the world are either located in, or have fled to, countries where HIV prevalence rates are high. These include: Mozambican refugees in Malawi, Zambia, and South Africa; Ethiopian refugees in Sudan; Liberian refugees in Cote d'Ivoire and Guinea; Ugandan and Rwandan refugees in Zaire; Cambodian and Laotian refugees in Thailand; and Sudanese refugees in Uganda.

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RECOMMENDATIONS

The technical recommendations in this report focus on the public health elements of an appropriate response program for refugees and displaced persons, however, the effectiveness of relief efforts will be enhanced if the affected communities and host countries have prepared for the emergency. Preparedness for sudden population displacement is critical and should be targeted at the most important public health problems identified in previous emergencies: malnutrition, measles, diarrheal diseases, malaria, ARI, and other communicable diseases (e.g., meningitis and hepatitis) that result in high death rates.

Preparedness requires that planning for emergencies be included as an integral part of routine health development programs in countries where sudden population displacements might occur. These programs include:

National public health programs should include detailed contingency planning for sudden population movements, both internally and from neighboring countries.

Response Preparedness

The critical components of a relief program responding to sudden population displacement comprise the provision of adequate food, clean water, sanitation, and shelter. In addition, the following elements of a health program should be established as soon as possible.

Health Information System

Diarrheal Disease Control

Immunization

Basic Curative Care

Endemic disease control and epidemic preparedness

The detailed recommendations that follow are organized according to either disease group (e.g., diarrheal diseases or malnutrition) or technical methods (e.g., rapid assessment). Nevertheless, it is critical to keep in mind the demographic groups that are most at risk during emergencies, namely young children and women. It is important that health services in refugee settings be organized in a way that facilitates access by these groups. In general, MCH services should be given higher priority than general outpatient dispensaries and hospitals.

Maternal and Child Health Care

MCH clinics should be established (ideally one MCH clinic per 5,000 population) and staffed by trained personnel to provide routine screening and preventive, and curative services to pregnant and lactating women and to children less than 2 years of age. If resources are adequate, these services should be extended to children between 2 and 5 years of age. Services for children should include routine growth monitoring, immunization, nutritional rehabilitation, vitamin A supplementation, and curative care, as well as health education for their mothers.

Female health workers should be trained and employed to provide culturally appropriate health education both at MCH clinics and within the community, and to refer pregnant women to the clinic for antenatal care. At least some of these health workers should be recruited from among traditional birth attendants in the community. Antenatal care should include screening for high-risk pregnancies and providing iron and folic acid supplementation (as well as iodine supplementation in areas of endemic goiter), tetanus toxoid immunization, and health education. Postnatal care should include nutritional supplementation, counselling on family spacing, provision of contraceptives, and education about breastfeeding and infant care. In certain cultural situations, curative care may need to be provided to all women of child-bearing age in a setting physically segregated from male outpatient facilities.

Program-Specific Recommendations

The following content areas are covered in these recommendations:

Rapid Health Assessment

Rapid health assessment of an acute population displacement is conducted to:

Preparations

The amount of time required to conduct an initial assessment of a refugee influx depends on the remoteness of the location, availability of transport, security situation in the area, availability of appropriate specialists, and willingness of the host country government to involve external agencies in refugee relief programs. In small countries with functioning communications facilities and secure borders, the assessment might be conducted in 4 days; in other countries, it might take 2 weeks.

Before the field visit, relevant information relating to the status of the incoming refugees, as well as the available resources of the host community, should be obtained from local ministries or organizations based in the capital city. Any maps of the area where the refugees are arriving and settling should likewise be obtained. Aerial photographs will also be of value, but may be considered sensitive by the military of the host country. International organizations like UNICEF, WHO, and the Red Cross/Red Crescent may also have demographic and health data concerning the refugee population.

In preparation for the field visit, establish whether food, medical supplies (including vaccines), or other relief supplies have been ordered or procured by any of the relief agencies involved. Additionally, the following conditions should be included in a field assessment.

Field assessment

The following demographic information is required to determine the health status of the population.

Why this information is needed. The total population will be used as the denominator for all birth, death, injury, morbidity, and malnutrition rates to be estimated later. The total population is necessary for the calculation of quantities of relief supplies. The breakdown of the population by age and sex allows for the calculation of age- and sex-specific rates and enables interventions to be targeted effectively (e.g., immunization campaigns).

Sources of information. Local government officials or camp authorities may be able to provide registration records. If no registration system is in effect, one should be established immediately. Information recorded should include the names of household heads, the number of family members by age and sex, former village and region of residence, and ethnic group, if applicable.

Refugee leaders may also have records, particularly if entire villages have fled together. In certain situations, political groups may have organized the exodus and may have detailed lists of refugee families.

A visual inspection of the settlement may provide a general impression of the demographic composition of the population. However, information obtained in this manner should be used judiciously as it is likely to provide a distorted view of the situation.

It may be necessary to conduct a limited survey on a convenience sample in order to obtain demographic information. Beginning at a randomly selected point, survey a sample (e.g., 50) of dwellings. Visit every fifth or 10th house until the predetermined number of houses have been surveyed. At each house, record the number of family members, the age and sex of each person, and the number of pregnant or lactating women. This process will establish an initial estimate of the demographic composition of the population. Estimate the number of persons in each house, as well as the total number of houses in the settlement, to gain a provisional estimate of the camp population. At the very least, this quick survey should give a rough estimate of the proportion of the total population made up of "vulnerable" groups; i.e., children less than 5 years of age and women of child bearing age. To determine the total population, a census may need to be conducted later.

Background health information

The information required includes:

Why this information is needed. Effective planning of health services will depend on this information. Planners need to be aware of traditional beliefs, taboos, and practices in order to avoid making costly mistakes and alienating the population.

Sources of information. Obtain documents and reports from the host government, international organizations, and nongovernment organizations pertaining to endemic diseases and public health programs in the displaced population's region of origin.

Interview refugee leaders, heads of households, women leaders (e.g., traditional midwives), and health workers among the refugee population.

Seek information from development agencies, private companies, missionaries, or other groups having experience with the displaced population.

Nutritional status

The information required includes:

Why this information is needed. Evidence exists to support the fact that the nutritional status of displaced populations is closely linked with their chances of survival. Initial assessment of nutritional status serves to establish the degree of urgency in delivering food rations, the need for immediate supplementary feeding programs (SFPs), and the presence of micronutrient deficiencies that require urgent attention.

Sources of nutritional information. If refugees are still arriving at the site:

If refugees are already located in a settlement:

In order to gather baseline data for evaluation of nutrition programs, plan to conduct a valid, cluster sample survey of the population as soon as possible (within 2 weeks). Appropriate technical expertise will be needed for the implementation and analysis of the survey.

Mortality rates

The information required includes crude, age-, sex-, and cause-specific mortality rates.

Why this information is needed. In the initial stages of a population displacement, mortality rates, expressed as deaths/10,000/day, are a critical indicator of improving or deteriorating health status.

In many African countries, the daily CMR (extrapolated from published annual rates) is approximately 0.5/10,000/day during non-emergency conditions. In general, health workers should be extremely concerned when CMRs in a displaced population exceed 1/10,000/day, or when less than 5 years of age mortality rates exceed 4/10,000/day.

Sources of mortality information. Check local hospital records and the records of local burial contractors. Interview community leaders.

Establish a mortality surveillance system. One approach is to designate a single burial site for the camp, which should be monitored by 24-hour grave watchers. Grave watchers should be trained to interview families, using a standard questionnaire, and then to record the data to determine gender, approximate age, and probable cause of death.

Other methods of collecting mortality data include registering deaths, issuing burial shrouds to families of the deceased to ensure compliance, or employing volunteer community informants who report deaths for a defined section of the population.

Demographic data are absolutely essential for calculating mortality rates. These provide the denominator for estimating death rates in the entire population and within specific vulnerable groups, such as children less than 5 years of age.

The population needs to be assured that death registration will have no adverse consequences (e.g., ration reductions). Morbidity

The information required includes age- and sex-specific data regarding the incidence of common diseases of public health importance, i.e., measles, malaria, diarrheal diseases, and ARI, as well as diseases of epidemic potential such as hepatitis and meningitis. The data should be collected by all health facilities, including feeding centers.

Why this information is needed. Data on diseases of public health importance may help plan an effective preventive and curative health program for refugees. These data will also facilitate the procurement of appropriate medical supplies and the recruitment and training of appropriate medical personnel, as well as focus environmental sanitation efforts (e.g., toward mosquito control in areas of high malaria prevalence).

Sources of morbidity information. Review the records of local clinics and hospitals to which refugees have access.

Where a clinic, hospital, or feeding center has already been established within the camp, examine patient records or registers and tally common causes of morbidity. Interview refugee leaders and health workers within the refugee population.

A simple morbidity surveillance system should be established as soon as curative services are established in the camp. Feeding centers should be included in the surveillance system. Community health workers should be trained as soon as possible to report diseases at the community level.

The initiation of certain public health actions should not be delayed until the disease appears. For example, measles immunization should be implemented immediately. Do not wait for the appearance of measles in the camp. Also, oral rehydration centers should be routinely established in all situations.

Environmental conditions

The information required includes:

Why this information is needed. Information on local environmental conditions affecting the health of displaced populations will help relief planners create priorities for public health programs. Sources of information. This assessment is made largely by visual inspection. In addition, interviews with local government and technical specialists will yield important information. In some cases, special surveys need to be conducted; e.g., entomologists may need to survey for local disease vectors, and water engineers may need to assess water sources.

Resources available

Food supplies --

Efforts to evaluate food supplies should include:

Food sources. Local, regional, and national markets need to be assessed. The cash and material resources of the displaced population should also be assessed in order to estimate its local purchasing power.

Food logistics. Assess transport and fuel availability, storage facilities (size, security), and seasonal conditions of access roads.

Feeding programs. Follow these guidelines to evaluate feeding programs:

Local health services. Follow these guidelines for assessing the capabilities of health services:

Camp health services. Follow these guidelines for assessing camp health services:

Taking action

Checklist For Rapid Health Assessment (*)

(*) Adapted from : WHO Emergency Relief Operations. Emergency Preparedness and Response: Rapid Health Assessment in Sudden Population Displacements. WHO, in collaboration with CDC and other WHO Collaborating Centers for Emergency Preparedness and Response. Geneva: January 1990.

Preparation

Field assessment

Health information

Nutritional status

Mortality rates

Morbidity

Environmental conditions

Resources available

Health Information System

A health information system (HIS) provides continuous information on the health status of the refugee community and comprises both ongoing routine surveillance and intermittent population-based sample surveys. This information may be used to:

Data collection

As soon as health services are established for a refugee population, a surveillance system should be instituted and should ideally be set up at the time of an initial, rapid assessment. Any agency or facility (including feeding centers) providing health services to the refugee population should be part of the reporting network. Any host community services to which the refugees might have access should also be part of the system.

Health information should be reported on a simple, standardized surveillance form. (A sample form, adapted from WHO Emergency Relief Operations, is located at the end of this section.) Each health facility should be held accountable for completing the reporting form at the appropriate interval and for returning it to the person or agency charged with compiling the reports, analyzing the information, and providing feedback. Each refugee settlement or camp should have a person responsible for coordinating the HIS. Forms should be translated into the appropriate local language(s) if community health workers are involved in information collection.

Health facilities should keep a daily record of patients; age, sex, clinical and laboratory diagnosis, and treatment should be specified. If personnel time is limited, a simple tally sheet should be used. In addition, the patient should be issued a health record card on which the date, diagnosis, and treatment are recorded. Each time a patient contacts the health-care system, whether for curative or preventive services, this should be noted on the health record card. Laboratory data should accompany diagnostic information whenever possible. Collecting Processing, Storing, and Shipping Diagnostic Specimens in Refugee Health-Care Environments * provides an overview of procedures for collecting and processing diagnostic specimens in the field.

* Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.

Data collection should be limited to that information that can and will be acted upon. Information that is not immediately useful should not be collected during the emergency phase of a refugee relief operation. Overly detailed or complex reporting requirements will result in noncompliance.

The most valuable data are generally simple to collect and to analyze. Standard case definitions for the most common causes of morbidity and mortality should be developed and put in writing. The data collected will fall into one of the following categories: a) demographic, b) mortality, c) morbidity, d) nutritional status, and e) health program activities.

Population. Camp registration records should provide most of the demographic information needed. If registration records are inadequate, a population census may be necessary. Conducting a census is often politically sensitive and may be delayed by the administrative authorities for a long period of time. Consequently, innovative methods may need to be devised. For example, organize a nutritional screening of all children less than 5 years of age. Count the children and estimate the percentage of the total population less than 5 years of age by doing a sample survey. From this information, estimate the total population size. For other methods to determine population size and structure see "Rapid Health Assessment".

It is important that population figures be updated on a regular basis, taking into account new arrivals, departures, births, and deaths. The total population is used as the denominator in the calculation of disease incidence, birth, and death rates. This total is also necessary to determine requirements for food and medical supplies and to estimate program coverage rates. Information about the population structure is needed to calculate age- and sex-specific morbidity and mortality rates, to estimate ration requirements, and to determine the target population for specific interventions, i.e., antenatal care and immunizations.

The rate of new arrivals and departures gives an indication of the stability of the population and will influence policy decisions about long-term interventions, such as TB therapy. This information is also used to predict future resource and program needs.

A birth registration system is usually simple, since the community expects an increase in the family food ration as a result of a new birth. Births might be reported in the community to volunteer health workers or traditional birth attendants. Alternatively, if good antenatal care services are established, follow-up of pregnant mothers will allow for a relatively complete registration of births. Examples of mortality surveillance systems are described in "Rapid Health Assessment". Deaths may be underreported if there is a fear of possible ration reduction; thus, an agreement might be negotiated with camp authorities not to decrease rations after a death occurs at least during the emergency phase. Arrivals and departures should be monitored through the camp registration system.

Mortality. Each health facility should keep a log of all patient deaths (with cause of death and relevant demographic information) and report the deaths on a standardized form. Because many deaths occur outside of the health-care system, a community-based mortality surveillance system should be established. Such a system may include the employment of grave watchers, the routine issuance of burial shrouds, and the use of community informants (see "Rapid Health Assessment").

Death rates are the most specific indicators of a population's health status and are the category of data to which donors and relief agencies most readily respond. During the emergency phase of a relief operation, death rates should be expressed as deaths/10,000/day to allow for detection of sudden changes. In refugee camps, relief programs should aim at achieving a CMR of less than 1/10,000/day as soon as possible. This rate still represents approximately twice the "normal" CMR for non-displaced populations in most developing nations and should not signal a relaxation of efforts. After the emergency phase, death rates should be expressed as deaths/1,000/month to reflect the usual reporting frequency and to facilitate comparison with baseline, non-refugee death rates.

Age- and sex-specific mortality rates will indicate the need for interventions targeted at specific vulnerable groups. During the early stage of a relief operation, specific death rates for persons less than 5 years of age and greater than 5 years of age may suffice. Later, further disaggregation by age may be feasible -- for example, less than 1 year, 1-4 years, 5-14 years, and greater than 15 years. Different male- and female-specific death rates may reflect inequitable access to resources or health services. Cause-specific mortality rates will reflect those health problems having the greatest impact on the refugee community and requiring the highest priority in public health program planning.

Morbidity. Health facilities and feeding centers should report morbidity information on the same form on which mortality is reported. Each disease reported in the system must have a written case definition that will guide health workers in their diagnosis and ensure the validity of data. Where practical, case definitions that rely on clinical signs and symptoms should be tested periodically for sensitivity and specificity as compared with a laboratory standard (e.g., malaria).

Knowledge of the major causes of illness and the groups in the affected population that are at greatest risk allows for the efficient planning of intervention strategies and the most effective use of resources. Morbidity rates are more useful than a simple tallying of cases, as trends can be followed over time, or rates compared with those from different populations. The monitoring of proportional morbidity (e.g., percentage of all morbidity caused by specific diseases) may be useful when specific control measures are being evaluated, although caution is needed in the interpretation of trends. A relative decrease in disease-specific proportional morbidity may merely reflect an absolute increase in the incidence of another disease.

Nutritional status. Data regarding nutritional status can be obtained through a nutritional assessment survey or a mass screening exercise. Surveys should be repeated at regular intervals to determine changes in nutritional status; however, not so frequently as to obscure true differences between surveys. All children less than 5 years of age should undergo a nutritional screening upon arrival at the camp and should continue to be weighed and measured monthly at MCH clinics in the camp. Information collected during these screenings should be included in HIS reports. If the initial screening identifies high prevalence rates of undernutrition, cross-sectional surveys should be repeated at intervals of 6-8 weeks until the undernutrition prevalence rate is below 10%. Thereafter, surveys every 6-12 months will suffice, unless routine surveillance data indicate that nutritional status has deteriorated. Measurement of nutritional status is described in the Rapid Nutrition Assessment Manual. (*)

(*) Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.

The prevalence of acute malnutrition acts as an indicator of the adequacy of the relief ration. A high prevalence of malnutrition in the presence of an adequate average daily ration may indicate inequities in the food distribution system, or high incidence rates of communicable diseases (e.g., measles and diarrhea). The presence of nutritional deficiency disorders (i.e., pellagra, anemia, or xerophthalmia) indicates the need for ration supplementation.

Programs. Each health facility should keep a log of all activities. Immunizations should be recorded in a central record, as well as on the person's health record card. Records of health sector activities will be useful in determining whether certain groups in the population are underserved, and in planning measures to reach a broader population base. Although approximate immunization coverage may be estimated from the number of vaccine doses administered, the preferred method is by annual population surveys.

Analysis and interpretation

Most data can be analyzed locally using a pen and paper. The use of computers and a data entry and analysis program, such as Epi Info, version 5, may be practical at the regional or national level. Trends in mortality, morbidity, and nutritional status should be monitored closely. Careful attention should be paid to changing denominators, and changes in proportional mortality or morbidity should be interpreted with particular caution. Where applicable, correlations between mortality, morbidity or nutritional status, and health sector activities should be examined. Likewise, the proportion of malnourished children identified in population surveys as enrolled in feeding programs can be used to estimate program coverage. All components of the HIS should be analyzed and interpreted in an integrated fashion. A single element examined alone will reveal only a small portion of the entire picture and may be easily misinterpreted. For example, an apparent decrease in malnutrition prevalence should be interpreted in the context of childhood mortality rates (1). The use of health information to guide program decision-making will be facilitated if targets and critical indicators are established at the beginning. For example, a measles incidence rate of 1/1,000/month might be an indicator that would initiate specific preventive actions. Similarly, during a cholera outbreak, a CFR of 3% in a given week might stimulate a critical review of case management procedures.

Control measures

The information gathered through the HIS should be used to develop recommendations and to implement specific control measures. Objectives for disease control programs should be established and progress towards these objectives regularly assessed. The presentation of data to decision-makers should make use of simple, clear tables and graphs. Most importantly, there should be regular feedback to the data providers through newsletters, bulletins, and frequent supervisory visits.

Assessment

The HIS should be periodically assessed to determine its accuracy, completeness, simplicity, flexibility, and timeliness. The utilization of the data by program planners and key decision-makers should also be assessed. The HIS should evolve as the need for information changes.

Reference

  1. Nieburg P, Berry A, Steketee R, Binkin N, Dondero T, Aziz N. Limitations of anthropometry during acute food shortages: high mortality can mask refugees' deteriorating nutritional status. Disasters, 1988;12:253-8.

Nutrition

Rations

For populations totally dependent upon food aid, a general ration of at least 1,900 kcal/person/day is required. At least 10% of the calories in the general ration should be in the form of fats and at least 12% should be derived from proteins.

The calculation of rations should account for calorie loss during transport and food preparation. Similarly, when the mean daily temperature falls below 20 C, the caloric requirement should be increased accordingly by 1% per degree of temperature below 20 C.

The standard requirement of 1,900 kcals is based on the following demographic structure of a population:

The calculation of ration requirements should be adjusted for deviations from the above population structure (age/gender breakdown), the underlying health and nutritional status of the population, and relative activity levels of the community.

Guidelines for ration distribution

Supplementary feeding programs

SFPs are designed to help prevent severe malnutrition and to rehabilitate moderately malnourished persons. SFPs are not intended to be used as a method of targeting food during an emergency phase. Similarly, SFPs are inappropriate as a long-term supplement to an inadequate general ration.

Implementation of a SFP is necessary under the following circumstances:

Inclusion and discharge criteria.

The following groups should be targeted for inclusion in a SFP:

Children should be discharged from the SFP after they have maintained greater than 85% of median WFH (or a Z-score greater than -1.5) for a period of 1 month.

Caloric requirements. A SFP should provide at least 500 kcal and 15 g protein/day in one or two feedings.

High energy milk (HEM), a calorie-dense milk mixture, may be used in a SFP. One milliliter of HEM provides 1 kcal of energy. The formula below makes 5 L of HEM:
420 g dried skimmed milk,
250 g sugar,
320 g oil, and
4.4 L water

If the general ration is inadequate (less than 1,900 kcal/person/day), the supplementary ration should provide 700-1,000 kcal/person/day in two to three feedings.

Types of SFPs. SFPs fall into two categories, either on-site feeding or take-home rations. Listed below are some of the advantages and disadvantages of each type of SFP (1).

On-site feeding. "Wet" rations are prepared by SFP staff and served to recipients in the feeding center. Listed below are the advantages of wet rations:

These are the disadvantages of wet rations:

Take-home programs. "Dry" rations are provided on a regular basis to supplement the general ration normally received. These are the advantages of dry rations: