Communicable disease

control in emergencies
A field manual
Edited by M.A. Connolly
WHO Library Cataloguing-in-Publication Data
Communicable disease control in emergencies: a field manual edited by M. A.
Connolly.
.Communicable disease control!met"ods #.Emergencies $.Disease outbrea%&
're(ention and control ).Manuals *.Connolly& M+ire A.
*,-. /# ) 0)11 1 2.LM Classification: WA 34
WHO5CD,5#330.#6
7 World Healt" Organi8ation& #330
All rig"ts reser(ed.
9"e designations em'loyed and t"e 'resentation of t"e material in t"is 'ublication
do not im'ly t"e e:'ression of any o'inion ;"atsoe(er on t"e 'ert of t"e World
Healt" Organi8ation concerning t"e legal status of any country& territory& city or area
or of its aut"orities& or concerning t"e delimitation of its frontiers or boundaries.
Dotted lines on ma' re'resent a''ro:imate border lines for ;"ic" t"ere may not yet
be full agreement.
9"e mention of s'ecific com'anies or of certain manufacturers< 'roducts does not
im'ly t"at t"ey are endorsed or recommended by t"e World Healt" Organi8ation in
'reference to ot"ers of a similar nature t"at are not mentioned. Errors and omissions
e:ce'ted& t"e names of 'ro'rietary 'roducts are distinguis"ed by initial ca'ital letters.
All reasonable 'recautions "a(e been ta%en by WHO to (erify "e information
contained in t"is 'ublication. Ho;e(er& t"e 'ublis"ed material is being distributed
;it"out ;arranty of any %ind& eit"er e:'ress or im'lied. 9"e res'onsibility for t"e
inter'retation and use of t"e material lies ;it" t"e reader. *n no e(ent s"all t"e World
Healt" Organi8ation be liable for damages arising in its use.
Layout: CME5-. Duret& =rance ! P"oto credits: to' left > bottom: ?nicef 5
middle: PAHO 5 to' rig"t: WHO!@ayer
CONTENTS
ACKNOWLEDGEMENTS..............................................................................(i
INTOD!CTION..............................................................................................
"# A$ID ASSESSMENT
%#" Ob&ecti'es................................................................................................0
%#% Com(osition of t)e team........................................................................1
%#* Met)ods of data collection.....................................................................1
%#+ Sur'e, and sam(ling met)ods..............................................................A
%#- Data to be collected................................................................................A
%#. Anal,sis and (resentation of results.....................................................#0
%# $E/ENTION
%#" S)elter.....................................................................................................#6
%#% Water.......................................................................................................$$
%#* Sanitation................................................................................................)3
%#+ /ector control.........................................................................................)1
%#- 0ood and nutrition.................................................................................1)
%#. /accination.............................................................................................6)
%#1 2ealt) education and communit, (artici(ation.................................AA
*# S!/EILLANCE
*#" General (rinci(les................................................................................../3
*#% Ob&ecti'es................................................................................................/
*#* Setting sur'eillance (riorities.............................................................../
*#+ Data collection met)ods........................................................................./$
*#- Case definitions....................................................................................../)
*#. Minimum data elements......................................................................../0
*#1 Data sources for routine sur'eillance...................................................//
*#3 Identif,ing tas4s and res(onsible (ersons...........................................3
*#5 Anal,sis and inter(retation of sur'eillance data................................3)
*#"6 0eedbac4...............................................................................................30
+# O!T7EAK CONTOL
+#" $re(aredness..........................................................................................36
+#% Detection.................................................................................................
+#* Confirmation..........................................................................................6
+#+ es(onse..................................................................................................#
+#- E'aluation...............................................................................................#A
-# DISEASE $E/ENTION AND CONTOL
-#" Acute res(irator, infections..................................................................$3
-#% 7acillar, d,senter, 8s)igellosis9............................................................$
-#* C)olera....................................................................................................$$
-#+ Ot)er diarr)oeal diseases......................................................................$1
-#- Con&uncti'itis.........................................................................................$A
-#. Dengue.....................................................................................................$/
-#1 Di()t)eria...............................................................................................)3
-#3 2e(atitis 8'iral9......................................................................................)#
-#5 2I/:AIDS...............................................................................................)0
-#"6 ;a(anese ence()alitis...........................................................................03
-#"" Leis)maniasis.......................................................................................0#
-#"% Malaria..................................................................................................00
-#"* Measles..................................................................................................1#
-#"+ Meningococcal meningitis 8e(idemic9................................................11
-#"- ela(sing fe'er 8louse<borne9.............................................................63
-#". Scabies...................................................................................................6
-#"1 Se=uall, transmitted infections...........................................................6#
-#"3 Tr,(anosomiasis> African 8African slee(ing sic4ness9.....................6A
-#"5 Tuberculosis..........................................................................................A
-#%6 T,()oid fe'e.........................................................................................A0
-#%" T,()us 8e(idemic louse<borne9...........................................................AA
-#%% /iral )aemorr)agic fe'ers 8/209....................................................../3
-#%* ?ello@ fe'er........................................................................................../)
ANNEAES
"# W2O reference 'alues for emergencies...................................................../6
%# 2ealt) assessment B sam(le sur'e, forms.................................................//
*# NC2S:W2O normaliCed reference 'alues for @eig)t for )eig)t b, se= #/
+# Wee4l, sur'eillance re(ort.........................................................................##
-# Case definitions............................................................................................##1
.# Outbrea4 in'estigation 4it..........................................................................#$#
1# OrganiCation of an isolation centre and calculation of treatment su((lies
........................................................................................................................#$1
3# Collection of s(ecimens for laborator, anal,sis........................................#)#
5# Setting u( a diagnostic laborator,.............................................................#0$
"6# Treatment guidelines...................................................................................#1A
""# Management of t)e c)ild @it) coug) or difficult, in breat)ing..............#60
"%# Assessment and treatment of diarr)ea......................................................#A3
"*# 0lo@c)arts for s,ndromic management of se=uall, transmitted infections
........................................................................................................................#A0
"+# 2ealt) card...................................................................................................#AA
"-# List of W2O guidelines on communicable diseases..................................#/3
".# List of (ublis)ers..........................................................................................#/$
"1# General references.......................................................................................#/)
ACKNOWLEDGEMENTS
Edited by M+ire Connolly& WHO5CD,.
Bic% -rennan 2*BC4& P"ili''e Calain 2WHO5CD,4& Mic"elle @ayer 2WHO5CD,4&
9im Healing 2Merlin4& Myriam Hen%ens 2M,=4& Cean Long 29rinity College& Dublin4&
,erge Male 2?.HCB4& Pamela Mbaba8i 2WHO5CD,4& Agostino Paganini 2?.*CE=4&
Cean Bigal 2M,=4& Mi%e Byan 2WHO5EPB4& Peter ,alama 2CDC4& Paul ,'iegel
2CDC4& Mi%e 9oole 2Macfarlane -urnet Centre for Medical Besearc" and Public
Healt"4 and Bon Waldman 2Mailman ,c"ool of Public Healt"& Columbia ?ni(ersity4
contributed e:tensi(ely to t"e de(elo'ment of t"is manual.
9"e follo;ing 'eo'le contributed to t"e de(elo'ment and re(ie; of t"is document
and t"eir in'ut is gratefully ac%no;ledged:
,amira Abouba%er 2WHO5CAH4& .at"alie Agata 2WHO5Et"io'ia4& Boberta
Andrag"etti 2WHO5EPB4& Bay Art"ur 2WHO5EPB4& O. -abu-,;ai 2?.HCB& Denya4&
Andre; -all 2WHO5H*E4& Claudio -eltramello 2WHO5CPE4& ,yl(ie -riand
2WHO5.9D4& .an -u8ard 2,'"ere ProFect4& Claire-Lise C"aignat 2WHO5.9D4&
Claire C"au(in 2WHO5*E-4& Denis Coulombier 2WHO5EPB4& C"arles Delacollette
2WHO5B-M4& Mi%e De''ner 2?.HCB& ?ganda4& P"ili''e DesFeu: 2WHO5CPE4&
Hans E(erts 2WHO5*E-4& Albis =rancesco @abrielli 2WHO5CPE4& -ernardus @anter
2WHO5E?BO4& Antonio @erbase 2WHO5H*E4& Bobin @ray 2WHO5EDM4& 9om
@rein 2WHO5EPB4& Malgosia @r8ems%a 2WHO5,9-4& Pierre @uillet 2WHO5.9D4&
Go"eir HallaF 2WHO5EMBO4& Ma: Hardiman 2WHO5EPB4& C"risto'"er Has%e;
2WHO5CPE4& Mary Healy 29rocaire& *reland4& Ana Maria Henao-Bestre'o
2WHO5*E-4& -rad Hers" 2WHO5*E-4& Da(id Heymann 2WHO5CD,4& @ottfried
Hirnsc"all 2WHO5H*E4& Cose Hueb 2WHO5PHE4& H(an Hutin 2WHO5*E-4& Cean
Cannin 2WHO5.9D4& EiFay Dumar 2WHO5,EABO4& CoIl Lagoutte 2*CBC& @ene(a4&
Daniel La(anc"y 2WHO5EPB4& DominiJue Legros 2E'icentre4& Alessandro Loretti
2WHO5HAC4& Paul Lusamba-Di%assa 2WHO5A=BO4& C"ris Ma"er 2WHO5Polio4&
=rKdKriJue Marodon 2WHO5CPE4& Adel"eid Marsc"ang 2*=BC4& Ga"ra Mirg"ani
2?.HCB4& Lulu Mu"e 2WHO5CAH4& Mi%e .at"an 2WHO5.9D4& Maria .eira
2WHO5CPE4& Hitos"i Os"itani 2WHO5WPBO4& -rian Pa8(a%a(amb;a 2WHO5H*E4&
William Perea 2WHO5EPB4& Pierre Perrin 2*CBC4& AafFe Biet(eld 2WHO5B-M4&
@uKnaIl Bodier 2WHO5C,B4& Cat"y Bot" 2WHO5EPB4& Maria ,antamaria
2WHO5C,B4& A%i"iro ,eita 2WHO5EMBO4& D"alid ,"ibib 2WHO5 HAC4& Eigil
,orensen 2WHO5DPBDorea4& Co"n 9abayi 2?.HCB& Et"io'ia4& .adia 9eleb
2WHO5EMBO4& Can 9"eunissen 2WHO5E?BO4& Mic"el 9"uriau: 2WHO5C,B4& A.
9iFtsma 2?.HCB4& Daat Eandemaele 2WHO5EPB4& Claude de Eille de @oyet 2WHO5
PAHO4& Gita Weise Prin8o 2WHO5.HD4& -rad Woodruff 2CDC4& .e(io Gagaria
2WHO5CPE4.
WHO ;ould li%e to t"an% t"e @o(ernment of *reland for its su''ort in t"e
de(elo'ment of t"is manual.
INTOD!CTION
9"is manual is intended to "el' "ealt" 'rofessionals and 'ublic "ealt"
coordinators ;or%ing in emergency situations 're(ent& detect and control t"e maFor
communicable diseases encountered by affected 'o'ulations. Emergencies include
com'le: emergencies and natural disasters 2e.g. floods and eart"Jua%es4. 9"e term
Lcom'le: emergenciesM "as been coined to describe Lsituations of ;ar or ci(il strife
affecting large ci(ilian 'o'ulations ;it" food s"ortages and 'o'ulation dis'lacement&
resulting in e:cess mortality and morbidityM.
*n t"is manual& t"e generic term LemergenciesM ;ill be used to encom'ass all
situations in ;"ic" large 'o'ulations are in need of urgent "umanitarian relief.
=ollo;ing an emergency& t"e affected 'o'ulation is often dis'laced and tem'orarily
resettled. 9"ey may be 'laced in cam's or become dis'ersed among t"e local
'o'ulation 2eit"er in to;ns or in rural communities4. Peo'le ;"o are dis'laced across
national borders are termed refugees ;"ereas t"ose ;"o "a(e been dis'laced ;it"in
t"eir country are called Linternally dis'laced 'ersonsM 2*DPs4. Besettlement in cam's
may entail "ig" 'o'ulation densities& inadeJuate s"elter& 'oor ;ater su''lies and
sanitation& and a lac% of e(en basic "ealt" care. *n t"ese situations& t"ere is an
increased t"reat of communicable disease and a "ig" ris% of e'idemics.
Communicable diseases are a maFor cause of mortality and morbidity in
emergencies& and 'articularly in com'le: emergencies& ;"ere colla'sing "ealt"
ser(ices and disease control 'rogrammes& 'oor access to "ealt" care& malnutrition&
interru'ted su''lies and logistics& and 'oor coordination among t"e (arious agencies
'ro(iding "ealt" care often coe:ist. 9"e main causes of morbidity and mortality in
emergencies are diarr"oeal diseases& acute res'ira-tory infections& measles and& in
areas ;"ere it is endemic& malaria. Ot"er communicable diseases& suc" as e'idemic
meningococcal disease& tuberculosis& rela'sing fe(er and ty'"us& "a(e also caused
large e'idemics among emergency-affected 'o'ulations. Malnutrition and trauma are
t"e t;o main additional causes of illness and deat".
Ensuring adeJuate s"elter& ;ater& sanitation and food and 'ro(iding basic "ealt"
care are t"e most effecti(e means of 'rotecting t"e "ealt" of t"ose affected by
emergencies. A systematic a''roac" to t"e control of communicable diseases is a %ey
com'onent of "umanitarian res'onse& and is crucial to 'rotect t"e "ealt" of affected
'o'ulations. 9"is reJuires co-o'eration among agencies ;or%ing at local& national and
international le(els& and collaboration among all sectors in(ol(ed in t"e emergency
res'onse ! "ealt"& food and nutrition& s"elter& ;ater and sanitation.
9"is field manual is t"e result of collaboration among a number of WHO
de'artments and se(eral e:ternal 'artner agencies in re(ie;ing e:isting guidelines on
communicable disease control and ada'ting t"em to emergency situations. 9"is
manual deals ;it" t"e fundamental 'rinci'les of communicable disease control in
emergencies& ;"ic" are:
A$ID ASSESSMENT: identify t"e communicable disease t"reats faced by
t"e emergency-affected 'o'ulation& including t"ose ;it" e'idemic 'otential&
and define t"e "ealt" status of t"e 'o'ulation& by conducting a ra'id
assessmentN
$E/ENTIOND 're(ent communicable disease by maintaining a "ealt"y
'"ysical en(ironment and good general li(ing conditionsN
S!/EILLANCED set u' or strengt"en disease sur(eillance system ;it" an
early ;arning mec"anism to ensure t"e early re'orting of cases& to monitor
disease trends& and to facilitate 'rom't detection and res'onse to outbrea%sN
O!T7EAK CONTOLD ensure outbrea%s are ra'idly detected and
controlled t"roug" adeJuate 're'aredness 2i.e. stoc%'iles& standard treatment
'rotocols and staff training4 and ra'id res'onse 2i.e. confirmation&
in(estigation and im'lementation of control measures4N and
DISEASE MANAGEMENTD diagnose and treat cases 'rom'tly ;it" trained
staff using effecti(e treatment and standard 'rotocols at all "ealt" facilities.
*t is "o'ed t"at t"is manual& by setting standards for communicable disease control
in emergencies& ;ill 'romote effecti(e& coordinated action to;ards t"e 're(ention and
control of communicable diseases in emergencies. W"ere a''ro'riate& t"e manual
'ro(ides suggestions for furt"er reading& ;it" references to rele(ant bac%ground
material& guidelines and re(ie;s. =inally& ;"ilst s"elter& food& ;ater and sanitation
sectors are co(ered& t"is manual s'ecifically aims to 'ro(ide detail on "ealt" issues.
Ste(s in ensuring communicable disease control in emergencies
Conduct ra(id )ealt) assessment
O *dentify main disease t"reats& including 'otential e'idemic diseases
O Obtain data on t"e "ost country& on t"e country of origin of dis'laced 'ersons and on
t"e areas t"roug" ;"ic" t"ey may "a(e 'assed
O *dentify 'riority 'ublic "ealt" inter(entions
O *dentify t"e lead "ealt" agency
O Establis" "ealt" coordination mec"anisms

$re'ent communicable diseases

O ,elect and 'lan sites
O Ensure adeJuate ;ater and sanitation facilities
O Ensure a(ailability of food
O Control (ectors
O *m'lement (accination cam'aigns 2e.g. measles4
O Pro(ide essential clinical ser(ices
O Pro(ide basic laboratory facilities

Set u( sur'eillance:earl, @arning s,stem

O Detect outbrea%s early
O Be'ort diseases of e'idemic 'otential immediately
O Monitor disease trends

Control outbrea4s
Pre'aration ! outbrea% res'onse team
! stoc%'iles
! laboratory su''ort
! standard treatment 'rotocols
Detection ! sur(eillance5early ;arning system
Confirmation ! laboratory tests
Bes'onse ! in(estigation
! control measures
E(aluation
"# A$ID ASSESSMENT
A ra'id "ealt" assessment must be conducted as soon as 'ossible after an
emergency& ideally ;it"in one ;ee%. 9"e aim is to identify t"e main commu-nicable
disease t"reats& outline t"e 'ublic "ealt" needs and 'lan 'riority inter(entions. 9"e
duration of a ra'id assessment de'ends on t"e si8e and geogra'"ical distribution of
t"e 'o'ulation affected& t"e security situation& t"e conditions of access& trans'ort and
logistics& t"e "uman resources a(ailable and t"e met"ods used. *t s"ould be com'leted
;it"in one ;ee%& de'ending on t"e e:tent of t"e emergency.
A more t"oroug" assessment& ;it" detailed Jualitati(e and Juantitati(e data and
inter(ention 'lans& s"ould be com'leted as soon as 'ossible after t"e ra'id assessment.
9"e assessment must be underta%en by ;ell-Jualified and e:'erienced
e'idemiologists. 9"e %ey acti(ities in(ol(ed in a ra'id assessment are outlined in
9able ..
Table "#" Ke, acti'ities in ra(id assessment
"# $lanning t)e mission
Com'osition of t"e "ealt" assessment team
Collection of bac%ground geo'olitical data
Collection of bac%ground "ealt" data on "ost country and country of origin
%# 0ield 'isit
Data: demogra'"y& en(ironment& "ealt" data& resource needs
Met"ods: aerial ins'ectionN direct obser(ationN inter(ie;s ;it" agencies& t"e ministry
of "ealt" and local aut"oritiesN collection of "ealt" data from medical facilitiesN ra'id
estimation of 'o'ulation si8e by ma''ing& re(ie; of records and ra'id sur(eys
*# Anal,sis
Demogra'"ic 'yramids
Priority "ealt" inter(entions
*dentification of "ig"-ris% grou's
+# e(ort @riting
-# Dissemination
"#"Ob&ecti'es
9"e obFecti(es of a ra'id assessment are:
to assess t"e e:tent of t"e emergency and t"e communicable disease t"reat to
t"e 'o'ulationN
to define t"e ty'e and si8e of inter(entions and 'riority acti(itiesN
to 'lan t"e im'lementation of t"ese acti(itiesN
to 'ass information to t"e international community& donors and t"e media in
order to mobili8e "uman and financial resources.
"#%Com(osition of t)e team
9"e ra'id "ealt" assessment team s"ould consist of:
a 'ublic "ealt" e:'ert5e'idemiologist&
a nutritionist&
a logistician5administrati(e officer&
a ;ater and sanitation5en(ironmental "ealt" s'ecialist.
One member must be designated as team leader.
9"e tas%s of t"e team during t"is initial '"ase are to:
're'are a ra'id "ealt" assessment c"ec%list&
're'are a timetable of assessment&
assign tas%s&
obtain necessary eJui'ment 2e.g. com'uters& scales& laboratory su''lies4&
organi8e (isas& trans'ort& (e"icles& fuel&
set u' a communication system&
inform t"e local aut"orities&
inform 'otential donors and %ey decision-ma%ers.
"#*Met)ods of data collection
9"e collection of data in an emergency may not 'roceed in a ste'-by-ste' manner&
but t"e 'lan for data collection and analysis must be systematic.
9"e four main met"ods of collecting data are:
re(ie; of e:isting information&
(isual ins'ection of t"e affected area&
inter(ie;s ;it" %ey informants&
ra'id sur(eys.
"#*#" e'ie@ of e=isting information
A re(ie; s"ould be underta%en of baseline "ealt" and ot"er information a(ailable
at national and regional le(els& from go(ernment& international and nongo(ernmental
sources& concerning:
t"e geogra'"ical and en(ironmental c"aracteristics of t"e country and affected
area 2e.g. national& subnational and district ma's s"o;ing admin-istrati(e and
'olitical di(isions of t"e affected area& settlements& ;ater sources& main
trans'ort routes and "ealt" facilities4N
t"e si8e& com'osition and 'rior "ealt" and nutritional condition of t"e
emergency-affected 'o'ulationN
t"e "ealt" ser(ices and 'rogrammes functioning before and during t"e
emergencyN
t"e resources already allocated& obtained or reJuested for t"e emergency
res'onse o'erationN
t"e security situation.
"#*#" /isual ins(ection of t)e affected area
W"ere tra(el is by air& useful obser(ations of t"e affected area can be made before
landing. An initial ;al% or dri(e t"roug" t"e area may allo; for a first roug" idea of
t"e adeJuacy of s"elter& food a(ailability& en(ironmental factors suc" as drainage and
ris%s of (ector breeding& and t"e general status of t"e 'o'ulation. During t"e initial
(isual ins'ection& t"e area s"ould be ma''ed& e(en if only crudely. 9"e resulting ma's
s"ould indicate t"e affected area& t"e distribution of t"e 'o'ulation and t"e location of
resources 2medical facilities& ;ater sources& food distribution 'oints& tem'orary
s"elters& etc.4.
Ma''ing also allo;s t"e estimation of 'o'ulation data& t"roug" t"e calculation of
t"e total surface area of t"e cam' and of sections of t"e cam's. 9"e met"od is based
on t"e ma%ing of a ma' of t"e cam'& ;it" its different sections. -y using random
sam'ling of se(eral %no;n surface areas one may count t"e number of 'ersons li(ing
in t"ese 8ones and establis" t"e a(erage 'o'ulation 'er area. One can calculate t"e
total 'o'ulation of t"e cam' by e:tra'olating t"e a(erage 'o'ulation 'er sJuare into
t"e total surface area of t"e site 2see e:am'le4.
"#*#* Inter'ie@s @it) 4e, informants
*nter(ie;s must be conducted ;it" %ey 'ersonnel in t"e area and ;it" t"e affected
'o'ulation& and must include 'eo'le from all sectors of t"e 'o'ulation in(ol(ed:
clan& (illage and community leaders&
area administrators or ot"er go(ernmental officials&
"ealt" ;or%ers& including traditional birt" attendants& "ealers& etc.&
'ersonnel from local and international emergency res'onse organi8ations&
including ?nited .ations organi8ations&
indi(iduals in t"e affected 'o'ulation.
Community organi8ational structures& normal dietary 'ractices& cultural 'ractices
relating to ;ater and "ygiene& and 'references for "ealt" care s"ould all be recorded.
"#*#+ a(id sur'e,s
Ba'id sur(eys ta%e time and s"ould be reser(ed for essential data not a(ailable
from ot"er sources. 9"ey may be used to determine t"e se: and age distribution of t"e
'o'ulation& t"e a(erage family si8e& t"e number of 'eo'le in (ulnerable grou's& recent
mortality rates 2retros'ecti(e mortality study4& t"e main causes of mortality and
morbidity& current nutritional status& (accination co(erage& and t"e use of formal and
informal "ealt" ser(ices. 9ec"niJues are rat"er ;ell codified& and are based on
(alidated sam'ling and analysis met"ods in order to 'ro(ide Juantitati(e estimates of
t"e situation ;it" reasonable accuracy and ;it"in acce'table delays. 9"is is essential
2a4 to guide emergency decisions on ;"ere and ;"en resources s"ould be allocated&
and 2b4 as a baseline for monitoring inter(entions. ,ur(eys and sam'ling met"ods are
outlined belo;. ,am'le "ouse"old sur(ey and ra'id assessment forms are included in
Anne: #.
"#+Sur'e, and sam(ling met)ods
"#+#" Introduction
9"e first 'riority ;"en entering an emergency area for t"e first time is to
underta%e a needs assessment so as to ensure an effecti(e use of limited resources.
*nadeJuate or incom'lete assessments can lead to ina''ro'riate res'onses and ;aste
of scarce resources& and 'ersonnel may be needlessly endangered.
W"ile most assessments ;ill be a straig"tfor;ard data collection e:ercise& a
structured and statistically analysable sur(ey may be needed to ans;er a 'articular
Juestion. *t is eJually im'ortant to underta%e re-sur(eys at inter(als& so as to %ee'
abreast of a c"anging situation. 9"is forms an im'ortant 'art of ongoing sur(eillance.
9"e use of a standard met"od t"roug"out means t"at t"e results of different
sur(eys5assessments can be com'ared directly. Any c"anges Juic%ly become
a''arent. 9"e use of suc" met"ods ma%es it easier to monitor t"e res'onse and
determine its effecti(eness.
*f 'ossible& ad(ice s"ould be ta%en from a biometrician before formal sur(eys are
underta%en& as it is im'ortant to structure t"e sur(ey so as to get re'resentati(e and
easily analysable results.
W"en 'ossible use E'i*nfo and E'iData for all as'ects of data entry and "andling.
*t is im'ortant to understand t"at t"ere may be security im'lications of
underta%ing sur(eys and assessments in c"aotic& unstable situations. Local 'eo'le may
(ie; Juestionnaires ;it" sus'icion: t"ey may not understand t"e idea of t"e sur(ey
and feel t"at 2for e:am'le4 t"ey are being earmar%ed for de'ortation. ,ome form of
ad(ance 'ublicity may be necessary& but s"ould be underta%en carefully so as not to
bias any sam'les. 9"e sur(ey5assessment may need to be underta%en ra'idly if t"e
situation is dangerous.
*n addition to t"e ra'id needs assessment& good e'idemiological sur(eillance
s"ould be 'ut in 'lace as soon as 'ossible.
Ba'id needs assessment s"ould not be (ie;ed in isolation but as one as'ect of
sur(eillance in emergency situations.
Attem'ts s"ould also be made to:
secure data from ot"er sources 2e.g. clinic data& local aut"orities& ot"er
nongo(ernmental organi8ations& community leaders& etc.4N
ensure t"at t"ere is ongoing sur(eillance& 'ossibly using sentinel sur(eillance
'oints& re'eat sur(eysN
regularly analyse e:isting "ealt" clinic data& etc.
"#+#* Sur'e,s
Alt"oug" t"e ideal ;ould be to measure t"e ;"ole of a 'o'ulation& t"is is rarely
'ossible 2it may occasionally be so in a small refugee cam'4. *n 'ractice a sam'le
must be ta%en. 9"e sam'le s"ould be re'resentati(e of t"e 'o'ulation& but a balance
must be struc% bet;een t"e ideal and t"e attainable. *n emergencies t"ere is al;ays a
trade-off bet;een ra'idity and accuracy.
9"e si8e of t"e sam'le must be adeJuate to accom'lis" ;"at is reJuired& but not
;asteful. *n an emergency t"e si8e of a sam'le may be go(erned by factors ot"er t"an
immediate statistical reJuirements 2e.g. accessibility& staff a(ailability& security& etc.4.
9"ere are se(eral essential ste's to be follo;ed in any sur(ey:
"# Defining t)e aims clearl,
9"is is t"e crucial first ste'& as all ot"er as'ects of t"e sur(ey stem from t"is. Most
sur(eys "a(e multi'le aims. 9"e %ey reasons for an agency to underta%e a sur(ey are
to ensure t"at t"e a''ro'riate aid is sent to t"ose ;"o need it in t"e acute '"ase of t"e
emergency& and to "a(e a baseline from ;"ic" to monitor t"e effect.
*t is im'ortant not to try to collect too many items of data in one sur(ey. Define
;"at you need to %no;& not ;"at you ;ould li%e to %no;. Consider cost& s'eed&
a(ailable resources and security.
%# Selecting t)e site
Hou need to decide ;"ic" area you ;ant to "a(e information about. 9"is could be&
for e:am'le& a 'ro(ince& a city& t"e area ;"ere an agency is acti(e or a damaged area
of a city 2if a large 'art ;as untouc"ed4. 9"e area selected s"ould be clearly defined&
toget"er ;it" t"e reasons for its selection. A suitable control area may need to be
selected. *f you are ;or%ing in a de(astated area& an untouc"ed area mig"t be needed
at t"e same time for com'arison.
*# Defining t)e basic sam(ling unit
*n random sam'ling met"ods t"e basic sam'ling unit is usually indi(iduals&
;"ereas in a cluster sur(ey it is usually occu'ied "ouse"olds. W"ate(er definition is
c"osen& it s"ould be stated in t"e re'ort.
+# Sam(le siCe
9"e si8e of t"e sam'le s"ould ideally be based on "o; reliable t"e final estimates
must be. A sam'le must re'resent t"e 'o'ulation as a ;"ole. Eac" indi(idual s"ould
"a(e an eJual c"ance of being sam'led& and t"e selection of an indi(idual s"ould be
inde'endent of t"e selection of any ot"er.
For calculating the sample size for a proportion:
9"e follo;ing items determine t"e si8e of t"e sam'le needed.
The confidence level and precision required
9"e use of a sam'le means t"at only an estimate of t"e results from t"e ;"ole
'o'ulation is obtained. ,ubseJuent sam'les are li%ely to gi(e different (alues& but
'ro(ided t"e sam'les "a(e been selected correctly t"ere ;ill be little (ariation
bet;een t"em. 9"e actual 'o'ulation (alue ;ill lie in a range around t"e obser(ed
(alue2s4. 9"e confidence inter(al is t"e u''er and lo;er limits of t"is range 2e.g.
result P #Q R #QN t"e confidence inter(al is 3!)Q4. 9"e si8e of t"e confidence
inter(al is related to t"e error ris% and t"e sam'le si8e. 9"e greater t"e 'recision
reJuired& t"e larger t"e sam'le must be.
The variability of the characteristics being measured in the study population
*f t"is is un%no;n you must assume ma:imum (ariability
The size of the population under study
?sually ;"at is reJuired is to find out ;"at 'ro'ortion of a 'o'ulation "as some
c"aracteristic. W"en t"is ty'e of information is soug"t& sam'le si8e is determined
using t"e follo;ing formula:
n = t
2
p q/d
2
;"ere: n P first estimate of sam'le si8e
t P confidence 2for /0Q use ./14
d P 'recision 2usually 3.30 or 3.34
p P 'ro'ortion of t"e target 'o'ulation ;it" t"e c"aracteristics being measured 2if
'ro'ortion is un%no;n& let p P 3.04
q P ! p
Once n is calculated& com'are it ;it" t"e si8e of t"e target 'o'ulation 2N4. *f n is
%no;n 2or strongly sus'ected4 to be less t"an 3Q of N& t"en use n as t"e final sam'le
si8e. *f n S3Q N& t"en use t"e follo;ing correction formula to recalculate t"e final
sam'le si8e 2nf4. 2*f t"e sam'le si8e is S3Q of t"e 'o'ulation a smaller sam'le can
be used.4
n
f
= n/ ! n/N
Once nf "as been determined& you need to decide ;"et"er it is 'ossible to ac"ie(e
t"at sam'le si8e under t"e circumstances of t"e mission. *f not& a smaller sam'le si8e
may "a(e to be acce'ted ;it" t"e ca(eat t"at t"is ;ill reduce 'recision.
As an e:am'le& ;e "a(e a 'o'ulation ;"ere t"e e:'ected disease rate is #Q. We
need to measure t"e 're(alence ;it" a 'recision of #Q. 9"e sam'le si8e reJuired is:
n = "#$
2

%"2 %"&&/%"%2
2
= %'
Ho;e(er& t"e 'o'ulation si8e is %no;n to be 1333 and t"is sam'le si8e is
t"erefore S3Q of t"e 'o'ulation si8e.
re(ised n =%'/ ( %'/$%%% = &$)
9o assist you& some sam'le si8es ;it" an error ris% of 0Q are gi(en in 9able .#.
2.-. 9"ese are not re(ised sam'le si8es.4
Table "#% Sam(le siCe according to e=(ected (re'alence in a
random or s,stematic sam(le @it) an error ris4 of -E
$re'alence $recision
"E %E *E +E -E
0Q A#0 )01 #3$

1Q #16 0)# #) $0

6Q #03 1#0 #6A 01 33
AQ #A#6 636 $) 66 $
/Q $)1 6A6 $03 /6 #1
3Q $)06 A1) $A) #1 $A
Q $61 /)3 )A #$0 03
#Q )306 3) )0 #0) 1#
$Q )$)0 3A1 )A$ #6# 6)
)Q )1#0 01 0) #A/ A0
0Q )A/A ##0 0)) $31 /1
1Q 01$ #/ 06) $#$ #36
6Q 0)#3 $00 13# $$/ #6
AQ 0163 )A 1$3 $0) ##6
/Q 0/# )6A 106 $63 #$1
#3Q 1)6 0$6 1A$ $A) #)1
$3Q A316 #36 A/1 03) $#$
)3Q /##3 #$30 3#) 061 $1/
03Q /13) #)3 316 133 $A)
For calculating the sample size for a mean* for e+ample the population mean:
W"en sam'le data is collected and t"e sam'le mean is calculated& t"at sam'le
mean is ty'ically different from t"e true 'o'ulation mean T . 9"is difference bet;een
t"e sam'le and 'o'ulation means can be t"oug"t of as an error. 9"e margin of error is
t"e ma:imum difference bet;een t"e obser(ed sam'le mean and t"e true (alue of
t"e 'o'ulation mean T :
E P zU,S V 5W
;"ere: zU,S5# is t"e Lcritical (alueM& t"e 'ositi(e (alue z t"at is at t"e (ertical
boundary for t"e area of U,S5# in t"e rig"t tail of t"e standard normal distribution
is t"e 'o'ulation standard de(iation
n is t"e sam'le si8e
Bearranging t"is formula& t"e sam'le si8e necessary can be calculated to gi(e
results accurate to a s'ecified confidence inter(al and margin of error.
n = X85U,S V Y
#
9"is formula is used ;"en you %no; and ;ant to determine t"e sam'le si8e
necessary to establis" t"e mean (alue T & ;it" a confidence of 2 ! 4& ;it"in R E of
error. 9"is formula can still be used if t"e 'o'ulation standard de(iation is un%no;n
and you "a(e a small sam'le si8e. Alt"oug" it is unli%ely t"at t"e standard de(iation
is %no;n ;"en t"e 'o'ulation mean is not %no;n& may be determined from a
similar 'rocess or from a 'ilot test5simulation.
-# T)e inter'ie@:Fuestionnaire
Only collect information t"at ;ill be used. Dee' Juestions sim'le and unam-
biguous ;it" yes5no ans;ers as often as 'ossible. Dee' as s"ort as 'ossible to sa(e
time. 9eams s"ould be ;ell trained and not allo;ed to introduce 'ersonal bias into t"e
sam'ling. 9"e 'eo'le c"osen s"ould be acce'table and non-intimidating to t"e general
'o'ulation.
Hou may ;is" to build c"ec%s into t"e Juestionnaire. =or e:am'le& t;o Juestions
may be included at different 'laces in t"e Juestionnaire t"at are differently ;orded
but ;"ose ans;ers are t"e same in ;"ole or in 'art. *f (ery different ans;ers are
recei(ed& t"e (eracity of t"e res'ondent may be Juestionable.
*t may be necessary to select times of day for inter(ie;s ;"en 'eo'le are li%ely to
be a(ailable.
"#+#* Sam(ling met)ods
9"e follo;ing met"ods are discussed:
. Census
#. ,im'le random sam'ling
$. ,ystematic sam'ling
). ,tratified sam'ling
0. Cluster sam'ling
"# Census
A census in(ol(es determining t"e si8e of a 'o'ulation and 2often4 obtaining ot"er
data at t"e same time. All t"e indi(iduals 2or at least re'resentati(es of all indi(iduals&
suc" as "eads of families4 need to be inter(ie;ed. 9"is may be useful in ;ell-defined
'o'ulations suc" as refugee cam's but can be e:tremely time consuming. Begistration
of refugees is notoriously unreliable& es'ecially ;"ere food is concerned. 9"e
situation in acute emergencies is often c"aotic and dynamic. Pre(ious census data are
often meaningless o;ing to massi(e 'o'ulation mo(ements. Census data may be
reJuired to determine 'arameters suc" as rates of infection in ;ell-defined
'o'ulations 2suc" as refugee cam's4& but suc" data can usually be obtained from t"e
agency running t"e cam'.
%# Sim(le random sam(ling
Bandom sam'ling is t"e only ;ay of meeting t"e t;o criteria: t"at eac" indi(idual
s"ould "a(e an eJual c"ance of being sam'led& and t"e selection of an indi(idual
s"ould be inde'endent of t"e selection of any ot"er. 9"e indi(iduals to be Juestioned
2t"e Lsam'ling unitsM4 are selected 'urely by c"ance from a com'lete list of t"e entire
'o'ulation being studied. 2=or e:am'le& eac" indi(idual can be gi(en a number and
t"en numbers selected from t"e total list by use of random number tables.4
9"is is a statistically reliable met"od but can be time consuming and reJuires an
accurate list of t"e indi(iduals in t"e area. Determining t"e a''ro'riate si8e of t"e
sam'le can be a 'roblem. 9"e list of indi(iduals could come from refugee registers&
census data& ta: registers& electoral registers& etc. *n a ;ar ;it" s"ifting 'o'ulations
suc" reliable data rarely e:ist and t"is limits t"e use of t"is met"od. *t may be
a''ro'riate in refugee cam's ;it" good registration data. .o control o(er t"e
distribution of t"e sam'le is e:ercised& so some sam'les may be unre'resentati(e.
9"ere are a number of s'eciali8ed tec"niJues& based on random sam'ling& t"at are
designed to ensure re'resentati(e sam'les.
Tables of random numbers can be generated b, E=cel in t)e
follo@ing @a,D
launc" E:cel
enter t"e follo;ing formula in t"e to' left corner cell of t"e table t"at you ;ant
to 'roduce: PBA.D2 4Z33
you can increase t"e range of (alues returned by t"e formula by adFusting t"e
(alue 33 in t"e formula. *f 33 is re'laced by n& random numbers from 3 to
2n !4 ;ill be 'roduced.
set t"e decimals to 3 by using t"e L=ormatM and LCellM menu o'tions& and
L.umberM and LDecimal 'lacesM tabs
co'y t"e cell containing t"e formula to t"e range of t"e table to be 'roduced
UPS
Tables of random numbers can be generated b, E(i Info in t)e
follo@ing @a,D
run EPED from t"e EP*1 menu
ma%e a Juestionnaire file containing only one field: .umber [[[[[[
run E.9EB and ma%e a .BEC file called BA.DOM but do not enter any
records
'ress U=3S to return to t"e EP*1 menu
run A.ALH,*, from t"e EP*1 menu and BEAD BA.DOM
set u' t"e random integers:
.?M-EB P BA.2334
@E.EBA9E 333
9"e integers ;ill be 'laced in t"e file. Hou can no; use t"e commands L*,9
.?M-EB& =BE\ .?M-EB or L*.E .?M-EB to c"ec% t"e distribution. 9o 'rint
t"em for use& use BO?9E PB*.9EB follo;ed by L*,9 .?M-EB. *f you ;ant real
numbers instead of integers& t"e B.D2334 command ;ill 'roduce t"ese.
*# S,stematic sam(ling
9"is met"od is used ;"en indi(iduals or "ouse"olds 2sam'ling units4 can be
ordered or listed in some manner. Bat"er t"an selecting all subFects randomly& a
selection inter(al is determined 2e.g. e(ery fift" indi(idual4 a starting 'oint on t"e list
'ic%ed at random and e(ery n
th
'erson& "ouse"old& etc. is selected 2;"ere n P t"e
sam'ling inter(al4 on t"e list. @ood geogra'"ical distribution 2according to 'o'ulation
density4 can be assured.
Ho;e(er& sam'ling units do not need to be listed in emergency situations as long
as:
t"e total number of units can be estimated&
t"e enumerators can go t"roug" t"e area and 'ass in front of eac" sam'ling
unit& selecting e(ery +
th
unit.
,ystematic sam'ling allo;s better re'resentati(eness t"an sim'le random
sam'ling 2assuming t"ere is no cyclic 'attern in t"e distribution of sam'ling units and
;"ic" ;ould be e:tremely rare4.
E=am(le B S,stematic sam(ling
.umber of "ouse"olds: 1333
,am'le si8e: )03 "ouse"olds
,am'le inter(al: 13335)03 P $ "ouse"olds
*nformation is collected e(ery $ "ouse"olds if t"e de'arture number is c"osen at
random bet;een and t"e sam'le inter(al.
*f for e:am'le t"e de'arture number is 0 2t"us t"e fift" "ouse"old beginning at
one e:tremity of t"e cam'4& t"en t"e selected "ouse"olds are numbers:
-& t"en "3 20]$4N t"en *" 2A]$4N t"en ++ 2$]$4& etc.
+# Stratified sam(ling
*n t"is met"od t"e target 'o'ulation is di(ided into suitable& non-o(erla''ing
sub'o'ulations 2strata4. Eac" stratum s"ould be "omogeneous ;it"in and
"eterogeneous bet;een strata. A random sam'le is t"en selected ;it"in eac" stratum.
,e'arate estimates can be obtained from eac" stratum& and an o(erall estimate
obtained for t"e ;"ole 'o'ulation defined by t"e strata. 9"e (alue of t"is tec"niJue is
t"at eac" stratum is accurately re'resented and o(erall sam'ling error is reduced.
-# Cluster sam(ling
One of t"e difficulties faced in most disasters is t"at t"e si8e of a 'o'ulation may
not be %no;n. 9"e EP* 2E:tended Programme on Eaccination4 cluster sam'ling
met"od is often used to o(ercome t"is difficulty& as it is reliable& relati(ely c"ea' and
ra'id. *t ;as originally de(elo'ed to assess le(els of small'o: co(erage& and "as been
e:tended for use in ot"er (accination 'rogrammes. *t is designed to 'roduce
re'resentati(e sam'les e(en if t"e 'o'ulation si8e is un%no;n. -ot" Jualitati(e and
Juantitati(e data can be collected. 9"is met"od "as been used in emergency
situations.
Cluster sam'ling met"ods are also (aluable ;"en a 'o'ulation is geo-gra'"ically
dis'ersed. 9"e units sam'led first are not members of t"e 'o'ulation but clusters
2aggregates4 of t"e 'o'ulation. 9"e clusters are selected in suc" a fas"ion t"at t"ey are
re'resentati(e of t"e 'o'ulation as a ;"ole. =or e:am'le& in a rural area a sam'le of
(illages may be selected and t"en some or all of t"e "ouse"olds included in t"e
sam'le. A maFor ad(antage of t"is a''roac" is t"at t"ere is a sa(ing of resources
2reduced tra(elling& fe;er staff4 but t"e met"od lac%s 'recision ;"en com'ared to
random sam'ling.
9"e EP* tec"niJue "as been modified for use in nutritional sur(eys. A furt"er
de(elo'ment for t"e ra'id assessment of "ealt" needs in disasters uses t"e tec"niJue
to assess multi'le aims& and conseJuently t"e basic sam'ling unit is no longer t"e
indi(idual but t"e "ouse"old.
A (ariant of t"is met"od& ;"ic" "as been used in emergency situations& is t"e
Modified t;o-stage cluster sam'ling met"od.
*t is im'ortant to reali8e t"e limitations of t"is sur(ey tec"niJue.
9"e sim'le $3 V 6 LEP*M design is adeJuate for relati(ely freJuent e(ents 2e.g.
loo%ing at (accination status in t"e under-0s 2;"en your sam'ling unit ;ould
be c"ildren under 04 but ;ill not 'ro(ide accurate estimates of relati(ely rare
e(ents suc" as mortality. 9o do t"is a muc" larger sam'le si8e ;ould be
needed.
9"e tec"niJue does not meet t"e second criterion for re'resentati(eness&
because t"e selection of an indi(idual in a cluster is not inde'endent of t"e
selection of ot"er indi(iduals. Members of a cluster are li%ely to be similar.
9"is is %no;n as t"e Ldesign effectM and may be es'ecially serious ;it"
communicable diseases o;ing to t"eir tendency to cluster close toget"er. *f
Juestions about mortality and s'ecific diseases are as%ed t"en great care
s"ould be ta%en not to dra; too many firm conclusions from t"e results.
Cluster sam'ling is more suited to Juestions related to& for e:am'le& access to
"ealt" care& 'eo'le currently ill& or need and a(ailability of medication. 9"e
design effect can be countered to some degree by doubling t"e si8e of t"e
sam'le reJuired in random or systematic sam'ling. Design effect as suc" does
not affect t"e 'oint estimate calculated on t"e sam'le& but t"e 'recision
2(ariance4 only. 9"e decrease in 'recision can be calculated during analysis by
com'aring t"e (ariance bet;een clusters o(er t"e global (ariance.
9"e use of t"is tec"niJue in emergencies needs furt"er rigorous e(aluation& but in
t"e mean time it seems to be t"e best met"od for data collection in urban areas t"at
"a(e been de(astated by ;ar or natural disaster.
9"e EP* met"od usually sam'les $3 clusters from t"e area of interest and t"en 6
subFects from adFacent "ouse"olds. 2*n 'rinci'le t"e more clusters t"e better t"e
randomness& but it s"ould be balanced against time and cost.4
An e:am'le of cluster sam'ling is gi(en belo;. 9"e 'o'ulation of different
sections in a settlement must be %no;n. 9"is met"od is di(ided into t;o stages as
described belo;.
Stage "D Selection of clusters
Calculate cumulati(e 'o'ulation total 2for e:am'le& 'o'ulation P /$334
Calculate t"e sam'ling inter(al
=or a cluster sam'ling sur(ey& a sam'le of $3 clusters of $3 "ouse"olds is
recommended 2re'resenting a''ro:imately )333 to 0333 'ersons& of ;"ic" /33 are
c"ildren bet;een 1 and 0/ mont"s4
9"e desired sam'le si8e is& t"erefore& $3 clusters of $3 "ouse"olds P /33
"ouse"olds
9"e sam'le inter(al for selecting t"e clusters is t"en calculated:
e#g# 5*66:*6 G *"6
Determine t"e first cluster by dra;ing& at random& a number bet;een and t"e
sam'le inter(al 2e:am'le in table P 634
9"e ot"er clusters are t"en 'ositioned in t"e cumulati(e list 263 ] $3 P )A3&
etc.4 and a number of clusters 'er section deri(ed
$o(ulation (er
section
Cumulati'e total Number of
clusters (er
section
H
P 033 0333 263& )A34 %
# P #333 #033 26/3& 33& )3&
6#3& #3$3& #$)34
.
$ P 033 )333 2#103& #/13& $#63&
$0A3& $A/34
-
) P 333 0333 2)#33& )03& )A#34 *
0 P $33 1$33 20$3& 0))3& 0603&
13134
+
1 P $333 /$33 21$63& 11A3& 1//3&
6$33& 613&
6/#3& A#$3& A0)3&
AA03& /134
"6
$o(ulation total 5*66
Stage %D Selection of indi'iduals
A direction is c"osen at random from t"e centre of eac" section& and t"e
number of "ouse"olds counted from t"e centre to t"e 'eri'"ery in t"is
direction.
A number bet;een and t"e number of "ouse"olds counted is c"osen at
random. 9"is number corres'onds to t"e "ouse"old t"at is t"e de'arture 'oint
for t"e selection of indi(iduals in t"e cluster.
*n eac" cluster& "ouse"olds are selected by mo(ing from one "ouse"old to t"e
nearest "ouse"old& until t"e reJuired cluster si8e is obtained 2a target of $3
"ouse"olds 'er cluster is recommended4.
W"en c"ildren from 1 to 0/ mont"s are t"e target of t"e sur(ey and t"ere are
se(eral of t"ese c"ildren in one "ouse"old& one is c"osen at random from eac"
"ouse"old.
If several clusters have been selected in one section, the same operation is
repeated from the centre of the section.
Note: ,hen possible* systematic sampling should be chosen by preference over
cluster sampling" -t is easier to carry out and* above all* is more rapid .one is able to
obtain a precision of results equivalent to cluster sampling* but /ith a much smaller
sample size0"
"#- Data to be collected
Data s"ould be collected in t"e follo;ing areas:
bac%ground "ealt" information&
demogra'"y&
mortality&
morbidity&
"ealt" ser(ices and infrastructure&
food&
nutritional status&
;ater&
sanitation&
s"elter and non-food items&
en(ironment&
coordination.
"#-#" 7ac4ground )ealt) information
-ac%ground "ealt" information com'rises:
t"e main "ealt" and nutritional 'roblems&
co(erage by 'ublic "ealt" 'rogrammes 2e.g. (accination co(erage rates4&
t"e "ealt" care infrastructure& staff a(ailable and use of traditional medicine&
t"e a(ailability of "ealt" ;or%ers&
im'ortant "ealt" beliefs and traditions&
social organi8ation.
W"en dis'laced 'o'ulations are at t"e centre of t"e "umanitarian emergency&
similar data s"ould be collected on t"eir 'lace of origin.
*f 'ossible& bac%ground information s"ould be collected before t"e field mission is
conducted& using as sources t"e Ministry of Healt"& WHO& international and
nongo(ernmental organi8ations and WHO ;eb sites.
*n t"e field& data s"ould be collected t"roug" inter(ie;s ;it" community leaders&
"eads of "ouse"olds& "ealt" ;or%ers and indi(iduals.
"#-#% Demogra(),
Demogra'"ic information com'rises:
total 'o'ulation si8e 2dis'laced 'ersons and "ost 'o'ulation4N
'o'ulation under 0 years of ageN
et"nic com'osition and 'lace of originN
se: ratioN
t"e number of 'ersons in t"e follo;ing "ig"-ris% grou's: 'regnant and
lactating ;omen& members of "ouse"olds "eaded by a ;oman& unaccom-
'anied c"ildren& disabled and ;ounded 'eo'le& and t"e elderlyN
t"e a(erage si8e of a family5"ouse"oldN
t"e number of arri(als and de'artures 'er ;ee%N
t"e 'redicted number of future arri(alsN
acti(ity 'atterns in t"e "ost 2and 'ossibly t"e dis'laced4 'o'ulations t"at may
affect t"e timing of sur(eys 2e.g. ;"en 'eo'le go to collect ;ater& to t"e fields&
etc.4.
9"e follo;ing sources can be used for retrie(ing demogra'"ic data:
ma''ingN
aerial or satellite 'icturesN
census dataN
records maintained by cam' administrators& local go(ernment officials& ?nited
.ations organi8ations& religious leaders& etc.N
inter(ie;s ;it" leaders among dis'laced grou's.
,ur(ey Juestionnaires in sam'led d;ellings s"ould include t"e number& age and
se: of family members and t"e number of 'regnant and lactating ;omen. 9"e a(erage
number of 'ersons 'er d;elling (isited and t"e total number of d;ellings in t"e cam'
or settlement s"ould be calculated.
"#-#* Mortalit,
During a ra'id initial assessment& and before any sur(eillance system can be 'ut in
'lace& any mortality data ;ill of necessity be retros'ecti(e. 9"e c"oice of t"e
retros'ecti(e time 'eriod used to calculate mortality rates ;ill de'end on ;"ic"
critical e(ent2s4 influencing mortality "a(e to be included in t"e sur(ey estimate. *t
;ill also de'end on cultural e(ents t"at stand out in t"e memories of t"ose
inter(ie;ed. A balance must be struc% bet;een e:'ectations of greater 'recision
2reJuiring longer recall 'eriods4 and a(oidance of recall bias.
9"e sur(ey Juestionnaire s"ould in any case ca'ture& in a culturally sensiti(e ;ay&
t"e follo;ing:
total deat"s for gi(en 'eriod 2e.g. one ;ee%4&
deat"s among t"ose under 0 years of age for t"e same 'eriod&
maFor causes of deat".
A''ro:imate daily deat" rates s"ould be calculated daily or ;ee%ly& de'ending on
t"e se(erity of t"e emergency. *n t"e acute '"ase of an emergency& daily deat"s rates
s"ould be calculated as follo;s:
crude mortality rate: number of deat"s 'er 3 333 'eo'le daily or ;ee%ly&
age-s'ecific mortality rates: number of deat"s 'er 3 333 'eo'le in t"e under-
0 and 0-and-o(er age grou's daily or ;ee%ly&
cause-s'ecific mortality rates: number of deat"s from a gi(en cause 'er 3 333
'eo'le daily or ;ee%ly.
Table "#* T)res)olds and calculations
T)res)olds Calculations
Crude mortalit, rate ULS
S 53 3335day: se(ere situation
S #53 3335day: critical situation
!nder - mortalit, rateD double a(erage 'o'ulation P 2.]D4 ] .5#
S #53 3335day: se(ere situation
S )53 3335day: critical situation 1 P number of deat"s during t"e study
'eriod
Normal and stable situationD N P number of 'eo'le of t"e sam'le
li(ing at t"e end of t"e study 'eriod De(elo'ing countries: 3.153 3335day
*ndustrialised countries: 3.$53 3335day sp = study 'eriod e:'ressed in days
9"e follo;ing met"ods can be used to collect mortality data.
Count t"e number of gra(es: designate a single burial site for t"e cam' or
settlement monitored by gra(e-;atc"ers #) "ours a day& and de(elo' a (erbal
auto'sy 'rocedure for e:'ected causes of deat" using standard forms.
C"ec% "os'ital5"ealt" facility records and records of organi8ations res'on-
sible for burial.
*nter(ie; community leaders.
=or t"e collection of 'ros'ecti(e mortality data& ot"er met"ods can be used&
suc" as mandatory registration of deat"s& issuing of s"rouds to families of t"e
deceased to "el' ensure com'liance& or em'loying (olunteer community in-
formants to re'ort deat"s for a defined section of t"e 'o'ulation 2e.g. 03
families4.
"#-#+ Morbidit,
9"e number of cases of disease s"ould include:
diseases t"at cause substantial morbidity 2i.e. diarr"oea& res'iratory infections
and malaria ;"ere 're(alent4N
diseases t"at "a(e t"e 'otential to cause e'idemics 2i.e. measles& c"olera&
meningitis and "aemorr"agic fe(ers4. Classical sources of morbidity data are:
'atient registers and records in cam' or settlement clinics& "os'itals or feeding
centresN
inter(ie;s ;it" "ealt" ;or%ers& mid;i(es ;it"in t"e dis'laced 'o'ulationN
records of local "os'itals or clinics. After t"e acute '"ase is o(er& a 'ro'erly
designed emergency sur(eillance system s"ould 'ro(ide more accurate
morbidity data 2see C"a'ter $4.
"#-#- 2ealt) ser'ices and infrastructure
Access
Access by t"e affected 'o'ulation to local& 're-e:isting "ealt" ser(ices.
Ability of local "ealt" ser(ices to absorb t"e influ: of 'eo'le affected by t"e
emergency.
0acilities
.umbers& names and ty'es of "ealt" facilities a(ailable& i.e. clinics& "os'itals&
feeding centres and laboratories.
Le(el of su''ort ! ministry of "ealt" or nongo(ernmental organi8ation.
Le(el of functioning.
Le(el of damage.
.umber of beds including maternity beds ! total and occu'ied currently.
A(erage number of out'atients seen 'er day ! 1 mont"s ago and current.
A(erage number of deli(eries during one ;ee% ! 1 mont"s ago and current.
A(ailability of o'erating t"eatres.
.umbers& ty'e& si8e and ca'acity of "ealt" facilities set u' for t"e dis'laced
'o'ulation if se'arate 2e.g. tent& local materials4.
AdeJuacy of ;ater su''ly& (accine cold c"ain 2free8ers and refrigerators4&
generators or to;n electricity& toilets and ;aste dis'osal facilities and food for
'atients or malnouris"ed.
2ealt) (ersonnel
Per "ealt" facility abo(e& ty'es and numbers of "ealt" 'ersonnel and rele(ant
s%ills and e:'erience 'resent in t"e "osting area ! 1 mont"s ago and current.
Healt" ;or%ers 'resent among t"e dis'laced 'o'ulation& including traditional
"ealers& traditional mid;i(es& doctors and nurses& laboratory tec"nicians& and
;ater and sanitation engineers.
A(ailability of inter'reters.
Drug and 'accine su((lies
A(ailability of essential drugs and medical su''lies 2see Anne: # ! Ba'id
Healt" Assessment& 9able 4.
A(ailability of t"e WHO .e; Emergency Healt" Dit& ;"ic" contains drugs
and medical su''lies for 3 333 'eo'le for a''ro:imately $ mont"s 2see
Anne: 34.
A(ailability of essential (accines and (accination eJui'ment 2e.g. measles
(accines& inFection material and cold c"ain eJui'ment4.
"#-#. 0ood
.umber of calories a(ailable 'er 'erson 'er day.
=reJuency of distribution of food rations.
Lengt" of time t"ese rations "a(e been 'ro(ided.
=ood bas%et monitoring.
2ources of data
Assessment of t"e Juality and ty'e of food a(ailable to t"e 'o'ulation.
*ns'ection of local mar%ets for food a(ailability and 'rices.
Assessment of local& regional and national mar%ets for a(ailability of
a''ro'riate emergency foods.
"#-#1 Nutritional status
2,ee also ,ection #.0.4
Pre(alence of acute malnutrition in c"ildren 1!0/ mont"s of age or 13!3 cm
in "eig"t.
Percentage of c"ildren se(erely and moderately malnouris"ed.
Pre(alence of clinically obser(able micronutrient deficiencies.
=eeding 'rogrammes currently being 'lanned ! number of c"ildren being
cared for daily in su''lementary feeding 'rogrammes 2,=P4 and t"era'eutic
feeding 'rogrammes 29=P4.
.umber of additional calories 'er day 'ro(ided by ,=P.
2ources of data
?nbiased re'resentati(e sam'ling.
Mass screening 2all c"ildren ;eig"ed and measured4.
"#-#3 Water
Litres of ;ater 'er 'erson 'er day.
Lengt" of time t"is Juantity "as been a(ailable.
,ource and Juality of ;ater.
.umber and ty'e of ;ater 'oints.
Water storage facilities.
Water 'urification met"ods a(ailable5in use.
Lengt" of time 'ersons must ;ait for ;ater.
.umber of 'ersons 'er ;ater 'oint.
9rans'ort and storage.
EJui'ment5e:'ertise on site& 'lanned or a(ailable if needed.
"#-#5 Sanitation
Current facilities for e:creta dis'osal and 'o'ulation 'er latrine or toilet.
Anal cleansing met"ods and a(ailability.
A(ailability of soa'.
Presence of (ectors 2art"ro'ods& mammals4.
AdeJuacy of burial sites.
"#-#"6 S)elter and non<food items
-lan%ets& clot"ing and domestic utensils.
,"elter.
Li(estoc%.
"#-#"" En'ironment
Climate.
9o'ogra'"y and drainage.
,uitability as site for settlement from "ealt" 'oint of (ie;.
Access 2routes to site& road surface& airfields& security issues4.
9rans'ort.
Amount of land: 'ersons 'er sJuare metre.
-uilding materials.
=uel a(ailability.
,torage facilities for food& medical su''lies.
Communication.
2ources of data
9"is assessment is largely carried out by (isual ins'ection. *nformation must
also be obtained from %ey informants suc" as local officials and ?nited
.ations& international and nongo(ernmental organi8ations.
=ocus grou' discussions ;it" t"e community may also be useful& addressing
suc" issues as t"eir cultural 'erce'tions of ;ater and sanitation& "o; t"ey bury
t"e dead& and ;"ere t"ey find food& fuel and s"elter materials.
"#-#"% Coordination
9"e follo;ing information s"ould be obtained from national& ?nited .ations&
international and nongo(ernmental organi8ations ;or%ing on t"e affected area.
W"at is t"e e:isting local res'onse ca'acity^
W"at is t"e 'resence and acti(ities of international or local organi8ations^
W"o is in c"arge of coordinating "ealt"& ;ater and sanitation acti(ities^
W"o su''lies ;"ic" ser(ices in t"ese sectors^
W"o coordinates food deli(ery to t"e area and its distribution to t"e affected
'o'ulations^
W"at "a(e t"ey ac"ie(ed to date^
W"at are t"e additional needs in terms of financial and material resources& and
of im'lementation ca'acity^
W"at are t"e 'riorities for immediate action^
A summary of t"e essential information to be collected during a ra'id assessment
is gi(en in 9able .).
"#-#"* Common sources of error
Logistic
*nsufficient trans'ort and5or fuel.
Eisas5security clearance not recei(ed in time.
*nadeJuate communication bet;een field& regional and national le(els:
aut"orities in c"arge not informed in time and not ready to assist.
OrganiCational
Lead organi8ation not identified& team leader not identified& res'onsibilities of
(arious organi8ations not ;ell defined.
Dey decision-ma%ers and donors not informed t"at an assessment is being
underta%en.
Assessment conducted too late or ta%es too long.
*nformation collected t"at is not needed for t"e emergency res'onse.
Tec)nical
,'ecialists ;it" a''ro'riate s%ills not in(ol(ed in t"e assessment.
Programmes t"at could be im'lemented immediately unnecessarily delayed
because of t"e assessment 2e.g. measles (accination4.
Assessment conclusions not re'resentati(e of t"e affected 'o'ulation.
,ur(eillance system de(elo'ed too slo;ly& t"us 're(enting monitoring and
e(aluation of emergency res'onse 'rogramme.
Table "#+ Essential information to be
collected during a ra(id
assessment
O -ac%ground to t"e emergency
O Estimate of si8e of affected 'o'ulation and 'o'ulation mo(ements
O Ma' of t"e site
O En(ironmental conditions
O ,ecurity conditions
O Healt" and nutritional status of t"e 'o'ulation affected by t"e emergency
O MaFor "ealt" t"reats ! communicable and noncommunicable diseases
O Diseases of e'idemic 'otential
O E:isting "ealt" facilities and staff ! ca'acity to deal ;it" t"e affected 'o'ulation
O Estimation of recent mortality rates
O ,ur(eillance system in 'lace 'rior to t"e emergency
O A(ailability of food and ;ater
O E:tent of in(ol(ement of t"e local aut"orities& es'ecially t"e Ministry of Healt"
O Presence and acti(ities of international or local organi8ations
"#. Anal,sis and (resentation of results
9"e ra'id assessment re'ort must be:
Clear Decision-ma%ers or staff of local&
national and interna-tional organi8ations
;"ose actions de'end on t"e results of
t"e ra'id assessment may not be trained
in e'idemio-logy. ?ser-friendly language
and gra'"s ma%e com'le: data and trends
easier to understand.
StandardiCed Besults s"ould be 'resented according to
a standard format so t"ey can be
com'ared ;it" ot"er assessments.
Action<oriented and (rioritiCed Clear recommendations s"ould be made
to im'lementing organi8ations& gi(ing
"ig"est 'riority needs.
Widel, distributed Co'ies of t"e re'ort s"ould be distributed
to all organi-8ations in(ol(ed in t"e
emergency res'onse.
Timel, 9"e assessment and re'ort s"ould be
finali8ed and distributed as Juic%ly as
'ossible& 'referably ;it"in $!) days.
Donors are often under 'olitical 'ressure
in t"e first fe; days after an emergency
to demonstrate su''ort by t"eir
go(ernment and "a(e access to funds.
9"ey must "a(e data to base t"eir
decisions on funding 'riorities.
"#.#" 0urt)er reading
Assefa = et al. Malnutrition and mortality in Do"istan district& Afg"anistan& A'ril
#33. 3ournal of the 4merican 5edical 4ssociation* #33& %3.D#6#$!#6#A.
@essner -D. Mortality rates& causes of deat"& and "ealt" status among dis'laced
and resident 'o'ulations of Dabul& Afg"anistan. 3ournal of the 4merican 5edical
4ssociation* //)& %1%D$A#!$A0.
E'i *nfo. Centers for Diseases Control and Pre(ention& Atlanta& @A& ?,A.
A(ailable from http/////"cdc"gov/epiinfo.
E'iData. 9"e E'iData Association& Odense& Denmar%. A(ailable from
http://///" epidata"d6.
Henderson BH& ,undaresan 9. Cluster sam'ling to assess (accination co(erage: a
re(ie; of e:'erience ;it" a sim'lified sam'ling met"od. 7ulletin of the ,orld 8ealth
9rganization& /A#& .6D#0$!#13.
L;anga ,D& Lemes"o; ,. 2ample size determination in health studies: a
practical manual. @ene(a& World Healt" Organi8ation& //.
Malilay C& =landers WD& -rogan D. A modified cluster-sam'ling met"od for
'ostdisaster ra'id assessment of needs. 7ulletin of the ,orld 8ealth 9rganization&
//1& 1+D$//!)30.
Porter CDH& (an Loo% =L& De(au: A. E(aluation of t;o Durdis" refugee cam's in
*ran& May //: t"e (alue of cluster sam'ling in 'roducing 'riorities and 'olicy.
1isasters& //$& "1D$)!$)6.
:apid health assessment protocols for emergencies. @ene(a& World Healt"
Organi8ation& ///.
Boberts L& Des'ines M. Mortality in eastern Democratic Be'ublic of Congo.
;ancet& ///& *-*2/64:##)/!##03.
Boberts L. 5ortality in eastern 1emocratic :epublic of <ongo: results from
eleven mortality surveys. =inal draft. .e; Hor%& *nternational Bescue Committee&
#33.
http://intranet"theirc"org/docs/mort--=report=small"pdf
http://intranet"theirc"org/docs/mort--=graphs"pdf
http://intranet"theirc"org/docs/mort--=map"pdf
http://intranet"theirc"org/docs/mort--=e+ec"pdf
Bot"enberg B- et al. Obser(ations on t"e a''lication EP* cluster sur(ey met"ods
for estimating disease incidence. 7ulletin of the ,orld 8ealth 9rganization& /A0&
.*D/$!//
%# $E/ENTION
9"is includes good site 'lanningN 'ro(ision of basic clinical ser(ices& s"elter&
clean ;ater and 'ro'er sanitationN mass (accination against s'ecific diseasesN a
regular and sufficient food su''lyN and control of disease (ectors. 9able #. lists t"e
main diseases and disease grou's targeted by suc" inter(entions.
Table %#" Diseases targeted b, (re'enti'e
measures
$re'enti'e measure Im(act on s(read ofD
,ite 'lanning diarr"oeal diseases& acute res'iratory
infections
Clean ;ater diarr"oeal diseases& ty'"oid fe(er& guinea
;orm
@ood sanitation diarr"oeal diseases& (ector-borne
diseases& scabies
AdeJuate nutrition tuberculosis& measles& acute res'iratory
infections
Eaccination measles& meningitis& yello; fe(er&
Ca'anese ence'"alitis& di'"t"eria
Eector control malaria& 'lague& dengue& Ca'anese
ence'"alitis& yello; fe(er& ot"er (iral
"aemorr"agic fe(ers
Personal 'rotection 2insecticide-treated
nets4
malaria& leis"maniasis
Personal "ygiene louse-borne diseases: ty'"us& rela'sing
fe(er& trenc" fe(er
Healt" education se:ually transmitted infections&
H*E5A*D,& diarr"oeal diseases
Case management c"olera& s"igellosis& tuberculosis& acute
res'iratory infections& malaria& dengue
"aemorr"agic fe(er& meningitis& ty'"us&
rela'sing fe(er
%#" S)elter
*n many emergency situations& t"e dis'laced 'o'ulation must be s"eltered in
tem'orary settlements or cam's. 9"e selection of sites must be ;ell 'lanned to a(oid
ris% factors for communicable disease transmission& suc" as o(ercro;ding& 'oor
"ygiene& (ector breeding sites and lac% of adeJuate s"elter. ,uc" conditions fa(our t"e
transmission of diseases suc" as measles& meningitis and c"olera. ?sually& t"e most
suitable land is already occu'ied by t"e local 'o'ulation& lea(ing less desirable areas
a(ailable to refugees or dis'laced 'eo'le. Critical factors to consider ;"en 'lanning a
site are: ;ater a(ailability& means of trans'ort& access to fuel& access to fertile soil and
for security reasons& a sufficient distance from national borders or frontlines.
9"e surrounding en(ironment may also 'ose a t"reat to "ealt" in t"e form of
(ectors not encountered in t"e 'o'ulation<s 're(ious 'lace of residence. *n order to
reduce suc" ris%s it is essential t"at site selection& 'lanning and organi-8ation be
underta%en as soon as 'ossible.
%#"#" Site selection criteria
,ettlements s"ould a(oid t"e maFor breeding sites of local (ectors& as ;ell as
mars"y areas and flat& lo;-lying ground at ris% of flooding. Preference s"ould be
gi(en to gently slo'ing& ;ell drained sites on fertile soil ;it" tree co(er& s"eltered
from strong ;inds. Local e:'ertise and %no;ledge of t"e biology of t"e (ectors
s"ould be considered& suc" as a(oiding forested "ills in some Asian countries ;"ere
(ectors 'roliferate. *f not already sufficiently documented by national and local "ealt"
ser(ices& t"e e'idemiological c"aracteristics of t"e area need to be assessed Juic%ly.
9"e follo;ing criteria s"ould be considered ;"en assessing site suitabilityN ot"er
criteria may also be rele(ant in s'ecific situations.
Water su((l,
9"e a(ailability of an adeJuate amount of safe ;ater t"roug"out t"e year "as
'ro(ed in 'ractice to be t"e single most im'ortant criterion for site location. 9"e ;ater
source s"ould be close enoug" to a(oid trans'orting ;ater by truc%s& 'um'ing it o(er
long distances or ;al%ing long distances to collect insufficient Juantities.
S(ace
9"ere must be enoug" s'ace for t"e 'resent number of emergency-affected
'o'ulation& ;it" 'ro(ision for future influ:es and for amenities suc" as ;ater and
sanitation facilities& food distribution centres& storage sites& "os'itals& clinics and
rece'tion centres.
To(ogra(), and drainage
@ently slo'ing sites abo(e t"e flood le(el is 'referred in order to 'ro(ide natural
drainage. =lat areas& de'ressions& s;am'& ri(er ban%s and la%es"ore sites s"ould be
a(oided. Windy sites are unsuitable& as tem'orary s"elters are usually fragile.
Soil conditions
9"e soil ty'e affects sanitation& ;ater 'i'elines& road and building construction&
drainage and t"e li(ing en(ironment 2in terms of dust and mud4. 9"e most suitable
soil ty'e is one t"at ;ill easily absorb "uman ;aste.
Access
9"e site s"ould be accessible at all times 2e.g. for food deli(eries& roads during
rains4.
/egetation
9"e site area s"ould "a(e good (egetation co(er if 'ossible. 9rees and 'lants
'ro(ide s"ade& "el' to 're(ent soil erosion& allo; rec"arge of t"e ground;ater
su''lies and "el' in reducing dust. *t may sometimes be necessary& "o;e(er& to
destroy 'oisonous trees or 'lants& for e:am'le ;"ere 'o'ulations are accustomed to
collecting berries or mus"rooms.
En'ironmental )ealt)
Areas near (ector breeding sites ;"ere t"ere is a ris% of contracting malaria&
onc"ocerciasis 2ri(er blindness4& sc"istosomiasis& try'anosomiasis& etc. s"ould be
a(oided.
Securit,
9"e site c"osen s"ould be in a safe area& sufficiently distant from national borders
and combat areas.
Local (o(ulation
9"e use of land for a cam' can cause friction ;it" local farmers& "erdsmen&
nomads and lando;ners. ,ome 'otential sites may "a(e s'ecial ritual or s'iritual
significance to local 'eo'le& and site selection must res'ect t"e ;is"es of t"e local
'o'ulation. ,treams or ri(ers used for bat"ing and laundry may cause 'ollution far
do;nstreamN ;ater abstraction ;ill reduce flo; rates. *ndiscriminate defecation in t"e
early stages may also 'ollute ;ater su''lies used by t"e local 'o'ulation.
0uel su((l,
=uel for coo%ing is an essential daily reJuirement. O'tions for fuel include ;ood&
c"arcoal and %erosene. *n 'ractice& ;ood from surrounding forests is t"e most li%ely
fuel. *t is im'ortant to liaise closely ;it" t"e local forestry de'artment to control
indiscriminate felling and collection.
%#"#% Site la,out and design
*t is im'ortant to 're'are a master 'lan of t"e cam'. 9"e site 'lan s"ould be
sufficiently fle:ible to allo; for a greater t"an e:'ected influ: of 'eo'le. A $!)Q 'er
year 'o'ulation gro;t" rate must also be 'lanned for.
O(erde(elo'ment of some areas of t"e site must be a(oided as it can cause "ealt"
'roblems& es'ecially for 'eo'le ;"o come from s'arsely 'o'ulated en(ironments.
9ribal& et"nic or religious differences may e:ist ;it"in t"e cam' 'o'ulation or
bet;een t"is 'o'ulation and t"e local 'eo'le& or suc" grou'ings may de(elo' or be
strengt"ened ;it" time. 9"e cam' must be 'lanned in suc" a ;ay t"at t"ese di(isions
are "onoured.
,ite 'lanning norms are 'resented in 9able #.#. 9"e recommended figures for
cam' layout and ser(ices are only guidelines. *n se(erely o(ercro;ded& s'ontaneously
settled cam's it may be (ery difficult to ac"ie(e t"e recommended figures during t"e
initial emergency '"ase and realistic com'romises ;ill "a(e to be made.
.e(ert"eless& t"e figures 'ro(ide t"e basis for 'lanning and are t"e targets at ;"ic" to
aim.
Table %#% Site (lanning norms
Area 'er 'erson for collecti(e acti(ities $3 m
# a
,"elter s'ace 'er 'erson $.0 m
# b
2).0!0.0 m
# c
in cold climates4
Distance bet;een s"elters # m minimum
Area for su''ort ser(ices 6.0 m
#
5'erson
.umber of 'eo'le 'er ;ater 'oint #03
.umber of 'eo'le 'er latrine #3
Distance to ;ater 'oint 03 m ma:imum
Distance to latrine $3 m
Distance bet;een ;ater 'oint and latrine 33 m
=irebrea%s 60 m e(ery $33 m
a
-n practice this may be difficult to achieve* for e+ample in areas /ith a high
population density /here little land is available" This figure includes roads*
services* shelter* etc" but depends on the layout and terrain" -t does not
include land for livestoc6 or agriculture" 4fter space for covered shelter and
support services* the remainder of the >% m
2
/person area is for family plot
space* latrines* /ashing and coo6ing areas* community space* roads*
firebrea6s* drainage* burial grounds and contingencies"
b
For a five(person family this equals a shelter $ by > meters in a plot ? by %
meters"
c
-n cold climates /here coo6ing is done indoors* e+tra shelter space is
required"
%#"#* Communit, (artici(ation
Ongoing community in(ol(ement in site 'lanning and management is crucial and
can ma:imi8e t"e effecti(eness of t"e inter(ention.
%#"#+ Location of famil, d@ellings
9"e layout of d;ellings relati(e to eac" ot"er can "a(e a significant im'act on
security and cultural acti(ities& and is im'ortant for t"e building of a social structure.
*t also affects t"e use of latrines and ;ater 'oints. Alt"oug" s"elters arranged in
straig"t lines on a close grid 'attern mig"t a''ear to ease some as'ects of cam'
management& suc" a 'attern is not normally conduci(e to social co"esion. 9"e cam'
s"ould be organi8ed into small community units or L(illagesM eac" of a''ro:imately
333 'eo'le. 9raditional li(ing 'atterns s"ould al;ays be ta%en into account. ,e(eral
(illages can be combined to form a grou'N se(eral grou's can form a sectionN and
t"ere can be se(eral sections in one cam'. 9able #.$ s"o;s t"e recommended
structural organi8ation for a cam' setting. Eac" grou' or section ;ill reJuire a number
of decentrali8ed ser(ices& ;"ic" are listed in 9able #.).
9"e grou'ing of family 'lots into community units 'ro(ides a defined& secure
s'ace ;it"in eac" unit. Peo'le %no; eac" ot"er and strangers ;ill stand out. 9"e
circumstances of an emergency may gi(e rise to additional 'ersonal security ris%s.
Women may be (ulnerable to "arassment and ra'e. Et"nic and factional di(isions can
'ro(o%e (iolent confrontations. *n t"ese circumstances t"e 'rotection as'ects of
Ls"elterM< may mean %ee'ing different refugee grou's a'art and5or t"e 'ro(ision of
secure com'ounds for 'articularly (ulnerable refugees.
Table %#* Cam( building bloc4s
family P )!1 'eo'le
1 families P A3 'eo'le P community
1 communities P #03 'eo'le P bloc%
) bloc%s P 0333 'eo'le P sector
) sectors P #3 333 'eo'le P cam'
%#"#- S)elter design
A minimum s"elter s'ace of $.0 m# 'er 'erson is recommended in emergency
situations. *f 'ossible& t"e emergency-affected 'o'ulation s"ould build t"eir o;n
s"elters& 'referably using local materials suc" as timber& grass& bamboo& mud& sand
and ;o(en mats. Wo(en matting& natural fibre screens and bamboo ma%e (ery good
(entilated ;alls. W"en necessary& rolled-u' 'lastic s"eeting can be let do;n to ma%e
t"ese ;alls ;ater-& draug"t- and dust-'roof. 9ents and 'lastic s"eeting 'ro(ide
reasonable 'rotection from t"e elements& but ;it" large numbers of 'eo'le many units
are reJuired. Plastic s"eeting may last only 1!/ mont"s& de'ending on t"e Juality
usedN it degrades as a result of e:'osure to t"e elements& es'ecially sunlig"t. Can(as
tents can last for u' to t;o years if ;ell maintained. 9"e build-u' of dirt or rain;ater
on t"e roof& or dirt on t"e ;alls& ;ill s"orten t"e life of a can(as tent.
*t is best to 'lan t"e layout of s"elter areas in community clusters adFacent to t"e
rele(ant latrines& ;ater 'oints and ;as"ing areas. 9"ese community units s"ould be as
close as 'ossible in design and layout to t"ose ;it" ;"ic" t"e 'o'ulation is most
familiar.
%#"#. Location of site ser'ices
Consideration must be gi(en to t"e location of roads& "ouses& food and ;ater
distribution 'oints& emergency ser(ices 2security& fire& medical4& drains& ;as"ing
areas& latrines and solid ;aste 'its. Public buildings reJuire access roads for (e"icles
and s"ould be centrally located ;"ere 'ossible.
=ood distribution centres must be centrally located& ;it" sufficient room for
cro;ds of 'eo'le ;aiting and for truc%s deli(ering food. @ood design can "el'
considerably in cro;d control and t"eft 're(ention. 9"e main "ealt" facility must be
in a safe and accessible 'lace& 'referably on t"e 'eri'"ery of t"e site to allo; for
future e:'ansion and to a(oid o(ercro;ding.
A site for a c"olera treatment centre must be identified in ad(ance& se'arate from
ot"er "ealt" facilities and in an area ;"ere ;ater su''lies cannot be contaminated.
,u''ort facilities must be located a;ay from dusty or 'otentially dangerous maFor
access roads.
Table %#+ Main facilities on settlements
CentraliCed DecentraliCed
Administration Community "ealt" centres
Coordination offices -at"ing and ;as"ing areas
Ware"ouse ,ocial centres
Begistration ,c"ools
Hos'ital 2for large cam's4 Becreation s'ace
9racing centres ,u''lementary feeding centres
9"era'eutic feeding centres Beligious buildings
=ood distribution centres Water 'oints
9raining centres Latrines
,anitation offices
Boads and firebrea%s
Mar%ets
%#"#1 ece(tion and registration
A rece'tion area must be set u' outside t"e settlement to recei(e and register ne;
arri(als before t"ey become integrated ;it"in t"e cam'. 9"e registration site s"ould
'referably be a large& flat& o'en s'ace ;it" a ;ater su''ly and latrines or defecation
areas. 9em'orary first-nig"t s"elter and land for accom'anying animals may be
needed.
%#"#3 Mar4ets
Mar%et areas are im'ortant trading and social centres& but t"ey can 'ose "ealt"
ris%s ;"ere food and drin% is for sale. 9"e 'lanning and layout of suc" areas are (ery
im'ortant. *f 'ossible t"e mar%et s"ould be outside t"e cam'& or se(eral small mar%et
areas can be establis"ed. Eector control& ;aste collection and dis'osal measures need
to be 'articularly stringent at mar%et areas.
Mar%ets must be di(ided into food and non-food areas. =ood areas s"ould be
furt"er di(ided into areas for ra; and 'rocessed foods.
Areas must be 'ro(ided for t"e slaug"ter of li(estoc%& if 'ossible ;it" a concrete
slab ;it" good drainage to carry a;ay blood and animal dro''ings 2alt"oug" one
needs to ensure t"at t"is does not drain directly into a ;atercourse4.
%#"#5 Noise a'oidance and traffic
@enerators and 'um's s"ould be located a;ay from family d;ellings and t"e
buildings "ousing t"em s"ould be sound'roofed& ;it" sufficient (entilation for t"e
esca'e of e:"aust fumes. 9raffic s"ould be limited to main routes.
%#"#"6 Cam( coordination
Coordination bet;een t"e (arious organi8ations ;or%ing in t"e emergency is
essential in order to ma:imi8e 'ositi(e im'act on t"e 'o'ulation by means of effecti(e
management and integration of relief acti(ities.
9"e follo;ing ste's are necessary to ac"ie(e t"is obFecti(e:
establis" clear leaders"i'&
create a coordinating body&
ensure t"at 'rogramme acti(ities are s"ared by agencies&
clarify t"e roles and res'onsibilities of all 'artners&
're(ent du'lication of acti(ities&
establis" good communication c"annels&
ensure t"at all needs are addressed&
create and im'lement agreed common 'olicies& standards and guidelines.
%#"#"" Liaison @it) local communities
Continued liaison ;it" local communities is essential. 9"e influ: of emergency-
affected 'o'ulations into t"eir area means t"at t"ey are no; affected by t"e
emergency. 9"ere is a real ris% of generating resentment if local 'eo'le feel t"at t"e
emergency-affected 'o'ulations are better ser(ed t"an t"ey are. 9"ere may be a need
to 'ro(ide medical or ot"er assistance to local communities& bot" to ensure eJuity and
to 're(ent t"e s'read of disease.
%#% Water
Water and sanitation are (ital elements in t"e transmission of communicable
diseases and in t"e s'read of diseases 'rone to cause e'idemics. Diarr"oeal diseases
are a maFor cause of morbidity and mortality among emergency-affected 'o'ulations&
most being caused by a lac% of safe ;ater& inadeJuate e:creta dis'osal facilities and
'oor "ygiene 2see 9able #.04.
9"e goal of a ;ater and sanitation 'rogramme is to minimi8e ris%s to t"e "ealt" of
a 'o'ulation& 'articularly one caug"t u' in t"e difficult circumstances of an
emergency ;it" its attendant dis'lacement and dangers. ,uc" a 'rogramme is an
integral 'art of 're(enti(e "ealt" acti(ities.
9"e main focus of suc" a 'rogramme is on:
t"e 'ro(ision of a safe and sufficient ;ater su''ly&
'ro(ision for e:creta dis'osal and t"e establis"ment of ot"er ;aste control and
"ygiene measures&
a 'rogramme of 'ublic education for t"e affected 'o'ulation on t"e issues of
"ygiene and ;ater use.
Table %#- Water<related diseases
Diseases t"at occur o;ing to a lac% of
;ater and 'oor 'ersonal "ygiene
,%in infections: scabies& im'etigo
O'"t"almic infections: conFuncti(itis&
trac"oma
Louse-borne diseases: ty'"us& rela'sing
fe(er& trenc" fe(er
Diseases t"at occur o;ing to 'oor
biological Juality of t"e ;ater
Caused by faecal 'ollution: c"olera&
ty'"oid& ot"er diarr"oeal diseases&
"e'atitis A& "e'atitis E& sc"istosomiasis
Caused by t"e urine of certain mammals:
le'tos'irosis
Conditions t"at occur o;ing to 'oor
c"emical Juality of t"e ;ater
Poisoning
Diseases caused by ;ater-based insect
(ectors
Malaria& dengue fe(er& onc"ocerciasis&
yello; fe(er& Ca'anese ence'"alitis&
guinea ;orm
*n an emergency& t"e affected 'o'ulations need immediate access to a ;ater
su''ly in order to maintain "ealt" and to reduce t"e ris% of e'idemics. *f t"e
emergency-affected 'o'ulation "a(e to be s"eltered in tem'orary settlements or
cam's& ;ater su''ly is an essential consideration in c"oosing t"e site location. An
adeJuate amount of safe drin%ing-;ater must be 'ro(ided for t"e entire dis'laced
'o'ulation.
9"e first obFecti(e is to 'ro(ide sufficient ;aterN Juality can be addressed later.
,ufficient ;ater of lo; Juality is better t"an (ery little ;ater of "ig" Juality. During
t"e ra'id assessment of a 'ro'osed site it is essential to 'rotect e:isting ;ater sources
from 'ossible contamination. *f t"e 'o'ulation "a(e already mo(ed into t"e area in
Juestion& t"en immediate measures s"ould be ta%en to isolate and 'rotect t"e ;ater
source& if it is on or near t"e site.
Essential @ater reFuirements
9"e minimum amount of ;ater reJuired in e:treme situations is 6 litres 'er
'erson 'er day 2only tolerable for a s"ort duration4. 9"is amount does not
reduce t"e ris% of e'idemics in t"e 'o'ulation as it 'ermits only a (ery lo;
le(el of "ygiene.
9"e emergency reJuirement guideline is #3 litres 'er 'erson 'er day. 9"is
allo;s for coo%ing& laundry& bat"ing and acti(ities essential to 're(enting t"e
transmission of ;ater-borne diseases.
%#%#" Guidelines for assessing t)e 'olume of @ater reFuired
9"e assessment of t"e (olume of ;ater reJuired must ta%e into account daily
'o'ulation reJuirements and t"e effects of climate on t"e ;ater source. 9"e effects on
;ater reJuirements of a c"ange in 'o'ulation si8e also need to be estimated. A factor
of 3!0Q s"ould be added to t"e total daily reJuirement of a cam' in order to
'ro(ide for 'ublic institutions. 9able #.1 details t"e ;ater reJuirements in "ealt"
facilities.
Table %#. Water reFuirements in )ealt)
facilities
Hos'ital ;ard 03 litres5'erson 'er day
,urgery5maternity 33 litres5'erson 'er day
Dressing5consultation 0 litres 'er dressing
=eeding centre #3!$3 litres5'erson 'er day
Ditc"en 3 litres5'erson 'er day
W"en ;ater is scarce& rationing s"ould be introduced to ensure t"at t"e ;ea% and
(ulnerable sur(i(e and t"at an eJuitable distribution is ac"ie(ed. *n t"is situation&
monitoring is essential.
%#%#% $ro'iding a @ater su((l,
Identification of (ossible sources
9"e affected 'o'ulation must be in(ol(ed in t"is 'rocess from t"e start& as t"ey
;ill be relied on for re'airs and maintenance in t"e future. All a(ailable sources of
;ater s"ould be considered: a combination of sources may be used.
Assessment of @ater sources
Assessment is needed to determine:
t"e Juality of t"e ;ater&
t"e ty'e of treatment needed&
t"e met"od of e:traction from t"e source&
t"e most suitable distribution system.
Water Fualit,
9"e %ey to disease 're(ention t"roug" ;ater su''ly is ensuring t"at ;ater is of a
"ig" Juality ;"en consumed& not only Fust after treatment or at distribution 'oints. *f
'eo'le do not "a(e enoug" ;ater of acce'table Juality& t"en t"ey ;ill ta%e ;ater from
ot"er sources& ;"ic" ;ill most li%ely be contaminated. *n an emergency& biological
Juality is of greater im'ortance t"an c"emical Juality. 9"e WHO guidelines detailed
in 9able #.6 list t"e basic reJuirements and 'arameters t"at must be measured.
@round;ater sources usually yield ;ater of good Juality& but c"emicals t"at 'roduce
a bad odour or taste may also be released into t"e ;ater from underlying roc%s.
Table %#1 W2O guidelines on @ater Fualit,
Criteria Guidelines
=aecal coliforms
a
U 3 'er 33 ml
Odour5taste not detectable
9urbidity
b
U 0 .9?
9otal dissol(ed solids
c
U 033 'arts 'er million
'H
d
1.0!A.0
a
Faecal coliforms are bacteria of faecal origin from the faeces of an animal
.including humans0" This parameter is the most important /hen testing /ater
for drin6ing" Fe/er than % coliforms per %% ml of /ater is acceptable" The
preferred level is zero* but this may not be practical in some cases"
b
Turbidity refers to /ater clarity" -t is measured in @nephelometric turbidity
unitsA .NTB0" Turbidity may only be of aesthetic importance* but this /ill
matter to the affected population" -t does inhibit the effectiveness of chlorine
in purifying the /ater and may also be an indication of the level of pollution"
c
Total dissolved solids refers to the quantity of dissolved matter in the /ater" -t
is measured in parts per million .ppm0" 1rin6ing(/ater should have less than
?%% ppm" 4gain* this relates to acceptability by the consumers"
d
p8 is a measure of the acidity or al6alinity of the /ater" 4lum .aluminium
sulfate* used in the flocculation of suspended solids0 /or6s more efficiently at
a p8 bet/een $ and &" The p8 should be less than ) before adding chlorine"
;ime can be added to raise the p8 and hydrochloric acid to lo/er it"
Water treatment
Water t"at does not meet t"e reJuired standards must be treated before it is
distributed to t"e 'o'ulation. 9able #.A 'resents t"e main met"ods of ;ater treatment&
t"e selection of ;"ic" de'ends on t"e e:tent and ty'e of 'urification reJuired.
9reatment is usually follo;ed by c"emical disinfection of t"e ;ater& t"e most
common and effecti(e disinfecting solution in emergency situations being c"lorine
2see 9able #./4.
Iualit, control
Water Juality c"ec%s must be made at regular inter(als t"roug"out all stages of
t"e ;ater distribution c"ain. 9ests are needed se(eral times a day at t"e beginning and
in t"e middle of t"e c"ain for free residual c"lorine. Wee%ly c"ec%s for faecal
coliforms are needed in emergency situations& and 'articularly during e'idemics.
Distribution
*f t"e ra'id assessment indicates t"at a suitable ;ater system ;ill ta%e some time
to de(elo'& s"ort-term measures suc" as truc%ing may "a(e to be considered. *n suc"
instances& rationing may be necessary to ensure eJual distribution among t"e entire
'o'ulation.
Once a satisfactory su''ly "as been establis"ed& enoug" storage and reser(e
systems must be de(elo'ed to allo; for maintenance and brea%do;ns in su''ly and
eJui'ment. ,torage of at least one day<s reJuirement must be 'ro(ided. Pre(enting
contamination from sanitation facilities and ot"er sources of 'ollution is of 'aramount
im'ortance. 9"e location& organi8ation and maintenance of ;ater 'oints is detailed in
9able #.3.
Table %#3 Met)ods of @ater treatment
Storage 9"is is t"e sim'lest met"od of im'ro(ing
;ater Juality. *f ;ater is stored in a co(ered
tan% for a 'eriod of time& 'at"ogenic
bacteria die off and sin% to t"e bottom by a
sim'le sedimentation 'rocess. 9;o days is
t"e minimum lengt" of storage
recommended. 9"e ;ater ;ill not
necessarily be totally free of contamination
by sim'le filtration.
,torage tan%s reJuire cleaning and de-
sludging at regular inter(als& de'ending on
t"e le(el of sediment in t"e ;ater. Algal
build-u' s"ould be 're(ented. .o animals
or unaut"ori8ed 'ersons s"ould be allo;ed
access to t"e tan%s.
Aeration Aeration is ac"ie(ed by allo;ing t"e ;ater
to cascade o(er layers of gra(el. Aeration
may be reJuired if iron or manganese is
'resent in t"e ;ater& since t"ese gi(e an
un'leasant taste and a bro;nis"
discoloration to food and clot"es.
Sedimentation Water from ri(er sources& es'ecially in t"e
rainy season& often "as a "ig" silt content.
,im'le storage met"ods are not sufficient
for t"is silt to settle. Along ;it" t"e natural
sedimentation 'rocess& t"e addition of a
c"emical coagulant& usually aluminium
sulfate 2alum4& is necessary.
9"e amount of alum needed de'ends on t"e
amount of sus'ended matter in t"e ;ater&
t"e turbidity& t"e 'H and t"e "ardness of t"e
;ater. Effluent ;ater s"ould not contain a
concentration of alum greater t"an t"e
guideline figure gi(en in t"e WHO
guidelines for drin%ing-;ater Juality.
0iltration ,lo; and ra'id sand filters.
Disinfection C"lorine is t"e most common and effecti(e
disinfecting solution in emergency
situations& and (arious dilutions are used in
different situations 2see 9able 34. 9"e
amount of c"lorine reJuired de'ends on t"e
Juantity of organic matter and of "armful
organisms in t"e ;ater.
9"e dose s"ould lea(e a residual le(el of
c"lorine of bet;een 3.# and 3.0 mg5litre 2a
"ig"er le(el ;ill lea(e a taste and 'eo'le
;ill not drin% t"e ;ater4. A sim'le dri'-
feed tan% can be designed to administer t"e
correct amount of c"lorine.
Table %#5 ecommended dilution and use of AFuatabs
J
T,(e of @ater and source
Clear 'i'ed
;ater
Protected
tube ;ells&
ring ;ells&
clear
rain;ater
?n'rotected
;ells and
cloudy
;ater: filter
before
'urifying
Water %no;n
to "a(e faecal
contamination:
filter before
'urifying
Tablet siCe C)lorine
(er tablet
/olume of @ater treated (er tablet 8litres9
8mg9
A.0 mg 0 0 #.0 3.0
6 mg 3 3 0 #
16 mg $/.) $/.) /.6 6.AA $./)
$)3 mg #33 #33 33 )3 #3
033 mg #/) #/) )6 0A.A #/.)
0ree a'ailable c)lorine
content after treatment
8residual9
mg5litre # mg5litre 0 mg5litre 3 mg5litre
Table %#"6 Water distribution (oints
Location Water distribution 'oints must be set u'
in suitable 'laces around t"e cam'. A
good location is an ele(ated s'ot in t"e
centre of a li(ing area.
*f t"e ;ater 'oints are from ground
sources& no sanitation facilities s"ould be
;it"in 03 metres& and definitely not
closer t"an $3 metres. *f t"e ;ater 'oint is
too far a;ay& 'eo'le ;ill not collect
enoug" ;ater or may use contaminated
sources nearby.
Design W"en designing ;ater 'oints consider t"e
follo;ing:
O traditional ;ater-carrying met"ods&
O t"e containers used: for e:am'le& a
raised area is suitable for 'eo'le ;"o
carry t"e buc%et on t"eir "eads&
O ;"o collects and carries t"e ;ater 2it is
usually t"e ;omen and c"ildren4&
O t"e a(ailability of s'are 'arts.
9"ere s"ould be enoug" s'ace on t"e
concrete slab around t"e ;ater 'oint for
laundry and bat"ing areas. *f sanitation is
com'romised& it may be felt necessary to
locate bat"ing and ;as"ing areas a;ay
from collection 'oints. Ho;e(er&
traditional 'ractices and "abits need to be
accommodated as muc" as 'ossible.
Animals must certainly be %e't a;ay. *f
t"ey are mobile "erds& ;atering facilities
s"ould be establis"ed some distance a;ay
and a fence erected around t"e ;ater
'oint.
Number One ta' 'er #33!#03 'eo'le is t"e ratio
recommended by t"e ?nited .ations
Hig" Commissioner for Befugees
2?.HCB4. 9"e more 'eo'le t"ere are 'er
ta'& t"e more ;ear and tear t"ere is.
.obody s"ould "a(e to ;ait longer t"an a
fe; minutesN if collection ta%es a long
time& 'eo'le ;ill return to old&
contaminated but Juic%er sources
$rotection All efforts must be made to reduce
contamination at t"e ;ater 'oint.
*n t"e case of ;ells& clean buc%ets must
be 'ro(ided. *deally& t"e ;ell ;ill be
sealed and a lifting de(ice installed.
9"ere s"ould be a concrete a'ron for t"e
;ater 'oint& angled so t"at sullage and
s'ilt ;ater is carried a;ay and dis'osed
of or used 2e.g. in a soa%a;ay 'it or
(egetable garden4. ,tanding ;ater around
a ;ater 'oint ;ill become contaminated&
attract animals& ma%e t"e a'ron muddy
and 'ro(ide a breeding site for
mosJuitoes. *t can also see' bac% into t"e
;ater source and contaminate it.
Maintenance Eac" ;ater 'oint must "a(e a careta%er to
loo% after it& %ee' it clean and ma%e sure
it is not abused 2;omen are usually t"e
most a''ro'riate careta%ersN in t"e long
term t"ey must be trained in maintenance
s%ills4. Careta%ers must li(e close to t"e
;ater 'oint.
Domestic storage
*t is im'ortant to 'ro(ide clean storage containers for use in t"e "ome. Pro(iding
"ig"-Juality ;ater at a ta'-stand is of little im'act if 'eo'le are unable to carry and
store t"at ;ater "ygienically or do not a''reciate t"e im'ortance of t"is. *ntensi(e
education ;ill im'ro(e "ygiene 'ractices.
*n t"e acute '"ase of an emergency& "ouse"old storage is li%ely to be in 'lastic
containers. Peo'le may use a 'lastic Ferrycan for carrying and storing ;ater and a
buc%et for ;as"ing. Closed Ferrycans of 3!#3 litres ca'acity are ideal as t"ey can be
carried by c"ildren. Eegetable oil is often distributed in t"is ty'e of container& and
t"ey can be used for ;ater ;"en em'ty. *f 'ossible& large containers 233!#33 litres4
;it" lids s"ould be made a(ailable. 9"ese allo; for t"e safe storage of ;ater& 'lus a
reser(e to co'e ;it" a s"ort brea% in su''ly.
Water can also be stored in concrete storage Fars t"at can be made on site. 9"ese
Fars im'ro(e storage and& in addition& t"e s%ills learned in ma%ing t"e Fars can be used
;"en t"e emergency is o(er. *t is essential t"at any ;ater container is %e't clean and
co(ered.
%#%#* 0urt)er reading
Da(is C& Lambert B. Cngineering in emergencies: a practical guide for relief
/or6ers& #nd ed. London& *9D@ Publis"ing& #33#.
House ,C& Beed BA. Cmergency /ater sources: guidelines for selection and
treatment. Loug"boroug"& Water& Engineering and De(elo'ment Centre& //6.
Dublic health engineering in emergency situations. Paris& MKdecins ,ans
=ronti_res& //).
,mout& *D& ed. Euidance manual on /ater supply and sanitation programmes.
Loug"boroug"& Water& Engineering and De(elo'ment Centre& //A.
,ater manual for refugee situations. @ene(a& Office of t"e ?nited .ations Hig"
Commissioner for Befugees& //#.
%#* Sanitation
9"e aim of a sanitation 'rogramme is to de(elo' '"ysical barriers against t"e
transmission of disease& in order to 'rotect t"e "ealt" of t"e emergency-affected
'o'ulation. 9"ese barriers include bot" engineering measures and 'ersonal "ygiene
measures. 9"e 'ro(ision of latrines and t"e de(elo'ment of met"ods of ;aste dis'osal
are essential elements of t"e 'rogramme. 9"ese measures are only fully effecti(e&
"o;e(er& ;"en com'lemented by a sanitation education 'rogramme.
%#*#" Waste dis(osalD )uman @aste
9"e efficient and safe dis'osal of "uman e:creta is as im'ortant as t"e 'ro(ision
of ;ater in its 'ositi(e effect on t"e "ealt" of t"e emergency-affected 'o'ulation.
Human e:creta is more li%ely to transmit disease t"an animal ;aste. *t contributes to
t"e transmission of numerous diseases 2;"ic" can be 'articularly ;"en combined
;it" lo; le(els of nutrition4 and can also be a breeding ground for flies and ot"er
insects. *n t"e acute '"ase of an emergency& any form of e:creta dis'osal is better
t"an none. 9"e sim'lest and Juic%est met"ods s"ould be ado'tedN t"ese can later be
im'ro(ed on and c"anged. *nitially& s'eedy action is im'ortant in a(erting "uman
catastro'"e.
Immediate action
E:cretion fields must be 're'ared on t"e first day.
*ndiscriminate defaecation needs to be controlled. Areas ;"ere defaecation cannot
be 'ermitted are:
near ri(ers& streams and la%es and ;it"in $3 metres of any ;ater source or
;ater 'oint&
near ;ater storage facilities&
u'"ill of t"e cam'&
u'"ill of ;ater sources&
along 'ublic roads&
near feeding centres& clinics& food storage de'ots and distribution centres.
9"ese areas s"ould be fenced off and guarded ;"ere necessary. 9"e use of ;ater
for anal cleansing may e:'lain defaecation near ;ater sources. Water must be
'ro(ided in alternati(e locations to control t"is 'ractice effecti(ely. 9"ese measures
must be announced t"roug"out t"e cam' ;it" t"e assistance of t"e community
leaders& and dis'layed on signs& using bot" ;ords and 'ictures.
Latrine design
9"e most common cause of failure of a sanitation system is t"e selection of t"e
;rong system of latrines for a gi(en situation. As 'otential latrine users ;ill be relied
on for ins'ection and maintenance& it is essential t"at t"ey be in(ol(ed from t"e
beginning in 'lanning& design and im'lementation. 9"is s"ould ensure t"e most
a''ro'riate latrine design for t"e custom and culture of t"e 'o'ulation.
*n designing t"e system& t"e reJuirements of ;omen& young c"ildren and 'eo'le
;it" disabilities need to be considered.
Education and (romotion
W"ere it is necessary to introduce unfamiliar ty'es of latrines& t"e emergency-
affected 'o'ulation may need training in t"e 'ro'er use of t"e system.
W"ere acce'table latrines are 'ro(ided& intensi(e education and 'romotion is still
needed to ma:imi8e t"e numbers of dis'laced 'ersons using t"em. 9"is is es'ecially
im'ortant for t"e c"ildren& ;"o may not "a(e used latrines before.
9"e design of latrines s"ould be suc" as to encourage c"ildren to use t"em. -abies
;ill not use latrines& and t"eir faeces are more dangerous t"an t"ose of an adult.
Mot"ers s"ould be encouraged to dig small "oles for t"eir babies< faeces and to co(er
t"em ;it" soil after;ards.
9"e digging of latrine 'its must begin as soon as 'ossible. A com'lete cam'
co(erage of one latrine 'er 03 'eo'le s"ould be t"e first targetN t"en one 'er four
familiesN and finally one 'er family. =unding or s'ace constraints may "inder reac"ing
t"e "ig"est ratios. Often t"e best ratio ac"ie(ed in an emergency situation is one
latrine 'er four families.
A''ro'riate anal cleansing facilities must be 'ro(ided.
%#*#% Waste dis(osalD solid @aste
,olid ;aste& if not 'ro'erly dis'osed of& acts as a breeding site for flies& coc%-
roac"es and rats. A system for t"e safe storage& collection and dis'osal of ;aste must
be im'lemented in t"e earliest stages of an emergency. Consultation ;it" t"e
emergency-affected 'o'ulation is (ery im'ortant& as t"ey may already be moti(ated to
carry out some of t"e necessary tas%s ;it"out outside inter(ention& and may also ;ant
to use t"eir ;aste in a constructi(e ;ay 2e.g. in com'ost 'roduction4. 9able #.
summari8es t"e o'tions for solid ;aste dis'osal.
E(ery "ouse"old must be no more t"an 0 metres a;ay from a refuse container&
;it" one ;aste container for ten "ouses. Old oil drums cut in "alf Holes drilled in t"e
bottom allo; liJuids to drain a;ay and also 're(ent t"em from being stolen and used
as ;ater storage containers. Containers must be 'ro'erly secured.
Table %#"" O(tions for solid @aste dis(osal
7urial of famil, @aste near t)e )ome *n a settlement ;it" sufficient s'ace& t"e
'o'ulation can be encouraged to dis'ose
of t"eir ;aste ;it"in t"eir o;n 'lots. A
small "ole can be dug and t"e ;aste& if
dry enoug"& can be burned before
burying.
Trans(ort of @aste b, )ouse)olders to
a communit, com(ost (it
*f t"e affected 'o'ulation are interested or
e:'erienced in com'osting t"eir ;aste&
com'ost 'its can ma%e a (ery efficient
dis'osal system.
9"ey must be ;ell managed in order to
%ee' t"e fly 'o'ulation do;n.
*f t"e 'its are small enoug" to be located
at (arious sites t"roug"out t"e cam'&
t"ere may be no need for solid ;aste
collection.
*f t"e 'o'ulation understand t"e dangers
of flies and rats t"ey ;ill be more
inclined to manage t"e com'ost "ea'
correctly. 9"ey may also be moti(ated by
t"e 'ossibility of utili8ing or selling t"e
com'ost.
Waste collection near )omes and
transfer to large dis(osal site
9"e most e:'ensi(e o'tionN often t"e
only solution in large& o(ercro;ded
settlements.
%#*#* Waste dis(osalD liFuid @aste
,ullage is ;aste;ater from bat"ing& laundry and food 're'aration. *t must be
drained a;ay as it attracts flies and mosJuitoes and can contaminate ;ater su''lies.
,ullage also 'ro(ides a breeding ground for <ule+ mosJuitoes& (ectors of filariasis&
Ca'anese ence'"alitis& and ot"er (ector-borne diseases.
Peo'le tend to do t"eir ;as"ing and bat"ing close to t"e ;ater source& suc" as a
ri(er or la%e& unless alternati(e facilities are 'ro(ided. 9"is adds to t"e ;ater 'ollution
'roblems in t"e cam'. ,e'arate areas must be 'ro(ided for laundry and bat"ing.
A ;as"ing area consists of a raised concrete 'latform and a drainage system. *f
;ater is in s"ort su''ly& ;ater distribution 'oints can be lin%ed to laundry areas as
s'illage at ta' stands can be drained to t"e clot"es-;as"ing area. Laundry ;as"ing
;ater needs to be drained carefully since it contains a large amount of '"os'"ates and
s"ould not be directed to;ard ;ater sources.
Waste;ater from bat"ing can be dealt ;it" easily. 9"ere is no need for a roof on a
s"o;er room& alt"oug" a screen-li%e su'erstructure is necessary. *f t"e sun dries t"e
room eac" day t"en any 'at"ogens e:isting in stagnant ;ater ;ill be %illed off.
,ullage can be c"annelled into t"e storm-;ater drains& but t"is ;ill not be ;as"ed
a;ay in t"e dry season. *f t"e sullage cannot be drained a;ay it may be necessary to
di(ert it into a soa%a;ay or a ;aste stabili8ation 'ond.
%#*#+ Waste dis(osalD medical @aste
Medical ;aste includes needles& scal'els& laboratory sam'les& dis'osable materials
stained ;it" body fluids& and body tissue. 9"is ;aste reJuires s'ecial care in "andling&
since needles and scal'els can cut "andlers and transmit diseases suc" as H*E5A*D,&
"e'atitis - and C and (iral "aemorr"agic fe(ers.
Medical ;aste s"ould be burnt in an incinerator& 'referably as close as 'ossible to
t"e source& e.g. ;it"in t"e clinic or "os'ital grounds& but also do;n;ind of "os'ital
buildings and d;ellings.
*n tem'orary situations& a #33-litre drum can be used as an incinerator& di(ided in
"alf by a metal grate and ;it" an access "ole at t"e bottom to 'ro(ide air for
combustion and as a ;ay of remo(ing as".
*n "os'itals ;"ere t"ere is no incinerator& 'lacenta 'its can be used for "uman
tissues. Organic ;aste suc" as 'lacentas and am'utated limbs can be burned and t"en
buried dee' ;it"in t"ese 'its& alt"oug" measures s"ould be ta%en to ensure t"at t"e
ground;ater ;ill not be contaminated.
At small medical facilities suc" as clinics& a small "ole m V m V m can be
dug for t"e burning and burial of "a8ardous ;aste& suc" as syringes and soiled
dressings.
@reat care s"ould be ta%en ;it" s"ar' materials suc" as bro%en glass& scal'els and
old syringes. 9"ey s"ould be 'laced ;it"in old metal containers 2coo%ing oil or mil%
'o;der tins4 t"at are sealed before burial 2see safe dis'osal of needles in ,ection
#.1.#4.
%#*#- Dust
Large amounts of dust can also be a "ealt" "a8ard& causing res'iratory 'roblems
and contaminating food. Pre(enting t"e destruction of (egetation is im'ortant in
controlling dust. ,ettlements ;it" little or no (egetation are not only dusty but are
also full of rubbis" blo;n from dis'osal sites. Dust can be settled by s'raying ;ater
on t"e ground: t"is is 'articularly useful around "ealt" centres and feeding centres.
%#*#. Dis(osal of t)e dead
9"e ris%s 'osed by t"e dead are of t;o ty'es: ris%s to t"ose "andling t"e cada(er&
and ris%s to t"e 'o'ulation in general.
*n t"e maFority of cases dead bodies do not 'ose a serious "ealt" ris%. 9"e
diseased li(ing are a far greater "a8ard t"an t"e deceased& because most 'at"ogens do
not long sur(i(e t"e c"emical and tem'erature c"anges t"at occur after t"e deat" of
t"eir "ost. E(en if t"ey do sur(i(e& t"e conditions suitable for multi'lication of t"e
organisms are rarely met. *n t"e li(ing& organisms multi'ly and are readily
transmitted.
W"en deat" "as been due to a "ig"ly infectious disease suc" as c"olera& ty'"us&
'lague or (iral "aemorr"agic fe(er& it may be necessary to dis'ose of t"e body as
Juic%ly as 'ossible.
*n t"e case of c"olera& bodies s"ould be disinfected ;it" a #Q c"lorine solution
and t"e orifices bloc%ed ;it" cotton ;ool soa%ed in c"lorine solutionN t"ey must t"en
be buried in 'lastic sac%s as soon as 'ossible.
9"ose ;"o "a(e died of ty'"us s"ould be bagged as soon as 'ossible to 're(ent
t"e migration of lice to ot"ers. *deally t"e cada(ers s"ould be treated ;it" insecticide.
*ndi(iduals ;"o "a(e died of (iral "aemorr"agic fe(er s"ould be "andled ;it" full
bio"a8ard 'recautions& ;ra''ed in sealed lea%'roof material 2body bag4 immediately&
and eit"er be cremated or buried at a de't" of at least # metres. *f body bags are not
a(ailable& ;ra''ing t"e cor'se in a fabric soa%ed in a disinfectant suc" as
formalde"yde& t"en co(ering ;it" a 'lastic s"eet and sealing in a 'lastic bag& is
recommended. 9"e clot"ing& bedding and ot"er belongings of t"e indi(idual s"ould be
burned.
9"e use of c"loride of lime s"ould be a(oided. *t generally "as little effect on t"e
disease ris% as it is ra'idly neutrali8ed and it 'resents a "a8ard to t"e "andlers.
*deally t"e met"od of dis'osal s"ould follo; t"e cultural 'ractices of t"e
'o'ulation of ;"ic" t"e deceased ;as a member. *n t"e acute '"ase of an emergency&
;"ere many deat"s "a(e occurred& t"ere may be 'ressure to conduct mass burials.
Ho;e(er& t"is s"ould be a(oided if at all 'ossible& to ensure relati(es of t"e deceased
"a(e t"e o''ortunity to identify t"e bodies and allo; burial in a mar%ed site. -urial
sites must be identified early on& and t"e site s"ould ideally be located at t"e outs%irts
of t"e settlement 2or community4 and a;ay from ;ater sources.
During an outbrea% ;it" a "ig" mortality rate& t"e collection of bodies and t"eir
ra'id burial is a 'riority. Cor'ses s"ould not be embalmed but buried or cremated
'rom'tly. Wit" a large number of bodies t"ere is not enoug" time to underta%e t"e
normal ceremonies of burial. *ndi(idual cremation is rarely 'ossible o;ing to
s"ortages of fuel. E(eryt"ing s"ould be done to try to record t"e names of t"e dead
and t"e number of bodies interred. *f 'ossible& a culturally a''ro'riate ceremony
s"ould be "eld at t"e end of t"e e'idemic.
@ra(eyard and crematorium attendants s"ould be in 'lace to record t"e name& age&
gender& and address of t"e deceased& t"e cause of deat"& t"e 'lot s'ace used and t"e
de't" of burial. Becords on t"e cause of deat" can be com'iled to dra; u' a 'icture of
t"e "ealt" 'roblems in a cam'.
-odies s"ould be co(ered by at least one meter of eart". *f a mound is made o(er a
s"allo; burial& t"ere s"ould be at least one meter bet;een t"e edge of t"e mound and
t"e cada(er. 9"e reason for t"is is to 're(ent access by carrion feeders 2suc" as
Fac%als4 or rodents 2many s'ecies can burro; at least t;o feet4 and also to 're(ent
access by burro;ing flies& some of ;"ic" can dig do;n at least )0 cm. W"ere soil
conditions allo; digging to a sufficient de't"& eac" burial 'lot can be used to contain
u' to t"ree bodies& 'ro(ided t"at: # mont"s ela'ses bet;een burialsN t"ere is a $3-cm
ga' bet;een cor'sesN and t"e last cor'se buried is a minimum of metre belo; t"e
surface.
%#*#1 Monitoring and e'aluation of @ater and sanitation
(rogrammes
9"e maFor com'onents of t"e ;ater and sanitation 'rogrammes must be monitored
and e(aluated at regular inter(als in order to assess t"eir effecti(eness and suitability.
Problems identified can be addressed by means of c"anges in design& location or
im'ro(ed education met"ods. Monitoring is essential in ensuring t"at all sectors of t"e
'o'ulation recei(e an adeJuate ;ater su''ly. Water s"ortages may result from:
an underestimation of 'o'ulation si8e&
t"e more 'o;erful grou's in t"e community ta%ing more t"an t"eir s"are&
;astage and losses&
a combination of t"ese factors.
9"e information in 9ables #.# and #.$ 'ro(ide baseline issues for monitoring
and e(aluation in ;ater and sanitation 'rogrammes.
Table %#"% Indicators for monitoring inter'entions t)at
(ro'ide clean @ater> drainage and @aste dis(osal
Water storage and
use
Water su((l, Drainage Waste dis(osal
,ources of ;ater
for t"e 'o'ulation
9otal 'o'ulation Drainage from all
;ater outlets
Met"ods of ;aste
dis'osal used 9otal number of
families
Pur'oses for ;"ic"
;ater is used
Litres 'ro(ided 'er
'erson 'er day
9y'e of drainage *nter(als of ;aste
dis'osal
Water collection
and storage
met"ods
9y'e and Juality of
'rotection of ;ater
sources
Means of
maintenance
Met"od of medical
;aste dis'osal 2'it&
incineration4
Access to stored
;ater
Water distribution
met"ods
-loc%ages Community
in(ol(ement
Harmful 'ractices
and 'ro'osed
solutions
9y'e and Juality of
'rotection of ;ater
outlets
Presence of
stagnant 'ools of
;ater in t"e cam'&
t"eir location and
origin
De'endence of
community on
e:ternal assistance
for dum'ing
\uantity of ;ater
collected 'er ca'ita
Means of rain;ater
drainage
Cleanliness of t"e
general area around
eac" s"elter
Met"od of ;ater
disinfection
Har(esting of
rain;ater and
means
Cleanliness of
mar%et site
.umber of ;ater
outlets
.umber of
functioning ;ater
outlets
.umber of
functioning ;ater
outlets 'rotected
Batio of laundry
areas to number of
families
Batio of bat"ing
areas to total
'o'ulation
\uantity of ;ater
;asted 2amount
and e:'ressed as a
'ercentage4
Table %#"* Indicators for monitoring
inter'entions t)at (ro'ide
sanitar, latrine (rogrammes
Latrine (ro'ision Kno@ledge> attitudes and (ractice in
relation to latrines
.umber of families in t"e area Peo'le using and not using latrines^
.umber of functioning latrines at t"e
beginning of t"e re'orting 'eriod
Beason for use of latrines^
.umber of latrines built during t"e
re'orting 'eriod
Beasons for non-usage of latrines^
.umber of latrines re'aired during t"e
re'orting 'eriod
Percei(ed benefits of t"e latrines
.umber of latrines re'orted as out of
order during t"e re'orting 'eriod
Percei(ed 'roblems ;it" t"e latrines
.umber of latrines functioning at t"e end
of t"e re'orting 'eriod
?sers< o'inions on "o; latrines s"ould be
used and maintained
Percentage of t"e 'o'ulation ;it" access
to functioning latrines
%#*#3 0urt)er reading
Da(is C& Lambert B. Cngineering in emergencies: a practical guide for relief
/or6ers& #nd ed. London& *9D@ Publis"ing& #33#.
Har(ey PA& -ag"ri ,& Beed BA. Cmergency sanitation: assessment and
programme design. Loug"boroug"& Water& Engineering and De(elo'ment Centre&
#33#.
Dublic health engineering in emergency situations. Paris& MKdecins ,ans
=ronti_res& //).
,mout& *D& ed. Euidance manual on /ater supply and sanitation programmes.
Loug"boroug"& Water& Engineering and De(elo'ment Centre& //A.
%#+ /ector control
9"e obFecti(e of t"is section is to 'ro(ide a basic understanding of (ector control
in emergency situations. 9"e 'ur'ose of a (ector control 'rogramme is to reduce
disease transmission by rendering t"e en(ironment unfa(ourable for t"e de(elo'ment
and sur(i(al of t"e (ector. Pre(ention is better t"an cure& and ;"en t"e 'lanning and
construction of cam's is underta%en& 're(enting t"e de(elo'ment of (ector 'roblems
s"ould be ta%en into account. Com'lete eradication of a (ector is rarely 'ossible nor
necessarily desirable& but t"e (ector 'o'ulation and its life e:'ectancy s"ould be %e't
to a minimum. Community ad"esion and 'artici'ation in a (ector control 'rogramme
is essential for its success. Early diagnostic and treatment are needed to 're(ent se(ere
forms of t"e disease 2es'ecially for malaria4 ;"en transmission control is needed to
reduce incidence. -ot" are com'lementary and t;o essential com'onents of any
effecti(e (ector borne disease control 'rogramme.
9"e maFor biological (ectors are mosJuitoes& sand flies& triatomine bugs& tsetse
flies& blac%flies& tic%s& fleas& lice& mites. *m'ortant carrier reser(oirs or intermediary
"osts are synant"ro'ic flies& snails and rodents.
9"e diseases most commonly s'read by (ectors are malaria& filariasis& dengue
fe(er& yello; fe(er& leis"maniasis& C"agas disease& slee'ing sic%ness& onc"o-cerciasis&
borreliosis& ty'"us& and 'lague. MaFor diseases transmitted by intermediate "osts or
carriers are sc"istosomiasis& diarr"oeal diseases and trac"oma.
9"e main met"ods of (ector 're(ention and control can be classified as 'ersonal
'rotectionN en(ironmental controlN cam'site& s"elter and food store sanitationN
community a;arenessN and c"emical control suc" as residual or s'ace s'raying&
insecticide-treated tra's& selecti(e lar(iciding and t"e use of rodenticides. Eector
control is (ery s'ecific to t"e ecology of t"e (ector& t"e e'idemiology of t"e disease&
t"e "uman and social en(ironment as ;ell as resources locally a(ailable 2e.g.
tec"nical staff& structures& logistics4.
*t is im'ortant to see% t"e ad(ice of an entomologist5en(ironmental "ygienist
;"en designing a (ector control 'rogramme. 9"is 'erson ;ill assist by:
identifying t"e (ectors res'onsible for local transmission of disease&
determining t"e factors t"at influence tramsmission&
locating breeding grounds& and adult resting "abits&
deciding ;"ic" control measures need to be im'lemented&
deciding ;"ic" s'ecific c"emical control measures to use&
deciding ;"ic" c"emicals to use&
deciding t"e met"od and inter(al of a''lication&
deciding t"e time and 'lace of a''lication&
deciding t"e safety 'recautions necessary in t"e storage and use of "a8ardous
c"emicals.
%#+#" Ma&or art)ro(od 'ectors and associated diseases
Care s"ould be ta%en to ensure t"at any insecticides& rodenticides& etc. t"at are
used in control acti(ities are registered for use in t"e rele(ant countries or t"at
'ermission to use t"em is obtained from t"e a''ro'riate go(ernment de'artments.
MosFuitoes
MosJuitoes are t"e (ectors of malaria& filariasis& dengue& Ca'anese ence'"alitis
and yello; fe(er. 9able #.) summari8es t"e associated morbidity and case fatality&
and main treatment and 're(ention measures.
Table %#"+ Diseases s(read b, mosFuitoes and t)eir treatment
and (re'ention
Disease Case fatalit, Treatment $re'ention
Malaria Antimalarial drugs OEector control:
Dlasmodium
falciparum
Often fatal to non
immune 'eo'le
! insecticide-
treated mosJuito
nets
D" viva+ ?sually considered
non-fatal
! long-lasting
insecticidal nets
D" ovale ?sually considered
non-fatal
! re'ellents
D" malariae ?sually considered ! residual s'raying
non-fatal
! en(ironmental
management
OCase management:
! 'ro'"ylactic
drugs
! ra'id diagnosis
and effecti(e case
management
Monitoring t"e
effecti(eness of
control met"ods
'articularly during
e'idemics
?ello@ fe'er =atal in u' to 03Q
of cases
.o s'ecific
treatment a(ailable
O*solation of
infected 'eo'le
OEaccination of t"e
'o'ulation
OC"emical control
2lar(iciding ] s'ace
s'raying4 and
en(ironmental
management to
limit urban
breeding sites of
4edes s''.
mosJuitoes
O*solation of
infected 'eo'le
OC"emical control
2lar(iciding ] s'ace
s'raying4 and
en(ironmental
management to
limit urban
breeding sites of
4edes s''.
mosJuitoes
;a(anese
ence()alitis
=atal in 3.0!13Q of
cases
.o s'ecific
treatment a(ailable
O*solation of
infected 'eo'le
OEaccination of t"e
'o'ulation
OEn(ironmental
management
0ilariasis .on-fatal& may
lead to
ele'"antiasis
Diet"ylcarbama8ine
2DEC4 or
i(ermectin ]
albenda8ole
OEn(ironmental
sanitation to
're(ent breeding of
<ule+ s''.
mosJuitoes in
'olluted ;aters
O9reated mosJuito
nets and residual
s'raying in areas
;"ere (ectors are
ano'"elines
=emale mosJuitoes may feed on "umans and a (ariety of mammals& birds and
re'tiles& eac" s'ecies "a(ing a 'reference for a 'articular source of blood. Many
s'ecies feed on "umans& but only some of t"em are (ectors of t"e diseases mentioned
in 9able #.0. 9"eir life cycle in(ol(es four stages: egg& lar(a& nym'" and adult. All
mosJuitoes lay t"eir eggs in moist areas& but eac" s'ecies "as a s'ecific 'reference for
a gi(en ty'e of area. 9"e control measures s"ould be s'ecific to t"e s'ecies and t"eir
ecological 'references. 9able #.0 'resents information on t"e biological 'references
of mosJuito s'ecies.
Table
%#"-
7iological information on mosFuito 'ectors
/ector
grou(
/ector
s(ecies
Disease T,(ical
breeding
sites
estin
g site
Tran<
smissio
n
7lood
source
Dis(ers
al
range
Ano'"elin
es
4nophel
es
malaria&
filariasis&
arbo(irus
es
.atural
'ools of
un'ollute
d ;ater
*ndoor
5
outdo
or
E(enin
g and
nig"t
Huma
ns and
animal
s
%m
Culicines 4edes filariasis&
yello;
fe(er&
dengue&
some
(iral
ence'"alit
is
Water
container
s& small
'ools of
stagnant
;ater
*ndoor
5
outdo
or
Day Huma
ns and
animal
s
3.!3.A
%m
<ule+ filariasis&
some
(iral
ence'"alit
is
Organical
ly
'olluted
;ater or
natural
'ools of
un'ollute
d ;ater
*ndoor
5
outdo
or
Day
and
nig"t
Huma
ns and
animal
s
3.!3.A
%m
5anson
ia
filariasis ?n'ollute
d ;ater
;it"
'lants
*ndoor
5
outdo
or
Day
and
nig"t
Huma
ns and
animal
s
3.!3.A
%m
9"e (arious o'tions for mosJuito control are outlined belo; in 9able #.1.
Table %#". C)oice of control met)ods for different mosFuitoes
MosFuito
be)a'iour
Control
(rogramme
/ector
s(ecies
Control of
transmission
Control
sc)edule
=or all
mosJuitoes
Local
destruction of
breeding sites
Most
mosJuito
(ectorsN not
9otally
effecti(e
Permanent
by drainage or
filling if
identifiable
suitable for
4n" gambiae
Lar(iciding
;it" teme'"os
#!$ ;ee%s
'artially
effecti(e
Be'eated e(ery
!# ;ee%s for
4nopheles and
e(ery # mont"s
for 4edes
,'ace
s'raying
All
mosJuitoes
Effecti(e Wee%ly
Eery effecti(e Daily in early
mornings or
e(enings
Be'ellents All
mosJuitoes
Lasts u' to 1
"ours ;it"
good
effecti(eness
A''ly daily
during biting
"ours
*ndoor biting ,creening of
doors and
;indo;s in
"ouse
4nopheles*
<ule+* 4edes*
5ansonia
Partially
effecti(e
Put in 'lace
;"en "ouse is
built& re'air
annually
*ndoor biting at
nig"t
MosJuito nets 4nopheles*
<ule+*
5ansonia
Partially
effecti(e
Pro'er use of
;ellmaintained
bed net&
c"ange e(ery
#! 0 years
*nsecticide-
treated
mosJuito nets
Partially or
com'letely
effecti(e
.et must be
im'regnated
;it"
'ermet"rin
e(ery 1!#
mont"s
*ndoor resting *ndoor
residual
s'raying
4nopheles*
<ule+*
5ansonia
and 4edes
aegypti
#!$ ;ee%s
'artially or
com'letely
effecti(e
E(ery $!1
mont"s& before
t"e
transmission
season
MosJuito lar(ae
attac" to roots of
aJuatic(egetation
Bemo(al of
(egetation&
es'ecially
;ater lettuce
from all
standing ;ater
5ansonia Partially
effecti(e
C"ec% 'ossible
breeding sites
;ee%ly in t"e
gro;ing
season
Lice
9"ere are t"ree s'ecies of louse: "ead& body and 'ubic. Head lice are not (ectors
of any 'articular disease but cause discomfort for t"ose infested. -ody lice are (ectors
of ty'"us& rela'sing fe(er and trenc" fe(er. Pubic lice are not disease (ectors. -ody
lice are ;ides'read in im'o(eris"ed communities in tem'erate climates or in
mountainous areas in tro'ical countries. Head lice and 'ubic lice are 'resent
t"roug"out t"e ;orld. Louse-borne diseases& associated morbidity and mortality&
treatment and 're(ention are 'resented in 9able #.6.
Louse-borne infections are common in o(ercro;ded situations& 'articularly in
settlements. Lice are s'read (ia "uman clot"ing. Control met"ods for lice are sim'le
and effecti(e and are listed in 9able #.A.
Table %#"1 Diseases s(read b, lice> t)eir treatment and (re'ention
/ector Disease Morbidit,
and mortalit,
@)en
untreated
Treatment $re'ention
-ody lice Louse-borne
ty'"us
=atal in 3!
)3Q of cases
Antimicrobial C"ange of
clot"ing
Bela'sing
fe(er
=atal in #!3Q
of cases
C"ange of
clot"ing
Delousing
2details in
9able #.A
9renc" fe(er 9y'ically non-
fatal
Delousing
Head lice .o disease ,ee 9able #.A
Pubic lice .o disease
Table %#"3 Control met)ods for lice
T,(e Control (rogramme Control of transmission
Head lice *f s"a(ing is culturally
acce'table& adults and
c"ildren can s"a(e t"eir
"eadsN blades can be
distributed to families
Delouse ne; arri(als
P"armaceutical anti-lice
insecticide lotions suc" as
malat"ion or 'ermet"rin
can also be used and are
recommended during a
mass cam'aign
Peo'le ;it" "ead lice ;"o
slee' under im'regnated
mosJuito nets commonly
lose t"e infestation
-ody lice *nformation 'rogramme on
t"e dangers of body lice
and 'ro'osed control
met"ods
Delouse ne; arri(als
C"ange all clot"ing
-oil or steam clot"ing for
0 minutes
Care s"ould be ta%en to
delouse all fe(eris"
'ersons as ;ell as cor'ses 9reat non-;as"able
clot"ing ;it" insecticide
and re'eat after ;ee%
*m'regnate clot"ing ;it"
'ermet"rin during rinsing
2see belo;4
or
=or mass cam'aigns&
administer 03 grams of
insecticidal dusting
'o;der to eac" indi(idual
in t"e 'o'ulation (ia t"e
nec% band& ;aistband and
slee(es& 'aying 'articular
attention to seams and
under;ear
Pubic lice P"armaceutical anti-lice
insecticide lotions suc" as
malat"ion or 'ermet"rin
Delouse ne; arri(als
-mpregnation of clothing /ith insecticides
*m'regnation of clot"ing ;it" 'ermet"rin or etofen'ro: ;"en rinsing is an
effecti(e ;ay of controlling art"ro'od ecto'arasites. Permet"rin is safe for t"is
'ur'ose& but if im'regnation is carried out t"e same safety 'recautions must be used
as for im'regnating mosJuito nets. *m'regnation s"ould be done at a central 'oint by
trained staff and not by indi(idual families. Clot"ing treated in t"is ;ay ;ill retain its
insecticidal 'ro'erties for se(eral ;as"es. A(oid t"e use of ot"er 'yret"roids&
es'ecially t"e cyano'yret"roids 2al'"a-cy'ermet"rin& cyflut"rin& deltamet"rin&
lambda-cy"alot"rin4& as t"ey may cause strong s%in irritation.
4pplication of dusts for control of body lice
A''lication of insecticidal dusts for louse control reJuires t"e a''ro'riate
a''aratus. ,im'le "and-'um'ed dusters are a(ailable and are effecti(e but not (ery
ra'id to use. =or mass treatment& 'o;ered dusters are more effecti(e but need to be
selected carefully. Dusts can easily clog s'ray no88les& es'ecially if t"e air is dam'.
Com'ressed air is t"erefore not ideal for 'ressuri8ing suc" eJui'ment. ,'rayers
'o;ered by carbon dio:ide "a(e been de(ised but are "ea(y and reJuire su''lies of
t"e gas.
Mass dusting 'rogrammes reJuire careful 'lanning and staff must be 'ro'erly
trained. 9"e 'ublic must be informed carefully about t"e nature of and reasons for t"e
'rogramme. ,taff ;ill need good 'rotecti(e clot"ing and effecti(e dust mas%s t"at
'rotect t"e ;"ole face.
0lies
=ilt" flies are considered im'ortant carriers of diarr"oeal disease and eye
infections. 9"e common filt" flies are t"e "ousefly 25usca domestica4& 5" sorbens&
and t"e blo;fly 2blue or green big flies4. 9"e "ousefly and 5" sorbens are t"e most
im'ortant in t"e s'read of disease. 9"e "ousefly is t"oug"t to be im'ortant in t"e
s'read of diarr"oea& ;"ile 5" sorbens s'reads t"e eye infection trac"oma. 9"e role of
blo;flies& 'roliferating in emergency settings& in t"e s'read of disease is un%no;n.
9able #./ 'resents some of t"e diseases s'read by (arious s'ecies of t"e fly
family& and t"eir associated morbidity and mortality& treatment and 're(ention.
Table %#"5 Main diseases in emergenc, situations s(read b,
flies and t)eir treatment and (re'ention
Disease Morbidit, and
mortalit, @)en
untreated
Treatment $re'ention
Diarr"oeal disease !3Q fatality rate Be"ydration @ood 'ersonal and
2e.g. s"igellosis or
salmonellosis4
2antimicrobial may
be needed4
%itc"en "ygiene&
safe ;ater and
sanitary dis'osal of
faeces
,anitation 2garbage
dis'osal& latrines...4
and fly control
9rac"oma .on-fatal ! eye
damage& including
blindness& in se(ere
untreated infections
Cleaning t"e eye @ood 'ersonal
"ygiene
Antimicrobial AdeJuate su''lies
of soa' and ;ater
for ;as"ing face
and "ands
9"e control of flies is (ery difficult as t"ey "a(e many breeding and resting sites.
9"e control measures t"at can be ado'ted include:
sanitation: safe faecal and garbage dis'osal systems&
selecti(e a''lication of insecticides in garbage containers& ;all and fences
around latrines as ;ell as resting site of flies&
'rom't burial of cor'ses&
screens for %itc"ens&
safe food storage systems&
good 'ersonal and en(ironmental "ygiene.
Mites
Mites are associated ;it" disease& eit"er as (ectors or as burro;ers into t"e fles"
leading to secondary infections. ,cabies and Figgers are e:am'les of burro;ing
infestations. 9"e trombiculid mite is t"e (ector for scrub ty'"us. *ts breeds in
(egetation and transmission occurs during t"e day. ,cabies is t"e main mite
infestation seen in refugee situations. 9able #.#3 'resents some of t"e diseases s'read
or caused by mites and t"e associated morbidity and mortality& treatment and
're(ention. 9able #.# details control measures for mites.
Table %#%6 Diseases s(read b, mites> t)eir treatment and
(re'ention
Disease Morbidit, and
mortalit, @)en
untreated
Treatment $re'ention
,cabies .on-fatal but
se(ere cases of
infection can lead
to ec8ema
,ulfur ointment or
ben8yl-ben8oate
@ood 'ersonal and
en(ironmental
"ygiene& adeJuate
su''lies of soa'
and ;ater& freJuent
bat"ing and
laundry
*(ermectin
treatment
,crub ty'"us !13Q fatality
rates
Antimicrobial A(oid scrub areas
or ;ear 'rotecti(e
clot"ing
A''ly disinfecting
lotion to s%in
or dust ;it" sulfur
'o;der before
going into infected Disinfect all bed
linen and
mattresses
areas
Table %#%" T)e c)oice of control met)ods for
mites
T,(e of mite Control (rogramme
9rombiculid mite 9reat infected 'ersons
Locate infested areas 2Lmite islandsM4
Destroy t"e mite by destroying scrub
areas or s'raying ;it" residual
'ermet"rin or deltamet"rin insecticide
s'ray around "ouses& "os'itals and cam'
sites
Tic4s
9ic%s are fairly rare and are unli%ely to be a maFor "a8ard in emergency situations.
9ic%-borne endemic rela'sing fe(er and Lyme disease are t"e main tic%-borne disease
t"at can afflict "umans. 9"e use of insecticide im'regnated clot"ing usually 'ro(ide a
(ery good 'rotection against tic% bites.
0leas
Plague and murine ty'"us are t"e t;o main diseases s'read by t"e flea& bot"
s'ecies usually li(ing on rats. E'idemics of 'lague may occur ;"ere t"ere is a "ig"
domestic rat 'o'ulation and5or a "umid en(ironment at 3!#3 `C. 9"e first signs of an
e'idemic is t"e occurrence of numerous deat"s among domestic rats& follo;ed t;o
;ee%s later by t"e first cases of 'lague among "umans. 9able #.## 'resents some of
t"e diseases s'read or caused by fleas and t"e associated morbidity and mortality&
treatment and 're(ention. 9able #.#$ details control measures for fleas. 9"e flea
'o'ulation must be controlled before t"e rat 'o'ulation or t"e fleas ;ill mo(e to
"umans.
Table %#%% Diseases s(read b, fleas and t)eir treatment and
(re'ention
Disease Morbidit, and
mortalit, @)en
untreated
Treatment $re'ention
Murine ty'"us !0Q fatality rate Antimicrobial @ood 'ersonal and
en(ironmental
"ygiene
*nsecticide dusting
'o;der for t"e
'atient& "is5"er
clot"ing and
bedding
Begular insecticide
use
Airing of bedding Air bedding
regularly
Dusting and
s'raying Pre(ent
conditions t"at
attract an
increasing rat
'o'ulation
Plague 03!/0Q case- Antimicrobial ! @ood 'ersonal and
fatality rate
de'ending on t"e
nutritional status of
t"e 'o'ulation
stre'tomycin en(ironmental
"ygiene
C"emo'ro'"yla:is
for close contacts
Pre(ent conditions
t"at attract an
increasing rat
'o'ulation
\uarantine for
'atients and
contacts
Eaccination is only
recommended for
"ig"-ris% grou's
e.g. "ealt" ;or%ers
and laboratory
'ersonnel and not
for immediate
'rotection in
outbrea%s
Table %#%* T)e c)oice of control met)ods for
fleas
T,(e Control (rogramme
=lea -aited tra's t"at %ill fleas first
2insecticide dust4 and rats subseJuently
2anticoagulant4
%#+#% /ector control strategies
9"e main met"ods of art"ro'od (ector control in emergency situations can be
classified into t"e follo;ing grou's:
residual s'raying&
'ersonal 'rotection&
en(ironmental control&
cam'site and s"elter design and layout&
community a;areness.
9"e c"oice of control strategies in an emergency situation de'ends on:
t"e ty'e of s"elter a(ailable ! 'ermanent "ousing& tents& 'lastic s"eeting&
"uman be"a(iour ! culture& slee'ing 'ractices& mobility&
(ector be"a(iour ! biting cycle& indoor or outdoor resting&
a(ailability of tools& eJui'ment and trained 'ersonnel for im'lementation.
Eector control is strongly recommended in order to reduce incidence of (ector
borne diseases and 're(ent outbrea%s suc" as malaria. *t is essential t"at any (ector
control inter(ention t"at is 'ro'osed s"ould be 'lanned& im'lemented in a timely
fas"ion and e(aluated by Jualified tec"nical 'ersonnel. *t "as to be carried out long
enoug" before t"e transmission season starts to "a(e t"e e:'ected im'act. 9"e o(erall
(ector control inter(entions s"ould be ready to start as soon as 'ossible.
Becommendations for selecting (ector control inter(entions and insecticides ;ill
de'end on ;"et"er t"e 'eo'le to be 'rotected are located in tem'orary settlements&
suc" as cam's& or in 'ermanent communities.
esidual s(ra,ing
Besidual s'raying can be conducted indoors or outdoors. *t is im'ortant to ensure
t"at:
t"e community is in(ol(ed in 'lanning t"e s'raying e:ercise and is a;are of
t"e conditions reJuired for an effecti(e s'raying 'rogrammeN
'ainting or a''lication of fres" mud or mortar is com'leted 'rior to t"e
s'raying e:erciseN
t"e li(ing accommodation and animal s"eds of e(ery "ouse"old are also
s'rayedN
t"e ;alls& ceiling and roof are co(ered ;it" t"e c"emical& 'aying 'articular
attention to corners and cre(icesN a''lication s"ould be re'eated according to
t"e residual life of t"e insecticide and t"e duration of t"e transmission season.
Indoor residual s(ra,ing is a recommended tec"niJue for controlling
mosJuitoes& sandflies and triatomine bugs. *t is t"e most common met"od in t"e 'ost-
emergency '"ase ;"en t"e dis'laced 'o'ulation is li(ing in more 'ermanent
d;ellings suc" as "uts or "ouses. 9"e local mosJuito (ector must be indoor-resting 2at
least s"ortly after blood feedingN see% e:'ert ad(ice4 and all "ouses must be treated&
;it" s'raying done Fust before t"e beginning of transmission season. *t ;ill also "el'
to control bedbugs 2;"ic" li(e in ;alls4 and may e(entually reduce domestic flea
'o'ulations. *B, is (ery effecti(e in almost all e'idemiological settings and
recommended as t"e first line inter(ention to control e'idemics. Ho;e(er&
im'lementation is facing gro;ing difficulties 2reduced acce'tance by 'o'ulations&
lac% of trained 'ersonnel& "ig" costs4 ;"ic" e:'lain ;"y many 'rogrammes are
currently s"ifting to insecticide-treated nets.
Ground s(ace s(ra,ing> eit"er ultra-lo;-(olume 2?LE4 cold mist or t"ermal
fogging& is not t"e 'referred inter(ention for malaria (ector control in emergency
situations. *t "as no residual effect and is not effecti(e against endo'"ilic mosJuitoes.
*n t"e conte:t of cam's& es'ecially in cro;ded areas& ground s'ace s'raying can be
resorted to if residual s'raying is delayed or cannot be im'lemented. 9reatment must
be done eit"er early in t"e morning or in t"e e(ening& before 'eo'le close t"e s"elters
for t"e nig"t. A''lications s"ould be re'eated at least once a ;ee%. Pyret"rins or
'yret"roids are t"e best c"oice for suc" a''lication but organo'"os'"ate insecticides
are also suitable.
Aerial s(ra,ing is not recommended in most emergency situations.
Insecticide resistance
*n t"e conte:t of an emergency& ;"ere inter(entions are 'lanned for limited
'eriods of time until dis'laced 'o'ulations can go bac% "ome& t"e selection of
insecticide is not a maFor concern. Pyret"roids used eit"er for residual a''lication&
treatment of nets or s'ace s'raying are most li%ely to be effecti(e enoug" for a fe;
;ee%s& e(en if some resistance mig"t occur. Ho;e(er& in some situations& resistance
mig"t be "ig" enoug" to limit t"e im'act of residual a''lications considerably&
es'ecially in t"e case of non e:cito-re'ellent insecticides suc" as organo'"os'"ate
and& to a certain e:tent& carbamates. 9"e situation ;ould be different for longer-term
treatments carried out in 'ermanent settlements.
$ersonal (rotection
Personal 'rotection against t"e s'read of disease includes a (ariety of met"ods:
insecticide-treated nets& treated s"eets and blan%ets& 'ersonal "ygiene& insect
re'ellents and clot"ing& and dusting 'o;der.
Insecticide<treated nets 8ITNs9 are 'rimarily used to 'rotect against mosJuito
bitesN "o;e(er& t"ey also 'ro(ide a barrier against ot"er (ectors suc" as sandflies&
triatomine bugs as ;ell as 'ests suc" as bed bugs or coc%roac"es.
.on-treated bednets 'ro(ide 'artial 'rotection against malaria.
9"e effecti(eness of bednets can be increased by im'regnating t"em ;it"
'yret"roid insecticides.
9"e bednets s"ould be soa%ed in insecticide after e(ery t"ird ;as" or at least
once a year.
After soa%ing in t"e c"emical& t"ey s"ould 'referably be dried flat so as to
maintain an e(en concentration of t"e c"emical t"roug"out t"e nets.
*9.s must be a(ailable to dis'laced 'o'ulations in time to be effecti(e.
Distribution of nets must be su''lemented by information and educational acti(ities&
;"ic" may be difficult in an emergency situation. *n addition& nets are not easy to
"ang in tents and are almost im'ossible to use in s"elters. *9.s are regarded more as a
tool for long-term 're(ention& ;"ic" s"ould be introduced into communities ;it" a
number of accom'anying measures in order to be effecti(e and sustainable. =ree
distribution of nets may lead to 'eo'le refusing to buy nets once t"ey are sold& e(en at
a subsidi8ed 'rice. Ho;e(er& *9.s s"ould be distributed if t"ey are a(ailable&
es'ecially if "ouse s'raying cannot be im'lemented or "as to be delayed. 9"e nets
s"ould be treated ;it" insecticide formulations and at dosages recommended by
WHO.
Long<lasting insecticidal nets 8LLINs9 are nets treated at factory le(el ;it"
insecticide eit"er incor'orated into or coated around t"e fibres& resistant to multi'le
;as"es and ;"ose biological acti(ity lasts as long as t"e net itself 2$ to ) years for
'olyester nets& ) to 0 years for 'olyet"ylene ones4.
LL*.s offer a 'ractical solution in terms of ;as" resistance& safe use of coloured
nets and 'urc"ase of ready-to-use 'retreated nets& 'ro(iding t"ey fulfill s'ecifications.
,o far& Juality control c"ec%s carried out by WHO and ?.*CE= ;it" t"e t;o LL*.s
eit"er recommended or under testing by WHO "a(e s"o;n e:cellent com'liance to
s'ecifications on bot" insecticide treatment and netting s'ecifications.
Ad'ice to control (rogrammes on t)e (urc)ase and use of LLINs
-e informed of WHO recommendations 2regular u'dates on LL*.s or tec"nical
information on netting materials and insecticides4.
Preferably use WHO-recommended LL*.s& es'ecially if difficulties in ensuring
'ro'er re-treatment rates are antici'ated.
A(oid 'urc"ase of factory 'retreated nets ot"er t"an LL*.s.
*n case LL*.s are not a(ailable or are not 'referred& 'urc"ase non-treated nets
;it" insecticide treatment %it2s4 bundled.
W"en and ;"ere 'ossible& use *9.s for 're(ention of se(eral diseases 2e.g.
malaria ] leis"maniasis or lym'"atic filariasis4.
C"ec%& ;"ene(er 'ossible& t"e Juality of nets and insecticides using WHO
s'ecifications.
Ensure regular re-treatment of con(entional nets already in use& 'referably
'ro(iding treatment free and& once a(ailable& use t"e ne; long-lasting di''ing
treatment %its.
Treated s)eets and blan4ets are easy to distribute and effecti(e. *n t"is case&
only 'ermet"rin 2#0:60 cis:trans isomeric ratio4 EC or etofen'ro: EW s"ould be used&
at a dose of g5m#. Ot"er 'yret"roids are not recommended for t"is ty'e of
a''lication for safety reasons and because of 'ossible s%in irritation. 9reat-ment can
be made by classical di''ing or by s'raying s"eets and blan%ets laid on t"e ground&
using eit"er a 'ressuri8ed "and s'rayer or a bac%'ac% motor-i8ed one. 9"e safety of
suc" treatment is ;ell establis"ed& and millions of mil-itary uniforms are treated e(ery
year ;it" 'ermet"rin.
Alt"oug" s"o;n to be effecti(e in a s'ecific e'idemiological situation
2Afg"anistan4& t"e use of treated s"eets and blan%ets against malaria (ectors reJuires
more study in Africa. ,ince it is al;ays ris%y to introduce ne; inter(entions in
emergency situations ;it"out 're(ious testing& t"is inter(ention is only recommended
as a tem'orary measure or to su''lement ot"er ;ell establis"ed met"ods. *nsecticide-
s'rayed tents for LtransitM buildings& tem'orary treatment facilities& and family
s"elters "a(e not been tested outside Asia. A ne; tec"nology is under de(elo'ment&
based on t"e incor'oration of insecticide into 'lastic s"eeting and tar'aulins used in
refugee settings. *nstead of being s'rayed in situ& insecticide is incor'orated ;it"in
'olymer used to 'roduce t"e 'lastic s"eet and is released o(er time to t"e surface of
t"e s"eeting. 9"e use of long-lasting insecticide-treated 'lastic s"eeting is 'romising
and undergoing field trials in countries including Angola& Liberia& Pa%istan and ,ierra
Leone.
$ersonal ),giene# Daily bat"ing& ;as"ing of "ands after using t"e latrine& regular
;as"ing of clot"es& and good food and ;ater storage 'ractices can 're(ent t"e s'read
of fly-borne diseases.
Insect re(ellents and clot)ing# -iting by mosJuitoes& flies and tic%s can be
reduced by ;earing long-slee(ed s"irts and long trousers& and by using insect
re'ellents. *nsect re'ellents can include traditional re'ellent mi:tures& mosJuito coils
or commercially 'roduced 'roducts. 9"ese s"ould be used during t"e biting "ours
;"en t"e s'ecies of mosJuito is acti(e. Wearing s"oes can 're(ent infestation ;it"
Figgers. Permet"rin-treated outer clot"ing ;orn in t"e e(ening or in bed is effecti(e in
sout" Asia but needs testing in "ig"ly endemic African conditions.
Dusting (o@der# A''ro'riate dusting 'o;ders can be used in t"e treatment of
flea and louse infestations. *t is im'ortant t"at t"e 'o;der is a''lied correctly and t"at
it co(ers t"e undergarments and t"e inner seams of clot"ing.
En'ironmental control
En(ironmental control strategies aim to minimi8e t"e s'read of disease by
reducing t"e number of (ector breeding sites. ,ome of t"e most im'ortant measures&
namely t"e 'ro(ision of clean ;ater& t"e 'ro(ision and maintenance of sanitary
latrines and t"e efficient and safe dis'osal of ;aste& are described earlier in t"is
manual.
Drainage of clean ;ater around ;ater ta' stands and rain;ater drains is a furt"er
im'ortant measure in t"e en(ironmental control of disease (ectors. 9"is may include
t"e drainage of 'onds& alt"oug" t"is may not be acce'table if t"e ;ater is used for
;as"ing.
Lar'icides destroy t"e lar(ae of mosJuitoes before t"ey mature into adults.
Lar(icides may be a''lied (ia "and-carried& (e"icle-mounted or aerial eJui'ment.
9"e lar(icide is added to ;ater at sites t"at are recogni8ed breeding grounds& suc" as
'onds or ;ater Fars& in areas ;"ere t"e breeding sites are limited in number. 9"is is
only a tem'orary solution& "o;e(er& as lar(iciding is generally not cost-effecti(e&
es'ecially against 4n" gambiae* t"e main (ector in Africa. 9"e multi'licity of 4n"
gambiae breeding sites is suc" t"at lar(iciding is almost im'racticable. *n addition&
t"e efficacy of lar(icides is (ery s"ort 2less t"an a ;ee%4 and treatment t"us reJuires
to be re'eated at ;ee%ly inter(als.
Lar(iciding can also be used for ;ell-locali8ed and accessible breeding sites of
4n" funestus 2'ermanent s;am's ;it" co(ering (egetation4 around cam's and
residential areas& but as a com'lement to ot"er met"ods. *n t"is case& 7acillus
thuringiensis israelensis 2-ti4 and teme'"os 2Abate4 ;ould be t"e 'referred lar(icide.
Anot"er 'roblem ;it" lar(iciding is t"at& e(en more t"an for ot"er inter(entions& t"e
necessary tec"nical e:'ertise and ca'acity s"ould be a(ailable for 'lanning and
im'lementation.
Longer-term measures& suc" as land drainage or filling& s"ould be 'lanned and
im'lemented to a(oid future s'raying.
Cam(site and s)elter design and la,out
,ite selection is discussed in detail in ,ection #... *t is im'ortant to reiterate t"e
im'ortance of a(oiding areas t"at are associated ;it" increased incidence of malaria&
onc"ocerciasis 2ri(er blindness4& sc"istosomiasis 2bil"ar8iasis4& tic% fe(ers and African
try'anosomiasis 2slee'ing sic%ness4.
9"e follo;ing are im'ortant as'ects of s"elter construction.
*deally s"elters s"ould be of adeJuate si8e and s'aced sufficiently a'art to
're(ent t"e s'read of communicable diseases.
9"e ;alls s"ould allo; residual s'raying against biting insects.
Crac%s and cre(ices s"ould be filled& as t"ey are 'erfect breeding grounds and
"abitats for certain (ectors.
O'enings in "ouses s"ould ne(er be sited do;n;ind& as t"is increases t"e
ability of t"e (ector to reac" its "ost.
Communit, a@areness and )ealt) education
Community 'artici'ation in a (ector control 'rogramme is essential for its
success.
*t allo;s t"e im'lementing agency to de(elo' an a;areness of community
'ractices t"at 're(ent or encourage t"e s'read of disease.
-ot" t"e community and t"e (ector control team can de(elo' strategies t"at
can be im'lemented ;it" some degree of success.
*nformation on t"e s'read of disease can be disseminated in a culturally
sensiti(e manner.
%#+#* odents and t)eir control
Bodents are disease (ectors& reser(oir "osts and 'ests in emergency situations.
9"e main 'roblems associated ;it" rodents are disease transmission& consum'tion
and s'oiling of food& damage to stored 'roducts& damage to electrical systems&
destruction of (egetable gardens& and biting and disturbing 'eo'le ;"ile t"ey slee'
2see 9able #.#)4.
Table
%#%+
Diseases s(read b, rodents and t)eir treatment and
(re'ention
ole Mode of
transmissio
n
Disease Morbidit,
and
mortalit,
@)en
untreated
Treatment $re'ention
As a
(ector
of
disease
Bodent urine Le'tos'irosis Lo; case-
fatality
rates
Antimicrobia Bodent-
'roofing of
food stores
and
containers
@ood
en(ironmenta
l and 'ersonal
"ygiene 2e.g.
;as"ing of
food before
eating and
storing of
coo%ed food
in sealed
containers
Bemo(al of
'ools of
standing
;ater
Bodent urine
and sali(a
Lassa fe(er 0!03Q
case
fatality
rate
Anti(iral
drug t"era'y
=ood
contami-
nated ;it"
rodent body
fluids
=ood
contami-
nated ;it"
rodent body
fluids
,almonellosis #!$Q case
fatality
among
"os'ital
cases
Be"ydration
Antimicrobia
l in selected
cases
Consum'tio
n of rodent
meat
9o:o'lasmosi
s
.on-fatal
but
recurrent
Drug t"era'y
As a
disease
reser(oi
r and
"ost to
'arasite
(ectors
=leas and mites ! see ,ection
#.). on diseases
9ic%s 9ularaemia Lo; case-
fatality
rates
Antimicrobia
l
Bic%ettsiosis 0!#3Q
casefatalit
y rate
Antimicrobia
l
9"e elimination of rodents is difficult& 'articularly in densely cro;ded cam's and
in (illages or to;ns& but t"e rodent 'o'ulation s"ould be %e't to a minimum. Bodent
control s"ould include safe and regular garbage dis'osal& tra''ing& 'oisoning in
selected circumstances& rodent 'roofing of stores and careful storage of food.
9"e control of rodents demands an a;areness of t"e be"a(iour of t"e ty'es of
rodent found in t"e area. =or e:am'le& bro;n rats tend to dis'lay neo'"obia 2fear of
ne; obFects4 and t"erefore to a(oid ne;ly 'laced tra's& bait 'oints& etc. House mice
do not s"o; t"is ty'e of be"a(iour. 5astomys rats 2t"e (ectors of Lassa fe(er4 tend to
a(oid bro;n and blac% rats and are t"erefore not usually found in large numbers in
urban en(ironments ;"ere t"e latter are common.
,taff underta%ing rodent control 'rogrammes must be 'ro'erly trained and gi(en
'ro'er 'rotecti(e clot"ing.
Public a;areness cam'aigns s"ould be underta%en to inform 'eo'le on "o; to
control rodents and "o; to detect e(idence of increasing rodent infestation.
Garbage dis(osal
9"is is discussed in ,ection #.$.
Tra((ing
Large numbers of tra's s"ould be used.
9"ere are (arious ty'es of rodent tra'N locally a(ailable tra's may be more
suitable for use by t"e staff and community t"an im'orted eJui'ment.
9"e bait must be softN a banana is ideal for attracting rodents.
Any rodents caug"t ali(e must be %illed immediately and carcasses burnt.
9ra's must be c"ec%ed and reset daily.
9ra's must be 'laced close to areas ;"ere rodents see% food& suc" as food
stores and drains& or ne:t to ;alls or co(erings ;"ere t"ey tend to mo(e.
9ra's s"ould be used ;it" care in d;ellings. ,na' tra's "a(e strong s'rings
t"at can damage c"ildren<s fingers. 9"e action of certain ty'es of tra' 2e.g.
sna' tra's4 can cause t"e e:'losi(e e:'ulsion of bodily fluids& ;"ic" can be
dangerous in t"e case of certain diseases 2e.g. Lassa fe(er4 t"at are s'read in
rodent e:creta.
$oisoning
Poisons must be used only in secure areas& suc" as stores& since t"ere is a
danger of c"ildren eating t"e 'oison or families eating 'oisoned rodents to
su''lement t"eir diet.
*f rodenticides are used& t"e community must be informed and ;arned not to
consume rodents.
9"e best rodenticides are t"e second-generation anticoagulants 2e.g.
difenacoum& brodifacoum4& ;"ic" can %ill rodents after only a single meal.
9"ose used s"ould contain -itre:& ;"ic" ma%es t"e 'oison too bitter for "uman
consum'tion.
Acute 'oisons suc" as red '"os'"orus and cyanide s"ould never be used.
Bodenticides based on 'at"ogens suc" as 2almonella are ineffecti(e and
dangerous to "umans.
Bodenticides based on re'roducti(e "ormones are not effecti(e.
Poisoning 'rogrammes s"ould al;ays be 'receded by t"e use of insecticides to
treat runs and burro;s to %ill fleas& ;"ic" ;ould ot"er;ise lea(e t"eir rodent
"osts and attac% "umans.
Poisoning cam'aigns are not effecti(e on t"eir o;n in t"e long term.
Ot"errodent control measures& suc" as remo(al of rubbis" and im'ro(ement of
food stores& s"ould al;ays be 'art of control 'rogrammes.
*f rubbis" "as accumulated and rodent 'o'ulations "a(e built u'& a rodenticide
'rogramme s"ould al;ays 'recede t"e remo(al of rubbis"& ot"er;ise t"e
rodents ;ill tend to mo(e into d;ellings and ;orsen t"e "ealt" 'roblem.
Ma4ing buildings rat<(roof
All doors s"ould be as tig"t-fitting as 'ossible and s"ould "a(e a gal(ani8ed
steel stri' at least $3 cm dee' attac"ed to t"e bottom to 're(ent rodent access.
@a's under doors s"ould be reduced to a fe; millimetres by careful 'lacement
of t"is metal stri'.
All "oles in ;alls s"ould be filled.
Any drain'i'es s"ould be fitted ;it" rat guards.
Wiring entering buildings s"ould be fitted ;it" rat guards.
All ;indo;s s"ould be co(ered ;it" 1-mm c"ic%en ;ire.
Eegetation s"ould be cleared from around buildings.
O(er"anging (egetation s"ould be remo(ed.
,tores must "a(e 'allets or s"el(es for storage 'ur'oses.
All o'ened food must be stored in airtig"t containers 2'referably metal or
metal co(ered4.
0ood storage guidelines
All foodstuffs must be stored on 'allets or on s"el(es off t"e floor at a
minimum "eig"t of )0 cm to minimi8e damage by ;ater or rodents. .o 'allets
s"ould be against t"e ;all as t"is ma%es cleaning (ery difficult.
Pallets s"ould be arranged in stac%s not more t"an four 'allets sJuare& ;it" at
least 13 cm bet;een stac%s to allo; access for cleaning.
Em'ty sac%s must be stored on 'allets and not against ;all in 'iles.
O'ened food must be 'laced in airtig"t metal bins.
9"e store must be ;ell lit and ;ell (entilated.
9"e store must be cleaned daily.
=ood in d;ellings s"ould be subFect to t"e same careful storage as t"at in main
stores. *f 'ossible it s"ould be stored in rodent-'roof 2metal or ;ell made
;ooden4 bins& ;"ic" s"ould be ins'ected regularly for signs of rodent attac%.
%#+#+ Monitoring and e'aluation of 'ector control
,uccessful baseline information "as been collected ;"en:
t"e (ectors 're(alent in t"e area "a(e been identified&
t"e ty'es and incidence of disease caused by t"ese (ectors "a(e been
ascertained&
t"e factors t"at assist in successful re'roduction "a(e been identified&
breeding and resting be"a(iour of t"e (ector2s4 "a(e been identified&
suitable control measures "a(e been determined.
,ome control measures reJuire t"eir im'lementation by indi(iduals or family units
t"emsel(es. 9"e indicators for measuring t"e co(erage of suc" a 'rogramme are:
t"e 'ercentage of t"e 'o'ulation t"at recei(ed t"e rele(ant information5
education&
t"e 'ercentage of t"e 'o'ulation t"at im'lemented t"e information&
t"e 'ercentage reduction or rise in t"e disease 2entomological e(aluation can
be im'lemented and analysed only by s'ecialists4.
C"emical control measures are usually im'lemented by s'ecially trained staff.
,ome indicators of t"e co(erage of suc" a 'rogramme are:
t"e 'ercentage of t"e target area co(ered ;it" t"e inter(ention&
t"e su''ly and safe a''lication of t"e c"emical according to WHO and
manufacturer<s guidelines&
t"e 'ercentage reduction or rise in t"e (ector 'o'ulation.
9"e maFor indicators for measuring an effecti(e 'rogramme are ;"en:
suitable control measures are 'ro'erly im'lemented and used&
control measures are successful in reducing incidence of disease 2same as
abo(e regarding entomological e(aluation4&
control measures can be sustained by t"e 'o'ulation.
%#+#- 0urt)er reading
Cquipment for vector control& $rd ed. @ene(a& World Healt" Organi8ation& //3.
Didd H& Cames CB. Desticide inde+: an inde+ of chemical* common and trade
names of pesticides and related crop(protection products& #nd ed. Cambridge& Boyal
,ociety of C"emistry& //.
9"omson MC. 1isease prevention through vector control: guidelines for relief
organizations" O:ford& O:fam& //0 2O:fam Practical Healt" @uide .o. 34.
Fector and pest control in refugee situations. @ene(a& Office of t"e ?nited
.ations Hig" Commissioner for Befugees& //0.
Fector control: methods for use by individuals and communities" @ene(a& World
Healt" Organi8ation& //6.
%#- 0ood and nutrition
=ood s"ortages and malnutrition are common features of emergency situations.
Ensuring t"at t"e food and nutritional needs of an emergency-affected 'o'ulation are
met is often t"e 'rinci'al com'onent of t"e "umanitarian res'onse to an emergency.
W"en t"e nutritional needs of a 'o'ulation are not met& t"is may result in 'rotein!
energy malnutrition and micronutrient deficiencies suc" as iron-deficiency anaemia&
'ellagra& scur(y and (itamin A deficiency. 9"ere is also a mar%ed increase in t"e
incidence of communicable diseases& es'ecially among (ulnerable grou's suc" as
infants and young c"ildren& and t"ese contribute furt"er to t"e deterioration of t"eir
nutritional status.
9"e obFecti(e of t"is section is to 'resent a brief o(er(ie; on t"e nutritional
reJuirements of 'o'ulations in emergency situations& nutrition inter(entions& t"e lin%
bet;een malnutrition and communicable diseases& and t"e 're(ention and control of
malnutrition.
9"e nutritional reJuirements of a 'o'ulation must be assessed to:
identify t"e nutritional needs of indi(iduals& families& (ulnerable grou's and
'o'ulations as a ;"ole&
monitor t"e adeJuacy of nutritional inta%e in t"ese grou's&
ensure t"at adeJuate Juantities of safe food and a''ro'riate food commodities
are 'rocured for general rations and selecti(e feeding 'rogrammes.
Mean daily 'er ca'ita reJuirements are influenced by a number of 'o'ulation and
en(ironmental factors& including t"e follo;ing& ;"ic" s"ould be assessed and ta%en
into account to ensure t"at energy and 'rotein reJuirements can be met:
t"e age and se: com'osition of t"e 'o'ulation&
mean adult "eig"ts and ;eig"ts 2men and ;omen4&
'"ysical acti(ity le(els&
en(ironmental tem'eratures&
malnutrition and ill-"ealt"&
food security.
*n t"e acute '"ase of an emergency& little may be %no;n about t"e 'o'ulation
e:ce't t"e a''ro:imate numbers of affected 'ersons. *n t"is situation& an estimated
mean daily 'er ca'ita reJuirement for a de(elo'ing country is #33 %cal
t"

. 9"e
a(erage safe 'rotein inta%e 'er 'erson 'er day is )1 g from a mi:ed diet 2cereal&
'ulses and (egetables4.
%#-#" 0ood reFuirements
9"e mean daily 'er ca'ita energy reJuirements for some 'o'ulation grou's are
described in 9able #.#0. Ho;e(er& energy reJuirements ;ill (ary de'ending on t"e
;eig"t& age& gender and '"ysical acti(ity of t"e indi(idual.
Energy reJuirements increase during certain s'ecific situations& suc" as:
t"e second and t"ird trimesters of 'regnancy&
lactation&
infection 2e.g. tuberculosis4 and reco(ery from illness 2for e(ery `C rise in
body tem'erature t"ere is a 3Q increase in energy reJuirements4&
cold tem'eratures 2an increase of 33 %cal
t"
'er 'erson for e(ery 0 `C belo;
#3 `C4&
moderate or "ea(y labour.
Table %#%- Energ, reFuirements for emergenc,<affected
(o(ulations in de'elo(ing countries
Age 8,ears9 Male 84cal
t)
9
a
0emale 84cal
t)
9
a
Male K female
84cal
t)
9
a
3!) $#3 #03 #/3
0!/ /A3 6$3 A13
3!) #$63 #3)3 ##3
0!/ #633 ##3 #)#3
#3!0/
b
#)13 //3 ##$3
13]
b
#33 6A3 A/3
Pregnant #A0 2e:tra4 #A0 2e:tra4
Lactating 033 2e:tra4 033 2e:tra4
W"ole 'o'ulation ##03 /3 #3A3
a
6calth = '"& 63
b
4dult /eight: males $% 6g* females ?2 6g"
The figures given here for energy requirements are for @lightA activity levels"
4dGustments need to be made for moderate and heavy activity and environmental
temperatures"
,ource: The 5anagement of nutrition in maGor emergencies" @ene(a& World
Healt" Organi8ation& #333.
9able #.#1 summari8es t"e main daily reJuirements used to calculate t"e a(erage
content of emergency rations.
Table %#%. Some im(ortant nutritional
reFuirements
0ood t,(e Iuantit,
Energy 9"e mean energy reJuirement is #33
%cal
t"
'er 'erson 'er day
=at5oil 6!#3Q of t"e energy s"ould be in t"e
form of edible fats or oils
Protein 3!#Q of t"e energy s"ould be in t"e
form of 'rotein
Becommended daily 'rotein inta%e: )1 g
from an a(erage mi:ed diet of cereals&
'ulses and (egetables
%#-#% Classification of malnutrition
9"e im'act of food s"ortages on t"e "ealt" of a 'o'ulation generally becomes
a''arent t"roug" signs of 'rotein!energy malnutrition 2PEM4& but it s"ould be %e't in
mind t"at micronutrient deficiencies are often 'resent as ;ell. *n some emergencies&
micronutrient deficiencies o;ing to t"e 'oor Juality of accessible food items can
reac" e'idemic 'ro'ortions 2e.g. t"e scur(y e'idemic among isolated 'o'ulations in
Afg"anistan4.
9"e most reliable indication of acute malnutrition is ;asting 2lo; ;eig"t-for
"eig"t4 in c"ildren aged 1 to 0/ mont"s. 9"e se(erity of PEM in a gi(en indi(idual is
t"us reflected by t"e de(iation of "is5"er ;eig"t from normal reference ;eig"t-for-
"eig"t (alues. 9"is can be e:'ressed by eit"er t"e standard de(iation score 2G score4&
t"e 'ercentage of t"e median (alue& or t"e 'ercentile.
Calculation of t)e SD score 8L score9 of @eig)t for )eig)tD
SD score G 8obser'ed 'alue9 B 8median reference 'alue9:standard de'iation of
reference (o(ulation
9ables are a(ailable 2Anne: $4 t"at indicate normali8ed reference (alues of
;eig"t-for-"eig"t toget"er ;it" t"e corres'onding standard de(iations& allo;ing one
to calculate t"e corres'onding indices e:'ressing ;eig"t-for-"eig"t de(iations. 9"e
'resence of symmetrical oedema is anot"er im'ortant sign of se(ere malnutrition.
,tunting or c"ronic malnutrition 2lo; "eig"t-for-age4 ! com'arison of a c"ild<s
"eig"t or lengt" ;it" t"e reference median "eig"t for c"ildren of t"e same age and se:
! is of limited (alue for nutritional screening or assessment sur(eys in emergencies
2e:ce't for c"ronic emergencies and for 'ost-emergency assessments4. ,tunting
indicates a slo;ing in s%eletal gro;t" and& since linear gro;t" res'onds (ery slo;ly
com'ared ;it" ;eig"t& it tends to reflect long-standing nutritional inadeJuacy&
re'eated infections& and 'oor o(erall economic and5or en(ironmental conditions.
9able #.#6 summari8es cut-off (alues for ,D scores& corres'onding to standard
definitions of moderate and se(ere malnutrition. 9"e terms L%;as"ior%orM and
LmarasmusM "a(e been omitted to a(oid confusion. 9"e clinical syndrome of
%;as"ior%or includes ot"er features t"an symmetrical oedema. ,e(ere ;asting "ere
corres'onds to marasmus 2;it"out oedema4.
Table %#%1 Classification of malnutrition
Classification
Moderate malnutrition Se'ere malnutrition
8t,(e9a
,ymmetrical oedema .o Hes
2oedematous malnutrition4
Weig"t-for-"eig"t !$ U ,D score U !# ,D score U !$
X63!6/QY
b
XU63QY 2se(ere ;asting4
Heig"t-for-age !$ U ,D-score U !# ,D score U !$
XA0!A/QY XUA0QY 2se(ere stunting4
a
The diagnoses are not mutually e+clusive"
b
Dercentage of the median ,89/National <entre for 8ealth 2tatistics
reference"
2ource: 5anagement of severe malnutrition: a manual for physicians and other
senior health /or6ers" @ene(a& World Healt" Organi8ation& ///.
Measurements of mid-u''er arm circumference 2M?AC4 'ro(ide an alternati(e
means of nutritional screening of c"ildren bet;een 1 mont"s and 0 years of age. 9"ey
are useful ;"en resources are limited and ;"ere ;eig"t and "eig"t measurements
cannot be madeN "o;e(er& arm circumference measurements can be inaccurate&
measuring tec"niJues are difficult to standardi8e and results can (ary ;idely& bot"
bet;een obser(ers and e(en ;it" t"e same obser(er at different times.
Micronutrient deficiencies in an emergency situation are among t"e main causes
of long-lasting or 'ermanent disability& and most of t"em are associated ;it" an
increased ris% of morbidity and mortality. *t is useful to distinguis" bet;een t"e
deficiencies t"at are common to many 'o'ulations 'articularly in de(elo'ing
countries& suc" as iron& iodine and (itamin A deficiencies& and t"ose t"at are
s'ecifically seen in emergencies& suc" as t"iamine& niacin and (itamin C deficiencies&
;"ic" must be loo%ed for systematically.
%#-#* Infection> immunit, and nutritional status
9"e combination of malnutrition and infection causes most of t"e 're(entable
deat"s in emergency situations& 'articularly among young c"ildren. During infection
t"ere is an increased need for energy and ot"er nutrients. Malnutrition and
micronutrient deficiencies also affect immunity. As a result& 'eo'le ;"o are
malnouris"ed and "a(e com'romised immunity are more li%ely to suffer from
diseases suc" as res'iratory infections& tuberculosis& measles and diarr"oeal diseases.
=urt"ermore& in malnouris"ed indi(iduals& e'isodes of t"ese diseases are more
freJuent& more se(ere and 'rolonged. *n addition to t"e effect of nutrition on disease&
t"e 'resence of disease leads to furt"er malnutrition& as a result of loss of a''etite&
fe(er& diarr"oea and (omiting& ;"ic" affect nutrient inta%e and cause malabsor'tion
of nutrients and altered metabolism 2see =ig. #.4. One can conclude t"at malnutrition
is not al;ays sim'ly a conseJuence of inadeJuate food su''lies but is also lin%ed to
re'eated infections.
9"e mec"anisms by ;"ic" malnutrition increases susce'tibility to and se(erity of
infection de'ends on t"e s'ecific disease. 9"e se(erity of diarr"oea may be increased
in malnouris"ed c"ildren because of destruction of t"e intestinal (illi& increased
secretion of fluids ;"en 'at"ogens enter t"e bo;el or reduced acidity in t"e stomac"&
;"ic" 're(ents t"e destruction of ingested 'at"ogens. Measles infection damages t"e
immune system and t"is is e:acerbated by (itamin A deficiency. Bes'iratory
infections are t"oug"t to "a(e an indirect effect on nutritional status t"roug" fe(er and
loss of a''etite.
0igure %#" MalnutritionBinfection c,cle
@i(en t"e strong synergy bet;een nutritional status and morbidity status& and in
order to assess and address all t"e causes of malnutrition in a 'o'ulation& it is
im'ortant to lin% nutritional data collected from sur(eys and nutritional sur(eillance
systems ;it" data on communicable diseases.
%#-#+ Emergenc, feeding (rogramme strategies
Nutrition inter'entionsD definitions
*n emergency situations& t"e aim s"ould be to ensure t"at t"e food needs of t"e
'o'ulation are met t"roug" t"e (ro'ision of an adeFuate general ration. *n certain
situations& "o;e(er& t"ere may be a need to 'ro(ide additional food for a 'eriod of
time to s'ecific grou's ;"o are already malnouris"ed and5or are at ris% of becoming
malnouris"ed. *t must be made (ery clear t"at selecti(e feeding is not designed to
com'ensate for t"e inadeJuacy of general food rations. 9"ere are t;o forms of
selecti(e feeding 'rogramme.
. ,u''lementary feeding 'rogrammes 2,=Ps4 'ro(ide nutritious food in addition
to t"e general ration. 9"ey aim to reduce t"e 're(alence of malnutrition and
mortality among (ulnerable grou's and to 're(ent a deterioration of nutritional
status in t"ose most at ris% by meeting t"eir additional needs& focusing
'articularly on young c"ildren& 'regnant ;omen and nursing mot"ers.
#. 9"era'eutic feeding 'rogrammes 29=Ps4 are used to re"abilitate se(erely
malnouris"ed 'ersons. 9"e main aim is to reduce e:cess mortality. *n most
emergency situations& t"e maFority of t"ose ;it" se(ere ;asting are infants and
young c"ildren. 9"ere "a(e& "o;e(er& been cases ;"ere large numbers of
adolescents and adults "a(e become ;asted. *n suc" situations& se'arate 9=P
facilities may be establis"ed for t"ese grou's.
9"e 're(alence of malnutrition is defined as t"e 'ercentage of t"e c"ild 'o'ulation
21 mont"s to 0 years of age4 ;"o are belo@ eit"er t"e reference median ;eig"t-for-
"eig"t !#,D or A3Q of t"e reference ;eig"t-for-"eig"t.
Pre(alence information is best obtained from conducting a sur(ey 2see sur(ey
sam'ling met"ods in ,ection .)4 in c"ildren aged 1!0/ mont"s 210!33 cm4.
7lan4et su((lementar, feeding 'rogrammes s"ould be needed only tem'orarily
;"en 're(alence of malnutrition e:ceeds 0Q& or 3Q in t"e 'resence of ot"er
aggra(ating factors 2see footnote to 9able #.#A for a definition of aggra(ating factors4.
Targeted su((lementar, feeding 2i.e. e:tra food gi(en to selected indi(iduals4 is
indicated if t"e 're(alence of malnutrition e:ceeds 3Q& or 0Q in t"e 'resence of
ot"er aggra(ating factors 2e.g. "ig" mortality and5or e'idemic infectious diseases4.
0igure %#% 0eeding (rogramme strateg,
,ource: BN8<:/,FD Euidelines for selective feeding programmes in emergency
situations" @ene(a& ?nited .ations Hig" Commissioner for Befugees& ///.
Indications for s(ecific inter'entions
9able #.#A 'ro(ides guidelines for t"e im'lementation of selecti(e feeding 'ro-
grammes. 9"e ty'es of selecti(e feeding 'rogramme are s"o;n in 9able #.#/.
Table %#%3 Decision c)art for t)e
im(lementation of selecti'e
feeding (rogrammes
a
0inding Action reFuired
=ood a(ailability at "ouse"old le(el
belo; #33 %cal 'er 'erson 'er day
Bnsatisfactory situation
*m'ro(e general rations until local food
a(ailability and access can be made
adeJuate
Malnutrition 're(alence 0Q or more 2erious situation
or H @eneral rations 2unless situation is
limited to (ulnerable grou's4& 'lus:
3!)Q ;it" aggra(ating factors
b
! blan6et su''lementary feeding for all
members of (ulnerable grou's es'ecially
c"ildren and 'regnant and lactating
;omen
! t"era'eutic feeding 'rogrammes for
se(erely malnouris"ed indi(iduals
Malnutrition 're(alence 3!)Q :is6y situation
or O .o general rations& but:
0!/Q ;it" aggra(ating factors
b
!su''lementary feeding targeted to
indi(iduals identified as malnouris"ed in
(ulnerable grou's
! t"era'eutic feeding 'rogrammes for
se(erely malnouris"ed indi(iduals
Malnutrition 're(alence under 3Q ;it"
no aggra(ating factors
4cceptable situation
H .o need for 'o'ulation inter(entions
O Attention for malnouris"ed indi(iduals
t"roug"
regular community ser(ices
a
9"is c"art is for guidance only and s"ould be ada'ted to local circumstances.
b
Aggra(ating factors:
general food ration belo; t"e mean energy reJuirement&
crude mortality rate more t"an 'er 3 333 'er day&
e'idemic of measles or ;"oo'ing coug"&
"ig" incidence of res'iratory or diarr"oeal diseases.
,ource: The management of nutrition in maGor emergencies" @ene(a& World
Healt" Organi8ation& #333"
Table %#%5 T,(es of selecti'e feeding (rogramme
$rogramme Ob&ecti'es Criteria for selection and
target grou(
9argeted selecti(e feeding
'rogramme
Correct moderate
malnutrition
C"ildren under 0 years
moderately malnouris"ed
Pre(ent t"e moderately
malnouris"ed from
becoming se(erely
malnouris"ed
Malnouris"ed indi(iduals
2based on ;eig"tfor-
"eig"t& M?AC or clinical
signs4: 24 older c"ildren& 0
to 3 yearsN 2#4
adolescentsN 2$4 adults and
elderly 'ersonsN 2)4
medical referrals
Beduce mortality and
morbidity ris% in c"ildren
under 0 years
,elected 'regnant ;omen
from date of confirmed
'regnancy and nursing
mot"ers until 1 mont"s
after deli(ery& for instance
using M?AC U## cm as a
cut-off indicator for
'regnant ;omen
Pro(ide nutritional su''ort
to selected 'regnant and
lactating ;omen
Beferrals from t"era'eutic
feeding 'rogrammes
Pro(ide follo;-u' ser(ices
to t"ose disc"arged from
t"era'eutic feeding
'rogrammes
-lan%et selecti(e feeding
'rogramme
Pre(ent deterioration of
nutritional situation
All c"ildren under $ or
under 0 years
Beduce 're(alence of
acute malnutrition in
c"ildren under 0 years
All 'regnant ;omen 2from
date of confirmed
'regnancy4N nursing
mot"ers 2until ma:imum 1
mont"s after deli(ery4
Ensure safety net measures Ot"er at-ris% grou's
Beduce mortality and
morbidity ris%
9"era'eutic feeding
'rogramme
Pro(ide
medical5nutritional
treatment for t"e se(erely
malnouris"ed
C"ildren under 0 years
se(erely malnouris"ed
,e(erely malnouris"ed
c"ildren older t"an 0 years&
adolescents and adults
admitted& based on
a(ailable ;eig"t-for-"eig"t
standards or 'resence of
oedema
Lo;-birt"-;eig"t babies
Or'"ans U year 2only
;"en traditional care
'ractices inadeJuate4
Mot"ers of c"ildren
younger t"an one year ;it"
breastfeeding failure 2only
in e:ce'tional cases ;"ere
relactation t"roug"
counselling and traditional
alternati(e feeding "as
failed4
,ource: BN8<:/,FD Euidelines for selective feeding programmes in emergency
situations" @ene(a& ?nited .ations Hig" Commissioner for Befugees& ///.
%#-#- 0ood safet,D (re'ention of infection in food (re(aration
=ood is an im'ortant (ector of 'at"ogens and t"ere is a ris% of diarr"oeal disease
e'idemics ;"en basic food safety 'rinci'les are not follo;ed. *t is estimated t"at 63Q
of diarr"oeal e'isodes in c"ildren under t"e age of 0 years are due to t"e consum'tion
of contaminated food. 9"ere are a number of routine 'ractices t"at s"ould be ad"ered
to ;"en 're'aring food& in bot" t"e "ouse"old and in "ealt" facilities.
Ensure an adeJuate ;ater su''ly.
W"en 're'aring food or ;as"ing utensils& use a c"lorinated ;ater su''ly.
,tore food in sealed containers.
Ensure t"at food is co(ered during coo%ing and 'rior to ser(ing.
Ensure t"at coo%ed food is consumed once 're'ared.
Co(er food ;"en ser(ed& if left unattended.
Place "and-;as"ing facilities outside latrines& li(ing areas and %itc"ens.
Ensure t"at 'eo'le use t"em.
Ensure an adeJuate number of sanitary latrines and t"at t"ey are maintained
and used.
All areas in a feeding centre must be cleaned daily using c"lorine as a
disinfectant.
Co(er ;ater containers at all times.
Ensure t"at ;ater is ta%en eit"er from a ta' or from a clean container.
Dis'ose of garbage safely.
%#-#. 0urt)er reading
<aring for the nutritionally vulnerable during emergencies: report of a Goint
,89/ BN8<: consultation" @ene(a& World Healt" Organi8ation& /// 2document
WHO5.HD5//.A4.
Field guide on rapid nutritional assessment in emergencies. Ale:andria& WHO
Begional Office for t"e Eastern Mediterranean& //0.
Food and nutrition handboo6. Bome& World =ood Programme& #333.
Euiding principles for feeding infants and young children during emergencies"
@ene(a& World Healt" Organi8ation& /// 2document WHO5.HD5//.34.
8andboo6 for emergencies& #nd ed. @ene(a& ?nited .ations Hig" Commissioner
for Befugees& ///.
5anagement of severe malnutrition: a manual for physicians and other senior
health /or6ers. @ene(a& World Healt" Organi8ation& ///.
The management of nutrition in maGor emergencies" @ene(a& World Healt"
Organi8ation& #333.
Nutritional guidelines. Paris& MKdecins ,ans =ronti_res& //0.
Dellagra and its prevention and control in maGor emergencies" @ene(a& World
Healt" Organi8ation& #333 2document WHO5.HD533.34.
2curvy and its prevention and control in maGor emergencies" @ene(a& World
Healt" Organi8ation& /// 2document WHO5.HD5//.4.
Thiamine deficiency and its prevention and control in maGor emergencies"
@ene(a& World Healt" Organi8ation& ///. 2document WHO5.HD5//.$4.
BN8<:/,FD Euidelines for selective feeding programmes in emergency
situations. @ene(a& ?nited .ations Hig" Commissioner for Befugees& ///.
%#. /accination
9"e maFor (accines used in emergency situations are t"ose against measles&
meningococcal meningitis and yello; fe(er. Measles (accination is one of t"e "ig"est
'riorities in t"e acute '"ase of an emergency if (accine co(erage rates in t"e affected
'o'ulation are belo; /3Q. 9"e main obFecti(e of a measles (accination 'rogramme is
to 're(ent an outbrea% of measles ;it" t"e "ig" mortality rates often associated ;it"
t"is disease in emergency situations. *n t"is ;ay& t"e measles (accine 'ro(ides one of
t"e most cost-effecti(e 'ublic "ealt" tools.
9"e use of c"olera (accine is recommended only in stable 'ost-emergency
situations. Once t"e acute '"ase of t"e emergency is o(er& 'lans s"ould also begin to
re-establis" t"e E:'anded Programme on *mmuni8ation 2EP*4 to routinely immuni8e
c"ildren against tetanus& di'"t"eria& 'olio and tuberculosis. 9"is s"ould be integrated
;it" t"e national EP* 'rogramme using national (accination 'olicies& and it is
im'ortant to in(ol(e t"e national EP* 'rogramme from t"e start of any 'lan or
acti(ity.
9"e organi8ation of a (accination cam'aign reJuires good management ability
and tec"nical %no;ledge. Bes'onsibilities for eac" com'onent of t"e (accination
'rogramme need to be e:'licitly assigned to agencies and 'ersons by t"e "ealt"
coordination agency. 9"e national EP* of t"e "ost country s"ould be in(ol(ed from
t"e outset. .ational guidelines regarding (accination s"ould be a''lied in emergency
situations as soon as 'ossible.
%#.#" $lanning and organiCation of an 'accination cam(aign
9"e %ey ste's in t"e 'lanning of an (accination cam'aign are outlined in 9able
#.$3.
Table %#*6 Ke, ste(s in t)e (lanning of an
'accination cam(aign
"# Identif, target (o(ulation: age grou'N numbers.
%# Obtain ma( of site: "ealt" facilitiesN roadsN accessN mar%et 'lacesN sc"ools.
*# $lan 'accination strategies: mass (accination cam'aigns (s. routine (accinationN
selecti(e (s. non-selecti(e (accination.
+# Define needs: number of (accine dosesN cold c"ain eJui'mentN ot"er su''lies
2auto-destruct syringes& safety bo:es& monitoring forms& (accination cards& tally
s"eets4N staff.
-# Im(lement 'accination cam(aign: safety of inFectionN safe dis'osal of inFection
material record %ee'ingN indi(idual (accination cardsN ot"er acti(ities 2e.g. nutritional
su''lementation and (itamin A& treatment of com'lications4N "ealt" education and
social 'romotion materials.
.# E'aluate: co(erage 'ercentage (accinated among estimated target 'o'ulation4N
incidence of side-effects 2'ost-(accination sur(eillance4.
Mass 'accination strategies
9o im'lement a mass (accination cam'aign in emergencies& t"ere are t;o main
strategies.
. Eaccination can be carried out at t"e screening centre on arri(al at a cam'.
9"is is 'ossible ;"en t"e screening facility "as been set u' and t"e influ: of
refugees is steady and moderate.
#. Eaccination sites can be set u' in different sections of t"e target area and mass
(accination carried out by outreac" teams. 9"is is necessary ;"en t"e
'o'ulation "as already settled at a site or t"e influ: "as been too ra'id to
organi8e a screening facility.
outine 'accination strategies
*n t"e case of measles& once t"e target 'o'ulation "as been immuni8ed in t"e mass
cam'aign& measles (accination must become 'art of "ealt" care acti(ities. Ongoing
(accination is reJuired to co(er:
c"ildren ;"o mig"t "a(e missed t"e initial (accination cam'aign&
c"ildren (accinated at t"e age of 1!/ mont"s ;"o must recei(e a second dose
of t"e (accine at / mont"s&
ne; grou's of c"ildren reac"ing t"e age of 1 mont"s.
Eaccination may be selecti'e& ;"ereby t"e (accination status of t"e c"ild is
c"ec%ed on t"e basis of a (accination card and t"e (accine is gi(en if t"ere is no
e(idence of 're(ious (accination. *n non<selecti'e (accination& (accination status is
not c"ec%ed and all c"ildren are immuni8ed regardless of t"eir immune status. A
second dose of measles (accine "as no ad(erse effect. .on-selecti(e (accination is
'referred in a mass cam'aign& as it is Juic%er and lea(es little c"ance for error.
Assessment of ris4
9"e first acti(ity is to assess t"e need for an (accination cam'aign by:
assessing t"e ris% of an e'idemic&
identifying t"e si8e of t"e 'o'ulation at ris% of t"e disease.
Data on bac%ground (accination co(erage in t"e emergency-affected 'o'ulation
s"ould be soug"t from t"e Ministry of Healt" in t"e country of origin& WHO or
?.*CE=. *f t"ese data are not a(ailable& (accine co(erage rates can be assessed by
means of a sur(ey using cluster-sam'ling met"odology 2see ,ection .)4. Perce'tions
of (accination can be assessed t"roug" focus grou' discussions ;it" re'resentati(e
grou's from t"e 'o'ulation and5or Juestions during t"e (accination sur(ey.
Assessing logistic reFuirements
9"e number of (accine doses reJuired for a (accination cam'aign is $0Q of t"e
number in t"e target 'o'ulation. 9"e same numbers of dis'osable needles and
syringes are also reJuired. 9"ese (accines ;ill reJuire refrigeration until t"e time of
administrationN refrigerators and cold bo:es are t"erefore reJuired to maintain t"e
cold c"ain. 9"ermometers and tem'erature monitors are reJuired to ensure t"e cold
c"ain "as been maintained.
9"e (accines& cold bo:es and t"ermometers may be a(ailable from t"e Ministry of
Healt"& ?.*CE= or WHON alternati(ely an agency may 'urc"ase (accines and
eJui'ment. ,yringes and needles ;ill normally also "a(e to be 'urc"ased and t"e
cards and registers 'rinted. Ad(ice s"ould be soug"t from t"e Ministry of Healt"&
?.*CE= or WHO on standard cards and registers& since t"ey may be able to ad(ise on
t"e best 'rinting com'any and lend registers and cards so t"at t"e cam'aign can be
started.
Needs in 'accines
Calculate number of doses based on si8e of target 'o'ulation& target co(erage&
'ro'ortion of (accine lost during mass cam'aignP0Q& and reser(es to be "eldP#0Q.
9otal 'o'ulation: 03 333
9arget 'o'ulation ! e.g. 1 mont"s to 0 years for measles 2)0Q of total4: ## 033
X9arget 'o'ulation ! e.g. # to $3 years for meningitis 263Q of total4: $0 333Y
Co(erage obFecti(e 33Q: ## 033
.umber of doses to administer : ## 033
*ncluding e:'ected loss of 0Q ## 0335A0Q #1 )63
Adding reser(e of #0Q #1 )63 : #0Q $$ 3AA
9o order: $) 333 doses
*f 03 doses 'er (ial& order 1A3 (ials
Needs in eFui(ment
In&ection materialD
One sterile needle for one sterile syringeN ,"ar's containers& trays& %idney dis"es
de'end on number of teams. *ncinerators for destruction of used material is essential.
Cold c)ain materialD
9rans'ort material:
Cool bo:es Electrolu: ty'e BCW # 2$333 doses& ) ice 'ac%s4 or BCW #0 26$33
doses& #) ice 'ac%s4: trans'ort of (accines& refrigeration 0!6 days
Eaccine carriers 2.6 litres4: trans'ort of (accines& refrigeration A "ours *ce
'ac%s: %ee' tem'erature do;n in cool bo:es& (accine carriers& (accination table
Cold storage eJui'ment:
Befrigerators: storage of (accines 203 333 doses in ## litres4
*ce-liners: storage of (accines ;"en electricity not a(ailable #) "ours 'er day
=ree8ers: to ma%e ice-'ac%s
Monitoring eJui'ment:
9"ermometers 2monitor tem'erature in eac" a''liance4& refrigerator control s"eet
2monitor tem'erature in refrigerator& monitoring s"eet 2indicate tem'erature of
refrigerature4
egistration and logistic eFui(mentD
Eaccination cards 2indi(idual4& tally s"eets. Bo'es& tar'aulins& stationery&
mega'"ones
Coordinated and consultati'e a((roac)
A successful cam'aign ;ill in(ol(e t"e community& t"e Ministry of Healt"&
?.*CE=& WHO and ot"er international and nongo(ernmental organi8ations in t"e
area. *t is im'ortant to in(ol(e all of t"e sta%e"olders& as t"is ;ill ensure t"at e(eryone
%no;s t"e 'ur'ose of t"e cam'aign& and ;"ic" 'eo'le need t"e (accine and ;"y.
*n(ol(ement of t"e community from t"e beginning is crucial& and 'olitical and
traditional leaders s"ould be in(ited to all maFor 'lanning meetings. ,maller meetings
can subseJuently be "eld ;it" different associations or formal grou's ;it"in t"e
'o'ulation& and used to establis" suitable times and 'laces for t"e (accination
cam'aign. Community "ealt" ;or%ers can counsel indi(idual families on t"e
im'ortance of t"e (accine in Juestion and reassure t"em about reactions to t"e
(accine.
OrganiCation of sites
Eaccination sites must be located in suc" a ;ay as to ensure easy accessN
additional sites may be reJuired for s'ecific et"nic or ot"er grou's. Eaccination
cam'aign sites must be organi8ed so t"at t"ey are comfortable and o'erate smoot"ly.
9"e follo;ing are essential 'oints in t"is res'ect.
A ;aiting area s"ould be 'ro(ided& ;it" 'rotection against t"e sun and rain
and ;it" seating arrangements and drin%ing-;ater. 9"e seating s"ould be
organi8ed on a Lfirst come& first ser(edM basis. 9"e 'erson2s4 organi8ing t"is
area can ensure t"at t"is 'rinci'le is maintained& and can also reiterate
information on t"e 'ur'ose of t"e (accine and 'ossible reactions to t"e
(accine.
9"e entrances and e:its must be at different ends of t"e site.
A registration 'oint must be 'laced at t"e entrance ne:t to t"e ;aiting area.
Here& t"e indi(idual<s details are entered in t"e register and "e or s"e is gi(en a
card.
9"e (accine administration site is located after t"e registration 'oint. 9;o
trained "ealt" 'ersonnel s"ould be allocated to t"is area& one dra;ing u' t"e
(accine and t"e ot"er inFecting. 9"ere may be more t"an one (accine
administration team.
At t"e e:it 'oint& a su'er(isor must c"ec% t"at t"e indi(idual "as recei(ed t"e
card& is registered and "as recei(ed t"e (accine.
Staff training
All staff ;ill need to be trained on t"e 'ur'ose of t"e (accination cam'aign and
t"e tec"nical issues 'ertinent to t"e s'ecific (accine2s4. 9"ey ;ill also need training
on cro;d control and communication ;it" t"e community. 9"e staff in(ol(ed in t"e
(accination team ;ill need training on safe inFection tec"niJues.
Monitoring co'erage
Once t"e cam'aign is com'lete& it is necessary to assess (accine co(erage among
t"e 'o'ulation at ris%. 9"is means t"at e(ery (accination site and "ealt" facility ;ill
submit t"e number of 'eo'le immuni8ed to a central location. 9"ese numbers ;ill be
combined to gi(e t"e total number immuni8ed& and t"is number ;ill t"en be di(ided
by t"e 'o'ulation at ris% and multi'lied by 33 to 'ro(ide t"e 'ercentage of t"e
'o'ulation co(ered. 9"ese data ;ill "el' determine if t"e (accine cam'aign is
adeJuate to a(ert an e'idemic& or to 're(ent furt"er s'read if t"e e'idemic "as already
started.
Co(erage can be furt"er (alidated t"roug" a (accination sur(ey using t"e EP* $356
cluster met"odology 2see C"a'ter for details4.
%#.#% Safet, of in&ections
9o ensure t"e safety of inFections& WHO and ?.*CE= "a(e issued a Foint 'olicy
statement ;"ereby t"e 'ro(ision of sufficient Juantities of auto-destruct syringes
2designed to ma%e reuse im'ossible4 and safety bo:es is automatically ta%en into
account& toget"er ;it" "ig"-Juality (accines& in t"e 'lanning and im'lementation of
all mass (accination cam'aigns.
.eedles must not be reca''ed after use& but s"ould be 'laced immediately into a
designated 2'uncture-resistant4 container and dis'osed of by incineration as soon as
'ossible.
Monitoring in&ection safet, during t)e cam(aign
9o e(aluate inFection safety& su'er(isors must be trained and rele(ant Juestions
included in t"eir su'er(isory c"ec%lists during im'lementation and after t"e
cam'aign.
WHO defines a safe inFection as one t"at:
does no "arm to t"e reci'ient&
does not e:'ose t"e "ealt" ;or%er to a(oidable ris%&
does not result in ;aste t"at 'uts ot"er 'eo'le at ris%.
A non-sterile inFection is usually caused by:
reusable syringes t"at are not 'ro'erly sterili8ed before use&
dis'osable& one-time-only syringes t"at are used more t"an once&
used syringes and needles t"at are not dis'osed of 'ro'erly.
?nsafe inFection 'ractices can result in many com'lications& t"e most ob(ious
being abscesses at t"e site of s%in 'enetration. *n most countries& transmission of
blood-borne (iruses is a less ob(ious but muc" more common and serious 'roblem.
He'atitis (iruses - and C as ;ell as H*E are t"e most common and 'otentially fatal
infectious agents t"at could be transmitted t"roug" unsafe inFections. Dried blood
containing "e'atitis - can be infecti(e after one ;ee%.
9"e Foint WHO5?.*CE= statement states t"at eac" inFection is to be gi(en ;it" a
sterile needle and a sterile syringe& and t"at single-use needles and syringes must be
safely stored and incinerated after use. =or all mass cam'aigns t"at use an inFectable
(accine& auto-destruct syringes and safety bo:es 2in ;"ic" needles and syringes can
be safely stored 'ending 'ro'er dis'osal4 are recommended. Donors are reJuested to
LbundleM t"e su''lies donated or 'urc"ased 2i.e. (accine& auto-destruct syringes and
safety bo:es4.
9"e 'erson administering t"e (accine s"ould 'ractise t"e follo;ing ste's to ensure
a safe inFection:
Place t"e 'atient in a comfortable 'ositionN if t"e 'atient is a c"ild ensure t"at
t"e 'arent5assistant "as a firm but not 'ainful gri' on t"e c"ild.
Ensure t"at you c"oose t"e correct needle for t"e reci'ient<s age and t"e
inFection route.
Ensure t"e correct syringe according to dose.
Ensure t"at bot" 'ieces of eJui'ment are sterile.
C"ec% t"e e:'iry date of t"e (accine.
Ensure t"at t"e (accine is diluted correctly.
Dra; u' t"e correct dose.
E:'el e:cess air.
C"oose a safe inFection site.
Clean t"e inFection site ;it" an alco"ol s;ab.
*nsert t"e needle at t"e correct angle for t"e recommended inFection route.
Wit"dra; to ensure you are not in a blood (essel.
@i(e t"e inFection slo;ly.
Dis'ose of eJui'ment in a safety bo: and ensure 'ro'er dis'osal at t"e end of
t"e (accination session.
%#.#* /accine storage
9"ere are se(eral ty'es of refrigerator and free8er a(ailable& 'o;ered by %erosene&
electricity& gas and solar energy. 9"e instructions for installation and maintenance t"at
accom'any t"e eJui'ment s"ould be follo;ed. A dial t"ermometer s"ould be %e't in
bot" t"e refrigerator and t"e free8er to monitor t"e tem'erature& ;"ic" s"ould be
c"ec%ed and recorded t;ice daily in a register on t"e front of t"e a''aratus. *f t"e
refrigerator tem'erature goes belo; 3 `C or abo(e A `C it needs to be readFusted. *f
t"e refrigerator brea%s do;n and t"e cold c"ain is disru'ted& t"e (accine in t"at
refrigerator must be discarded as its efficacy can no longer be guaranteed.
9"e refrigerator must be defrosted regularly. W"en t"is is done all (accines must
be 'laced in a cold bo:. W"en (accines are 'laced in a cold bo: for any 'ur'ose& a
t"ermometer s"ould be 'ut in t"e bo: ;it" t"em and t"e tem'erature monitored.
9"ere are t;o ty'es of cold bo: a(ailable: t"e small bo: allo;s (accines to be stored
for #) "ours& ;"ile t"e larger bo: stores (accines safely for u' to 6 days.
%#.#+ Measles
$ublic )ealt) im(ortance
Measles remains a maFor cause of c"ild"ood mortality in de(elo'ing countries.
9"is disease is one of t"e most serious "ealt" 'roblems encountered in emergency
situations and "as been re'orted as a leading cause of mortality in c"ildren in many
recent emergencies. One of t"e im'ortant ris% factors for measles transmission is
o(ercro;ding. Common com'lications of measles include malnutrition& diarr"oea and
'neumoniaN t"ese can all lead to case-fatality ratios of 3!$3Q among dis'laced
'o'ulations.
Measles 'accination
Pre(ention of measles in emergency situations "as t;o maFor com'onents: routine
(accination and measles outbrea% res'onse. 9"e disease can be 're(ented by t"e
administration of measles (accine. ,ome /0Q of indi(iduals (accinated ;"en o(er /
mont"s old gain lifelong immunity.
Mass (accination is a 'riority in emergency situations ;"ere 'eo'le are dis'laced&
t"ere is disru'tion of normal ser(ices& t"ere are cro;ded or insani-tary conditions
and5or ;"ere t"ere is ;ides'read malnutrition& regardless of ;"et"er a single case of
measles "as been re'orted or not. A measles (accination cam'aign s"ould begin as
soon as t"e necessary "uman resources& (accine& cold c"ain eJui'ment and ot"er
su''lies are a(ailable. Measles (accination s"ould not be delayed until ot"er (accines
become a(ailable or until cases of measles "a(e been re'orted 2if cases are re'orted
t"e cam'aign s"ould begin ;it"in 6# "ours of t"e first re'ort4. Eaccination is also a
'riority in refugee 'o'ulations from countries ;it" "ig" (accination rates& as studies
"a(e s"o;n t"at large outbrea%s of measles can occur e(en if (accine co(erage
e:ceeds A3Q. *t is im'ortant to remember t"at measles is a "ig"ly contagious disease
reJuiring /1Q co(erage for "erd immunity to be establis"ed.
9"e 'resence of se(eral cases of measles in an emergency setting does not
'reclude a measles (accination cam'aign. E(en among indi(iduals ;"o "a(e already
been e:'osed and are incubating t"e natural (irus& measles (accine& if gi(en ;it"in $
days of infection& may 'ro(ide 'rotection or modify t"e clinical se(erity of t"e illness.
*f cases of measles occur& isolation is not indicated and c"ildren ;it" measles
'artici'ating in selecti(e feeding 'rogrammes s"ould not be ;it"dra;n.
9"e emergency-affected 'o'ulation must be (accinated during t"e first days of t"e
emergency and all ne; arri(als s"ould be (accinated. 9"e target age grou' de'ends
on t"e (accine co(erage in t"e country of origin of t"e affected 'o'ulation. 9"e
o'timal age grou' to (accinate for measles is 1 mont"s t"roug" ) years of age if
'ossible& ;it" a minimum acce'table age range of 1 mont"s t"roug" ) years of age.
9"e target age grou' for (accination must be c"osen based on (accine a(ailability&
funding& "uman resources and local measles e'idemiology. A measles control 'lan
s"ould be de(elo'ed and im'lemented as ra'idly as 'ossible ;"ile ensuring "ig"
Juality in co(erage& cold c"ain5 logistics& and (accination safety. C"ildren aged
bet;een 1 and / mont"s s"ould be re(accinated as soon as t"ey reac" / mont"s of
age.
Measles (accination s"ould be accom'anied by (itamin A distribution in
c)ildren aged . mont)s to - ,ears to decrease mortality and 're(ent
com'lications.
A 're-(accination count of t"e target 'o'ulation s"ould be conducted& but t"is
s"ould not delay t"e start of t"e (accination 'rogramme. *n long-term refugee "ealt"
'rogrammes& (accination s"ould be targeted at all c"ildren aged bet;een / mont"s
and 0 years.
*f t"ere is insufficient (accine a(ailable to immuni8e t"e entire target 'o'ulation&
t"e follo;ing "ig"-ris% grou's s"ould be targeted 2in order of 'riority4:
undernouris"ed or sic% c"ildren aged 1 mont"s to # years ;"o are enrolled in
feeding centres or in'atient ;ards&
all ot"er c"ildren aged 1!#$ mont"s&
all ot"er c"ildren aged #)!0/ mont"s.
Older c"ildren and adults may need to be immuni8ed if sur(eillance data s"o;
t"at t"ese age grou's are being affected during an outbrea%. 9able #.$ summari8es
t"e %ey 'oints concerning measles (accination and (accines.
Malnutrition is not a contraindication for measles (accinationN on t"e contrary& it
s"ould be considered a strong indication for (accination. ,imilarly& fe(er& res'iratory
tract infection and diarr"oea are not contraindications for measles (accination.
C"ildren ;it" H*E infection or clinical A*D, s"ould recei(e measles (accine because
of t"e greater ris% of se(ere measles in suc" cases.
Table %#*" Measles 'accination
recommendations
Age *n emergency situations& all c"ildren from
1 mont"s to ) years of age s"ould be
immuni8ed& ;it" a minimum age range of
1 mont"s to ) years if resources are
limited. *n stable situations& measles
(accine is usually gi(en bet;een / and #
mont"s of age as 'art of t"e routine EP*
Dosage A single dose of 3.0 ml
*f t"e first dose is gi(en at 1!A mont"s of
age& a second dose must be gi(en at /
mont"s of age.
More t"an one dose can be administered
to an indi(idual& as it does no "arm and
can strengt"en immunityN it is a ;aste of
(accine& "o;e(er
Boute ,ubcutaneous inFection& usually in t"e
arm& using a ne; sterile dis'osable needle
2#$ gauge4 and syringe for eac"
indi(idual
Beactions ,ome 0!0Q of t"ose (accinated de(elo'
a fe(er and ras"
,ide-effects A small number of cases of ence'"alitis
"a(e been re'orted
Contraindications Pregnancy
*nstructions for carers 9"e carer s"ould be told t"at fe(er and
ras" may occurN it s"ould be e:'lained
t"at t"is is a (ery mild form of t"e disease
and& unless t"e tem'erature is "ig"& t"ere
is no need for s'ecial action
Becords Eac" indi(idual s"ould recei(e a card
stating t"e (accine gi(en and if a furt"er
dose is reJuired
9"e name& date of birt"& se: and location
of eac" (accinated indi(idual s"ould be
recorded in an a''ro'riate (accine
register
,torage Measles (accine is (ery sensiti(e to "eat
and s"ould be stored at a tem'erature of
#!A `C 2usually on t"e to' s"elf of t"e
fridge or in a (accine carrier4
Beconstitution Beconstitute ;it" t"e sterile ;ater t"at
accom'anies t"e (accineN follo; t"e
instructions gi(en on t"e (ial& al;ays
c"ec% t"at t"e (accine is ;it"in its e:'iry
date before reconstitutionN unused
reconstituted (accines must be discarded
after A "ours
,torage once reconstituted 9"e reconstituted (accine s"ould be
'laced in t"e circular "ollo; of t"e
ice'ac% in a s"ady 'lace
9"e WHO5?.*CE= global measles elimination strategy recommends t"at a
second o''ortunity for measles re(accination s"ould be offered to all c"ildren from /
mont"s t"roug" ) years& ;it" a minimum inter(al of one mont" bet;een t"e # doses.
%#.#- Meningococcal meningitis
$ublic )ealt) im(ortance
9"e most common bacterial 'at"ogen causing e'idemic meningitis in most
countries is t"e meningococcus& Neisseria meningitidis. Meningococcal meningitis is
c"aracteri8ed by sudden onset ;it" fe(er& intense "eadac"e& stiff nec%& occasional
(omiting and irritability. A 'ur'uric ras" is a feature of meningococcaemia. E'idemic
meningitis "as been recogni8ed as serious 'ublic "ealt" 'roblem for almost #33 years.
9"e main source of t"e infection is naso'"aryngeal carriers. 9"e infection is usually
transmitted from 'erson to 'erson in aerosols in cro;ded 'laces. Bural-to-urban
migration and o(er-cro;ding in 'oorly designed and constructed buildings in cam's
and slums can contribute to transmission. 9"e disease can be treated effecti(ely ;it"
a''ro'riate antimicrobial and& ;it" ra'id treatment& t"e case-fatality in an e'idemic is
usually bet;een 0Q and 0Q.
,erogrou' A and C meningococci are t"e main causes of e'idemic meningitis. *n
sub-,a"aran Africa& serogrou' A meningococcal disease is t"e most common and can
lead to 'eriodic& large-scale e'idemics during t"e "ot and dry ;eat"er in t"e
Lmeningitis beltM. *n East Africa& ;"ic" is outside t"is belt& t"e e'idemics tend to
occur during t"e cold and dry mont"s. *n #333!#33& serogrou' W
$0
meningococci
;ere identified during outbrea%s in ,audi Arabia& and are no; s'reading in sub-
,a"aran Africa.
*n stable 'o'ulations& t"e e'idemic t"res"old is generally an incidence of 0 cases
'er 33 333 in"abitants 'er ;ee%& in ;ee% if t"e 'o'ulation is greater t"an $3 333&
and 0 cases in ;ee% or doubling of t"e number of cases o(er a $-;ee% 'eriod if t"e
'o'ulation is less t"an $3 333. W"en t"e e'idemic t"res"old is reac"ed& a mass
(accination cam'aign s"ould be im'lemented in t"e at-ris% 'o'ulation 2for more
details see ,ection ).#.#4.
*n emergency-affected 'o'ulations& "o;e(er& 'articularly in o(ercro;ded
situations& t"e t"res"old for action is lo;er and t"e decision to im'lement a
(accination cam'aign must be ta%en locally in consultation ;it" t"e rele(ant
aut"orities& suc" as WHO or t"e Ministry of Healt". Microbiological confirmation
s"ould be soug"t as a matter of urgency& but t"is s"ould not delay t"e start of a
(accination cam'aign.
Meningitis 'accine
Meningococcal meningitis A and C can be 're(ented by (accination. 9"e (accine
is effecti(e ;it"in A!) days. ,ome /3Q of reci'ients o(er A!#) mont"s of age
serocon(ert and are 'rotected against t"e disease. Eaccine-induced immunity lasts
about 0 years in adults and older c"ildren& ;"ile younger c"ildren are 'rotected for
a''ro:imately # years. A Juadri(alent (accine is also a(ailable for combined
(accination against serogrou's A& C& H and W$0. Eaccination recommendations for
meningococcal meningitis are summari8ed in 9able #.$#.
Table %#*% Meningococcal meningitis
'accination recommendations
Age 9"e grou' at "ig"est ris% of
meningococcal meningitis is c"ildren
aged #!3 yearsN t"is s"ould be t"e
'riority grou' during (accination
cam'aigns
Dosage A single dose of 3.0 ml
Boute Dee' subcutaneous or dee'
intramuscular& using a ne; sterile
dis'osable needle and syringe for eac"
indi(idualN mi:ing t"e meningitis (accine
in t"e same (ial or syringe as li(e (irus
(accines& suc" as measles& is not
recommended
,ide effects ?' to 6Q of t"e reci'ients ;ill de(elo'
a mild local reaction at t"e inFection siteN
;it" current& "ig"ly 'urified (accine
're'arations& fe(er is seen in less t"an #Q
of (accinees
Contraindications =ebrile illness& %no;n "y'ersensiti(ity&
'regnancy
*nstructions for carers or reci'ients 9"e carer5reci'ient s"ould be told to
e:'ect a fe(er and s;elling around t"e
inFection siteN it s"ould be e:'lained t"at
t"is is a (ery mild form of t"e disease& but
if t"e fe(er is "ig" t"ey s"ould gi(e
'aracetamol and return to t"e doctor
Becords Ensure t"at t"e indi(idual is gi(en a
record of t"e (accine and also t"at t"e
(accinators retain a record in a register
,torage ,tore at #!A `CN do not allo; t"e (accine
to free8e
Beconstitution 9"ere is a s'ecific diluent ;it" eac" (ial
of (accine& and t"is is t"e only diluent to
be used ;it" t"e (accineN read t"e (ial
and follo; t"e instructions gi(en& al;ays
c"ec% t"at t"e (accine is ;it"in its e:'iry
date before reconstitution
,torage once reconstituted ?nused (accine s"ould be dis'osed of
;it"in "our of reconstitution
%#.#. ?ello@ fe'er
$ublic )ealt) im(ortance
Hello; fe(er is a (iral disease transmitted by mosJuitoes and occurs 'rimarily in
Africa and ,out" America. 9"ere is no s'ecific treatment& but su''orti(e t"era'y for
'atients s"ould be 'ro(ided. 9"e o(erall case-fatality rate is less t"an 0Q& alt"oug"
t"e rate among 'atients ;it" Faundice is #3!03Q.
?ello@ fe'er 'accine
Eaccination is t"e 'rimary means of 're(enting yello; fe(er. 9"e yello; fe(er
(accine offers a "ig" le(el of 'rotection& ;it" serocon(ersion rates of /0Q or "ig"er
for bot" adults and c"ildren. 9"e duration of immunity is at least 3 years and
'robably lifelong. 9"e serological res'onse to yello; fe(er (accine is not in"ibited by
simultaneous administration of -C@& di'"t"eria& 'ertussis& tetanus& measles and
'oliomyelitis (accines. Beactions to yello; fe(er (accine are generally mild. *t can be
gi(en to asym'tomatic 'atients infected ;it" H*E& but s"ould not be gi(en to
sym'tomatic H*E-infected 'ersons or ot"er immuno-su''ressed indi(iduals. =or
t"eoretical reasons& yello; fe(er (accine is not routinely recommended for 'regnant
;omenN "o;e(er& t"ere is no e(idence t"at (accination of a 'regnant ;oman is
associated ;it" abnormal effects on t"e fetus. *n an outbrea%& t"e ris% of disease
;ould out;eig" t"e small t"eoretical ris% to t"e fetus from (accination.
Becommendations regarding yello; fe(er (accination are summari8ed in 9able #.$$.
Table %#** ?ello@ fe'er 'accination
recommendations
Age All indi(iduals o(er 1 mont"s of age and
t"e members of a "ig"-ris% 'o'ulation
s"ould recei(e t"e (accineN in some
countries t"e (accine is 'art of t"e
national EP* 'rogramme and is gi(en at
t"e same time as measles (accine
Dosage A single dose of 3.0 ml
Boute Dee' subcutaneous inFection using a ne;
sterile dis'osable needle 2#$ gauge4 and
syringe for eac" indi(idual
,ide effects ,ome 0Q of indi(iduals de(elo' a lo;-
grade fe(er& "eadac"e or myalgia ;it"in
t"e first 3 days after (accination
*mmediate "y'ersensiti(ity reactions ;it"
ras"& urticaria or ast"ma occur in less
t"an 'er million indi(iduals and usually
among t"ose ;it" %no;n egg allergy
,erious ad(erse reactions are e:tremely
rare: ## cases of ence'"alitis "a(e been
re'orted to WHO since /)0& in relation
to o(er #33 million doses of 6D yello;
fe(er (accine gi(en ;orld;ide. Most of
t"ose affected ;ere c"ildren under )
mont"s of age
Contraindications C"ildren under 1 mont"s of age&
'regnancy& and sym'tomatic H*E-
infected 'ersons or ot"er
immunosu''ressed indi(iduals
*nstructions for carers or reci'ients 9"e indi(idual s"ould be told t"at a lo;-
grade fe(er& "eadac"e or myalgia may
occur ;it"in t"e first 3 days after
(accination& and t"at if any ot"er
condition de(elo's t"ey s"ould see%
medical attention
Becords Eac" indi(idual s"ould recei(e a
certificate as a record of (accinationN
eac" indi(idual<s name s"ould be
recorded in an a''ro'riate (accine
register
,torage Li(e attenuated 6D yello; fe(er (accine
is "eat-sensiti(e& and s"ould be
trans'orted and stored eit"er fro8en or at
a tem'erature of )!A `C
Beconstitution Beconstitute ;it" t"e diluent t"at
accom'anies t"e (accineN follo; t"e
instructions gi(en on t"e (ialN al;ays
c"ec% t"at t"e (accine is ;it"in its e:'iry
date 'rior to reconstitution
,torage once reconstituted Beconstituted (accine is (ery unstable
and s"ould ideally be discarded ;it"in
"our& alt"oug" it can last for 1 "ours if
%e't cool
%#.#1 Oral c)olera 'accines
.e; generation orally administered c"olera (accines 2OCE4 "a(e 'assed t"e stage
of researc" and de(elo'ment and t;o formulas are commercially a(ailable. Currently&
t"e main users of mar%eted OCE "a(e been indi(idual tra(elers from industriali8ed
countries ;"o e:'ect to be e:'osed tem'orarily to t"e ris% of c"olera ;"ile tra(eling
in endemic areas. Becently& t"ere "as been rene;ed interest in using oral c"olera
(accines in mass (accination cam'aigns& in conFunction ;it" traditionally
recommended control measures suc" as 'ro(ision of safe ;ater and im'ro(ed
sanitation.
,e(eral mass-(accination cam'aigns using OCE "a(e been 'erformed ;it" t"e
su''ort of WHO. *n #333& t"e =ederated ,tates of Micronesia e:'osed to an ongoing
outbrea% in Po"n'ei *sland decided on using t"e li(e-attenuated oral c"olera (accine
CED 3$-HgB to limit t"e s'read of t"e outbrea%. A retro-s'ecti(e analysis suggested
t"at mass (accination ;it" OCEs can be a useful adFunct tool for controlling
outbrea%s& 'articularly if im'lemented early and in association ;it" ot"er standard
control measures. =urt"er& cam'aigns using t"e recombinant %illed ;"ole cell oral
c"olera (accine r-,-WC "a(e been conducted in Mo8ambiJue 2#33$5#33)4& Darfur
2#33)4 and ,umatra 2#3304 to 'rotect at ris% 'o'ulations from 'otential c"olera
outbrea%s. 9"e e:'erience gained as a result from t"ose inter(entions is encouraging.
-ig c"allenges "o;e(er remain ;it" regard to ris% assessment& identification of t"e
target 'o'ulation and logistics among ot"ers.
Currently& OCEs may 'ro(e useful in t"e stable '"ase of emergencies as ;ell as
in endemic settings es'ecially ;"en gi(en 're-em'ti(ely. A(ailable data indicates t"at
current OCE are safe and offer good 'rotection for an acce'table 'eriod of time. 9"e
use of OCE s"ould be t"roug" ;ell designed demonstration 'roFects and s"ould be
com'lementary to e:isting c"olera control strategies. 9"ese demonstration 'roFects
s"ould result in gaining e(idence on ;"en best to use OCEs as an additional 'ublic
"ealt" tool.
9raditional inFectable c"olera (accines are considered insufficiently 'rotecti(e and
too reactogenic. 9"eir use "as ne(er been recommended by WHO.
%#.#3 0urt)er reading
,89(BN-<CF policy statement for mass immunization campaigns" @ene(a&
World Healt" Organi8ation& //6 2document WHO5EP*5LH*,5/6.3)4.
Measles
<onduite I tenir en cas dJKpidKmie de rougeole L5anagement of measles
epidemicsM. Paris& MKdecins ,ans =ronti_res& //1.
9oole MC et al. Measles 're(ention and control in emergency settings. 7ulletin of
the ,orld 8ealth 9rganization& /A/& .1D$A!$AA.
,89(BN-<CF Goint statement on :educing measles mortality in emergencies
World Healt" Organi8ation& #33) 2document WHO5E>-53).$4.
E(idemic meningitis
5anagement of epidemic of meningococcal meningitis. Paris& MKdecins ,ans
=ronti_res& #33).
<ontrol of epidemic meningococcal disease: ,89 practical guidelines& #nd ed.
@ene(a& World Healt" Organi8ation& //A 2document WHO5EMC5-AC5/A.$4.
Detecting meningococcal meningitis e'idemics in "ig"ly endemic African
countries: WHO recommendation. ,ee6ly Cpidemiological :ecord& #333&
1-2$A4:$31!$3/.
?ello@ fe'er
Ad(erse e(ents follo;ing yello; fe(er (accination. ,ee6ly Cpidemiological
:ecord& #33& 1.:#6!#A.
1istrict guidelines for yello/ fever surveillance. @ene(a& World Healt"
Organi8ation& //A 2document WHO5EP*5@E.5/A.3/4.
Bobertson ,E. The immunological basis for vaccination" 5odule &: yello/ fever.
@ene(a& World Healt" Organi8ation& //$ 2document WHO5EP*5@E.5/$.A4.
Bobertson ,E et al. Hello; fe(er: a decade of re-emergence. 3ournal of the
4merican 5edical 4ssociation& //1& %1.D06!1#.
,il(a C et al. Faccine safety: yello/ fever vaccine" :eport of the Technical
4dvisory Eroup on Faccine(Dreventable 1isease. Was"ington& DC& Pan American
Healt" Organi8ation& #333.
Nello/ fever !Technical <onsensus 5eeting* Eeneva* 2!> 5arch ##&. @ene(a&
World Healt" Organi8ation& //A 2document WHO5EP*5@E.5/A.3A4.
Oral c)olera 'accines
Dotential use of oral cholera vaccines in emergency situations" :eport of a ,89
meeting* Eeneva* 2/itzerland* 2!> 5ay ###. @ene(a& World Healt" Organi8ation&
/// 2document WHO5CD,5C,B5EDC5//.) ! ;;;.;"o.int5to'ics5'ublications4.
<holera vaccines: 4 ne/ public health toolO Be'ort& 3! December #33#&
@ene(a&,;it8erlandNWHO5CD,5CPE5G=D5#33).0 ;;;.;"o.int5to'ics5'ublications4.
C"olera (accines: Publis"ed on #3 A'ril #33& Eol. 61& ".:6!#)
2;;;.;"o.int5(accines-documents5PP-WEB5;er611.'df4.
Calain P et al. Can oral c"olera (accination 'lay a role in controlling a c"olera
outbrea%^ Faccine* #33)& %%D#)))-#)0.
Lucas ME et al. Effecti(eness of mass oral c"olera (accination in -eira&
Mo8ambiJue. Ne/ Cngland 3ournal of 5edicine* #) =eb. #330N *-%839D606!616.
?'date on c"olera (accines. ,ee6ly epidemiological record* #330& 362$4:#10!
#1A.
%#1 2ealt) education and communit, (artici(ation
Healt" education and community 'artici'ation in inter(entions 'lay a %ey role in
communicable disease 're(ention and control.
Some areas @)ere )ealt) education and communit, (artici(ation can
be beneficialD
*m'ro(ing recognition of se(ere disease by t"e 'o'ulation.
*m'ro(ing "ealt"-see%ing be"a(iour.
Promotion of early and a''ro'riate use of OB, in treatment of diarr"oeal
disease.
Promotion of (ector control 'rogrammes e.g. use of *9.s.
Promotion of "ygiene5"and-;as"ing for 're(ention of diarr"oeal disease.
Promotion of safe ;ater use and storage.
Promotion of a''ro'riate sanitation.
Promotion of en(ironment management to 're(ent degradation and (ector
re'roduction.
Acti(e case-finding in outbrea%s.
Communicable disease sur(eillance system.
Data collection for mortality and 'o'ulation statistics.
Community mobili8ation for (accination cam'aigns5(accination.
$rinci(les of effecti'e communit, (artici(ation in emergenciesD
Ha(e %no;ledge of dis'laced or refugee& and "ost 'o'ulation communities:
social structure&
(ulnerable grou's&
members of formal organi8ations&
members of semi-formal organi8ations suc" as sc"ools& fait"-based
organi8ations& social organi8ations&
community leaders or s'o%es'eo'le&
family5%in net;or%s&
roles ;it"in community&
customs and 'ractices& e.g. belief against gi(ing ;ater to sic% c"ildren 2use
of colouring to ma%e ;ater loo% li%e medicine to render it culturally
acce'table4& use of c"addars as to'-s"eets for slee'ing 2can im'regnate
;it" 'ermet"rin for 're(ention of mosJuito bites4.
*dentify community concerns and 'riorities.
?se community members to collect data.
*n(ol(e community in im'lementation of acti(ities& e.g. sur(eillance of deat"s&
case-finding& "ealt" education& sanitation and en(ironmental im'ro(ement.
Ensure effecti(e communication bet;een 'o'ulation& "ost communities&
go(ernment and agencies in(ol(ed in res'onse.
/olunteer collaboration
Eolunteer collaboration ;it"in a community enables 'artici'atory ma''ing of
'riorities and needs& allo;s ;or%ing ;it" elders and leaders for ad(ocacy and su''ort&
identifies (olunteers ;"o can "el' in organi8ing t"e community to address 'roblems&
and enables re'orting information to t"e coordination body or local district. ,uccess
de'ends on ;"et"er (olunteers< actions are measurable and ma%e a difference.
*m'ortant Juestions to as% include: Are t"ere (olunteers in eac" community^ Are
t"ere enoug" (olunteers to co(er t"e ;"ole community^ Do t"e (olunteers %no; t"e
community and "o; to a''roac" "ealt" to'ics^ Do t"e (olunteers %no; %ey messages
for eac" "ealt" 'roblem^ Do t"e (olunteers %no; ;"at information to collect in order
to measure effecti(eness^
Eolunteers s"ould be from t"e community in ;"ic" t"ey ;or%& e(en in
emergencies. 9"ey s"ould ;or% ;it" t"eir elders& leaders and local "ealt" staff 2"ealt"
;or%ers and traditional birt" attendants4. Eolunteers s"ould %no; t"e traditional
beliefs about diseases and %no; ;"at 'riority "ealt" 'roblems t"e community ;ants
to sol(e. 9"ey s"ould also %no; ;"at ot"er grou's are doing in t"eir community
about 'riority "ealt" 'roblems and %no; t"e families and (isit t"em regularly to
'ro(ide %ey messages.
Eolunteers are 'art-time and need to reorgani8e t"emsel(es in order to accom'lis"
t"eir designated tas%s. Community action ;"ere grou's of (olunteers ;or% at t"e
same time on a 'roFect reJuires a leader to ensure coordination.
*# S!/EILLANCE
9"is c"a'ter outlines t"e %ey ste's in setting u' and running a sur(eillance system
in an emergency.
*#" General (rinci(les
Sur'eillance is t)e ongoing s,stematic collection> anal,sis and inter(retation
of data in order to (lan> im(lement and e'aluate (ublic )ealt) inter'entions#
A sur(eillance system s"ould be sim'le& fle:ible& acce'table and situation-
s'ecific. *t s"ould be establis"ed at t"e beginning of 'ublic "ealt" acti(ities set u' in
res'onse to an emergency.
Public "ealt" sur(eillance classically com'rises si: core acti(ities 2detection&
registration& confirmation& re'orting& analysis and feedbac%4 t"at are made 'ossible
t"roug" four su''ort acti(ities 2communication& training& su'er(ision and resource
'ro(ision4.
0igure *#" Conce(tual frame@or4 of (ublic )ealt) sur'eillance and action
*f systematic sur(eillance acti(ities are not 'ossible& for e:am'le due to lac% of
access& an alternati(e means of monitoring s'ecific "ealt"-related trends is to sam'le
t"e 'o'ulation t"roug" re'eated "ealt" sur(eys& using design and Juestionnaires
similar to t"ose used for t"e initial ra'id assessment 2see C"a'ter 4.
*#% Ob&ecti'es
9"e obFecti(es of a sur(eillance system in an emergency are to:
identify 'ublic "ealt" 'rioritiesN
monitor t"e se(erity of an emergency by collecting and analysing mortality
and morbidity dataN
detect outbrea%s and monitor res'onseN
monitor trends in incidence and case-fatality from maFor diseasesN
monitor t"e im'act of s'ecific "ealt" inter(entions 2e.g. a reduction in malaria
incidence rates after t"e im'lementation of (ector control 'rogrammes4N
'ro(ide information to t"e Ministry of Healt"& agency "eadJuarters and donors
to assist in "ealt" 'rogramme 'lanning& im'lementation and ada'tation& and
resource mobili8ation.
DATA IN0OMATION ACTION
.umber of
deat"s
Crude mortality
rate
Mortality
reduction
measures
-efore starting to design a sur(eillance system& t"e follo;ing Juestions s"ould be
as%ed:
W"at is t"e 'o'ulation under sur(eillance: dis'laced 'o'ulation& local
'o'ulation^
W"at data s"ould be collected and for ;"at 'ur'ose^
W"o ;ill 'ro(ide t"e data^
W"at is t"e 'eriod of time of t"e data collection^
Ho; ;ill t"e data be transferred 2data flo;4^
W"o ;ill analyse t"e data and "o; often^
Ho; ;ill re'orts be disseminated and "o; often^
*#* Setting sur'eillance (riorities
*t is not 'ossible to monitor e(eryt"ing in an emergency. At field le(el& t"e "ealt"
coordination team must identify a limited number of 'riority diseases t"at 'ose a
t"reat to t"e "ealt" of t"e 'o'ulation. 9"is selection 'rocess must be done at t"e
beginning of "ealt" care acti(ities in an emergency.
9"e c"oice of sur(eillance 'riorities s"ould ans;er t"e follo;ing Juestions:
Does t"e condition result in a "ig" disease im'act 2morbidity& disability&
mortality4^
Does it "a(e a significant e'idemic 'otential 2e.g. c"olera& meningitis&
measles4^
*s it a s'ecific target of a national& regional or international control
'rogramme^
Will t"e information to be collected lead to significant and cost-effecti(e
'ublic "ealt" action^
E:'erience from many emergency situations "as s"o;n t"at certain diseases5
syndromes must al;ays be considered as 'riorities and monitored systematically. *n
t"e acute '"ase of an emergency& t"e maFor diseases5syndromes t"at s"ould be
re'orted are:
bloody diarr"oea&
acute ;atery diarr"oea&
sus'ected c"olera&
lo;er res'iratory tract infection&
measles&
meningitis.
*n certain geogra'"ical areas& ot"er diseases t"at are endemic or t"at re'resent an
e'idemic t"reat& suc" as malaria or (iral "aemorr"agic fe(ers may "a(e to be
included.
*n t"e 'ost-emergency '"ase& additional diseases t"at s"ould be re'orted include:
tuberculosis&
H*E5A*D,&
neonatal tetanus&
se:ually transmitted infections.
,ee Anne: 0 for case definitions for eac" disease5syndrome.
W"en setting u' sur(eillance systems& it is im'ortant to be a;are of "ealt"
conditions t"at "a(e local distribution and include t"ese in t"e sur(eillance
'rogramme. *n 'arts of West Africa& for e:am'le& Lassa fe(er s"ould be included in
t"e list of 'riority diseases for sur(eillance. *n areas ;"ere ty'"us "as caused
'roblems in t"e 'ast& routine sur(eillance s"ould include re'orting bot" of
sus'ected5confirmed cases of t"e condition and of infestations ;it" body lice& t"e
(ector of t"e disease.
*n addition& ot"er "ealt" e(ents of im'ortance& e.g. inFuries& ;ound infections may
need to be added to t"e list of sur(eillance 'riorities.
*#+ Data collection met)ods
9"ere are t"ree main met"ods for collecting data in emergency situations: routine
re'orting 2including e'idemic-'rone diseases reJuiring immediate notification4&
sur(eys and outbrea% in(estigations 2see 9able $.4.
Table *#" Data collection met)ods
Met)od Indication 0reFuenc,
Boutine re'orting:
endemic
Boutine sur(eillance Wee%ly 2emergency
'"ase4& t"en mont"ly
Alert system: e'idemic
2early ;arning4
E'idemic-'rone diseases *mmediate notification
Outbrea% in(estigations Declared outbrea%s Ad "oc
,ur(eys Delays in setting u'
routine sur(eillance& or
De'ends on s'ecific needs
or Juestions addressed
House"old-based data 2e.g.
nutrition& basic needs&
(accination4
*n routine re'orting& clinical ;or%ers collect data on t"e number of cases and
deat"s from 'riority diseases. Data are re'orted as 'art of t"e day-to-day ;or% of t"e
"os'ital& "ealt" clinic or outreac" 'ost. Boutine data are usually recorded in an
in'atient or out'atient register& and are t"en transferred to summary tally s"eets at t"e
end of eac" ;ee%. At t"e end of t"e re'orting 'eriod& t"e infor-mation is sent to t"e
"ealt" coordinator for com'ilation and analysis. Case definitions for e'idemic-'rone
diseases listed in t"e sur(eillance system s"ould include s'ecific indications on ;"en
immediate notification is mandatory: eit"er as soon as a single case is sus'ected 2e.g.
"aemorr"agic fe(ers& measles& yello; fe(er4 or after an indicated alert t"res"old is
reac"ed 2e.g. e'idemic meningitis4.
,ur(eys aim at collecting data on a re'resentati(e sam'le of t"e emergency-
affected 'o'ulation 2or of a defined subgrou'4. W"en t"e organi8ation of a sustainable
sur(eillance system "as to be delayed& iterati(e sur(eys can 'ro(ide t"e information
needed for emergency decisions. ,ur(ey 'rinci'les and met"ods are described in
C"a'ter .
Outbrea%s entail acti(e case-finding and in-de't" in(estigation& ;"ereby attem'ts
are made to identify t"e cause of an unusual number of cases of deat" or disease and
to im'lement control measures. 9"ese in(estigations are dealt ;it" in C"a'ter ).
*#- Case definitions
Case definitions must be de(elo'ed for eac" "ealt" e(ent5disease5syndrome.
,tandard WHO case definitions are gi(en in Anne: 0& but t"ese may "a(e to be
ada'ted according to t"e local situation. *f 'ossible& t"e case definitions of t"e "ost
country<s Ministry of Healt" s"ould be used if t"ey are a(ailable. W"at is im'ortant is
t"at all of t"ose re'orting to t"e sur(eillance system& regardless of affiliation& use t"e
same case definitions so t"at t"ere is consistency in re'orting.
Case definitions considered "ere are designed for sur(eillance 'ur'oses only. A
sur(eillance case definition is not to be used for t"e management of 'atients and is not
an indication of intention to treat.
*n many emergency situations& ;"ere t"ere is no timely laboratory access for
confirmation of certain diseases 2e.g. c"olera4& 'ublic "ealt" action can be based on a
'resum'ti(e diagnosis. ,ur(eillance case definitions s"ould indicate& if a''ro'riate&
;"en a case is sus'ect& 'robable or confirmed.
Table *#% Case classification
T,(e of case Criteria
,us'ected case Clinical signs and sym'toms com'atible
;it" t"e disease in Juestion but no
laboratory e(idence of infection
2negati(e& 'ending or not 'ossible4
E:am'le for meningococcal meningitis:
sus'ected case P meets clinical case
definition
Probable case Com'atible clinical signs and sym'toms&
and additional e'idemiological 2e.g.
contact ;it" a confirmed case4 or
laboratory 2e.g. screening test4 e(idence
for t"e disease in Juestion
=or meningococcal meningitis: 'robable
case P sus'ected case ] turbid C,= or
ongoing e'idemic or e'idemiological lin%
to confirmed case
Confirmed case Definite laboratory e(idence of current or
recent infection& /hether or not clinical
signs or sym'toms are or "a(e been
'resent
=or meningococcal meningitis: confirmed
case P sus'ected or 'robable case ]
laboratory confirmation
.ote t"at in outbrea%s of certain diseases&
clinical sym'toms are not 'resent in a
'ro'ortion of 'eo'le& "o;e(er t"ey are
counted as confirmed cases ;it"
laboratory e(idence since subclinical
infection is a maFor source of
transmission
,ome infectious diseases& suc" as neonatal tetanus& normally do not reJuire
laboratory confirmation and can be re'orted on t"e basis of 'ure clinical criteria.
Ot"ers& suc" as 'ulmonary tuberculosis& need to be confirmed by laboratory tests
before official re'orting of a case. *n ot"er instances& disease 'resentation can
corres'ond to (arious or multi'le causati(e organisms 2e.g. se:ually-transmitted
infections4 and t"e demonstration of t"e etiologic agent2s4 is irrele(ant for adeJuate
case management or 'ublic "ealt" action. *n suc" cases& a LsyndromicM case definition
is adeJuate. Presum'ti(e 2sus'ect or 'robable4 or syndromic case definitions may
assist t"e Outbrea% Control 9eam in establis"ing t"e li%ely occurrence of an outbrea%
and in ta%ing a''ro'riate control measures& before laboratory results become
a(ailable.
Case definitions may "a(e to be ada'ted to t"e circumstances& as illustrated by t"e
follo;ing t;o classic e:am'les.
9"e case definition recommended by WHO for sus'ected c"olera (aries&
de'ending on cases being seen during a confirmed outbrea% or not 2see Anne:
04.
=or malaria& a clinical case definition may need to suffice during t"e acute
'"ase of an emergency since microsco'y confirmation of all sus'ected cases
may be difficult& 'articularly in "ig"-transmission areas ;"ere t"e case-load is
largeZ. *n unstable endemic areas& e(en t"e best clinical algorit"ms may
;rongly classify a disease e'isode as being malaria and may also fail to
identify many true cases of malariaN diagnosis by microsco'y or BD9s s"ould
be 'ro(ided as soon as 'ossible to im'ro(e case management and sur(eillance.
*n stable "ig"-transmission areas& ;"ere a "ig" 'ro'ortion of t"e 'o'ulation
can "a(e 'arasitaemia ;it"out sym'toms& microsco'y may not be so useful for
t"e definition of casesN anaemia in c"ildren and 'regnant ;omen& lo; birt"
;eig"t and "ig" rates of s'lenomegaly 2alt"oug" not (ery s'ecific4 may ser(e
as su''orting indicators.
*#. Minimum data elements
9"roug" a''ro'riate data collection met"ods 2see ,ection $.)4& t"e sur(eillance
system must ca'ture at least t"e follo;ing categories of "ealt"-related 'arameters:
mortality&
morbidity&
'o'ulation figures and trends 2demogra'"ic data4&
nutrition&
basic needs&
'rogramme acti(ities 2including (accination4.
=or eac" category& %ey indicators must be calculated to allo; analysis of trends
and com'arison of t"e data. *deally& mortality and morbidity data s"ould be re'orted
as t"e incidence for a gi(en si8e of 'o'ulation& so demogra'"ic data are needed to
calculate t"em 2e.g. incidence of malaria 'er 333 'o'ulation 'er mont"4.
*f t"e 'o'ulation denominators are not ta%en into account& or demogra'"ic
c"anges are not monitored& sim'le c"anges in numbers of cases of a disease5
syndrome can be "ig"ly misleading in terms of assessment of 'otential e'idemics&
since t"ey may re'resent c"anges in t"e numbers of t"e targeted 'o'ulation rat"er
t"an c"anges in incidence. .e(ert"eless& case numbers s"ould be collected and
re'orted 2;it" suitable disclaimers as to accuracy4 e(en in t"e absence of
demogra'"ic data. E(en if t"e increased numbers of cases of a disease are not
indicati(e of an outbrea%& t"ey ne(ert"eless 'resent medical staff and logistic ser(ices
;it" an increased demand t"at must be Juantified and met.
Malnutrition and com'romised access to basic needs are freJuently seen in
emergencies and "a(e a maFor im'act on disease susce'tibility. A(ailable data
2'referably from "ouse"old sur(eys4 on malnutrition& basic "ouse"old needs and
(accination co(erage s"ould be collected as ;ell& and included in t"e 'eriodical
analysis of sur(eillance data& toget"er ;it" communicable diseases. ,am'le
"ouse"old sur(ey forms are included in Anne: #.
*#.#" Mortalit,
9"e crude mortality rate 2CMB4 is t"e most im'ortant indicator in an emergency&
as it indicates t"e se(erity and allo;s monitoring of t"e e(olution of an emergency. *n
most de(elo'ing countries& t"e a(erage crude mortality rate is about A deat"s 'er
333 'o'ulation 'er year& i.e. 3.0 'er 3 333 'er day. Early in an emergency&
mortality is e:'ressed in deat"s 'er 3 333 'eo'le 'er day. 9"e acute '"ase of an
emergency is defined as ;"en t"e CMB goes abo(e 'er 3 333 'er day in a
dis'laced 'o'ulation 2see 9able $.34.
Crude mortalit, rate is t"e total number of deat"s in t"e 'o'ulation 2o(er ;ee%
or mont"4& di(ided by t"e a(erage 'o'ulation at ris% during t"at time 2;ee%5mont"4&
multi'lied by 333 2t"is gi(es number of deat"s 'er 333 'er time frame c"osen4.
9"is can t"en be con(erted to deat"s 'er 3 333 'er day.
On causes of deat":
$ro(ortionate mortalit,D Pro'ortionate mortality describes t"e 'ro'ortion of
deat"s in a s'ecified 'o'ulation o(er a 'eriod of time attributable to different causes.
Eac" cause is e:'ressed as a 'ercentage of all deat"s& and t"e sum of t"e causes must
add to 33Q. 9"ese 'ro'ortions are not mortality rates& since t"e denominator is all
deat"s& not Fust t"e 'o'ulation in ;"ic" t"e deat"s occurred. =or a s'ecified
'o'ulation o(er a s'ecified 'eriod: Pro'ortionate mortality P Xdeat"s due to a
'articular cause 5 deat"s from all causesY : 33
Cause<s(ecific mortalit, rateD 9"e cause-s'ecific mortality rate is t"e mortality
rate from a s'ecified cause for a 'o'ulation. 9"e numerator is t"e number of deat"s
attributed to a s'ecific cause. 9"e denominator is t"e at-ris% 'o'ulation si8e at t"e
mid'oint of t"e time 'eriod.
*#.#% Morbidit,
Priority diseases5syndromes ;ill "a(e been selected by t"e "ealt" coordination
team de'ending on t"e main disease t"reats in t"e emergency area. =or ma:imum
efficiency& it is im'ortant to limit t"e number of diseases re'orted and t"e data
collected for eac" case. Healt" facilities are generally t"e main source of morbidity
data in an emergency. W"ere access to or use of "ealt" facilities is limited& suc" data
mig"t not be re'resentati(e of t"e condition of t"e o(erall 'o'ulation. =or certain
e'idemic-'rone diseases& "o;e(er& it is essential t"at all cases are detected in t"e
community and re'orted. ,ocial mobili8ation by community ;or%ers may be useful in
t"e acute '"ase of an emergency to ensure t"at t"ose among t"e emergency-affected
'o'ulation t"at are ill access to "ealt" care ser(ices.
9"e incidence is t"e number of ne; cases of a s'ecified diseases re'orted o(er a
gi(en 'eriod. 9"e number of ne; cases re'orted s"ould be counted 2o(er
;ee%5mont"4& di(ided by t"e a(erage 'o'ulation at ris% during t"at time 2mid-;ee%5
mont"4& and multi'lied by 333 2or any ot"er global number to allo; easy
inter'retation4. 9"e incidence is t"en s'ecified as number of ne; cases 'er 333
'eo'le 2or t"e number t"at you "a(e multi'lied by4.
Case<fatalit, rate 8C09D t"e 'ercentage of 'ersons diagnosed as "a(ing a
s'ecified disease ;"o die as a result of t"at disease ;it"in a gi(en 'eriod& usually
e:'ressed as a 'ercentage 2cases 'er 334.
Attac4 rate 8outbrea4s9D 9"e cumulati(e incidence of cases 2'ersons meeting
case definition since onset of outbrea%4 in a grou' obser(ed o(er a 'eriod during an
outbrea%.
*#.#* $o(ulation figures and trends
Demogra'"ic data deal ;it" t"e si8e and com'osition of t"e 'o'ulation affected
by an emergency. 9"ey are needed to calculate:
t"e si8e of t"e 'o'ulation targeted for "umanitarian assistance&
t"e si8e of "ig"-ris% grou's 2e.g. under-fi(es4&
t"e denominators for mortality& morbidity and ot"er rates&
t"e resource needs for "ealt" inter(entions.
*n most emergencies& demogra'"ic data can be obtained from 'ublic institutions
or ?nited .ations agencies. *t is im'ortant t"at all agencies ;or%ing in an emergency
agree on and use t"e same 'o'ulation figures. *n certain emergency situations
in(ol(ing dis'laced 'ersons& t"e local 'o'ulation in t"e affected area s"ould also be
included in t"e total 'o'ulation. 9"e demogra'"ic data t"at need to be collected are
gi(en in 9able $.$.
Table *#* Demogra()ic data to be collected
O 9otal 'o'ulation si8e
O Po'ulation under 0 years of age
O .umbers of arri(als and de'artures 'er ;ee%
O Predicted number of future arri(als 2if a(ailable4
O Place of origin
O .umber of 'eo'le in (ulnerable grou's& suc" as unaccom'anied c"ildren& single
;omen& 'regnant ;omen& ;oman-"eaded "ouse"olds& destitute elderly 'eo'le and
'eo'le ;it" disabilities
9able $.) gi(es t"e standard age distribution in de(elo'ing countries. Ho;e(er&
t"e age structure of dis'laced 'o'ulations is often "ea(ily distorted& ;it" e:cess
numbers of c"ildren& ;omen and t"e elderly. Houng males of military age are often
under-re'resented.
Table *#+ Standard age distribution in
de'elo(ing countries
Age grou( $ro(ortion of total (o(ulation
3!) years 6Q
0!) years #AQ
0] years 00Q
Total "66E
Women 0!)) years #3Q
*#.#+ 7asic needs
-asic needs in emergencies are listed in Anne: 2see also nutritional reJuire-
ments in ,ection #.0.4.
W"ile Juestionnaires can be easily administered on con(enience sam'les of t"e
'o'ulation (isiting "ealt" facilities& results of suc" sur(eys are biased and do not
re'resent t"e basic needs of t"e ;"ole 'o'ulation. -asic needs are better addressed
t"roug" "ouse"old-based sur(eys& using t"e same tec"niJues as t"ose used for t"e
initial ra'id sur(ey.
*#.#- Nutrition
Data from 'aediatric centres or malnutrition clinics are im'ortant in monitoring
t"e 'erformance of "ealt"-centre-based 'rogrammes& but t"ey do not re'resent t"e
nutritional status of t"e ;"ole 'o'ulation affected by t"e emergency. As ;it" basic
needs& malnutrition s"ould be assessed at "ouse"old le(el if rele(ant community-
based actions "a(e to be 'lanned.
*#.#. $rogramme acti'ities> including routine 'accination
Monitoring acti(ities at all le(els of t"e "ealt" system set u' in emergencies is an
integral 'art of sur(eillance. 9y'ical acti(ities to be registered include: number of
(accinations& number of consultations& number of admissions& and number of c"ildren
in su''lementary or t"era'eutic feeding 'rogrammes.
*#.#1 $ost<emergenc, ()ase
As t"e emergency e(ol(es from t"e acute to a more c"ronic '"ase& t"e minimal
sur(eillance system initially 'ut in 'lace "as to e:'and. ?seful ada'tations can
include:
more detailed data: indices by se:& "ig" ris% grou's&
better Juality of data&
u'dating denominators&
ca'turing more e(ents 2e.g. re'roducti(e "ealt"& c"ild "ealt"& H*EN
tuberculosis& se:ually transmitted infections4.
*#1 Data sources for routine sur'eillance
9"e si: categories of data are collected from t"e sources gi(en in 9able $.0.
Table *#- Categories and sources of data
Categories Sources
Mortality Healt" facilities& "ome (isitors& gra(e-
;atc"ers& numbers of s"rouds issued&
community leaders
Morbidity Healt" facilities& "ome (isitors
Demogra'"y Local "ealt" and administrati(e ser(ices&
ot"er agencies
-asic needs Agencies in(ol(ed in ;ater5sanitation&
food distribution
.utrition .utritional sur(eys& food distribution
agencies
Programme acti(ities& including
(accination
Healt" facilities& EP* 'rogramme
9"e main sources of data for routine sur(eillance are clinic registers used for day-
to-day acti(ity in "ealt" facilities. Becording t"e number and causes of deat" in an
emergency can be difficult& as many deat"s may ta%e 'lace outside t"e "ealt" facility.
Home (isitors can 'lay an im'ortant role in collecting information on numbers and
causes of deat"s& using a L(erbal auto'syM met"od ;it" t"e family of t"e deceased
'erson.
Data on demogra'"y and basic needs ;ill usually be a(ailable from s'eciali8ed
agencies& suc" as ?.HCB and nongo(ernmental organi8ations 'ro(iding
re"abilitation of ;ater and sanitation facilities.
A standard form s"ould be de(elo'ed for clinical ;or%ers to com'ile t"e data at
t"e end of eac" ;ee% 2sam'le ;ee%ly morbidity and mortality forms are 'ro(ided in
Anne: )4. 9"ese forms s"ould be sim'le& and clear& "a(e enoug" s'ace to ;rite
information clearly and as% only for information t"at ;ill be used. 9"e minimum data
needed for eac" "ealt" e(ent5disease under routine sur(eillance include:
case-based data for re'orting and in(estigation: name& date of birt" 2or age&
a''ro:imate if necessary if date of birt" is not %no;n4& cam' district5area& date
of onset& treatment gi(en 2Hes5.o4 and outcomeN t"is is not necessary for all
e(ents and often a tally may suffice as& in a maFor emergency& "ealt" 'ersonnel
;ill not "a(e t"e time to record case-based informationN
aggregated data for re'orting: number of cases 2less t"an 0 years old& 0 years
old and o(er4 and number of deat"s.
Outbrea% alert forms s"ould also be a(ailable for clinical ;or%ers for immediate
re'orting of a disease of e'idemic 'otential 2Anne: 14.
*t is im'ortant in filling out t"e forms t"at clinical ;or%ers:
record t"e e:it diagnosis 2based on agreed case definitions4N
a(oid double counting ! if a 'atient comes to t"e "ealt" centre for a follo;-u'
(isit for t"e same condition & "e5s"e s"ould be counted only onceN
only count t"ose cases diagnosed by a 'rofessional "ealt" ;or%er& unless ;ell
moti(ated community ;or%ers trained in s'ecific 'rogramme areas can be
identified as reliable sources of information 2e.g. for t"e 'oliomyelitis
eradication 'rogramme4.
9"e system s"ould include Cero re(orting. Eac" site s"ould re'ort for eac"
re'orting 'eriod& e(en if it means re'orting 8ero cases. 9"is a(oids t"e confusion of
eJuating Lno re'ortM ;it" Lno casesM. ,ources of mortality& morbidity and
demogra'"ic data are gi(en in 9ables $.1!$.A.
Table *#. Sources of mortalit, data
2ealt) facilities
Hos'ital5"ealt" facility deat" records ! in'atient registers5out'atient registers
2ome 'isitors:communit, @or4ers
@ra(e-;atc"ers trained to 'ro(ide #)-"our co(erage on a designated single burial site
and re'ort on t"e daily number of burials
Home (isitors trained to use t"e (erbal auto'sy met"od for e:'ected causes of deat"
;it" standard forms
Beligious5community leaders
Community ;or%ers trained to re'ort deat"s for a defined section of t"e 'o'ulation&
e.g. 03 families
Ot)er agencies
Becords of organi8ations res'onsible for burial
Agencies distributing s"rouds free of c"arge to families of t"e deceased to encourage
re'orting of deat"s
Table *#1 Sources of morbidit, data
Healt" care facility records: out'atient de'artment 2OPD4and in'atient de'artment
2*PD4 registers and records in cam' clinics& "os'itals& feeding centres and local
communities
Healt" ;or%ers and mid;i(es ;it"in t"e dis'laced 'o'ulation
Table *#3 Sources of demogra()ic data
Begistration records maintained by cam' administrators& local go(ernment officials&
?nited .ations agencies& religious leaders& etc.
Ma''ing
Aerial '"otogra'"s or global 'ositioning systems
Census data
*nter(ie;s ;it" community leaders among t"e dis'laced 'o'ulation
Cross-sectional sur(eys
*#3 Identif,ing tas4s and res(onsible (ersons
9"e sur(eillance team must include a "ealt" coordinator& clinical ;or%ers&
community ;or%ers& a ;ater and sanitation s'ecialist and re'resentati(es of local
aut"orities. 9"e "ealt" coordinator is usually t"e team leader. 9"e team s"ould meet at
least daily in t"e acute '"ase of t"e emergency and ;ee%ly or mont"ly ;"en t"e
situation stabili8es.
One of t"e most im'ortant reJuirements for a good sur(eillance system is a
net;or% of moti(ated clinical ;or%ers trained in case detection and re'orting.
9"ese clinical ;or%ers ;ill "a(e many ot"er duties& 'rimarily t"e clinical care of
'atients. *t is essential from t"e beginning t"at t"ese ;or%ers a''reciate t"e
im'ortance of sur(eillance in t"e control of communicable diseases. 9"e data
collected must be sim'le and rele(ant. Constant feedbac% is necessary to maintain
moti(ation.
One clinical ;or%er in eac" "ealt" facility s"ould be assigned t"e tas% of data
collection and re'orting& and if necessary be gi(en on-site training. One 'erson&
normally assigned by t"e Ministry of Healt"& s"ould be res'onsible for: 2a4 liaison
;it" ?nited .ations agencies and nongo(ernmental organi8ations& to collect data and
re'ort to t"e Ministry of Healt"& 2b4 analysing data from "ealt" facilities and 2c4
'ro(iding feedbac%. Eac" member of t"e sur(eillance team must "a(e s'ecified tas%s
to be com'leted ;it"in a defined time 'eriod.
0igure *#% Information flo@ for communicable disease sur'eillance in emergencies
*#3#" 2ealt) @or4ers
9"is is t"e first contact t"at a sic% 'erson "as ;it" t"e "ealt" ser(ices. Be'orting
of data is only one of many tas%s for t"e clinical @or4er at t"is le(el. Data must be
sim'le and t"e number of items s"ould be limited. ,tandard case definitions s"ould be
distributed and used for t"e diseases or syndromes under sur(eillance. Becording
s"ould be in line ;it" clinical record-%ee'ing 'ractices. 9ally s"eets are (ery useful
for t"is 'ur'ose. ,us'ected cases rat"er t"an confirmed cases s"ould be re'orted. Gero
re'orting 2;"en t"ere are no cases4 is also essential. *mmediate re'orting of an
e'idemic disease s"ould be follo;ed by an immediate res'onse according to 'reset
standard 'rocedures.
*n many emergency situations& t"ere are communit, @or4ers a(ailable for acti(e
case-finding& ;"o can 'ro(ide "ome treatment for mild cases and refer moderate or
se(ere cases in a designated geogra'"ical area. 9"ese 'eo'le& if trained& can increase
t"e Juality and com'leteness of t"e sur(eillance system.
Communit, 4e, informants may be used to collect birt"& deat" and migration
information.
*#3#% 2ealt) coordinator
At t"is le(el& data are collected from t"e "ealt" facilities 2according to 're-
arranged timing4& usually under t"e res'onsibility of t"e "ealt" coordinator of t"e
district5 area or agency. Distribution of forms and guidelines must be ensured by t"e
"ealt" coordinator. 9"e function of t"is le(el is t"e ongoing analysis of data in order
to recogni8e outbrea%s or c"anges in disease trends. ,im'le 'rocedures s"ould lead to
an a''ro'riate res'onse suc" as in(estigation of sus'ected outbrea%s. Organi8ation for
s"i'ment and laboratory confirmation of sam'les from selected cases s"ould be
conducted at t"is le(el. =eedbac% of data to clinical ;or%ers is essential. Data s"ould
be re'orted to t"e Ministry of Healt".
*#3#* Ministr, of )ealt):)ead )ealt) agenc,
Data at t"is le(el s"ould feed into t"e national sur(eillance system of t"e "ost
country. 9"e data can also be used for ad(ocacy& fundraising& donor re'orts&
'rogramme re(ie;s and o(erall e(aluation of t"e effecti(eness of "ealt" care
inter(entions.
9"e tas%s of t"e (arious "ealt" ;or%ers at %ey ste's in sur(eillance are
summari8ed in 9able $./.
Table
*#5
Tas4s of )ealt) @or4ers at 4e, ste(s in sur'eillance
2ealt)
@or4er
Detecti
on
e(orti
ng
In'estigation Anal,
sis
es(onse
Laborat
ory
E'idem
io-logy
Contr
ol
Poli
cy
=eedba
c%
Clinical
@or4er
: : : :
2ealt)
coordinat
or
: : : : : : :
Ministr,
of
: : : : :
2ealt):L
ead
)ealt)
agenc,
*#5 Anal,sis and inter(retation of sur'eillance data
Data analysis must be done at t"e field le(el by t"e "ealt" coordinator. *n t"e
initial stages of an emergency& t"e most im'ortant data elements to be analysed are
t"e number of deat"s and t"e number of (ictims of an emergency. ?sing t"ese data&
t"e crude mortality rate s"ould be monitored daily during t"e acute '"ase. As t"ose
under 0 years of age are at "ig"er ris% of deat" in an emergency situation& mortality
rate in t"is age grou' s"ould also be calculated. *f 'o'ulation data for t"e under-fi(e
age grou' are not a(ailable& an estimate of 6Q of t"e total 'o'ulation may be used.
=or t"e under-fi(es& t"e cut-off (alue is more t"an #53 333 'er day. 9"e cut-off
(alues for mortality in an emergency situation are s"o;n in 9able $.3.
Table *#"6 Crude mortalit, rate cut<off 'alues in an
emergenc, situation
$)ase Crude mortalit, rate
8deat)s:"6 666
(o(ulation (er da,9
!nder<fi'e crude
mortalit, rate 8deat)s:"6
666 under<fi'es (er da,9
Normal 3.$!.3 3.1!#.3
Alert S.3 S #.3
Se'ere S #.3 S ).3
=or endemic diseases& morbidity trends o(er time are analysed by calculating
incidence rates 'er 333 'o'ulation. =or e'idemic-'rone diseases& 'articularly t"ose
for ;"ic" one confirmed case constitutes an outbrea% 2e.g. c"olera4& absolute numbers
of cases and attac% rates must be analysed by 'lace and 'erson& i.e. location ;it"in t"e
area and under 0& 0 and o(er& age grou's. 9"is information s"ould be 'resented in a
;ee%ly re'ort by t"e "ealt" coordinator in t"e emergency '"ase and t"en in a mont"ly
re'ort once t"e situation stabili8es. ,im'le summary tables& gra'"s and ma's s"ould
be used as muc" as 'ossible so t"at t"e information is readily understandable.
*#"6 0eedbac4
*#"6#"W), feedbac4 dataM
=eedbac% is needed to:
moti(ate clinical ;or%ers and gi(e t"em an incenti(e to re'ort dataN
inform "ealt" centre5clinical ;or%ers about t"e main "ealt" 'roblems locally
and at ot"er "ealt" centresN
'ro(ide e:am'les of control measures: yello; fe(er (accination& clean ;ater&
isolation& distribution of oral re"ydration salts& ne; defecation fieldN
feed for;ard to effect 'olicy c"ange.
One ;ay to 'ro(ide feedbac% of sur(eillance data is in a mont"ly e'idemio-logical
re(ie; 2during an emergency& a ;ee%ly re(ie; is often reJuired4& ;"ic" is a one-'age
summary of t"e maFor disease 'roblems o(er t"e 'ast mont".
*#"6#% $erformance indicators for t)e e'aluation of a
sur'eillance s,stem
e(orting
*ndicators of re'orting are:
8ero re'orting 2see ,ection $.14N
timeliness:
'ercentage of ;ee%ly re'orts recei(ed ;it"in )A "ours of end of re'orting
'eriod&
'ercentage of cases of e'idemic 'rone diseases re'orted ;it"in )A "ours of
onset of illness&
'ercentage of cases in(estigated ;it"in )A "ours of re'orting of alertN
com'leteness.
Laborator, efficienc,
*ndicators of laboratory efficiency may include& for e:am'le:
t"e number of c"olera cases for ;"ic" sam'les ;ere confirmed by t"e
laboratoryN
t"e number of malaria cases confirmed by blood smear.
In'estigation efficienc,
*ndicators of efficiency are 'eriods5delays bet;een:
date of onset of t"e first caseN
date of re'orting using outbrea% alert formN
date of in(estigationN
date of res'onse.
*#"6#* 0urt)er reading
Western DA. Cpidemiologic surveillance after natural disaster. Was"ington& DC&
Pan American Healt" Organi8ation& /A#.
,89 recommended surveillance standards. @ene(a& World Healt" Organi8ation&
/// 2document WHO5EMC5D*,5/6.4.
+# O!T7EAK CONTOL
9"is c"a'ter outlines t"e %ey acti(ities of outbrea% control in an emergency on a
ste'-by-ste' basis. An e'idemic is t"e occurrence of a number of cases of a disease
t"at is unusually large or une:'ected for a gi(en 'lace and time. Outbrea%s and
e'idemics refer to t"e same t"ing 2alt"oug" lay 'ersons often regard outbrea%s as
small locali8ed e'idemics4. 9"e term outbrea% ;ill be used in t"is manual. Outbrea%s
can s'read (ery ra'idly in emergency situations and lead to "ig" morbidity and
mortality rates. 9"e aim is to detect an outbrea% as early as 'ossible so as to control
t"e s'read of disease among t"e 'o'ulation at ris%.
Control measures s'ecific to different diseases are detailed under indi(idual
disease "eadings in C"a'ter 0.
*t must ne(er be forgotten t"at an increase in t"e number of cases of a disease may
result from a sudden influ: of dis'laced indi(iduals. W"ile t"is may not be an
outbrea% stricto sensu 2t"at is to say& an increase in rate abo(e a set (alue4& it may
ne(ert"eless 'resent t"e "ealt" ser(ices ;it" a tas% eJual to t"at of res'onding to an
outbrea%. *ndeed& t"e tas% may be greater& since t"ere may be a mar%ed increase in t"e
numbers of cases of se(eral diseases rat"er t"an of a single disease and eac" of t"ese
may reJuire a different res'onse. 9"is may not be an outbrea%& but it may generate a
medical emergency.
+#" $re(aredness
*n eac" emergency situation& t"e lead agency for "ealt" is res'onsible for
're'aration for and res'onse to a s"ar' increase in t"e numbers of cases of disease. 9o
're'are for suc" an e(entuality& it is essential t"at:
a sur(eillance system is 'ut in 'lace to ensure early ;arning of an increase in
t"e incidence or numbers of cases of diseasesN
an outbrea% res'onse 'lan is ;ritten for t"e disease ! co(ering t"e resources&
s%ills and acti(ities reJuiredN
standard treatment 'rotocols for t"e disease are a(ailable to all "ealt" facilities
and agencies and t"at clinical ;or%ers are trainedN
stoc%'iles of essential treatment su''lies 2medication and material4 and
laboratory sam'ling %its are a(ailable for t"e 'riority diseases& suc" as oral
re"ydration salts& intra(enous fluids& (accination material& tents& trans'ort
media and ;ater 'urification su''liesN
a com'etent laboratory is identified for confirmation of casesN
sources of rele(ant (accines are identified in t"e e(ent t"at a mass (accination
cam'aign is reJuired& and t"at su''lies of needles and syringes are adeJuateN
sources of additional treatment su''lies are identified for non (accine-
're(entable diseases in case of e:'ansion of outbrea%N
t"e a(ailability and security of a cold c"ain are establis"ed.
9"ere are a limited number of diseases ;it" e'idemic 'otential t"at 'ose a maFor
t"reat to t"e "ealt" of a 'o'ulation facing an emergency situation 2see 9able ).4.
9"ese diseases s"ould be identified during t"e ra'id assessment.
Table +#" Ma&or diseases @it) e(idemic
(otential in emergenc, situations
O C"olera
O Meningococcal disease
O Measles
O ,"igellosis
*n certain geogra'"ical areas& t"e follo;ing diseases may "a(e to be included:
O Malaria
O Louse-borne ty'"us
O Hello; fe(er
O 9ry'anosomiasis
O Eisceral or cutaneous leis"maniasis
O Eiral "aemorr"agic fe(ers
O Bela'sing fe(er
O 9y'"oid
O He'atitis A and E
*n addition& t"e lead "ealt" agency s"ould dra; u' a list of t"e main ris% factors
for outbrea%s in t"e emergency-affected 'o'ulation. Potential ris% factors are
'resented in 9able ).$.
A basic 'lan for resource reJuirements in t"e e(ent of an outbrea% s"ould be
de(elo'ed 29able ).)4. =or eac" disease& an outline res'onse 'lan s"ould be a(ailable
on site.
Table +#% S!MMA?D Ste(s in t)e
management of a communicable
disease outbrea4
"# $E$AATION
O Healt" coordination meetings.
O ,ur(eillance system: ;ee%ly "ealt" re'orts to Ministry of Healt" and WHO 2during
an outbrea%& t"is may be daily rat"er t"an ;ee%ly4
O Outbrea% res'onse 'lan for eac" disease: resources& s%ills and acti(ities reJuired.
O ,toc%'iles: sam'ling %its& a''ro'riate antimicrobial& intra(enous fluids& (accines
O Contingency 'lans for isolation ;ards in "os'itals 2see Anne: 6 for organi8ation of
an isolation centre4.&
O Laboratory su''ort.
%# DETECTION
9"e sur(eillance system must "a(e an early ;arning mec"anism for e'idemic-'rone
diseases 2see Anne: ) for guidelines on use of sur(eillance system and alert
t"res"olds4. *f cases of any of t"e follo;ing diseases5syndromes are diagnosed 2i.e.
alert t"res"old is 'assed4& inform t"e "ealt" coordinator as soon as 'ossibleN t"e "ealt"
coordinator s"ould inform t"e Ministry of Healt" and WHO:
! acute ;atery diarr"oea in o(er 0-year olds&
! bloody diarr"oea&
! sus'ected c"olera&
! measles&
! meningitis&
! acute "aemorr"agic fe(er syndrome&
! acute Faundice syndrome&
! sus'ected 'oliomyelitis 2acute flaccid 'aralysis4&
! a cluster of deat"s of un%no;n origin
& 2diseases5syndromes in list to be modified according to country 'rofile4.
9a%e clinical s'ecimen 2e.g. stool& serum& cerebros'inal fluid4 for laboratory
confirmation. *nclude case in ;ee%ly "ealt" re'ort.
*# ES$ONSE
Confirmation
O 9"e lead "ealt" agency s"ould in(estigate re'orted cases or alerts to confirm t"e
outbrea% situation ! number of cases "ig"er t"an e:'ected for same 'eriod of year and
'o'ulationN clinical s'ecimens ;ill be sent for testing.
O 9"e lead "ealt" agency s"ould acti(ate an outbrea% control team ;it" members"i'
from rele(ant organi8ations: Ministry of Healt"& WHO and ot"er ?nited .ations
organi8ations& nongo(ernmental organi8ations in t"e fields of "ealt" and ;ater and
sanitation& (eterinary e:'erts.
In'estigation
O Confirm diagnosis 2laboratory testing of sam'les4.
O Define outbrea% case definition.
O Count number of cases and determine si8e of 'o'ulation 2to calculate attac% rate4.
O Collect5analyse descri'ti(e data to date 2e.g. time5date of onset& 'lace5location of
cases and indi(idual c"aracteristics suc" as age5se:4.
O Determine t"e at-ris% 'o'ulation
O =ormulate "y'ot"esis for 'at"ogen5source5transmission.
O =ollo; u' cases and contacts.
O Conduct furt"er in(estigation5e'idemiological studies 2e.g. to clarify mode of
transmission& carrier& infectious dose reJuired& better definition of ris% factors for
disease and at-ris% grou's.
O Write an in(estigation re'ort 2in(estigation results and recommendations for action4.
Control
O *m'lement control and 're(ention measures s'ecific for t"e disease.
O Pre(ent e:'osure 2e.g. isolation of cases in c"olera outbrea%4.
O Pre(ent infection 2e.g. (accination in measles outbrea%4.
O 9reat cases ;it" recommended treatment as in WHO5national guidelines.
+# E/AL!ATION
O Assess a''ro'riateness and effecti(eness of containment measures.
O Assess timeliness of outbrea% detection and res'onse..
O C"ange 'ublic "ealt" 'olicy if indicated 2e.g. 're'aredness4.
O Write and disseminate outbrea% re'ort.
Table +#* is4 factors for outbrea4s in
emergenc, situations
Acute res'iratory infections *nadeJuate s"elter ;it" 'oor (entilation
*ndoor coo%ing& 'oor "ealt" care ser(ices
Malnutrition& o(ercro;ding
Age grou' under year old
Large numbers of elderly
Cold ;eat"er
Diarr"oeal diseases O(ercro;ding
*nadeJuate Juantity and5or Juality of
;ater
Poor 'ersonal "ygiene
Poor ;as"ing facilities
Poor sanitation
*nsufficient soa'
*nadeJuate coo%ing facilities
Malaria Mo(ement of 'eo'le from endemic into
malaria-free 8ones or from areas of lo;
endemicity to "y'erendemic areas
*nterru'tion of (ector control measures
*ncreased 'o'ulation density 'romoting
mosJuito bites
,tagnant ;ater
*nadeJuate "ealt" care ser(ices
=looding
C"anges in ;eat"er 'atterns
Measles Measles (accination co(erage rates belo;
A3Q in country of origin& o(ercro;ding&
'o'ulation dis'lacement
Meningococcal meningitis Meningitis belt 2alt"oug" t"e 'attern is
c"anging to include eastern& sout"ern and
central Africa4
Dry season
Dust storms
O(ercro;ding
Hig" rates of acute res'iratory infections
9uberculosis Hig" H*E sero're(alence rates
O(ercro;ding
Malnutrition
Eiral "aemorr"agic fe(er Contact ;it" a'e carcasses 2filo(iruses4
Contact ;it" ;ild-caug"t rodents 2Lassa
fe(er4
9ic%-infested areas 2Crimea-Congo
"aemorr"agic fe(er4
Poor infection control in "ealt"-care
facilities
Louse-borne ty'"us Hig"land areas
Poor ;as"ing facilities
.umerous body lice
.umerous body lice Endemic
ty'"us5cases of -rill-Ginsser disease
Table + #+ E=am(le of resources needed for
outbrea4 res(onse
O Personnel 2trained staff4
O ,u''lies 2e.g. oral re"ydration salts& intra(enous fluids& ;ater containers& ;ater-
'urifying tablets& drin%ing cu's& (accines& (itamin A& monitoring forms& (accination
cards& tally s"eets4
O 9reatment facilities 2location& beds a(ailable& stoc%s of basic medical su''lies4
O Laboratory facilities 2location& ca'acity& stoc%s of reagents& etc.4
O 9rans'ort 2sources of emergency trans'ort and fuel& cold c"ain4
O Communication lin%s 2bet;een "ealt" centresN bet;een Ministry of Healt"&
nongo(ernmental organi8ations and ?nited .ations agencies4
O Com'uters for data analysis
O *n an outbrea% reJuiring a (accination cam'aign:
! safe inFection eJui'ment 2e.g. auto-destructible syringes and safety bo:es 2'uncture-
resistant bo:es4
! (accination facilities 2location& ca'acity4
! cold c"ain eJui'ment 2number and condition of refrigerators& cold bo:es& (accine
carriers& ice-'ac%s4
0igure +#" Detection of an outbrea4
+#%#" Sur'eillance
9o ensure early detection of an outbrea% in an emergency situation& a basic
sur(eillance system ;it" an early ;arning mec"anism agreed by all o'erational
agencies is essential. Be'orting forms& case definitions and re'orting mec"anisms
s"ould be de(elo'ed by t"e lead "ealt" agency at t"e beginning of t"e emergency and
consensus reac"ed ;it" all agencies. Clinical ;or%ers at t"e 'rimary and secondary
care le(els are t"e %ey com'onent of t"is early ;arning system. 9"ey must be trained
to re'ort any sus'ected case of a disease ;it" e'idemic 'otential immediately to t"e
"ealt" coordinator& using direct communication and5or t"e outbrea% alert form 2Anne:
14.
9o ensure ra'id detection of an outbrea% in an emergency situation& it ;ill be
necessary:
to set u' an early ;arning system ;it"in t"e sur(eillance system& ;it"
immediate re'orting of diseases ;it" e'idemic 'otentialN
to train clinical ;or%ers to recogni8e 'riority diseases5syndromesN
to train clinical ;or%ers to re'ort cases of 'riority diseases5syndromes
immediately to t"e "ealt" coordinatorN
for t"e "ealt" coordinator to re'ort to t"e lead "ealt" agencyN
to arrange for en"anced sur(eillance during "ig"-ris% 'eriods and in "ig"ris%
areas& e.g. for meningococcal meningitis during t"e dry season in t"e
meningitis belt.
9"e analysis of t"ese re'orts by t"e "ealt" coordinator ;ill allo; for t"e
identification of clusters. *t is (ital t"at all sus'ected cases are follo;ed u' and
(erified. *n cam's establis"ed after large 'o'ulation dis'lacements& an immediate
res'onse is necessary because of 'otentially "ig" case attac% rates and "ig" mortality
rates. Early detection can "a(e a maFor im'act in reducing t"e numbers of cases and
deat"s during an outbrea% 2see =ig. ).#4.
9"e sur(eillance system ;ill ideally "a(e detected an outbrea% in t"e early stages.
Once an outbrea% occurs& in(estigation ;ill be reJuired to:
confirm t"e outbrea%&
identify all cases and contacts&
detect 'atterns of e'idemic s'read&
estimate 'otential for furt"er s'read&
determine ;"et"er control measures are ;or%ing effecti(ely.
0igure +#% T)e im(act of earl, detection and res(onse in reducing t)e disease
burden caused b, an outbrea4 in an emergenc, situation
OCTD Outbrea4 control team
W"ile routine sur(eillance de'ends on 'assi(e met"ods 2i.e. t"e "ealt" ;or%ers
re'ort data ;ee%ly or mont"ly as 'art of t"eir o(erall duties4& in an outbrea% t"ere may
be a need for acti(e sur(eillance& ;"ere a member of t"e outbrea% control team 2OC94
s'ecifically goes to t"e "ealt" facilities and re(ie;s t"e records to detect furt"er cases.
9"is is 'articularly im'ortant for "ig"ly infectious diseases& suc" as (iral
"aemorr"agic fe(er. Acti(e case-finding may also be necessary ;"ere a "ome (isitor
goes into t"e community searc"ing for furt"er cases of t"e disease and refers to t"e
"ealt" facility. Eac" case is t"en re'orted to t"e OC9.
9"e amount of data needed for eac" outbrea% (aries ;it" t"e disease and t"e
number of cases. *n an e:'losi(e outbrea% ;it" large numbers of cases t"ere ;ill not
be time to collect detailed information& so t"e 'riority is to collect numbers of cases
and deat"s on a line listing form. =or outbrea%s t"at are smaller in si8e or t"at e(ol(e
more slo;ly 2suc" as a meningitis outbrea%4& a case in(estigation form s"ould be
com'leted for eac" case to obtain information suc" as contacts 2see Anne: 14.
+#%#% E(idemic t)res)olds
9"e term e'idemic t"res"old refers to t"e le(el of disease abo(e ;"ic" an urgent
res'onse is reJuired. 9"e t"res"old is s'ecific to eac" disease and de'ends on t"e
infectiousness& ot"er determinants of transmission and local endemicity le(els. =or
certain diseases& suc" as c"olera or "aemorr"agic fe(er& one case is sufficient to
initiate a res'onse. =or ot"er diseases& suc" as malaria& establis"ing a t"res"old ideally
reJuires t"e collection of incidence data o(er a 'eriod of mont"s or years.
Ho;e(er& most e'idemic t"res"olds "a(e been de(elo'ed for stable 'o'ulations&
because t"ese t"res"olds reJuire longitudinal data o(er a 'eriod of years. 9"ere are
fe; data on t"e use of t"ese e'idemic t"res"olds in emergency situations ;it"
recently dis'laced 'o'ulations. .e(ert"eless& t"e establis"ment of a sur(eillance
system early in an emergency situation ;ill ensure t"at baseline data on diseases ;it"
e'idemic 'otential are a(ailable. 9"is ;ill allo; an assessment of ;"et"er an increase
in numbers of cases or deat"s reJuires action or not. At t"e onset of "ealt" acti(ities&
t"e "ealt" coordination team s"ould set a t"res"old for eac" disease of e'idemic
'otential abo(e ;"ic" an emergency res'onse must be initiated 2see 9able ).04.
Table +#- E(idemic t)res)olds
One sus'ected case of t"e follo;ing diseases re'resents a 'otential outbrea% and
reJuires immediate in(estigation:
O c"olera
O measles
O ty'"us
O 'lague
O yello; fe(er
O (iral "aemorr"agic fe(er
An increase in t"e number of cases abo(e a gi(en t"res"old 2or in numbers of cases
'er 333 'o'ulation4 of t"e follo;ing diseases indicates a 'otential outbrea% and
reJuires immediate in(estigation:
O malaria
O s"igellosis
O (isceral leis"maniasis
O meningococcal meningitis
O "uman African try'anosomiasis
O ot"ers 2e.g. ty'"oid fe(er& "e'atitis A4
=or areas of Africa ;"ere meningococcal disease is "ig"ly endemic& generic
t"res"olds "a(e been defined based on ;ee%ly sur(eillance of meningitis. 9;o
t"res"olds are recommended to guide different sets of acti(ities& de'ending on t"e
'"ase of de(elo'ment of an outbrea%.
#
9"e alert threshold is used to: 2a4 sound an early ;arning and launc" an
in(estigation at t"e start of an outbrea%N 2b4 c"ec% e'idemic 're'arednessN 2c4
start a (accination cam'aign if t"ere is an outbrea% in a neig"bouring areaN and
2d4 'rioriti8e areas for (accination cam'aigns in t"e course of an outbrea%.
,am'le alert t"res"olds are gi(en in Anne: ).
9"e epidemic threshold is used to confirm t"e emergence of an outbrea% so as
to ste' u' control measures& i.e. mass (accination and a''ro'riate case
management. 9"e e'idemic t"res"old de'ends on t"e conte:t& and ;"en t"e
ris% of an outbrea% is "ig" a lo;er t"res"old& more effecti(e in t"is situation& is
recommended 2see 9able ).14.
Wee%ly meningitis incidence is calculated at "ealt" district le(el& for a 'o'ulation
ranging from $3 333 to about 33 333 in"abitants. *ncidence calculated for a large
'o'ulation 2suc" as a city of more t"an $33 333 in"abitants4 mig"t not reac" t"e
t"res"old& e(en ;"en t"e t"res"old is e:ceeded in some areas. *n order to detect
locali8ed outbrea%s& t"e region or city s"ould be di(ided into areas of a''ro:imately
33 333 'eo'le for t"e 'ur'ose of calculating incidence.
=or 'o'ulations of less t"an $3 333& an absolute number of cases is used to define
t"e alert and e'idemic t"res"olds. 9"is is to a(oid maFor fluctuations in incidence
o;ing to t"e small si8e of t"e 'o'ulation& and so as not to declare an outbrea% too
"astily on t"e basis of a small number of cases.
Table +#. Incidence t)res)olds for detection and
control of e(idemic meningococcal meningitis
in )ig)l, endemic countries in Africa
Inter'ention
a
$o(ulation
N *6 666 O *6 666
4lert threshold O =i(e cases 'er 33 333
in"abitants 'er ;ee%
O 9;o cases in ;ee%
O *nform aut"orities or
O *n(estigate O An increase in t"e
number of cases com'ared
to 're(ious non-e'idemic
years
O Confirm
O 9reat cases
O ,trengt"en sur(eillance
O Pre'are
Cpidemic threshold *f 24 no e'idemic for $
years and (accination
co(erage U A3Q or 2#4
alert t"res"old crossed
early in t"e dry season:
O =i(e cases in ;ee%
O Mass (accination O 3 cases 'er 33 333
in"abitants 'er ;ee%
or
O Distribute treatment to
"ealt" centres
*n ot"er situations: O Doubling of t"e number
of cases in a $-;ee% 'eriod
O 9reat according to
e'idemic 'rotocol
O 0 cases 'er 33 333
in"abitants 'er ;ee%
or
O *nform t"e 'ublic O Ot"er situations s"ould
be studied on a case-by-
case basis
a
-f there is an epidemic in a neighbouring area* the alert threshold becomes the
epidemic threshold"
+#%#* Outbrea4 control team 8OCT9
Once t"e sur(eillance system detects an outbrea%& or alerts "a(e been recei(ed& t"e
lead "ealt" agency must set u' an OC9 to in(estigate. Members"i' ;ill essentially be
similar to t"e "ealt" coordination team but may "a(e to be e:'anded de'ending on t"e
disease sus'ected and t"e control measures reJuired. 9"e OC9 s"ould include:
a "ealt" coordinator&
a clinical ;or%er&
a laboratory tec"nician&
a ;ater5sanitation s'ecialist&
a (ector control s'ecialist&
a re'resentati(e of t"e local "ealt" aut"ority&
"ealt" educators&
community leaders.
One member of t"e team s"ould be t"e team leaderN t"is is usually t"e "ealt"
coordinator of t"e lead "ealt" agency. Eac" agency s"ould be gi(en a clear role for
res'onse to an outbrea%& suc" as t"e establis"ment of an isolation centre or t"e
im'lementation of a mass (accination 'rogramme.
*n t"e e(ent of a sus'ected outbrea%& t"e OC9 must:
meet daily to re(ie; t"e latest data on sus'ected cases5deat"s and follo; u'
any alertsN
im'lement t"e outbrea% res'onse 'lan 2see 're'aredness section4 for t"e
disease co(ering t"e resources& s%ills and acti(ities reJuiredN
identify sources of additional "uman and material resources for managing t"e
outbrea%& e.g. treatment sites in a c"olera outbrea%N
define t"e tas%s of eac" member in managing t"e outbrea%& e.g. sur(eillance&
(accinationN
ensure t"e use of standard treatment 'rotocols for t"e disease by all agencies
and train clinical ;or%ers if necessaryN
coordinate ;it" t"e local "eat" aut"orities& nongo(ernmental organi8ations
and ?nited .ations agencies.
+#* Confirmation
0igure +#* Confirmation of an outbrea4
+#*#" /erification of an outbrea4 and laborator, confirmation
Be'orts and alerts of outbrea%s are freJuent in emergency situations and must
al;ays be follo;ed u'. *t is im'ortant to a;are t"at in some languages one ;ord may
be used for more t"an one disease 2e.g. in ,erbo-Croat and its (ariants t"e same ;ord
is used for ty'"us and ty'"oid4. Diagnosis must be confirmed eit"er on a clinical basis
by senior clinical ;or%ers 2e.g. for measles4 or by laboratory tests& in ;"ic" case
s'ecimens 2e.g. blood& serum& faeces or cerebros'inal fluid4 must be sent to a
laboratory for testing. Material reJuired for an outbrea% in(estigation is listed in
Anne: 1.
An assessment of current clinical and e'idemiological information is t"e starting
'oint for dealing ;it" t"e 'roblem of an outbrea% of un%no;n origin. 9"e "istorical
%no;ledge of regional endemic and e'idemic diseases& as ;ell as t"eir seasonality&
furt"er defines t"e 'ossible causes. ,ince a (ariety of infectious agents can cause a
similar clinical 'icture& t"e initial ste's of t"e outbrea% in(estigation 2case definitions&
Juestionnaires& etc.4 s"ould generally elaborate on %no;n syndromes 2e.g. fe(er of
un%no;n origin& acute neurological syndrome& acute Faundice4 rat"er t"an on any
'reconcei(ed diagnosis. One or more s'ecimen ty'es may be reJuired to define t"e
cause of t"e outbrea%.
Laboratory confirmation of initial cases is necessary for most diseases ;"en an
outbrea% is sus'ected. 9"ere must be an efficient mec"anism for getting t"e correct
sam'les in good condition from t"e 'atient to t"e laboratory and getting t"e result
bac% to t"e OC9 and clinical ;or%ers. At t"e onset of "ealt" care acti(ities in a cam'&
t"e lead "ealt" agency must set out t"e met"od for sam'ling& t"e ty'e of sam'les to be
ta%en and t"e tests to be underta%en& and identify t"e rele(ant laboratories ;it"
com'lete addresses. 9"e agency must assess t"e diagnostic ca'ability of t"e local
laboratory& including t"e a(ailability of ra'id diagnostic %its. A reference laboratory
must also be identified at regional or international le(el to test& for e:am'le& for t"e
antimicrobial sensiti(ity of 2higella s''. 9able ).6 outlines t"e ste's in laboratory
confirmation.
Table +#1 Ste(s in laborator, confirmation
Collection of sam'les ,am'ling eJui'ment& s'ecimen
containers& training of clinical ;or%ers in
sam'ling tec"niJues
9rans'ort of sam'les On-site5referral laboratory
,afe 'ac%aging A''ro'riate lea%-'roof trans'ort
containers
9esting sam'les \uality assurance in laboratory
Be'orting result W"en& to ;"om
*nter'reting result *m'lications for control measures
*f a certain 'at"ogen& source or mode of transmission is sus'ected& control
measures s)ould not be dela,ed if laboratory confirmation is not yet a(ailable# *n
t"e absence of laboratory confirmation& e'idemiological information s"ould continue
to be collected& as t"is ;ill facilitate t"e initial control measures.
Table +#3 Laborator, s(ecimens reFuired for tests for
s(ecific causati'e agents
Sus(ected disease S(ecimen Diagnostic test Additional
information
needed
C"olera =res" stool5 rectal
s;ab in trans'ort
medium
Culture Antimicrobial
sensiti(ity testing
He'atitis - ,erum 2]) `C4 Antigen detection
Malaria -lood 2t"ic% and
t"in smears4
,taining
Ba'id diagnostic
tests 2for D"
falciparum and D"
viva+4
Meningococcal
meningitis
C,=
a
@ram stain ,erogrou'ing
-lood Ba'id diagnostic
test
,"igellosis =res" stool5 rectal
s;ab in trans'ort
medium
Culture ,erogrou'ing
Ba'id diagnostic
test
Antimicrobial
sensiti(ity testing
9y'"oid fe(er -lood in culture
bottles
Culture
9y'"us ,erum 2]) `C4 ,erology
Eiral "aemorr"agic
fe(ers
-lood Antigen detection
Note: 5easles is diagnosed clinically and does not require laboratory
confirmation"
a
<2F: cerebrospinal fluid
+#*#% $lanning for s(ecimen collection
After t"e clinical syndrome and sus'ect 'at"ogen2s4 "a(e been defined& t"e
clinical s'ecimens for collection and a''ro'riate laboratory diagnosis s"ould be
determined 29able ).A4.
*n t"e e(ent of an outbrea%& one agency s"ould coordinate t"e trans'ort of
s'ecimens and follo; u' on t"e results of laboratory tests. Laboratories ;it" t"e
ca'acity to test 2a4 stool sam'les for 2higella* 2almonella and c"olera and 2b4 C,=
sam'les for meningococci s"ould be identified ra'idly. WHO maintains an u'dated
database of international reference laboratories for testing of stool sam'les for
'olio(irus& or serum sam'les for dengue fe(er& Ca'anese ence'"alitis and agents of
(iral "aemorr"agic fe(ers.
+#*#* S(ecimen collection and (rocessing
,'ecimens obtained in t"e acute '"ase of t"e disease& 'referably before
administration of antimicrobial drugs& are more li%ely to yield laboratory
identification of t"e cause. -efore s'ecimen collection begins& t"e 'rocedure s"ould
be e:'lained to t"e 'atient and "is5"er relati(es. 9"e a''ro'riate 'recautions for
safety during collection and 'rocessing of sam'les must be follo;ed.
Procedures for collection of s'ecific s'ecimens are detailed in Anne: A.
Labelling and identification of s(ecimens
*n an outbrea% in(estigation& t"e information contained in t"e case in(estigation
and laboratory reJuest forms is collected along ;it" t"e s'ecimen. Eac" 'atient
s"ould be assigned a uniJue identification number by t"e collection team. *t is t"e lin%
bet;een t"e laboratory results on t"e line listing form& t"e s'ecimens and t"e 'atient&
;"ic" guides furt"er in(estigation and res'onse to t"e outbrea%. 9"is uniJue
identification number s"ould be 'resent and used as a common reference toget"er
;it" t"e 'atient<s name on all s'ecimens& e'idemiological databases& and forms for
case in(estigation or laboratory reJuest.
Label s(ecimen container:slide
Labels 2at least fi(e4 s"ould be used ;"ene(er 'ossible. 9"e label s"ould be
'ermanently affi:ed to t"e s'ecimen container. *t s"ould contain:
t"e 'atient<s name&
t"e uniJue identification number&
t"e s'ecimen ty'e and date and 'lace of collection&
t"e name or initials of t"e s'ecimen collector.
Case in'estigation and laborator, forms
A case in(estigation form s"ould be com'leted for eac" 'atient at t"e time of
collection. 9"e originals remain ;it" t"e in(estigation team& and s"ould be %e't
toget"er for analysis and later reference. A laboratory form must also be com-'leted
for eac" s'ecimen. 9"e e'idemiological and clinical data gat"ered in t"e in(estigation
can t"en easily be tied to t"e laboratory results for analysis later.
9"e form includes:
'atient information: age 2or date of birt"4& se:& com'lete address&
clinical information: date of onset of sym'toms& clinical and (accination
"istory& ris% factors& antimicrobials ta%en before collection of s'ecimens&
laboratory information: acute or con(alescent s'ecimen& ot"er s'ecimens from
t"e same 'atient.
9"e form must also record t"e date and time ;"en t"e s'ecimen ;as ta%en and
;"en it ;as recei(ed by t"e laboratory& and t"e name of t"e 'erson collecting t"e
s'ecimen.
+#*#+ Storage of s(ecimens
9o 'reser(e bacterial or (iral (iability in s'ecimens for microbiological culture or
inoculation& s'ecimens s"ould be 'laced in a''ro'riate media and stored at
recommended tem'eratures. 9"ese conditions must be 'reser(ed t"roug"out trans'ort
to t"e laboratory and ;ill (ary according to trans'ortation time. 9"ey ;ill differ for
different s'ecimens and 'at"ogens& de'ending on t"eir sensiti(ity to desiccation&
tem'erature& nutrient and 'H.
Many s'ecimens ta%en for (iral isolation are (iable for # days if maintained in
ty'e-s'ecific media at )!A `C. 9"ese s'ecimens must be fro8en only as directed by
e:'ert ad(ice& as infecti(ity may be altered.
,'ecimens for bacterial culture s"ould be %e't in a''ro'riate trans'ort media at
t"e recommended tem'erature. 9"is ensures bacterial (iability ;"ile minimi8ing
o(ergro;t" of ot"er microorganisms. Wit" t"e e:ce'tion of cerebros'inal fluid& urine
and s'utum& most s'ecimens may be %e't at ambient tem'erature if t"ey ;ill be
'rocessed ;it"in #) "ours. =or 'eriods S #) "ours& storage at )!A `C is ad(isable
e:ce't for 'articularly cold-sensiti(e organisms suc" as 2higella s''.& meningococcus
and 'neumococcus. 9"ese e:ce'tions must be %e't at ambient tem'erature. Longer
delays are not ad(isable& as t"e yield of bacteria may fall significantly.
,'ecimens for antigen or antibody detection may be stored at )!A `C for #)!)A
"ours& or at !#3 `C for longer 'eriods. ,era for antibody detection may be stored at )!
A `C for u' to 3 days. Alt"oug" not ideal& room tem'erature may still be useful for
storing serum sam'les for antibody testing& e(en for 'rolonged 'eriods 2;ee%s4. 9"us
sam'les t"at "a(e been collected s"ould not be discarded sim'ly because t"ere are no
refrigeration facilities a(ailable.
9rans'ort of s'ecimens reJuires a''ro'riate safety bo:es& cold bo:es and coolant
bloc%s and may reJuire a suitable cold c"ain.
+#+ es(onse
+#+#" In'estigation of source and modes of transmission
9"e OC9 s"ould:
meet daily to u'date t"e team on outbrea% de(elo'mentsN
re(ie; t"e "uman& logistic 2stores& stoc%s& etc.4 and financial resources
a(ailable to manage t"e outbrea%N
o(ersee t"e in(estigation of re'orted cases to assess 'at"ogen& source and
transmissionN
ensure t"at clinical ;or%ers re'ort sus'ected cases to t"e team immediatelyN
ensure t"at clinical ;or%ers are using standard treatment 'rotocolsN
ensure t"at cases are Juantified by time and 'laceN
'roduce s'ot ma's and e'idemic cur(esN
o(ersee t"e im'lementation of control measures.
Collection and anal,sis of descri(ti'e data and de'elo(ment of
),(ot)eses
9"e systematic recording of data on cases and deat"s 2time& 'lace and 'erson4 in
an outbrea% is essential to ensure accurate re'orting. 9"ese data are necessary to form
a "y'ot"esis of t"e 'at"ogen in(ol(ed and its source and route of transmission& and to
measure t"e effecti(eness of control measures. 9"is 'rocess is summari8ed in t"e si:
%ey Juestions: W"o^ W"at^ W"en^ W"ere^ W"y^ Ho;^
A sim'le& clear& easily understood case definition must be used consistently from
t"e beginning of an outbrea% and must be 'laced cons'icuously at t"e to' of eac" case
re'orting form. 9"is case definition& t"e outbrea6 case definition* may "a(e to be
ada'ted from t"e sur(eillance case definition. 9"e syndromic definitions often used
by t"e sur(eillance system for early detection may not be sufficiently s'ecific in t"e
e(ent of an outbrea% and could lead to an o(erestimation of cases. *n most outbrea%s&
basic e'idemiological data on time& 'lace& 'erson and basic laboratory confirmation
are sufficient for t"e design and im'lementation of effecti(e control measures.
Cases may be 'laced in t;o categories: sus'ected or confirmed. A sus'ected case
is one in ;"ic" t"e clinical signs and sym'toms are com'atible ;it" t"e disease in
Juestion but laboratory confirmation of infection is lac%ing 2negati(e or 'ending4. A
confirmed case is one in ;"ic" t"ere is definite laboratory e(idence of current or
recent infection& /hether or not clinical signs or sym'toms are or "a(e been 'resent.
Once laboratory in(estigations "a(e confirmed t"e diagnosis in t"e initial cases& t"e
use of a clinical5e'idemiological case definition may be sufficient and t"ere may be
no need to continue to collect laboratory s'ecimens from ne; cases for t"e 'ur'oses
of notification.
During an e'idemic& data s"ould be analysed ra'idly to determine t"e e:tent of t"e
outbrea% and t"e im'act of actions ta%en to date 2=ig. ).)4.
0igure +#+ Collection and anal,sis of descri(ti'e data
9"e follo;ing ste's s"ould be ta%en by members of t"e outbrea% control team in
c"arge of t"e e'idemiological in(estigation.
Define t"e e:tent of t"e outbrea% in time& 'lace and 'erson:
;"en did t"e cases occur ! dates of onset 2e.g. e'idemic cur(e4^
;"ere do cases li(e 2e.g. s'ot ma'4^
;"o are t"ey 2e.g. tables of age& (accination status4^
Measure t"e se(erity of t"e outbrea%:
"o; many cases ;ere "os'itali8ed^
"o; many cases suffered com'lications^
"o; many cases died as a 'ro'ortion of all cases 2case-fatality rate4^
Dra; an e'idemic cur(e& i.e. a gra'" s"o;ing cases by date of onset. 9"is
"el's to demonstrate ;"ere and "o; an outbrea% began& "o; Juic%ly t"e
disease is s'reading& t"e stage of t"e outbrea% 2start& middle or end '"ase4 and
;"et"er control efforts are "a(ing an im'act 2=ig. ).)4.
Dra; a gra'" or table of age distribution and (accination status of casesN t"is
s"ould be constructed from t"e line listing of cases. 9"is information is used
for identifying cases t"at ;ere not 're(entable 2e.g. t"ose de(elo'ing measles
before t"e sc"eduled age of (accination4. *f 'o'ulation data are a(ailable&
calculate age-s'ecific attac% rates.
*f a''ro'riate& estimate t"e (accine efficacy. *n t"e case of a (accine-
're(entable disease suc" as measles& (accine efficacy and t"e 'ro'ortion of
cases t"at ;ere (accine-'re(entable s"ould be calculated. ?sing (accination
"istory data it is 'ossible to tabulate t"ose immuni8ed but not 'rotected
2(accine failures4 and t"ose ;"o failed to be immuni8ed.
Dra; a s'ot ma'. A ma' of t"e cam' or community s"ould be mar%ed ;it"
t"e location of all cases and deat"s. 9"e outbrea% control team can use t"is
ma' to identify areas ;it" clusters of disease. =urt"er in(estigation of t"ese
areas may re(eal t"e source of infection or modes of transmission. E(en ;"en
a cam' is in(ol(ed& it is essential t"at t"e effect on t"e local community
outside t"e cam' is documented 2t"is may be t"e source4 and t"e local "ealt"
aut"orities assisted in controlling t"e outbrea% if it "as s'read.
Pro(ide summary data of t"e outbrea%& by calculating t"e basic
e'idemiological indices set out in 9able )./.
Table +#5 7asic e(idemiological indices
T)e case<fatalit, rate 8C09 is t)e (ercentage of cases t)at result in deat)
O Count t"e number of cases ;"o died of t"e disease
O Di(ide by t"e total number of cases of t"e disease
O Multi'ly t"e result by 33
T)e @ee4l, attac4 rate is t)e number of cases (er "6 666 (eo(le (er @ee4
O Di(ide 3 333 by t"e total emergency-affected 'o'ulation
O Multi'ly t"e result by t"e number of cases t"at occurred in a gi(en ;ee%
T)e age<s(ecific @ee4l, attac4 rate is t)e number of cases (er "6 666 (eo(le in
one age grou( 8e#g# N - ,ears9
O Calculate t"e number of 'ersons in t"at age grou' in t"e cam'
O Count t"e number of cases in t"e age grou' for t"e c"osen ;ee%
O Di(ide 3 333 by t"e number of 'ersons
O Multi'ly t"e result by t"e number of cases in t"at grou'
0ollo@<u( of cases and contacts
=or eac" case& information s"ould be collected on name& age& location& date of
onset and outcomeN for some diseases& additional information on (accination status&
;ater source and duration of disease may be collected.
An alert registry must be establis"ed to record alerts of cases systematically. One
site s"ould be dedicated to t"is acti(ity. 9"e registry must "a(e close lin%s to "ome
(isitors and t"e local community and its e:istence must be ;idely ad(ertised. *t
s"ould be carefully maintained and used to 'ro(ide material for t"e team.
Acti(e case-finding may be reJuired& de'ending on t"e infectiousness of t"e
disease and t"e ris% to t"e 'o'ulation. Contact-tracing may also be reJuired&
'articularly in t"e case of outbrea%s of (iral "aemorr"agic fe(er. 9"e OC9 must
define ;"at constitutes a contact& s'ecify t"e 'eriod of ris% and agree on t"e met"od
of follo;-u'& e.g. acti(e contact-tracing.
0urt)er in'estigation:e(idemiological studies
*n some outbrea%s& routine data do not gi(e sufficient information about items
suc" as t"e source of t"e outbrea%& ris% factors& local c"aracteristics of t"e causati(e
agent 2e.g. resistance& seroty'e4 or mode of transmission. =urt"er in(estigation& suc"
as case control studies or en(ironmental assessments 2e.g. (ector breeding sites4& may
be reJuired to identify t"e source of t"is outbrea%& ris% factors in res'ect of se(erity&
or modes of transmission. 9"is may need t"e 'artici'ation of e:ternal agencies ;it"
s%ills in e'idemiological in(estigation or in s'ecific diseases.
+#+#% Control
9"e data gat"ered in t"e course of t"ese in(estigations s"ould re(eal ;"y t"e
outbrea% occurred and t"e mec"anisms by ;"ic" it s'read. 9"ese in turn& toget"er
;it" ;"at is %no;n about t"e e'idemiology and biology of t"e organism in(ol(ed&
;ill ma%e it 'ossible to define t"e measures needed to control t"e outbrea% and
're(ent furt"er 'roblems.
An outbrea% may be controlled by eliminating or reducing t"e source of infection&
interru'ting transmission and 'rotecting 'ersons at ris%. *n t"e initial stage of an
outbrea% in an emergency situation& t"e e:act nature of t"e causati(e agent may not be
%no;n and general control measures may "a(e to be ta%en for a sus'ected cause.
Once t"e cause is confirmed& s'ecific measures suc" as (accination can be
underta%en. 9"ese disease-s'ecific measures are detailed in C"a'ter 0.
Control strategies fall into four maFor categories of acti(ity.
. Drevention of e+posure: t"e source of infection is reduced to 're(ent t"e
disease s'reading to ot"er members of t"e community. De'ending on t"e
disease& t"is may in(ol(e 'rom't diagnosis and treatment of cases using
standard 'rotocols 2e.g. c"olera4& isolation and barrier nursing of cases 2e.g.
(iral "aemorr"agic fe(ers4& "ealt" education& im'ro(ements in en(ironmental
and 'ersonal "ygiene 2e.g. c"olera& ty'"oid fe(er& s"igellosis& "e'atitis A and
"e'atitis E4& control of t"e animal (ector or reser(oir 2e.g. malaria& dengue&
yello; fe(er& Lassa fe(er4 and 'ro'er dis'osal of s"ar' instruments 2e.g.&
"e'atitis -4.
#. Drevention of infection: susce'tible grou's are 'rotected by (accination 2e.g.
meningitis& yello; fe(er and measles4& safe ;ater& adeJuate s"elter and good
sanitation.
$. Drevention of disease: "ig"-ris% grou's are offered c"emo'ro'"yla:is 2e.g.
malaria 'ro'"yla:is may be suggested for 'regnant ;omen in outbrea%s4 and
better nutrition.
). Drevention of death: t"roug" 'rom't diagnosis and management of cases&
effecti(e "ealt" care ser(ices 2e.g. acute res'iratory infections& malaria&
bacterial dysentery& c"olera& measles& meningitis4.
,election of control measures de'ends on:
feasibility 2tec"nical5o'erational4&
a(ailability 2stoc%'iles4&
Oacce'tability&
safety 2of o'erators and 'o'ulation4&
cost.
$atient isolation
9"e degree of isolation reJuired de'ends on t"e infectiousness of t"e disease.
,trict barrier isolation is rarely indicated in "ealt" facilities& e:ce't for outbrea%s of
"ig"ly infectious diseases suc" as (iral "aemorr"agic fe(ers. 9"e isolation room must
be in a building se'arate from ot"er 'atient areas and access must be strictly limited.
@ood (entilation ;it" screened doors is ideal& but fans s"ould be a(oided as t"ey raise
dust and dro'lets and can s'read aerosols. -io"a8ard ;arning notices must be 'laced
at t"e entrances to 'atients< rooms. Patients must remain isolated until t"ey "a(e fully
reco(ered.
During outbrea%s& isolation of 'atients or of t"ose sus'ected of "a(ing t"e disease
can reinforce stigmati8ation and "ostile be"a(iour of t"e 'ublic to;ard ill 'ersons.
9"e establis"ment of isolation rules in a community or in a "ealt" facility is not a
decision to be ta%en lig"tly& and s"ould al;ays be accom'anied by careful
information and education of all members of t"e in(ol(ed community. E(ery isolated
'atient s"ould be allo;ed to be attended by at least one family member. Pro(ided t"at
enoug" su''lies are a(ailable& designated family attendants s"ould recei(e barrier
nursing eJui'ment& and be instructed on "o; to 'rotect t"emsel(es ;"en in contact
;it" t"e 'atient.
E(ery outbrea% reJuires a res'onse s'ecific to t"e disease. Control measures for
t"e main communicable diseases encountered by dis'laced 'o'ulations are described
under disease-s'ecific sections in C"a'ter 0.
7io)aCardous materials
,afe dis'osal of body fluids and e:creta is essential& es'ecially in t"e case of
"ig"ly contagious diseases. 9"is may be ac"ie(ed by disinfecting ;it" bleac" or by
incineration. *f contaminated material "as to be trans'orted& it s"ould be 'laced in a
double bag.
9"e t"reat of infection from body fluids of 'atients ;it" diseases suc" as c"olera&
s"igellosis or (iral "aemorr"agic fe(ers is serious& and strict 'roce-dures for dis'osal
of "a8ardous ;aste must be maintained. Laboratory s'ecimens and contaminated
eJui'ment s"ould also be carefully sterili8ed or dis'osed of. W"en 'ossible& "eating
met"ods suc" as autocla(ing& incineration or boiling can be used to disinfect. Pro'er
dis'osal of s"ar' obFects suc" as needles is essential.
9able $.3 outlines t"e general 'recautions to be ta%en in relation to isolation of
cases. ,ee ,ection #.$.1 for 'rocedures for t"e dis'osal of t"e dead.
Table *#"6 General (recautions to be ta4en for isolation of cases
in outbrea4s
Isolation
measure
Contagious<
ness of cases
oute of
transmission
T,(e of
(rotecti'e
measure
Diseases
,tandard
'recautions
Moderate Direct or
indirect contact
;it" faeces&
urine& blood&
body fluids
and contami-
nated articles
Hand-;as"ing&
safe dis'osal
of
contaminated
articles
Most
infectious
diseases e:ce't
t"ose
mentioned
belo;
Enteric
isolation
Hig" Direct contact
;it" 'atients
and ;it"
faeces and oral
secretions
Contact
'recautions
C"olera&
s"igellosis&
ty'"oid fe(er
@astroenteritis
caused by
rota(irus& C"
coli* "e'atitis
A
Bes'iratory
isolation
Hig" Direct contact
;it" 'atients
or oral
secretions and
dro'lets
,e'arate room&
mas%s& contact
'recautions
Meningococcal
meningitis&
di'"t"eria&
measles
,trict isolation Airborne ,e'arate room&
bio"a8ard
notification
Eiral
"aemorr"agic
fe(ers
Direct contact
;it" infected
bloods&
secretions&
organs or
semen
$rom(t diagnosis and effecti'e case management
9"ere are t;o ste's in t"is 'rocess: timely 'resentation to t"e "ealt" facility and
effecti(e diagnosis and treatment by t"e clinical ;or%ers. Home (isitors and "ealt"
educators can 'lay an im'ortant role in ensuring t"at t"e community is a;are of t"e
sym'toms and signs a disease& and t"at t"ey %no; t"at effecti(e treatment is a(ailable
at t"e "ealt" facility. 9"e second ste' is t"e use of standard treatment 'rotocols by
clinical ;or%ers ;ell trained in t"eir use. 9"e early diagnosis of a disease is
im'ortant& not only to a(oid serious seJuelae and deat" in t"e 'atient but also to
're(ent furt"er transmission.
0igure +#- Control strategies for an outbrea4
+#- E'aluation
After an outbrea%& t"e outbrea% control team must carry out a t"oroug" e(aluation
of t"e follo;ing:
cause of t"e outbrea%&
sur(eillance and detection of t"e outbrea%&
're'aredness for t"e outbrea%&
management of t"e outbrea%&
control measures.
9"e s'ecific issues under eac" "eading t"at s"ould be e(aluated include:
timeliness of detection and res'onse&
effecti(eness&
cost&
lost o''ortunities&
ne;5re(ised 'olicies.
9"e findings of t"is e(aluation s"ould be documented in a ;ritten re'ort
containing clear recommendations on:
t"e e'idemiological c"aracteristics of t"e e'idemic&
sur(eillance&
're'aredness&
control measures carried out.
E(aluation s"ould feed bac% into 're'aredness acti(ities for future outbrea%s.
+#-#" 0urt)er reading
7asic laboratory methods in medical parasitology. @ene(a& World Healt"
Organi8ation& //.
7ench aids for the diagnosis of malaria infections. @ene(a& World Healt"
Organi8ation& #333.
C"eesbroug" M. 1istrict laboratory practice in tropical countries* Dart .
Cambridge& Cambridge ?ni(ersity Press& //A.
C"eesbroug" M. 1istrict laboratory practice in tropical countries& Dart 2"
Cambridge& Cambridge ?ni(ersity Press& #333.
El-.age" MM. 2pecimen collection and transport for microbiological
investigation. Ale:andria& WHO Begional Office for t"e Eastern Mediterranean& //)
2WHO Begional Publications& Eastern Mediterranean ,eries& .o. A4.
El-.age" MM et al. 8ealth laboratory facilities in emergency and disaster
situations. Ale:andria& WHO Begional Office for t"e Eastern Mediterranean& //)
2WHO Begional Publications& Eastern Mediterranean ,eries& .o. 04.
Euidelines for the safe transport of infectious substances and diagnostic
specimens. @ene(a& World Healt" Organi8ation& //6 2document WHO5EMC5/6.$4.
Euidelines for the collection of clinical specimens during field investigation of
outbrea6s. @ene(a& World Healt" Organi8ation& #333 2document WHO5CD,5C,B5
EDC5#333.)4.
-nfection control for viral haemorrhagic fevers in the 4frican health care setting.
@ene(a& World Healt" Organi8ation& //A 2document WHO5EMC5E,B5/A.#4.
Co"ns W& El-.age" MM. 2election of basic laboratory equipment for laboratories
/ith limited resources. @ene(a& World Healt" Organi8ation& #333"
Beingold AL. Outbrea% in(estigations ! a 'ers'ecti(e. Cmerging -nfectious
1iseases& //A& +24:#!#6.
-# DISEASE $E/ENTION AND CONTOL
-#" Acute res(irator, infections
7asic facts
Acute res'iratory infections can in(ol(e:
t"e u''er res'iratory tract ! common cold& otitis media and '"aryngitisN
t"e lo;er res'iratory tract ! bronc"itis& bronc"iolitis and 'neumonia.
9"e maFority of acute res'iratory infections in(ol(e t"e u''er res'iratory tract
only& are mild and resol(e s'ontaneously.
Acute lo;er res'iratory tract infections 2LB9*s4 are a maFor cause of mortality
and morbidity in emergency situations.
,ome #0Q!$3Q of deat"s in c"ildren under 0 years of age are due to LB9*sN
/3Q of t"ese deat"s are due to 'neumonia.
*t is t"erefore im'ortant t"at 'neumonia is recogni8ed Juic%ly and treated
a''ro'riately. A sim'lified a''roac" ada'ted to 'rimary "ealt" care is
indicated in Anne: .
Causati(e organisms may be bacterial 2mainly 8aemophilus influenzae and
2treptococcus pneumoniae4 or (iral.
Bis% factors for 'neumonia include lo; birt" ;eig"t& malnutrition& (itamin A
deficiency& 'oor breastfeeding 'ractices& bad (entilation in s"elters& c"illing in
infants and o(ercro;ding.
Case management
Priority s"ould be gi(en to early recognition and adeJuate treatment of
'neumonia.
All c"ildren 'resenting ;it" coug" and5or difficult breat"ing s"ould be
carefully assessed.
,igns of malnutrition s"ould also be assessed& as t"is increases t"e ris% of
deat" from 'neumonia.
,e(erely malnouris"ed c"ildren must be referred to "os'ital.
Management of 'neumonia consists of antimicrobial t"era'y.
C"oice of antimicrobial de'ends on national 'rotocols and a(ailable drugs.
9"e .e; Emergency Healt" Dits 2see Anne: 34 contain co-trimo:a8ole&
;"ic" co(ers a broad s'ectrum of bacterial agents of 'neumonia and is
costeffecti(e.
Alternati(es are amo:icillin and c"loram'"enicol.
=or se(ere 'neumonia& inFectable antimicrobial suc" as 'enicillin& am'icillin
or c"loram'"enicol s"ould be used.
,u''orti(e measures& suc" as oral fluids to 're(ent de"ydration& continued
feeding to a(oid malnutrition& anti'yretics to reduce fe(er and 'rotection from
cold& are essential.
Eaccination against measles& di'"t"eria and ;"oo'ing coug" is effecti(e in
reducing t"e im'act of acute res'iratory infections.
9able $ of Anne: lists treatment guidelines using t"e most commonly
a(ailable antimicrobial: co-trimo:a8ole& amo:icillin and 'rocaine 'enicillin.
0urt)er reading
4cute respiratory infections in children: case management in small hospitals in
developing countries" 4 manual for doctors and other senior health /or6ers. @ene(a&
World Healt" Organi8ation& //# 2document WHO5AB*5/3.04.
,89(BN-<CF Goint statement on 5anagement of pneumonia in community
settings" World Healt" Organi8ation& #33) 2WHO5=CH5CAH53).314.
-#% 7acillar, d,senter, 8s)igellosis9
7asic facts
-acillary dysentery is an acute bacterial disease in(ol(ing t"e large and small
intestine.
*t is caused by bacteria of t"e genus 2higella& of ;"ic" 2" dysenteriae ty'e
causes t"e most se(ere disease and t"e largest outbrea%s 2ot"er s'ecies include
2" fle+neri* 2" sonnei and 2" boydii0"
*t is t"e most im'ortant cause of acute bloody diarr"oea.
Shigella dysenteriae t,(e "
9"e disease is most se(ere in young c"ildren& t"e elderly and t"e
malnouris"ed.
Dis'laced 'o'ulations are at "ig" ris% in situations of o(ercro;ding& 'oor
sanitation and limited access to safe ;ater.
*n an outbrea%& u' to one-t"ird of t"e 'o'ulation at ris% may be infected.
9ransmission occurs t"roug" contaminated food and ;ater and from 'erson to
'erson.
9"e disease is "ig"ly contagious ! t"e infecti(e dose is only 3!33
organisms.
9reatment is ;it" antimicrobials& ;"ic" decrease t"e se(erity and reduce t"e
duration of illness.
9"e disease is not usually associated ;it" a mar%ed loss of fluid and
electrolytes.
Wit"out 'rom't& effecti(e treatment t"e case-fatality rate can be as "ig" as
3Q.
A'art from 2" dysenteriae ty'e and ot"er 2higella s'ecies& dysentery can be
caused by <ampylobacter GeGuni& entero-in(asi(e Cscherichia coli& 2almonella and&
less freJuently& Cntamoeba histolytica"
9y'es of 'atients at "ig" ris% of contracting bacillary dysentery are listed in 9able
0..
Table -#" 2ig)<ris4 (atients
O C"ildren under 0 years of age& and es'ecially infants& se(erely malnouris"ed
c"ildren and c"ildren ;"o "a(e "ad measles in t"e 'ast 1 ;ee%s
O Older c"ildren and adults ;"o are ob(iously malnouris"ed
O Patients ;"o are se(erely de"ydrated& "a(e "ad a con(ulsion& or are seriously ill
;"en first seen
O Adults 03 years of age or older
Clinical features
-loody diarr"oea is often associated ;it" fe(er& abdominal cram's and rectal
'ain.
9"e incubation 'eriod is usually !$ days& but may be u' to ;ee% for
2"dysenteriae ty'e infection.
Com'lications include se'sis& rectal 'rola'se& "aemolytic uraemic syndrome
and sei8ures.
Diagnosis
-lood is obser(ed in a fres" stool s'ecimen.
2"dysenteriae ty'e is isolated from stool sam'les 2see Anne: A for stool
sam'ling and trans'ort 'rocedures4.
Case management
Befer seriously ill or se(erely malnouris"ed 'atients to "os'ital immediately.
C"ec% t"e results of antimicrobial sensiti(ity tests ;it" t"e laboratory.
@i(e an antimicrobial effecti(e against local 2" dysenteriae ty'e 2,d4
strains 'rom'tly to all 'atients& 'referably as in'atients 2see 9able 0.#4.
9reat de"ydration ;it" oral re"ydration salts or intra(enous fluids if se(ere.
*f t"e antimicrobials used are effecti(e& clinical im'ro(ement s"ould be noted
;it"in )A "ours.
*f antimicrobials used are effecti(e& clinical im'ro(ement s"ould be noted
;it"in )A "ours. 9reatment ;it" ci'roflo:acin s"ould be gi(en for $ days.
IM$OTANT# Do not gi(e antimicrobials %no;n to be ineffecti(e. 9"e
antimicrobial used s"ould be in line ;it" national guidelines and selected on t"e basis
of susce'tibility testing of local ,d strains.
W"en t"e su''ly of an effecti(e antimicrobial is limited& 'riority s"ould be gi(en
to "ig"-ris% 'atients 2see 9able 0.4.
Table -#% ecommended antibiotics for treatment of Shigella
dysenteriae t,(e "
AD!LTSD 033 mg t;ice a day by mout" for $
days ci(roflo=acin
C2ILDEND 0 mg5%g t;ice a day by mout" for $
days ci(roflo=acin
0O C2ILDEN
AGED !NDE .
MONT2SD
8inc 3 mg daily by mout" for #
;ee%s
add Cinc
0O C2ILDEN
AGED .
MONT2S TO *
?EASD
8inc #3 mg daily by mout" for #
;ee%s
add zinc
Note: rapidly evolving antimicrobial resistance is a real problem" 2higella is
usually resistant to ampicillin and trimethoprim sulfametho+azole .T5D(25P0
0urt)er reading
Euidelines for the control of shigellosis including epidemics due to ,"igella
dysenteriae type " World Healt" Organi8ation #330 2*,-. /# ) 0/0$$ 34.
The management of bloody diarrhoea in young children. @ene(a& World Healt"
Organi8ation& //) 2document WHO5CDB5/).)/4.
-#* C)olera
7asic facts
C"olera is an acute bacterial enteric disease caused by t"e @ram-negati(e
bacillus Fibrio cholerae.
Fibrio cholerae 'roduces a 'o;erful enteroto:in t"at causes 'rofuse ;atery
diarr"oea by a secretory mec"anism.
*nfection results from ingestion of organisms in food and ;ater& or directly
from 'erson to 'erson by t"e faecal!oral route.
Acute carriers& including t"ose ;it" asym'tomatic or mild disease& are
im'ortant in t"e maintenance and transmission of c"olera.
*t is asym'tomatic in more t"an /3Q of cases.
Attac% rates in dis'laced 'o'ulations can be as "ig" as 3!0Q 2e.g. @oma&
Democratic Be'ublic of Congo in //)4& ;"ereas in normal situations it is
estimated at !#Q.
Case-fatality rates are usually around 0Q but "a(e reac"ed )3Q in large
outbrea%s in refugee cam's 2e.g. @oma& Democratic Be'ublic of Congo in
//)4.
Wit" a''ro'riate treatment 2oral re"ydration in most cases4 t"e case-fatality
rate can be reduced to Q or less.
Clinical features
9"e incubation 'eriod is usually bet;een and 0 days.
,ym'toms begin ;it" t"e abru't onset of co'ious ;atery diarr"oea& classically
rice-;ater stools& ;it" or ;it"out (omiting.
Loss of ;ater and electrolytes can lead to ra'id and 'rofound de"ydration& lo;
serum 'otassium le(els and acidosis.
=e(er is unusual& e:ce't in c"ildren.
Eomiting ;it"out associated nausea may de(elo'& usually after t"e onset of
diarr"oea.
,e(ere de"ydration leads to loss of s%in turgor& malaise& tac"y'noea and
"y'otension.
Early detection of c"olera is im'ortant to ensure 'rom't treatment and reduction
of en(ironmental contamination. C"olera s"ould be sus'ected ;"en:
a 'atient o(er 0 years of age de(elo's se(ere de"ydration from acute ;atery
diarr"oea 2usually ;it" (omiting4N or
any 'atient o(er # years of age "as acute ;atery diarr"oea in an area /here
there is an outbrea6 of cholera.
Diagnosis
*solation of Fibrio cholerae O or O$/ from stools is still t"e only acce'table
standard for confirmation of c"olera.
Ba'id 'oint-of-care diagnostic tests on stool sam'les are a(ailable in some
countries& but no data e:ist on t"eir 'erformance under field condition. 9"eir
use mig"t be considered in t"e future& as (alidation and standardi8ation
become better documented.
2,ee Anne: A for stool sam'ling and trans'ort 'rocedures.4
Case management
9"e 're(ention and treatment of de"ydration are t"e mainstay of c"olera
management 2Anne: #4.
9"e use of antimicrobials 2do:ycycline5tetracycline4 is not essential for t"e
treatment of c"olera but may be recommended to reduce t"e (olume of
diarr"oea and s"orten t"e duration of e:cretion. *n emergencies& systematic
administration of antimicrobials is Fustified only for se(ere cases and in
situations ;"ere bed occu'ancy& 'atient turno(er or stoc%s of intra(enous
fluids are e:'ected to reac" critical le(els in res'ect of case management
ca'acity.
9reatment is single dose of do:ycycline $33 mg or tetracycline for $ days.
A sensiti(ity 'rofile of t"e outbrea% strain must be a(ailable as soon as
'ossible to decide on t"e 'ossible c"oice of antimicrobial for se(ere cases.
Oral antimicrobials only must be gi(en& and after t"e 'atient "as been
re"ydrated 2usually in )!1 "ours4 and (omiting "as sto''ed.
$re'ention and control measures
Prom't diagnosis and a''ro'riate treatment of 'atients must be carried out.
C"olera treatment centres s"ould be establis"ed& ;it" barrier nursing
'rocedures s'ecific to enteric 'at"ogens 2see Anne: 6 for organi8ation of an
isolation centre& essential rules in a C9C& disinfectant 're'aration& and
calculation of treatment needs4.
=aecal material and (omit must be 'ro'erly disinfected and dis'osed of.
Healt" education 'rogrammes s"ould be conducted on "ygiene and
disinfection measures ;it" sim'le messages on safe ;ater& safe food and
"and-;as"ing.
=unerals s"ould be "eld Juic%ly and near t"e 'lace of deat".
9"ose ;"o 're'are t"e body for burial must be meticulous about ;as"ing t"eir
"ands ;it" soa' and clean ;ater.
Promote ;as"ing of "ands ;it" soa' and clean ;ater ;"ene(er food is being
"andled.
Ina((ro(riate control measures
Mass c"emo'ro'"yla:is "as ne(er succeeded in limiting t"e s'read of c"olera.
9rade and tra(el restrictions do not 're(ent t"e s'read of c"olera and are
unnecessary. 2,ee ,ection #.1.6 for use of ne; oral c"olera (accines.4
0urt)er reading
,anc"e8 CL& 9aylor D.. C"olera. ;ancet& //6& *+52/31A4:A#0!A$3.
<holera outbrea6: assessing the outbrea6 response and improving preparedness"
World Healt" Organi8ation& #33). 2document WHO5CD,5CPE5G=D5#33).)4
First steps for managing an outbrea6 of acute diarrhoea" World Healt"
Organi8ation& #33) 2document WHO5CD,5.C,5#33$.6 Be( 4.
4cute diarrhoeal diseases in comple+ emergencies: critical steps" World Healt"
Organi8ation& #33) 2document WHO5CD,5CPE5G=D5#33).14.
-#+ Ot)er diarr)oeal diseases
7asic facts
Diarr"oeal diseases are a maFor cause of morbidity and mortality in emergency
situations& mainly because of inadeJuate ;ater su''ly in terms of Juality and
Juantity& insufficient& 'oorly maintained sanitation facilities and o(ercro;ding. *n
cam' situations& diarr"oeal diseases "a(e accounted for more t"an )3Q of deat"s in
t"e acute '"ase of t"e emergency. O(er A3Q of deat"s are among c"ildren under #
years of age.
Common sources of infection are s"o;n in 9able 0.$.
Table -#* Common sources of infection in
emergenc, situations
Outbrea% in(estigations in emergency situations "a(e identified t"e follo;ing ris%
factors for infection:
O 'olluted ;ater sources 2e.g. by faecally contaminated surface ;ater entering an
incom'letely sealed ;ell4& or contamination during storage or trans'ort 2e.g. by
contact ;it" "ands soiled by faeces4N
O s"ared ;ater containers and coo%ing 'otsN
O lac% of soa'N
O contaminated food items 2e.g. dried fis"& s"ellfis"4#
Clinical features
Diarr"oea is defined as t"ree or more abnormally loose or fluid stools o(er a
'eriod of #) "ours. -acteria suc" as 2almonella 2commonly 2" Enteritidis or 2"
9y'"imurium4 and Cscherichia coli can cause diarr"oea& but t"e most se(ere
outbrea%s are caused by 2higella dysenteriae ty'e and Fibrio cholerae 2see ,ections
0.# and 0.$4. Ot"er 'at"ogens t"at cause diarr"oea include 'roto8oa 2suc" as Eiardia
lamblia* C" histolytica* <" parvum4 and (iruses 2suc" as rota(irus and .or;al% (irus4.
Diarr"oea may occur as one of t"e sym'toms of ot"er infections 2e.g. measles4.
9"e maFor com'lications of diarr"oea are de"ydration and t"e negati(e effect on
nutritional status.
Diagnosis
9"e diagnosis of diarr"oeal diseases is usually based on clinical signs and
sym'toms. Ho;e(er& in outbrea% situations stool sam'les must be collected from 3!
#3 cases to confirm t"e cause and to identify antimicrobial sensiti(ity. Once t"e
outbrea% "as been confirmed& it is not necessary to obtain laboratory confirmation for
e(ery 'atient as t"is de'letes laboratory su''lies.
IM$OTANT. Do not ;ait for laboratory results before starting
treatment5control acti(ities.
Case management
=or assessment and case management of diarr"oea& see Anne: #.
$re'ention and control measures
9"e 're(ention of diarr"oeal diseases de'ends on t"e 'ro(ision and use of safe
;ater& adeJuate sanitation and "ealt" education 2see 9able 0.)4. An adeJuate ;ater
su''ly is essential to 'rotect "ealt" and is one of t"e "ig"est 'riorities for cam'
'lanners. A su''ly of adeJuate Juantities of ;ater 2reasonably clean if 'ossible4 in
emergency situations is more im'ortant t"an a su''ly of small Juantities of
microbiologically 'ure ;ater.
Table -#+ Ke, com(onents in t)e
(re'ention of diarr)oeal diseases
$ractices or acti'ities Inter'entions to mo'e t)eor, to
(ractice
,afe drin%ing-;ater Pro(ision of an adeJuate su''ly&
collection& trans'ort and storage system
Pro(ision of information on t"e
im'ortance of clean ;ater ;it"
a''ro'riate use of ;ater container lids
and "ouse"old storage
,afe dis'osal of "uman e:creta Pro(ision of adeJuate facilities for t"e
dis'osal of "uman ;aste
Pro(ision of information on t"e
im'ortance of "uman ;aste dis'osal& also
co(ering t"e use and maintenance of t"e
facilities
=ood safety Pro(ision of adeJuate storage facilities
for food 2bot" uncoo%ed and coo%ed4&
coo%ing utensils& adeJuate Juantity of
;ater& and fuel to allo; for coo%ing and
re"eating
Pro(ision of information on t"e
im'ortance of food safety
Hand-;as"ing ;it" soa' Pro(ision of soa'& allo;ing for bat"ing
and laundry
Pro(ision of information on t"e diseases
s'read t"roug" lac% of or 'oor "and-
;as"ing& and demonstration of good
"and-;as"ing
-reastfeeding Pro(ision of information on: t"e
'rotecti(e Jualities of breastfeeding and
t"e im'ortance of breastfeeding sic%
c"ildren
Practical su''ort to enable mot"ers to
breastfeed sic% c"ildren
0urt)er reading
1iarrhoea Treatment Euidelines: -ncluding ne/ recommendations for the use of
9:2 and Qinc supplementation" WHO5?.*CE= recommendations& #33).
The Treatment of diarrhoea: 4 manual for physicians and other senior health
/or6ers" World Healt" Organi8ation& #33$. 2*,-. /# ) 0/$A 34.
-a"l B et al. Effect of Ginc su''lementation on clinical course of acute diarr"oea.
Be'ort of a Meeting& .e; Del"i& 6!A May #33. 3ournal of 8ealth* Dopulation and
Nutrition* Dec. #33& Eol. /2)4:$$A!$)1.
-#- Con&uncti'itis
7asic facts
ConFuncti(itis is acute inflammation of t"e conFuncti(a of bacterial& (iral or
allergic origin.
-acterial conFuncti(itis is cause for most concern in emergency situations.
,ome outbrea%s of acute "aemorr"agic conFuncti(itis due to entero(irus 63
"a(e been obser(ed in refugee 'o'ulations.
*n areas ;"ere trac"oma is 're(alent& a large 'ro'ortion of eye disease seen in
disaster-affected 'o'ulations may be due to <hlamydia trachomatis infection.
ConFuncti(itis is transmitted by contact ;it" disc"arges from t"e conFuncti(a
of infected 'eo'le& from contaminated fingers or clot"ing& and also 'ossibly
t"roug" mec"anical transmission by gnats or flies in some areas.
Occurrence is ;ides'read t"roug"out t"e ;orld.
E'idemics may occur in o(ercro;ded conditions follo;ing dis'lacement.
Clinical features
9"e clinical course may last from # days to #!$ ;ee%s.
9"ere is redness& irritation and lacrimation of one or bot" conFuncti(a&
follo;ed by oedema of t"e eyelids and a muco'urulent disc"arge.
Case management
Was" bot" eyes ;it" sterile ;ater or 3./Q saline 2or at least ;it" clean boiled
;ater4 )!1 times daily.
A''ly Q tetracycline eye ointment t;ice daily for one ;ee%.
.e(er use to'ical steroids.
Diagnosis
Diagnosis is essentially clinicalN it does not reJuire microsco'ic e:amination
of eye disc"arge in most cases.
$re'ention and control measures
Ensure adeJuate clean ;ater and soa' for 'ersonal "ygiene and "and;as"ing.
*ntroduce (ector control to reduce t"e fly 'o'ulation if 'ossible.
Disinfect articles contaminated by conFuncti(al and nasal disc"arges.
*n "ealt" facilities& ensure (igorous ;as"ing of "ands by "ealt" staff to a(oid
cross-contamination& and 'ro'er dis'osal of infected material.
-#. Dengue
7asic facts
Dengue is an acute febrile (iral illness c"aracteri8ed by sudden onset of a
fe(er t"at lasts for $!0 days.
Dengue (iruses belong to t"e family =la(i(iridae and include seroty'es & #& $
and ).
9ransmission occurs t"roug" t"e bite of an infected mosJuito 24edes aegypti4.
9"is mosJuito is a daytime-biting s'ecies ;it" increased biting # "ours after
sunrise and se(eral "ours before sunset.
9"e lar(ae t"ri(e in ;ater in artificial or natural containers close to "uman
"abitations& e.g. in old tyres& flo;er 'ots& ;ater storage containers or oil
drums.
Beco(ery from infection ;it" one seroty'e does not confer 'rotection against
t"e ot"er t"ree seroty'es.
E'idemics are e:'losi(e and may affect a "ig" 'ercentage of t"e 'o'ulation.
=atalities in t"e absence of t"e more se(ere dengue "aemorr"agic fe(er are
rare.
Clinical features
Dengue (irus infection may be asym'tomatic& may cause undifferentiated
febrile illness& dengue fe(er 2D=4& or dengue "aemorr"agic fe(er 2DH=4&
including dengue s"oc% syndrome 2D,,4.
9"e incubation 'eriod is $!) days& usually 1!6 days.
,ym'toms include intense "eadac"e& myalgia& art"ralgia& retro-orbital 'ain&
anore:ia and ras".
Beco(ery can be associated ;it" 'rolonged fatigue and de'ression.
C"ildren usually "a(e a milder disease t"an adults.
Diagnosis
,erum sam'les are tested for (irus-s'ecific antibodies& generally using EL*,A
tec"niJues. Ba'id tests based on dot-blot tec"niJues are commercially
a(ailable.
*gM antibody& indicating recent or current infection& is usually detected by day
1!6 after t"e onset of illness.
Case management
,u''orti(e treatment s"ould be gi(en ! t"ere is no s'ecific t"era'eutic agent.
Carefully monitored (olume re'lacement can be life-sa(ing in DH=5D,,.
9"ere is no a(ailable (accination.
Contacts s"ould be in(estigated ! determine t"e 'lace of residence of t"e
'atient for t"e # ;ee%s before t"e onset of illness.
$re'ention and control measures
Eliminate lar(al "abitats of 4edes mosJuitoes in urban or 'eri-urban areas.
Protect against daytime-biting mosJuitoes& including t"e use of screening&
'rotecti(e clot"ing and re'ellents.
Conduct a community sur(ey to determine t"e density of (ector mosJuitoes
and identify lar(al "abitats.
*n an outbrea%& use lar(icide on all 'otential "abitats of 4e" aegypti"
@round a''lications of ultra-lo;-(olume insecticides can reduce t"e (ector
'o'ulation in an outbrea%.
Carry out social mobili8ation cam'aigns to eliminate breeding sites as muc"
as 'ossible.
0urt)er reading
Drevention and control of dengue and dengue haemorrhagic fever:
comprehensive guidelines. .e; Del"i& WHO Begional Office for ,out"-East Asia&
/// 2WHO Begional Publications& ,out"-East Asia ,eries& .o. #/4.
1engue haemorrhagic fever: diagnosis* treatment* prevention and control* #nd
ed. @ene(a& World Healt" Organi8ation& //6.
-#1 Di()t)eria
7asic facts
Di'"t"eria is an acute bacterial disease of t"e tonsils& '"aryn:& laryn:& nose&
s%in and sometimes t"e conFuncti(a or genitalia.
*t is caused by an aerobic @ram-'ositi(e rod& <orynebacterium diphtheriae.
9ransmission is by contact 2usually direct& rarely indirect4 ;it" t"e res'iratory
dro'lets of a 'atient or carrier& mainly from t"e nose and t"roat.
Case-fatality rates& at 0!3Q& "a(e c"anged little in 03 years.
A massi(e outbrea% of di'"t"eria began in t"e Bussian =ederation in //3 and
s'read to all countries of t"e former ,o(iet ?nion. *t ;as res'onsible for more
t"an 03 333 re'orted cases and 0333 deat"s. All age grou's ;ere affected.
Eaccine containing di'"t"eria to:oid 2'referably 9d4 is a(ailable and s"ould
be gi(en to a 'o'ulation at ris% as soon as 'ossible during an e'idemic.
Clinical features
9"e incubation 'eriod is usually #!0 days& occasionally longer.
?ntreated 'atients are infectious for #!$ ;ee%sN antimicrobial treatment
usually renders 'atients non-infectious ;it"in #) "ours.
Classical res'iratory di'"t"eria is c"aracteri8ed by insidious onset and
membranous '"aryngitis ;it" lo;-grade fe(er.
Alt"oug" not al;ays 'resent& t"e membrane is ty'ically grey or ;"ite in
colour& smoot"& t"ic%& fibrinous and firmly ad"erent.
*t is essential t"at all cases of di'"t"eria are ra'idly identified and 'ro'erly
in(estigated.
Di'"t"eria s"ould be sus'ected ;"en a 'atient de(elo's an u''er res'iratory
tract illness ;it" laryngitis or '"aryngitis or tonsillitis plus ad"erent
membranes of tonsils or naso'"aryn:.
A 'robable case definition is a sus'ected case 'lus one of t"e follo;ing:
recent 2U # ;ee%s4 contact ;it" a confirmed case&
di'"t"eria e'idemic currently in t"e area&
stridor&
s;elling5oedema of t"e nec%&
submucosal or s%in 'etec"ial "aemorr"ages&
to:ic circulatory colla'se&
acute renal insufficiency&
myocarditis and5or motor 'aralysis !1 ;ee%s after onset.
Diagnosis
9"roat and naso'"aryngeal s;abs s"ould be ta%en before antimicrobial
treatment is started.
2,ee Anne: A for descri'tion of sam'le collection tec"niJue.4
Case management
*f di'"t"eria is strongly sus'ected& s'ecific treatment ;it" antito:in and
antimicrobial s"ould be initiated immediately.
IM$OTANTD Do not @ait for laborator, results before initiating treatment#
Antito:in gi(en intramuscularly is t"e mainstay of treatment: #3 333!33 333
units in a single dose& immediately after t"roat s;abs "a(e been ta%en.
Antimicrobial are necessary to eliminate t"e organism and 're(ent s'readN
t"ey are not a substitute for antito:in treatment.
Management of close contacts
Close contacts include "ouse"old members and ot"er 'ersons ;it" a "istory of
direct contact ;it" a di'"t"eria 'atient& as ;ell as "ealt" care staff e:'osed to
t"e oral or res'iratory secretions of a 'atient.
All close contacts s"ould be clinically assessed for sym'toms and signs of
di'"t"eria and %e't under daily sur(eillance for 6 days from t"e last contact.
Adult contacts must a(oid contact ;it" c"ildren and must not be allo;ed to
"andle food until 'ro(en not to be carriers.
All must recei(e a single dose of ben8at"ine ben8yl'enicillin intramuscularly
2133 333 units for c"ildren under 1 years& .# million units for t"ose 1 years or
older4. *f t"e culture is 'ositi(e& antimicrobial s"ould be gi(en as outlined
abo(e.
*n an e'idemic in(ol(ing adults& immuni8e grou's t"at are most affected and
at "ig"est ris%.
-#3 2e(atitis 8'iral9
7asic facts
Acute "e'atitis 2ty'ically 'resenting as acute Faundice4 is generally caused by
"e'atitis A& -& C and E (iruses& ;"ic" belong to different (irus families. 9"ese
(iruses also differ in t"eir 2a4 modes of transmission& 2b4 geogra'"ical and
e'idemiological 'atterns& ;"ic" e:'lain (arious age-related incidence 'rofiles& and 2c4
'ro'ensity to result or not in c"ronic infections. He'atitis D 2not detailed any furt"er
"ere4 is a 'articular case& being caused by a defecti(e (irus t"at can re'licate and
cause disease only in indi(iduals already co-infected or c"ronically infected ;it" t"e
"e'atitis - (irus.
9able 0.0 illustrates t"e main differences bet;een t"e "e'atitis (iruses.
Table -#- C)aracteristics of t)e )e(atitis 'iruses
/irus 0amil, Transmission Main grou(s
at ris4 of
infection
Com(lications
He'atitis A Picorna(iridae =aecal!oral .on-immune
tra(ellers to
regions ;"ere
sanitation is
'roblematic 2in
lo;
endemicity
areas4 Houng
c"ildren&
usually
asym'tomatic
2in "ig"
endemicity
areas4
=ulminant
"e'atitis
He'atitis - He'adna(iridae Parenteral ]
se:ual
*nFecting drugs
users Contact
;it" infected
blood or blood
'roducts Hig"-
ris% se:ual
be"a(iour
=ulminant
"e'atitis
C"ronic
"e'atitis&
cirr"osis& li(er
cancer
He'atitis C =la(i(iridae Parenteral 2]5!
se:ual4
*nFection drugs
users Contact
;it" infected
blood or blood
'roducts
=ulminant
"e'atitis
C"ronic
"e'atitis&
cirr"osis& li(er
cancer
He'atitis E Currently
unclassified
=aecal!oral Large
outbrea%s in
communities
;it"
inadeJuate
;ater5;aste
;ater facilities
.on-immune
tra(ellers to
regions ;"ere
HEE is
endemic 2(ery
rare4
=ulminant
"e'atitis
Mortality u' to
#3Q in
'regnancy
Cases of (iral "e'atitis are seen all o(er t"e ;orld& occurring eit"er s'oradically or
during e'idemics of (arious magnitudes. Outbrea%s of "e'atitis A and "e'atitis E
"a(e been documented in refugee and internally dis'laced 'erson cam's 2C"ad&
Denya& Doso(o& .amibia& ,udan4.
9"is can be e:'lained by t"e s'ecific 'atterns of transmission of (iral "e'atitis.
He'atitis A (irus transmitted by t"e faecal!oral route is already "ig"ly
're(alent in countries ;it" 'oor sanitary infrastructure. ?nder suc"
circumstances& transmission generally occurs during c"ild"ood& at an age
;"en most of t"e infections due to t"ese (iruses are mild or generally
asym'tomatic. 9"is lea(es t"e bul% of adult 'o'ulations largely immune to
ne; infections& and t"erefore 'rotected against t"e most se(ere forms of t"e
diseases ty'ically seen at older ages. He'atitis E "as been found confined to
geogra'"ical areas ;"ere faecal contamination of drin%ing-;ater is common.
Most outbrea%s "a(e occurred follo;ing monsoon rains& "ea(y flooding&
contamination of ;ell ;ater& or massi(e u'ta%e of untreated se;age into city
;ater-treatment 'lants. =urt"er disru'tion of social and "ealt" infrastructures
during emergencies in de(elo'ing countries is e:'ected at most to increase
transmission of "e'atitis A and E. Only ;"en disasters "it 'o'ulations
're(iously enFoying good standards of sanitation& or countries ;it" transition
economies& is t"ere a t"eoretically increased ris% of outbrea%s of "e'atitis A or
E.
9ransmission of "e'atitis - and "e'atitis C could 'otentially be of concern
during emergencies under circumstances fa(ouring t"e increased use of unsafe
inFection 'ractices& illicit inFecting drug use& unsafe se:ual acti(ities& or t"e use
of unreliable blood transfusion facilities. 9ransmission of "e'atitis among
s'ecific grou's at ris% under suc" circumstances is unli%ely to be detected
during t"e acute '"ase of an emergency& but s"ould be ta%en into
consideration in t"e 'lanning of 're(enti(e acti(ities and in t"e design of an
integrated "ealt" sur(eillance system.
Clinical features
De'ending on t"e age at infection& t"e ty'e of (irus& and ot"er 2generally
un%no;n4 factors& (iral "e'atitis can lead to:
asym'tomatic infection&
acute uncom'licated Faundice&
fulminant "e'atitis.
2C"ronic infection is not rele(ant in t"e situation of an emergency.4
Diagnosis
,'oradic cases of acute Faundice ;it" no or moderate fe(er are generally due
to acute (iral "e'atitis& es'ecially in young adults. Careful clinical
e:amination s"ould detect ot"er causes of Faundice 'ossibly reJuiring s'ecific
treatment 2e.g. surgery and antimicrobial t"era'y for obstructi(e Faundice4.
Clusters of cases of acute Faundice s"ould lead to e'idemiological
in(estigations to e:clude transmissible diseases ;it" im'ortant 'ublic "ealt"
im'lications 2yello; fe(er& le'tos'irosis& etc.4.
Boutine laboratory tec"niJues to confirm t"e diagnosis of acute "e'atitis and
its etiology are not al;ays a(ailable in emergency situations. W"en an
outbrea% is sus'ected& serum sam'les s"ould be sent to a reference laboratory
for determination of t"e causati(e organism.
,erodiagnostic tests are a(ailable to screen 'otential blood donors for "e'atitis
- and C 2and H*E4 infection. Ba'id tests t"at do not reJuire s'ecific
laboratory eJui'ment are being de(elo'ed for t"e detection of serological
mar%ers.
Case management
Acute uncom'licated (iral "e'atitis sim'ly reJuires su''orti(e t"era'y.
Acute fulminant "e'atitis carries a 'oor 'rognosis and reJuires intensi(e
treatment ca'acities t"at are generally beyond t"e tec"nical 'ossibilities
a(ailable in emergencies.
-arrier nursing s"ould be carried out of 'atients 'resenting ;it" acute
Faundice of 'ossibly infectious origin.
Acute "e'atitis in 'regnant ;omen 2'articularly during t"e last trimester4
reJuires careful monitoring& as "e'atitis E constitutes a maFor ris% of deat"
from com'lications of 'regnancy 2including s'ontaneous deat" of t"e embryo4
or of fulminant "e'atitis.
$re'ention and control measures
Control and 're(ention of "e'atitis A or E reJuire t"e enforcement of ;ater
and food sanitation 2see C"a'ter #4.
Control and 're(ention of "e'atitis - and C reJuire safe inFection 'ractices
2see ,ection #.1.#4. W"ere blood transfusion ser(ices are 'ro(ided& screening
of all blood 'roducts is mandatory for "e'atitis - and C and H*E.
Eaccines are a(ailable t"at 'rotect against "e'atitis A and - for se(eral years.
9"ere is no indication for mass (accination against "e'atitis - in emergencies.
*n t"e case of an outbrea% of "e'atitis A& targeted (accination of 'o'ulation
grou's at ris% is recommended. Healt" ;or%ers s"ould be immune to "e'atitis
- o;ing to 're(ious (accination. ,ystematic (accination mig"t be considered
for "ealt" ;or%ers e:'ected not to be immune to "e'atitis A and -& and t"ose
e:'osed to 'articular ris%s o;ing to t"e emergency.
-#5 2I/:AIDS
7asic facts
AcJuired immunodeficiency syndrome 2A*D,4 is t"e late clinical stage of
infection ;it" t"e "uman immunodeficiency (irus 2H*E4.
,ub-,a"aran Africa accounts for more t"an 13Q of all 'eo'le li(ing ;it" H*E&
yet t"e region "as Fust o(er 3Q of t"e ;orld<s 'o'ulation.
*n #33)& an estimated )./ million 'eo'le globally became ne;ly infected&
;"ile $. million died of A*D,.
At t"e end of #33)& an estimated $/.) million 'eo'le ;ere li(ing ;it" H*E
globally.
Women and girls ma%e u' almost 06Q of adults li(ing ;it" H*E in sub-
,a"aran Africa.
9"ere are four main modes of transmission of H*E:
se:ual intercourse 2(aginal or anal4 ;it" an infected 'artner& es'ecially in
t"e 'resence of a concurrent ulcerati(e or non-ulcerati(e se:ually
transmitted infection 2,9*4N
contaminated needles 2inFecting drug use& needlestic% inFuries& inFections4N
transfusion of infected blood or blood 'roductsN
mot"er-to-c"ild transmission during 'regnancy& labour and deli(ery or
t"roug" breastfeeding.
29"e main ris% factors for increased H*E transmission in emergencies are s"o;n
in 9able 0.1.4
Clinical features
9"e incubation time is (ariable. On a(erage& t"e time from H*E infection to
t"e de(elo'ment of clinical A*D, is eig"t to ten years& t"oug" A*D, may be
manifested in less t"an t;o years or be delayed in onset beyond ten years.
*ncubation times are s"ortened in resource-'oor settings and in older 'atients.
9"ey can be 'rolonged by 'ro(ision of 'rimary 'ro'"yla:is for o''ortunistic
infections or antiretro(iral treatment.
*nfected 'eo'le may t"en be free of clinical signs or sym'toms for many
mont"s to years.
*nfectiousness is obser(ed to be "ig" during t"e initial 'eriod after infection.
,tudies suggest it increases furt"er ;it" increasing immune deficiency&
clinical sym'toms and t"e 'resence of ot"er ,9*s.
9"e se(erity of H*E-related o''ortunistic infection is correlated ;it" t"e
degree of immune system dysfunction.
Modified "53- W2O case definition for AIDS sur'eillance 8t)e
P7angui definitionQ9
a>b
An adult or adolescent 2S # years of age4 is considered to "a(e A*D, if at least
t;o of t"e follo;ing maFor signs are 'resent in combination ;it" at least one of t"e
minor signs listed belo;& and if t"ese signs are not %no;n to be due to a condition
unrelated to H*E infection.
5aGor signs
Weig"t loss S3Q of body ;eig"t
C"ronic diarr"oea for S mont"
Prolonged fe(er for S mont" 2intermittent or constant4
5inor signs
Persistent coug" for S mont"c
@enerali8ed 'ruritic dermatitis
History of "er'es 8oster
Oro'"aryngeal candidiasis
C"ronic 'rogressi(e or disseminated "er'es sim'le: infection
@enerali8ed lym'"adeno'at"y
9"e 'resence of eit"er generali8ed Da'osi sarcoma or cry'tococcal meningitis is
sufficient for t"e diagnosis of A*D, for sur(eillance 'ur'oses.
a
,ource: ,ee6ly Cpidemiological :ecord& //)& .5D#6$!#60.
b
Clinical under re(ie;: see -nterim ,89 clinical staging of 8-F/4-12 and
8-F/4-12(case definitions for surveillance 2document WHO5H*E5#330.3#4.
c
=or 'atients ;it" tuberculosis& 'ersistent coug" for more t"an a mont" s"ould
not be considered a minor sign.
Table -#. is4 factors for increased 2I/
transmission in emergencies
Dopulation movement
O *n emergency situations& 'o'ulation mo(ement often causes brea%do;n in family
and social ties& and erodes traditional (alues and co'ing strategies. 9"is can result in
"ig"er-ris% se:ual be"a(iour& ;"ic" increases t"e ris% of t"e s'read of H*E.
O *n "ig"-incidence regions& refugees from areas ;"ere H*E is uncommon may find
t"emsel(es e:'osed to a "ig"er H*E ris%& ;"ic"& toget"er ;it" little 'rior %no;ledge
of H*E ris%s and 're(ention& ;ill increase t"eir (ulnerability to infection.
9vercro/ding
O @rou's ;it" differing le(els of H*E a;areness& and differing rates of infection& are
often 'laced toget"er in tem'orary locations suc" as refugee cam's& ;"ere t"ere is a
greater t"an normal 'otential for se:ual contact.
Door access to health services
O Wit"out adeJuate medical ser(ices ,9*s& if left untreated in eit"er 'artner& greatly
increase t"e ris% of acJuiring H*E.
O *m'ortant materials for H*E 're(ention& 'articularly condoms& are li%ely to be
lac%ing in an emergency situation.
2e+ual violence
O Befugees and internally dis'laced 'ersons are often '"ysically and socially
'o;erless& ;it" ;omen and c"ildren at 'articular ris% of se:ual coercion& abuse or
ra'e.
O ,e:ual (iolence carries a "ig"er ris% of infection because t"e 'erson (iolated cannot
'rotect "erself or "imself from unsafe se:& and because t"e (irus can be transmitted
more easily if body tissues are torn during (iolent se:.
2e+ /or6
O E:c"ange of se:ual fa(ours for basic needs& suc" as money& s"elter& security& etc.& is
common in or around refugee cam's& and ine(itably in(ol(es bot" t"e refugee and t"e
"ost community. -ot" se: ;or%ers and clients are at ris% of H*E infection if
un'rotected se: is 'ractised.
-nGecting drug use
O *n t"e ty'ical conditions of an emergency& it is "ig"ly li%ely t"at drug inFectors ;ill
be s"aring needles& a 'ractice t"at carries a (ery "ig" ris% of H*E transmission if one
of t"e 'eo'le s"aring is infected.
Bnsafe blood transfusions
O 9ransfusion ;it" H*E-infected blood is a "ig"ly efficient means of transmitting t"e
(irus. *n emergency situations& ;"en regular transfusion ser(ices "a(e bro%en do;n&
it is 'articularly difficult to ensure blood safety.
4dolescent health
O C"ildren in refugee settings may "a(e little to occu'y t"emsel(es& ;"ic" may lead
t"em to e:'eriment ;it" se: earlier t"an c"ildren in ot"er situations.
"55+ e=(anded W2O case definition for AIDS sur'eillance 8to be
used @)ere 2I/ serological testing is a'ailable9
An adult or adolescent 2S# years of age4 is considered to "a(e A*D, if a test for
H*E antibody gi(es a 'ositi(e result& and one or more of t"e follo;ing conditions are
'resent:
a greater t"an 3Q body ;eig"t loss or cac"e:ia& ;it" diarr"oea or fe(er or
bot"& intermittent or constant& for at least mont"& not %no;n to be due to a
condition unrelated to H*EN
cry'tococcal meningitisN
'ulmonary or e:tra'ulmonary tuberculosisN
Da'osi sarcomaN
neurological im'airment sufficient to 're(ent inde'endent daily acti(ities& not
%no;n to be due to a condition unrelated to H*E infection 2e.g. trauma or
cerebro(ascular accident4N
candidiasis of t"e oeso'"agus 2;"ic" may be 'resum'ti(ely diagnosed based
on t"e 'resence of oral candidiasis accom'anied by dys'"agia4N
clinically diagnosed life-t"reatening or recurrent e'isodes of 'neumonia& ;it"
or ;it"out etiological confirmationN
in(asi(e cer(ical cancer.
Diagnosis
9"is is most commonly done by detecting H*E antibody in serum sam'les
using en8yme-lin%ed immunoassay 2EL*,A or E*A4. W"en t"is test is
'ositi(e& it must be confirmed ;it" anot"er test of "ig"er s'ecificity suc" as
t"e Western blot& t"e indirect fluorescent antibody 2*=A4 test or a second
EL*,A test t"at is met"odologically and5or antigenically inde'endent.
9"e ra'id tests& ;"ic" are recommended by WHO& "a(e been e(aluated at
WHO collaborating centres and "a(e le(els of sensiti(ity and s'ecificity
com'arable to WHO-recommended EL*,A tests. 9"e use of ra'id H*E tests
may afford se(eral ad(antages in emergency and disaster settings.
Ba'id tests t"at do not reJuire refrigeration ;ill be more suitable for
remote and rural areas and sites ;it"out a guaranteed electricity su''ly.
Long s"elf life is also im'ortant& es'ecially for remote areas and sites
'erforming smaller numbers of tests.
Many ra'id tests reJuire no laboratory eJui'ment and can be 'erformed in
settings ;"ere electricity and ;ater su''lies need not be guaranteed.
Ba'id tests can detect H*E antibodies in ;"ole blood 2finger 'ric%
sam'les4 as ;ell as serum5'lasma& and testing may t"erefore be 'erformed
by non-laboratory 'ersonnel ;it" adeJuate training and su'er(ision.
Ba'id tests reduce t"e incidence of 'ersons failing to obtain test results. *n
emergency situations 'ersons may be relocated freJuently and t"erefore
not obtain t"eir results.
9"e WHO bul% 'urc"asing sc"eme "as reduced t"e 'rice of ra'id H*E
tests to bet;een ?,a 3.)# and ?,a # 'er test. Ba'id tests are slig"tly more
e:'ensi(e t"an EL*,A tests& but since EL*,A tests are multi'le tests& t"e
cost 'er test is in 'ractice considerably "ig"er unless all reagent ;ells 2)3!
/34 are used.
EL*,A tests ;ere originally de(elo'ed for blood screening and t"ese assays
are suitable for batc" testing 2testing at least )3!/3 s'ecimens 'er run4. EL*,A
tests are suitable for large voluntary counselling and testing 2EC94settings&
but in many EC9 sites t"e ability to 'erform single tests or small numbers of
tests is an ad(antage.
Case management
Pro(ide "ig"-Juality care and su''ort to all 'eo'le li(ing ;it" H*E5A*D, t"at
includes counselling& 'syc"osocial su''ort& treatment for o''ortunistic
infections 2e.g. tuberculosis4& 'alliati(e care and access to antiretro(iral
t"era'y ;"ere feasible.
,u''ort 'eo'le li(ing ;it" H*E5A*D, to li(e normal and 'roducti(e li(es t"at
are free of stigmati8ation and discrimination.
$re'ention and control measures 2see 9able 0.64
Table -#1 $re'ention and control measures
to reduce 2I/ transmission in
emergenc, situations
:educe se+ual and mother(to(child transmission
O A;areness and life s%ills education& es'ecially for young 'eo'le& to ensure t"at all
'eo'le are ;ell informed of ;"at does and does not constitute a mode of
transmissionN of "o; and ;"ere to acJuire free condoms and medical attention if
necessaryN and of basic "ygiene.
O Condom 'romotion& ;"ic" ;ould ensure t"at good Juality condoms are freely
a(ailable to t"ose ;"o need t"em& toget"er ;it" culturally sensiti(e instructions and
distribution.
O ,9* control& including for se: ;or%ers& using t"e syndromic ,9* management
a''roac" 2as laboratory ser(ices for confirmation are unli%ely to be a(ailable in
emergencies4& ;it" 'artner notification and 'romotion of safer se:.
O Beduction of mot"er-to-c"ild transmission of H*E by:
! t"e 'rimary 're(ention of H*E among ;omen& es'ecially young ;omenN
! a(oiding unintended 'regnancies among H*E-infected ;omen and 'romoting
family 'lanning met"ods& 'articularly in ;omen ;"o are infected ;it" H*EN
! 're(enting t"e transmission of H*E from infected 'regnant ;omen to t"eir infants
by:
O using an antiretro(iral 'ro'"yla:is regimen&
O a(oiding unnecessary in(asi(e obstetrical 'rocedures& suc" as artificial ru'ture of
membranes or e'isiotomy&
O modifying infant feeding 'ractices 2re'lacement feeding gi(en ;it" a cu' ;"en
acce'table& feasible& affordable& sustainable and safe& ot"er;ise e:clusi(e
breastfeeding for t"e first mont"s of life is recommended4.
7lood safety
O H*E testing of all transfused blood
O A(oidance of non-essential blood transfusion.
O Becruitment of safe blood donor 'ool.
Bniversal precautions
O Was"ing "ands t"oroug"ly ;it" soa' and ;ater& es'ecially after contact ;it" body
fluids or ;ounds.
O ?sing 'rotecti(e glo(es and clot"ing ;"en t"ere is ris% of contact ;it" blood or
ot"er 'otentially infected body fluids.
O ,afe "andling and dis'osing of ;aste material& needles and ot"er s"ar' instruments.
Pro'erly cleaning and disinfecting medical instruments bet;een 'atients.
Dhysical protection
O Protecting t"e most (ulnerable& es'ecially ;omen and c"ildren& from (iolence and
abuse is not only an im'ortant 'rinci'le of "uman rig"ts but also essential for
reducing t"e ris% of H*E infection.
Drotecting health care /or6ers
O 9o reduce nosocomial transmission& "ealt" ;or%ers s"ould strictly ad"ere to t"e
uni(ersal 'recautions ;it" all 'atients and laboratory sam'les& ;"et"er or not %no;n
to be infected ;it" H*E.
O Healt" care ;or%ers s"ould "a(e access to (oluntary counselling& testing and care.
Often "ealt" ;or%ers de'loyed in com'le: emergencies e:'erience significant
occu'ational stress& and t"ose tested as 'art of t"e management of occu'ational
e:'osures ;ill reJuire additional su''ort.
O Post-e:'osure 'ro'"yla:is 2PEP4 %its must be made a(ailable to 'rotect
"umanitarian ;or%ers ;"o "a(e been se:ually assaulted. PEP %its s"ould include
emergency contrace'tion and double5tri'le antiretro(iral treatment. PEP %its are
distributed t"roug" t"e ?nited .ations dis'ensary system.
<ounselling and voluntary testing programmes
O *n t"e acute emergency& it is im'ortant t"at a(ailable resources for H*E testing
s"ould be de(oted to ensuring a safe blood su''ly for transfusions.
O 9"e establis"ment of (oluntary testing and counselling ser(ices to "el' indi(iduals
ma%e informed decisions on H*E testing s"ould be considered ;"en relati(e stability
is restored. Often refugees are coerced into testing& or are reJuired to ma%e a decision
;it" regard to testing& ;"en t"ey are suffering acute or 'ost-traumatic stress disorders.
O As refugees are often tested before resettlement in ot"er countries& it is critical t"at
t"ey recei(e counselling on t"e legal and social im'lications of t"e test. Often
migration or tem'orary residency status is contingent on t"e a''licant being
seronegati(e.
& O Post-test counselling is essential for bot" seronegati(e and sero'ositi(e results.
Befugees and conflict sur(i(ors ;"o are already traumati8ed ;ill reJuire additional
'syc"osocial su''ort if t"ey test sero 'ositi(e. 9y'ically t"e su''ort net;or%s of
dis'laced 'ersons are disru'ted& and suicide ris% assessment forms an im'ortant 'art
of 'ost-test counselling in a refugee or conflict conte:t.
O 9esting of or'"aned minors s"ould be done& ;it" t"e consent of t"eir official
guardians& only ;"ere t"ere is an immediate "ealt" concern or benefit to t"e c"ild.
9"ere s"ould be no mandatory screening before admittance to substitute care.
Faccination
O Asym'tomatic H*E-infected c"ildren s"ould be immuni8ed ;it" EP* (accines.
O ,ym'tomatic H*E-infected c"ildren s"ould not recei(e -C@ or yello; fe(er (accine
0urt)er reading
?.A*D, re'ort summaries in BN4-12 1ecember 2%%' epidemic update at:
"tt':55;;;.unaids.org5;ad#33)5re'ortb'df."tml
Euidelines for 8-F -nterventions in Cmergency 2ettings* 2%%'" ?. *nteragency
,tanding Committee 2*A,C4& 9as%force on H*E5A*D, in Emergency ,ettings.
5igrant populations and 8-F/4-12: the development and implementation of
programmes: theory* methodology and practice. @ene(a& Coint ?nited .ations
Programme on H*E5A*D,& #333 2?.A*D, -est Practice Collection ! Dey Material4.
-#"6 ;a(anese ence()alitis
7asic facts
Ca'anese ence'"alitis 2CE4 is an acute inflammatory disease caused by a
fla(i(irus& in(ol(ing t"e brain& s'inal cord and meninges.
Less t"an Q of "uman infections are clinically a''arent& but t"e casefatality
rate among 'ersons ;it" clinical disease is #0!03Q.
*nfants and elderly 'eo'le are most susce'tible to se(ere disease.
9"e disease occurs in eastern& sout"-eastern and sout"ern Asia.
t"e disease is es'ecially associated ;it" rice-gro;ing areas.
9ransmission is t"roug" t"e bite of an infected mosJuito of s'ecies commonly
found in rice fields. <ule+ tritaeniorhynchus is t"e most common& but ot"er
<ule+ s'ecies including <+" annulirostris* <+" vishnui com'le: and <+"
gelidus may be in(ol(ed locally4.
9"e reser(oirs of t"e (irus are 'igs and some s'ecies of ;ild bird 2es'ecially
"erons and egrets4.
Clinical features
9"e incubation 'eriod is usually 0!0 days.
,ym'toms can include: "eadac"e& fe(er& meningeal signs& stu'or&
disorientation& coma& tremors& 'aresis 2generali8ed4& "y'ertonia& loss of
coordination. 9"e ence'"alitis cannot be distinguis"ed clinically from ot"er
central ner(ous system infections.
,e(ere infections are mar%ed by acute onset& "eadac"e& "ig" fe(er& meningeal
signs and coma.
CE infections are common and t"e maFority are asym'tomatic. 9"ey may occur
concurrently ;it" ot"er infections causing central ner(ous system sym'toms&
and serological e(idence of recent CE (iral infection may not be correct in
indicating CE to be t"e cause of t"e illness.
Diagnosis
Diagnosis is by demonstration of s'ecific *gM in acute-'"ase serum or
cerebros'inal fluid.
Case management
,u''orti(e treatment s"ould be gi(en ! t"ere is no s'ecific t"era'eutic agent.
Contacts s"ould be in(estigated ! determine t"e 'lace of residence of t"e
'atient for t"e t;o ;ee%s before t"e onset of illness.
$re'ention and control measures
A(oid e:'osure to mosJuitoes and use 'rotecti(e clot"ing and re'ellents.
,creen slee'ing and li(ing Juarters.
House 'igs a;ay from li(ing Juarters.
Ca'anese ence'"alitis (accines are a(ailable for tra(ellers to endemic areas&
and systematic "uman mass (accination "as 'robably contributed signifi-
cantly to t"e declining incidence in se(eral endemic countries.
Eaccination of 'igs and fogging ;it" insecticide from aircraft "a(e 'ro(ed
effecti(e as control measures during outbrea%s& but bot" met"ods of control
are (ery e:'ensi(e.
0urt)er reading
9"ongc"aroen P. Ca'anese ence'"alitis (irus ence'"alitis: an o(er(ie;. 2outheas
4sian 3ournal of Tropical 5edicine and Dublic 8ealth* /A/& %6D00/!06$.
*garas"i A. E'idemiology and control of Ca'anese ence'"alitis" ,orld 8ealth
2tatistics Ruarterly& //#& +-D#//!$30.
-#"" Leis)maniasis
7asic facts
9"e causal agents are ;eishmania s''.& 'roto8oa transmitted by t"e bite of
sandflies. ,ome $3 s'ecies of sandfly are 'ro(en (ectorsN t"e usual reser(oir
"osts are domestic and5or ;ild animals 28oonotic leis"maniasis4. *n some
cases& "umans are t"e sole reser(oir "osts 2ant"ro'onotic leis"maniasis4.
9"e main clinical forms of t"e disease are: (isceral leis"maniasis 26ala azar4&
locali8ed cutaneous leis"maniasis and 2mainly in t"e ;estern "emis'"ere4
mucocutaneous leis"maniasis. 9able 0.A sets out t"e reser(oirs of t"ese t"ree
forms.
Table -#3 eser'oirs of leis)maniasis
0orm Animal reser'oir 2uman reser'oir
8Coonotic forms9 8ant)ro(onotic forms9
Eisceral leis"maniasis
2EL4
Dogs E'idemic situations or
H*E co-infection
Cutaneous leis"maniasis
2CL4
Bodents 2rural foci4 ?rban foci
Mucocutaneous
leis"maniasis 2MCL4
,yl(atic mammals .ot a''licable
9"e leis"maniases are currently 're(alent on all continents e:ce't Australia
and Antarctica& and are considered to be endemic in AA countries& 6# of ;"ic"
are de(elo'ing countries:
/3Q of (isceral leis"maniasis cases occur in -anglades"& -ra8il& *ndia&
.e'al and ,udanN
/3Q of mucocutaneous leis"maniasis cases occur in -oli(ia& -ra8il and
PeruN
/3Q of cutaneous leis"maniasis cases occur in Afg"anistan& -ra8il& *ran
Peru& ,audi Arabia and ,yria.
9"e incubation 'eriod (aries from ;ee%s to mont"s.
E'idemics are lin%ed to "uman migrations from rural to 'oor suburban areasN
in 8oonotic foci& e'idemics are related to en(ironmental c"anges and
mo(ement of non-immune 'eo'le to rural areas. 9"ere "a(e been se(ere
e'idemics of (isceral leis"maniasis among refugees and internally dis'laced
'ersons in recent years& notably in ,udan. Ant"ro'onotic cutaneous
leis"maniasis reac"es e'idemic 'ro'ortions in Afg"anistan& t"e most
im'ortant focus in t"e ;orld being in t"e ca'ital& Dabul.
Clinical features
Cutaneous leis"maniasis is c"aracteri8ed by t"e a''earance of one or more
s%in lesions& ty'ically on unco(ered 'arts of t"e body 2face& nec%& arms and
legs4. A nodule may a''ear at t"e site of inoculation and may enlarge to
become an indolent ulcer. 9"e sore remains in t"is stage for a (ariable time
before "ealing& ty'ically lea(ing a de'ressed 'ermanent scar. Ot"er aty'ical
forms may occur.
*n some indi(iduals& certain strains of mucocutaneous leis"maniasis can
disseminate and cause e:tensi(e and disfiguring mucosal lesions of t"e nose&
mout" and t"roat ca(ities.
Eisceral leis"maniasis is c"aracteri8ed by 'rolonged irregular fe(er& s'leno-
megaly& "e'atomegaly& anaemia and ;eig"t loss. *t is usually fatal if
untreated.
Diagnosis
9"e diagnosis of cutaneous leis"maniasis is essentially clinical but may
reJuire a stained smear in aty'ical casesN no serological test is a(ailable.
9"e diagnosis of mucocutaneous leis"maniasis is clinical& but may reJuire
stained smear in aty'ical cases. ,erological tests are also a(ailable.
*n t"e case of (isceral leis"maniasis& s'lenic as'iration is t"e most sensiti(e
tec"niJue but e:'oses t"e 'atient to freJuent com'lications 2sometimes
let"al4. 9"e 'rocedure reJuires 'reliminary confirmation of normal
coagulation tests& and t"e a(ailability of blood transfusion and emergency
surgery ser(ices s"ould com'lications occur. ,uc" 'recautions ma%e t"e
'rocedure unsuitable for routine use in district "os'itals in endemic areas and
in most emergency situations. A ra'id and sensiti(e serological test& t"e direct
agglutination test& is a(ailable. *t is recommended as t"e basis of test!
treatment strategies for (isceral leis"maniasis in areas ;"ere t"e disease is
endemic.
Case management
Current treatments are based on 'enta(alent antimonials as first-line drugs. *n t"e
'resence of resistance t"e use of second-line drugs is 'ossible 2am'"otericin -&
aminosidine 'lus 'enta(alent antimonials or 'entamidine iset"ionate4 but t"ese are
unli%ely to be a(ailable and5or affordable in emergency situations.
Most cases of cutaneous leis"maniasis can be treated by intralesional inFections of
'enta(alent antimony. Eisceral leis"maniasis& mucocutaneous leis"maniasis and
multilesional or se(ere forms of cutaneous leis"maniasis reJuire long courses of
'arenteral inFections of first- or second-line drugs.
Besistance of (isceral leis"maniasis to 'enta(alent antimony treatment is
;ides'read in nort"-eastern *ndia.
Leishmania:2I/ co<infection
A*D, and ot"er immunosu''ressi(e conditions increase t"e ris% of ;eishmania-
infected 'eo'le de(elo'ing (isceral illness. Leis"maniasis accelerates t"e onset of
A*D, by cumulati(e immunosu''ression and by stimulating t"e re'lication of t"e
(irus.
;eishmania5H*E co-infections "a(e already been re'orted from o(er $3 countries&
and t"e e:tension of t"e geogra'"ical o(erla' of (isceral leis"maniasis and A*D, is
on t"e increase.
9"e ris% of transmission of (isceral leis"maniasis is increasing t"roug" t"e s"aring
of infected needles by intra(enous drug users.
$re'ention and control measures
,ee 9able 0./.
Table
-#5
Control measures for leis)maniasis
Measure /isceral leis)maniasis Cutaneous leis)maniasis Mucocutane
ous
leis)maniasi
s
Ant)ro(ono
tic
Loonotic Ant)ro(ono
tic
Loonotic Loonotic
Beinforce
d
sur(eillan
ce& early
detection
and
treatment
Priority inter(ention
Beduction
of animal
reser(oirs
.ot
a''licable
Large-scale
screening&
follo;ed
by %illing
of infected
dogs in
emergency
situations
.ot
a''licable
9o be
ada'ted to
eac"
'articular
s'ecies of
animal
reser(oir
.ot feasible
o;ing to
ecology of
animal
reser(oirs
Eector Besidual Besidual Besidual En(ironmen En(ironment
control insecticide
"ouse
s'raying
recommende
d in se(ere
e'idemic
situations
insecticide
s'raying of
"ouses and
animal
s"elters
recommend
ed in
se(ere
e'idemic
situations
insecticide
"ouse
s'raying
recommende
d in se(ere
e'idemic
situations
tal
managemen
t
al
management
*ndi(idual
'rotection
against
(ector:
insecticid
e
im'regnat
ed bednets
Essential in e'idemic situations .ot
recommend
ed
.ot
recommende
d
Healt"
'romotion
5 social
mobili8ati
on
Essential in e'idemic situations
0urt)er reading
5anual on visceral leishmaniasis control. @ene(a& World Healt" Organi8ation&
//1 2document WHO5LE*,H5/1.)34.
,89 report on global surveillance of epidemic(prone infectious diseases"
<hapter %" ;eishmaniasis and ;eishmania/8-F co(infection. @ene(a& World Healt"
Organi8ation& #333 2document WHO5CD,5C,B5*,B5#333.4.
-#"% Malaria
7asic facts
Malaria is a 'arasitic disease caused by 'roto8oan 'arasites of t"e genus
Dlasmodium.
Only four 'lasmodium s'ecies de(elo' in "umans: D" falciparum 2causing t"e
life-t"reatening form of malaria4& D" viva+* D" ovale and D" malariae" Of t"ese&
only D" viva+ and D" ovale "a(e 'ersistent li(er forms t"at may lead to rela'ses
after t"e initial blood infection "as been cured.
D"falcipar um and D"viva+ are t"e main s'ecies of 'ublic "ealt" im'ortance.
D"falcipar um is t"e commonest s'ecies t"roug"out t"e tro'ics and sub-tro'ics
! u' to A3!/3Q of malaria cases in sub-,a"aran African countries are due to
D" falciparum.
9"e disease is transmitted from 'erson to 'erson by 4nopheles mosJuitoes&
;"ic" mainly bite bet;een dus% and da;n.
*n t"e blood& 'arasites de(elo' ase:ual 2tro'"o8oite4 and se:ual 2game-tocyte4
forms& ;"ic" are res'onsible for clinical attac%s and disease transmission&
res'ecti(ely.
Malaria 'arasites can also be transmitted by transfusion of blood from an
infected to a "ealt"y 'erson and occasionally from mot"er to fetus.
Almost $33 million malaria cases occur e(ery year ;it" more t"an million
deat"s& /3Q of ;"ic" 2according to WHO estimates4 occur in African
countries& sout" of t"e ,a"ara.
Natural )istor,
De'ending on tem'erature and "umidity& t"e a(erage de(elo'ment 'eriod in
t"e mosJuito is # days for D" falciparum& $!6 days for D" ovale and D"
viva+ 2but in some strains u' to / mont"s4 and #A!$3 days for D" malariae"
9"e incubation 'eriod in "umans is t"e time bet;een t"e infecti(e bite and t"e
first a''earance of clinical signs& of ;"ic" fe(er is t"e most common. *t (aries
according to Dlasmodium s'ecies& being t"e s"ortest for D" falciparum 2/!$
days4 and t"e longest for D" malariae 2years4.
9"e minimum 'eriod of time bet;een t"e initial infection of t"e mosJuito and
t"e de(elo'ment of clinical sym'toms in "umans is $!) ;ee%s.
Clinical case definitions
*n uncomplicated malaria& t"e 'atient 'resents ;it" fe(er or "istory of fe(er
;it"in t"e last )A "ours 2;it" or ;it"out ot"er sym'toms suc" as nausea&
(omiting and diarr"oea& "eadac"e& bac% 'ain& c"ills and myalgia4.
*n a high malaria ris6 area or season& c"ildren ;it" fe(er and no general
danger sign or stiff nec% s"ould be classified as "a(ing malaria. Alt"oug" a
substantial number of c"ildren ;ill be treated for malaria ;"en in fact t"ey
"a(e anot"er febrile illness& 'resum'ti(e treatment for malaria is Fustified in
t"is category gi(en t"e "ig" rate of malaria ris% and t"e 'ossibility t"at anot"er
illness mig"t cause t"e malaria infection to 'rogress.
*n a lo/ malarial ris6 area or season& c"ildren ;it" fe(er 2or "istory of fe(er4
and no general danger sign or stiff nec% are classified as "a(ing malaria& and
gi(en an antimalarial only if t"ey "a(e no runny nose 2a sign of AB*4& no
measles& and no ot"er ob(ious cause of fe(er 2'neumonia& sore t"roat& etc.4.
*n severe malaria& 'atients 'resent ;it" sym'toms as for uncom'licated
malaria& and also dro;siness ;it" e:treme ;ea%ness and associated signs and
sym'toms related to organ failure& suc" as disorientation& loss of
consciousness& con(ulsions& se(ere anaemia& Faundice& "aemoglobinuria&
s'ontaneous bleeding& 'ulmonary oedema and s"oc%.
Diagnosis
Laboratory diagnosis is by demonstration of malaria 'arasites in a blood film
2t"ic% or t"in smear4. Ba'id diagnostic tests are useful but can be user-
de'endent and s'urious if stored at S $3`.
*n "ig"ly endemic areas of Africa& 'eo'le gradually de(elo' immunity to t"e
disease and 'arasitaemia may occur ;it"out clinical sym'toms& es'ecially in
adults. *n t"ese situations& t"e clinical 'icture is used to guide treatment
decisions. *n non-immune 'o'ulations and less endemic areas& all 'ara-
sitaemias may lead to clinical disease and s"ould be treated.
Laboratory diagnosis may not be 'ossible in t"e acute '"ase of an emergency
;"ere laboratory ser(ices are una(ailable. *n t"is situation& diagnosis must
de'end on clinical sym'toms combined ;it" %no;ledge of t"e ris% of malaria.
9"is is generally not (ery accurate& and an attem't s"ould be made to at least
define t"e 'ercentage of malaria 'atients among all t"ose ;it" fe(er. Ba'id
diagnostic tests can be useful& 'articularly in emergency settings.
9"e relati(ely "ig" cost of ra'id diagnostic tests may be Fustified in areas
;"ere drug resistance necessitates t"e use of ne;er& more e:'ensi(e
antimalarial drugs.
Microsco'ic diagnosis is essential for t"e management of sus'ected treatment
failures& es'ecially in areas ;"ere D" viva+ and drug-resistant D" falciparum
occur simultaneously.
Treatment
Dlasmodium falciparum
9reatment 'olicy s"ould be based on %no;ledge of drug resistance 'atterns in t"e
area. 9"is is 'articularly im'ortant as dis'laced 'o'ulations are es'ecially (ulnerable
o;ing to lo; immunity 2from malnutrition or lac% of 're(ious e:'osure to malaria4
and to t"e ris% of being unable to see% re-treatment if treatment fails.
Local& u'-to-date information on drug resistance is essential for de(elo'ing an
a''ro'riate treatment 'olicy. Local "ealt" aut"orities& ;"ic" may "a(e t"e
information already& and o'erational agencies s"ould collaborate in obtaining t"e
information. Ot"er causes of treatment failure& suc" as non-com'liance& (omiting and
'oor-Juality drugs& s"ould al;ays be monitored. Drug efficacy monitoring s"ould
follo; standard 'rocedures as de(elo'ed by WHO
.$
As drug resistance is ra'idly
de(elo'ing& it is also im'ortant to e(aluate second-line or future treatments
'ros'ecti(ely. 9"e first-line treatment may need to be c"anged if drug resistance
studies s"o; t"at t"e national 'olicy is ineffecti(e 2i.e. ;it" 0Q resistance to
t"era'y4.
Combinations of artemisinin deri(ati(es 2suc" as artesunate& artemet"er&
di"ydroartemisinin4 and (arious ot"er antimalarials are increasingly being used as
first-line treatment 'olicy.
)
Artemisinin-based combination t"era'y 2AC94 "as distinct
ad(antages: t"e artemisinins 'roduce ra'id clinical and 'arasitological cureN t"ere is
as yet no documented 'arasite resistance to t"emN t"ey reduce t"e gametocyte carrier
rate and t"us reduce transmissionN and t"ey are generally ;ell tolerated. 9"is o'tion
includes& for instance& artesunate 'lus amodiaJuine& artesunate 'lus sulfado:ine-
'yrimet"amine 2,P4 and artemet"er!lumefantrine 2Coartem
c
4. A dra;bac% of
artemisinins is t"e limited data on safety in 'regnancy. Artemisinin com'ounds are
not recommended in t"e first trimester of 'regnancy and currently Juinine is used as
an alternati(e. AC9 may be used in t"e second or t"ird trimester of 'regnancy if t"ere
is no better alternati(e. 9"e lac% of data for t"e use of t"e 1-dose regimen of
Coartem
c
& under 3 %g body ;eig"t currently limits its use in small c"ildren ;"o
s"ould be treated ;it" Juinine.
9"e details of t"e management of se(ere falci'arum malaria are discussed
else;"ere.
0
9"e use of daily intramuscular artemet"er is o'erationally 'referable to A!
#-"ourly Juinine administration for t"e management of se(ere malaria in
emergencies and ot"er situations ;it" limited nursing care.
Dlasmodium viva+
C"loroJuine is t"e treatment of c"oice in areas ;"ere only D"viva+ occurs. O;ing
to com'liance and o'erational constraints& ;ide-scale use of )-day 'rimaJuine anti-
rela'se treatment is usually not feasible in emergency situations. Anti-rela'se
treatment is not useful for 'atients li(ing in endemic areas ;it" unabated
transmission.
W"ere D"falcipar um and D"viva+ co-e:ist and microsco'y is not a(ailable&
D"viva+ generally res'onds ;ell to t"e drugs used for D" falciparum. 9"e e:ce'tion is
,P& ;"ic" is not suitable for treatment of D" viva+. 9"us& in countries suc" as 9imor-
Leste& ;"ere t"ere is a relati(ely "ig" 'ercentage of D"viva+ infections among malaria
cases and ;"ere D"falcipar um "as become increasingly resistant to c"loroJuine& t"e
first-line 'olicy for clinically diagnosed cases is no; a combination of ,P 2against D"
falciparum4 'lus c"loroJuine 2against D" viva+4. 9"ese 'olicies sti'ulate t"at 'atients
;it" microsco'ically confirmed malaria recei(e eit"er c"loroJuine or ,P& de'ending
on t"e s'ecies identified. Locali8ed D" viva+ resistance to c"loroJuine "as been
re'orted from se(eral countries in Asia and t"e Americas.
C)emo(ro(),la=is and intermittent (re'enti'e treatment
Malaria c"emo'ro'"yla:is is essential for non-immune e:'atriate staff ;or%ing in
cam's and communities in D" falciparum-endemic areas. *t s"ould be combined ;it"
rigorous 'rotection against mosJuito bites. 9"e c"oice of drugs is bet;een
c"loroJuine ] 'roguanil& mefloJuine& do:ycycline and ato(aJuone-'roguanil. *n D"
viva+(only areas& c"loroJuine 'ro'"yla:is may be used to 're(ent malaria. 9"e
recommended 'ro'"yla:is regimen (aries by areaN details are a(ailable in
-nternational travel and health at http://///"/ho"int/ith.
*n "ig"ly endemic D" falciparum areas& ;"ere malaria in 'regnancy is associated
;it" "ig" maternal and infant morbidity and mortality& semi-immune 'rimigra(idae
and secundigra(idae 2first and second 'regnancies4 s"ould recei(e intermittent
're(enti(e treatment 2*P94 ;it" an effecti(e 2'referably single-dose& suc" as ,P4
antimalarial drug deli(ered in t"e conte:t of antenatal care. ,uc" intermittent
're(enti(e treatment s"ould be started from t"e second trimester on;ards. *P9 doses
s"ould not be gi(en more freJuently t"an mont"ly.
All 'regnant ;omen s"ould recei(e at least # doses of *P9 after Juic%ening 2onset
of fetal mo(ements4& during routinely sc"eduled antenatal clinic (isits as
recommended by WHO 2) antenatal (isits& ;it" $ (isits after Juic%ening4. 9"ere is no
e(idence t"at recei(ing $ or more doses of *P9 ;it" ,P ;ill result in an increased ris%
of ad(erse drug reactions. ,tudies indicate t"at H*E-'ositi(e 'regnant ;omen may
need suc" intermittent 're(enti(e treatment on a mont"ly basis during all 'regnancies
to ac"ie(e o'timal benefit. 9o ac"ie(e o'timal benefit in settings ;it" H*E
're(alence in 'regnant ;omen of greater t"an #Q& it is more cost-effecti(e to treat
all ;omen ;it" $ or more doses of *P9 ;it" ,P& instead of screening for H*E and
'ro(iding t"is regimen only to H*E-'ositi(e ;omen.
*n areas of unstable malaria transmission& ;omen of re'roducti(e age "a(e
relati(ely little acJuired immunity to malaria& and "ence all 'regnant ;omen are at
similar ris% for malaria infection. *ts conseJuences in t"ese settings are maternal
illness& se(ere malaria ;it" central ner(ous system com'lications& anaemia& and
ad(erse re'roducti(e outcomes& including stillbirt"s& abortions& and lo; birt" ;eig"t.
Abortion is common in t"e first trimester& and 'rematurity is common in t"ird
trimester. Ot"er conseJuences during 'regnancy commonly associated ;it" D"
falciparum infection include "y'oglycaemia& "y'er'yre:ia& se(ere "aemolytic
anaemia& and 'ulmonary oedema.
9"e effects during 'regnancy of t"e ot"er t"ree 'arasites t"at cause malaria in
"umans 2D" viva+* D" malariae* and D" ovale4 are less clear. *n t"ese areas& D" viva+
infections are li%ely to result in febrile illness. A study among non-immune 'regnant
;omen in 9"ailand re'orted t"at D" viva+ malaria during 'regnancy is associated ;it"
maternal anaemia and lo; birt" ;eig"t& but to a lesser e:tent t"an D" falciparum.
9"ere is also a need to assess ;"et"er antimalarial 'ro'"yla:is ;it" c"loroJuine may
be Fustified in areas ;"ere D" viva+ infection among 'regnant ;omen is common and
contributes to maternal anaemia and infant lo; birt" ;eig"t.
$re'ention and control measures
9"e main met"ods of 're(enting malaria and reducing transmission in emergency
situations are 2s'ecific indications are detailed in (ector control strategies in ,ection
#.).#4:
Ba'id diagnosis and effecti(e case management ! im'ortant in reducing
malaria transmission.
*nsecticide-treated mosJuito nets 2*9.4 ! ;"ere t"e 'o'ulation is sensiti8ed
and s"elters are a''ro'riate for "anging nets.
Permet"rin-s'rayed blan%ets& s"eets and c"addors 2'ro(en efficacy in Asia and
undergoing field trials in Africa under "ig"ly endemic conditions4.
Permet"rin-treated outer clot"ing ;orn in t"e e(ening or in bed 2effecti(e in
sout" Asia4.
*ndoor residual s'raying of insecticide 2L"ouse s'rayingM4 ! t"e met"od of
control most often used in emergency situations.
En(ironmental control ! difficult during t"e acute '"ase e:ce't on a local
scale& and im'act is often limited.
*nsecticide-treated 'lastic s"eeting ! is currently undergoing field trials.
Malaria outbrea4
*n a sus'ected D" falciparum malaria outbrea%& t"ere may be a need to de(iate
from national treatment 'rotocols if t"e first-line treatment is s"o;n to be ineffecti(e.
WHO recommends t"e use of an efficacious 233Q4& safe& acce'table regimen t"at
allo;s good com'liance.
=or uncom'licated malaria& AC9 is currently t"e only treatment t"at fits t"is
recommendation e:ce't in some regions 2suc" as Central America4 ;"ere t"ere are
strong data on t"e "ig" efficacy of ot"er drugs. W"ere AC9 is not used& 'rimaJuine as
a single-dose gametocidal s"ould be used to reduce transmission. *n 'regnant ;omen&
AC9 is contraindicated in t"e first trimesterN it may be used in t"e second or t"ird
trimester if t"ere is no better alternati(e.
=or se(ere malaria& t"e guiding 'rinci'le for c"oice of drugs in an outbrea% s"ould
be to use an efficacious& safe drug 2minor side-effects are tolerable4 t"at reduces staff
;or%load and does not reJuire com'licated infrastructure. *ntramuscular artemet"er is
t"e drug of c"oice as it "as similar efficacy to Juinine but "as lo;er reJuirements for
monitoring. Artesunate su''ositories may be used as 're-referral medication. *f t"e
'atient cannot be transferred& rectal artesunate can be continued until oral inta%e is
establis"ed.
*n a 'ure D" viva+ outbrea%& c"loroJuine s"ould be t"e first-line t"era'y.
Antirela'se t"era'y ;it" 'rimaJuine is unnecessary during an outbrea%. 9"e minimal
information reJuired to reduce mortality is 'resented in 9able 0.3.
Deciding on t"e inter(ention to ado't ;ill de'end on a(ailable resources& t"e
ca'acity of t"e "ealt" system and ot"er "ealt" 'riorities. 9"e main aim of t"e res'onse
is to reduce mortality and disease burden. 9"ree strategies for case management are
feasible de'ending on t"e situation:
mass treatment of fe(er cases in absence of ra'id diagnostic tests&
acti(e case detection t"roug" mobile outreac" ser(ices&
'assi(e case detection.
*n a se(ere outbrea%& t"e maFority of fe(er cases may be due to malaria. E(en if
microsco'y is a(ailable t"ere may not be time to confirm t"e diagnosis of e(ery
sus'ected case. Ba'id diagnostic tests are (ery useful in t"ese situations& alt"oug" a
negati(e test does not 'reclude treatment. *n t"e absence of t"ese tests& mass treatment
of febrile cases is t"en Fustified. Microsco'y is& "o;e(er& (ery useful for monitoring
e'idemic trends t"roug" t"e monitoring of slide 'ositi(ity rates 2i.e. malaria as a
'ro'ortion of all febrile illness4 in sam'les of slides ta%en from fe(er cases at regular
inter(als.
Healt" ser(ices s"ould reac" as dee'ly into t"e community as 'ossible and ma%e
full use of community "ealt" ;or%ers if a(ailable. Acti'e detection of malaria cases in
t"e community is Fustified during an outbrea% if e:cess mortality is documented& t"e
'o'ulation is dis'ersed& t"ere is a lac% of "ealt" facilities and referral systems are
una(ailable. Again& ra'id diagnostic tests can be (ery useful for case detection.
*deally& treatments s"ould be efficacious& s"ort and sim'le to a(oid t"e necessity for
follo;-u' or t"e c"ances of se(ere malaria de(elo'ing. Outreac" clinics s"ould
include a "ealt" education com'onent and ideally s"ould be eJui''ed to manage
se(ere cases.
Clinic-based (assi'e case detection is more suited to c"ronic situations once
mortality is under control. Laboratory ser(ices ;it" Juality control are essential not
Fust for case management but also for sur(eillance of disease trends. ,uc" data may be
used to Fustify im'lementing (ector control or 'ersonal 'rotection 'rogrammes& and to
assess t"e im'act of control inter(entions. W"en refugees or dis'laced 'eo'le are
settled in numerous cam's or communities& consolidated microsco'y and 'o'ulation
data may be used as an indicator of ;"ic" cam's s"ould be gi(en 'riority for
targeting inter(entions. 9"e monitoring and Juality control of field laboratories by a
central reference laboratory is essential in ensuring an accurate diagnosis.
Table -#"6 Minimum information reFuired
to in'estigate a sus(ected malaria
outbrea4
$o(ulation
O W"o is affected^
O W"ere are t"ey from^
O Ho; are t"ey li(ing^
Disease
O .umber ;it" acute febrile illness
O .umber ;it" confirmed uncom'licated malaria
O .umber ;it" microsco'ically confirmed se(ere malaria
O .umber of malaria deat"s
O .umber of maternal deat"s due to malaria
O Pro'ortion of c"ildren ;it" anaemia
O Pro'ortion of 'regnant ;omen ;it" anaemia
O Drug resistanceN 'ro'ortion of treatment failures
Management
O .umber of "ealt" facilities 2'eri'"eral and referral4
O A(ailable staff and e:'ertise
O Access of 'o'ulation to t"e "ealt" facilities
O A(ailability of drugs and su''lies
O Malaria 'olicy and treatment guidelines
Monitoring malaria burden
E'idemiological information systems are essential in all malaria control
'rogrammes to assess t"e country<s malaria situation& allo; t"e forecasting of
e'idemics& define ris% grou's and monitor 'rogramme 'rogress.
0urt)er reading
NSGera 34" 5alaria control among refugees and displaced populations. @ene(a&
World Healt" Organi8ation& //1 2document C9D5MAL5/1.14.
5anagement of severe malaria ! a practical handboo6& #nd ed. @ene(a& World
Healt" Organi8ation& #333.
The use of antimalarial drugs. @ene(a& World Healt" Organi8ation& #33
2document WHO5CD,5B-M5#33.$$4.
-est 'ractice and lessons learnt: im'lementing malaria control in com'le:
emergencies in Africa #333!#33). WHO5B-M Consultation& 0!6 .o(ember #33)&
@ene(a 2document WHO5H9M5MAL5#3304.
-#"* Measles
7asic facts
Measles is a "ig"ly communicable (iral infection s'read (ia res'iratory
dro'lets from 'erson to 'erson.
*t is a se(ere disease caused by t"e rubeola (irus& ;"ic" damages e'it"elial
surfaces and t"e immune system.
Measles can increase susce'tibility to ot"er infectious agents suc" as
'neumococcus* 8aemophilus influenzae and 2taphylococcus aureus.
*t can lead to or e:acerbate (itamin A deficiency& t"us increasing t"e ris% of
:ero'"t"almia& blindness and 'remature deat".
9"e most (ulnerable are c"ildren bet;een t"e ages of / mont"s and 0 years in
de(elo'ing countries& but t"is de'ends on (accination co(erage rates.
Deat"s are mostly due to com'lications suc" as 'neumonia& crou' and
diarr"oea and are freJuently associated ;it" malnutrition.
Natural )istor,
9"e incubation 'eriod is usually 3!# days from e:'osure to onset of fe(er.
*nitial sym'toms and signs are "ig" fe(er& runny nose& cory8a& coug"& red eyes
and Do'li% s'ots 2small ;"ite s'ots on t"e buccal mucosa4.
A c"aracteristic eryt"ematous 2red4 maculo'a'ular 2blotc"y4 ras" a''ears on
t"e t"ird to se(ent" day& commencing be"ind t"e ears and on t"e "airline and
t"en s'reading to t"e rest of t"e body.
9"e tem'erature subsides after $!) days and t"e ras" fades after 0!1 days.
Measles is "ig"ly infectious from t"e start of t"e 'rodromal 'eriod until
a''ro:imately )!0 days after t"e ras" a''ears.
Case-fatality rates are estimated at $!0Q in de(elo'ing countries& but may be
as "ig" as 3!$3Q in dis'laced 'o'ulations.
Com(lications
,ome 0!3Q of 'atients de(elo' com'lications.
Com'lications occurring in t"e first ;ee% of t"e illness& suc" as crou'&
diarr"oea and 'neumonia& are usually due to t"e effects of t"e measles (irus
and are rarely life-t"reatening.
Later com'lications are usually due to secondary (iral or bacterial infections.
Post-measles 'neumonia& diarr"oea and crou' are t"e most common life-
t"reatening com'lications 2see 9able 0.4.
Table -#"" Com(lications of measles
Pneumonia ?sually se(ere& freJuent bacterial
su'erinfection
Diarr"oea Caused eit"er by t"e (irus or by a
secondary infection& e.g. 2higella
Malnutrition Preci'itated by anore:ia& stomatitis&
fe(er& (omiting& diarr"oea and ot"er
,tomatitis Com'romises suc%ing and eating
Eitamin A deficiency DeratoconFuncti(itisN measles increases
t"e need for (itamin A and often
'reci'itates :ero'"t"almia and5or
blindness due to scarring
Ence'"alitis Acute measles ence'"alitis occurs in
a''ro:imately in 333 infected
c"ildren& ty'ically during con(alescence
.-: t"e most common neurological
manifestation of measles infection is
febrile con(ulsions
Otitis media 9"is is a common com'lication of
measles: t"e ear is 'ainful and "earing is
reduced
Crou' Laryngotrac"eobronc"itis causing air;ay
obstruction
,ubacute sclerosing 'anence'"alitis ,ubacute sclerosing 'anence'"alitis
2,,PE4 occurs in a''ro:imately in
333 333
Onset is late& usually after #!3 years
Case management
A "istory s"ould be ta%en from t"e mot"er and t"e c"ild s"ould be e:amined for
t"e signs and sym'toms set out in 9able 0.#.
Table -#"% S,m(toms and signs indicating
measles
S,m(toms Signs
Ability to ta%e feeds or fluids .utritional status
Coug" and difficult breat"ing -reat"ing rate& c"est indra;ing& stridor
Diarr"oea or blood in stools De"ydration and fe(er
,ore mout"& eyes or ears Mout" ulcers& sore and disc"arging ears
and eyes& -itot<s s'ots
a

Le(el of consciousness
a
7itotJs spots are superficial* foamy gray or /hite* irregularly shaped patches*
/hich appear on the conGunctiva .or /hite0 of the eyeball" They are due to
severe vitamin 4 deficiency"
Case management of uncom(licated measlesD )ealt) centre
Most c"ildren ;ill "a(e uncom'licated measles and reJuire su''orti(e care as
out'atients. @ood su''orti(e care can im'ro(e a c"ild<s outcome. *solation of 'atients
;it" measles is not indicated in emergency situations. All c"ildren ;it" measles in
t"ese settings s"ould "a(e t"eir nutritional status monitored and be enrolled in a
selecti(e feeding 'rogramme if necessary.
9"e c"ild s"ould be nursed in a s"aded and ;ell (entilated area& as t"is is
generally more comfortable for t"e c"ild. ,unlig"t can be 'ainful for t"e eyes
and a cool en(ironment can %ee' t"e tem'erature do;n.
Control t"e fe(er by te'id s'onging and administration of 'aracetamol.
Dee' t"e 'atient ;ell "ydratedN treat diarr"oea ;it" oral re"ydration salts.
Obser(e t"e 'atient closely for com'lications.
@i(e 'ro'"yla:is against :ero'"t"almia: (itamin A on days and # 2see 9able
0.$4.
Table -#"* Dosages of 'itamin A in measles treatment
regimens
Age Immediatel, on diagnosis 0ollo@ing da,
*nfants U 1 mont"s 03 333 *? 03 333 *?
*nfants 1! mont"s 33 333 *? 33 333 *?
C"ildren S mont"s #33 333 *? #33 333 *?
Maintain an adeJuate 'rotein!calorie inta%e: inform mot"ers of t"e
im'ortance of freJuent small meals.
Continue breastfeeding.
Pro(ide su''lementary feeding if a(ailable. 9"e diet must be soft ;it" a "ig"
calorie density& so t"at small 'ortions go a long ;ay. Protein& unless in t"e
form of egg& is unli%ely to be eaten 2remember t"e c"ild "as a sore mout" and
'oor a''etite4.
Do not admit 'atients to general feeding centres until after t"e infectious
'eriod.
*f t"ere are large numbers of cases it may be necessary to set u' a small unit
for c"ildren ;it" measles& as t"ey and t"eir mot"ers need a lot of su''orti(e
care.
?se antimicrobials only ;"en indicated.
?nderta%e acti(e case-finding during t"e e'idemic& if 'ractical 2"ome (isits4.
Case management of com(licated measlesD )ealt) centre:)os(ital
Control fe(er& 'ro(ide nutritional su''ort and ensure t;o doses of (itamin A
"a(e been gi(en 2as for uncom'licated measles4.
A t"ird dose must be gi(en after # ;ee%s.
Antimicrobials s"ould not be gi(en routinely.
*ndications for antimicrobial t"era'y are of t;o ty'es: 2a4 documented
com'lications suc" as 'neumonia& otitis media and dysenteryN and 2b4 c"ildren
at significant ris% of secondary bacterial infection 2e.g. se(ere malnutrition&
H*E infection or :ero'"t"almia4. A broad-s'ectrum antimicrobial suc" as
am'icillin or co-trimo:a8ole s"ould be used.
*n case of coug" and ra'id breat"ing 2)3 breat"s 'er minute or more if o(er
year of ageN 03 breat"s 'er minute if less t"an year4 gi(e an antimicrobial
suc" as am'icillin& amo:icillin or co-trimo:a8ole. *f t"e c"ild<s condition does
not im'ro(e after #)!)A "ours& c"ange t"e antimicrobial to an
antista'"ylococcal drug suc" as clo:acillin or c"loram'"enicol.
*f t"ere are t"ree or more loose or ;atery stools in #) "ours& assess for
associated de"ydration. *f t"ere is blood in t"e stool& t"e c"ild "as dysentery.
9"e commonest cause of dysentery is 2higella s''. 2see ,ection 0.# for details
of managing cases of s"igellosis4.
9"e maFor eye 'roblems associated ;it" measles are measles conFuncti(itis& or
%eratitis ;it" ensuing corneal damage due to (itamin A deficiency. 9"e mere
obser(ation of red and ;atery eyes ;it"out ot"er com'lications does not
Fustify s'ecific treatment. ,tic%y eyes and 'us in t"e eyes are due to secondary
bacterial infection: clean t"e eye at least t"ree times a day ;it" cooled boiled
;ater& using cotton ;ool or a clean clot". ?se tetracycline ointment t"ree
times a day for 6 days.
IM$OTANT# .EEEB use steroid eye ointments.
$re'ention and control measures
,ee ,ection #.1.).
IM$OTANT# W"ile t"is section details t"e diagnosis and case management of
measles& (accination remains t"e most im'ortant strategy for measles control. Measles
(accination cam'aigns are one of t"e "ig"est 'riorities in emergency situations.
0urt)er reading
<onduite I tenir en cas dJKpidKmie de rougeole"L5anagement of a measles
outbrea6M Paris& MKdecins ,ans =ronti_res& //1.
Treating measles in children. @ene(a& World Healt" Organi8ation& //6
2document WHO5EP*59BAM5/6.3#4.
,89(BN-<CF Goint statement on reducing measles mortality in emergencies
2document WHO5E>-53).3$ or ?.*CE=5PD5Measles53#4.
5easles Technical ,or6ing Eroup: 2trategies for measles control and
elimination" Be'ort of a meeting. !# May #333. @enen(a& World Healt"
Organi8ation #33 2document WHO5E>-53.$64.
-#"+ Meningococcal meningitis 8e(idemic9
7asic facts
Meningococcal meningitis is an acute inflammation of t"e meninges& usually
caused by bacteria.
Large outbrea%s of meningitis are mainly due to t"e meningococcus Neisseria
meningitidis 2serogrou's A& C and& more recently& W$0]A]C4.
N" meningitidis also causes meningococcal se'ticaemia& a se(ere disease ;it"
signs of acute fe(er& 'ur'ura and s"oc%. *t is less common but t"e case-fatality
rate is "ig".
N" meningitidis& 2treptococcus pneumoniae and 8aemophilus influenzae
account for A3Q of all cases of bacterial meningitis.
Eiral meningitis is rarely serious and may be caused by any of a number of
(iruses 2suc" as co:sac%ie (irus or entero(irus4.
Dis'laced 'o'ulations are at increased ris% of meningitis o;ing to o(er-
cro;ding& 'oor "ygiene and 'oor access to "ealt" care.
E'idemics in refugee cam's "a(e mainly been due to N" meningitides
serogrou' A.
Endemic attac% rates in sub-,a"aran Africa range from under 3 to o(er #3
'er 33 333 'o'ulation.
E'idemic attac% rates in Africa can be as "ig" as 333 'er 33 333 'o'ulation.
,ome A3Q of cases of meningococcal meningitis occur in t"ose under $3
years of age.
Wit"out a''ro'riate treatment& t"e case-fatality rate in meningococcal
meningitis can be as "ig" as 03QN ;it" treatment t"is can be reduced to 0!
0Q.
Eaccines are a(ailable against meningococcus A& C& H and W$0& and t"ese
are (ery effecti(e in controlling e'idemics. W"en used in ra'id mass cam-
'aigns& (accination can contain an outbrea% ;it"in #!$ ;ee%s. 9"e (accine
efficacy rate is /3Q one ;ee% after inFection for t"ose o(er # years of age.
Clinical features
9"e clinical case definition is sudden onset of fe(er 2S $A.3 `C a:illary4 and one
of t"e follo;ing: nec% stiffness& altered consciousnessN ot"er meningeal signN or
'etec"ial or 'ur'ural ras".
*n 'atients under year of age& meningitis is sus'ected ;"en fe(er is accom'anied
by a bulging fontanelle.
Diagnosis
Lumbar 'uncture is necessary to determine ;"et"er acute meningitis is bacterial&
and to identify t"e meningococcus 2and e:clude ot"er causati(e 'at"ogens& suc" as
'neumococcus and 8" influenzae4. Lumbar 'uncture s"ould be done as soon as
meningitis is sus'ected before starting antimicrobial treatment.
*n bacterial meningitis& t"e cerebros'inal fluid is usually cloudy or 'urulent 2but
may be clear or bloody4. 9"e basic laboratory e:amination consists of a ;"ite cell
count 2WCC4& 'rotein concentration and @ram stain.
,e(eral ne; ra'id diagnostic tests are a(ailable t"at can be useful in confirming
meningococcal meningitis including seroty'es A& C& H& and W$0 of Neisseria
meningitidis.
Meningococcal meningitis ifD
WCC S 333 cells5mm$ 2U$ in normal C,=4 ;it" S13Q 'olymor'"s.
Protein concentration S 3.A3 g5l 2U 3.13 g5l in normal C,=4.
@ram stain: @ram-negati(e di'lococci 2intra- or e:tracellular4 in A3Q of cases not
're(iously treated.
1ifferential diagnosis
A lumbar 'uncture s"ould be 'erformed and t"e cerebros'inal fluid e:amined to
differentiate (iral from bacterial meningitis 2see Anne: A for guidelines on collection
of C,= s'ecimens4.
9"ic% and t"in smears s"ould be made to differentiate meningococcal meningitis
from cerebral malaria in malaria-endemic areas.
Case management
-acterial meningitis& 'articularly meningococcal meningitis& is 'otentially
fatal and is a medical emergency.
Eiral meningitis is rarely serious and reJuires su''orti(e care& but a lumbar
'uncture is necessary to differentiate it from bacterial meningitis.
All sus'ected meningitis 'atients s"ould be admitted to "os'ital or a "ealt"
centre for diagnosis and case management.
Antimicrobial treatment s"ould be started immediately after ta%ing a lumbar
'uncture ;it"out ;aiting for t"e results.
9reatment ;it" antimicrobials s"ould not be delayed if lumbar 'uncture
cannot be 'erformed.
*ntra(enous administration of ben8yl'enicillin& am'icillin& ceftria:one or
cefota:ime is recommended for bacterial meningitis.
*n 'atients for ;"om t"e intramuscular or intra(enous route is not 'ossible&
oral administration is acce'table but "ig"er doses are necessary.
During large e'idemics among refugees or dis'laced 'o'ulations& a single-
dose regimen of oily c"loram'"enicol intramuscularly can be used if resources
or circumstances do not 'ermit t"e administration of a full course of standard
treatment.
Table -#"+ Initial em(irical antimicrobial t)era(, for
(resumed bacterial meningitis
Age grou( $robable
(at)ogens
Antimicrobial t)era(,
0irst c)oice Alternati'e
Epidemic situations
All age grou's N" meningitidis -en8yl'enicillin or
oily
c"loram'"enicol
Am'icillin or
ceftria:one or
cefota:ime or co-
trimo:a8ole
Non-epidemic situations
Adults and c"ildren
S 0 years
N" meningitidis -en8yl'enicillin or
oily
c"loram'"enicol
Am'icillin or
ceftria:one or
cefota:ime or co-
trimo:a8ole
2" pneumoniae
C"ildren mont"
to 0 years
8" influenzae Am'icilin or
amo:ycilin or
c"loram'"enicol
Ceftria:one or
cefota:ime 2" pneumoniae
N" meningitidis
.eonates @ram-negati(e
bacteria
Am'icillin and
gentamicin
Ceftria:one or
cefota:ime or
c"loram'"enicol @rou' -
stre'tococci
;isteria s''.
*n meningococcal se'ticaemia ;it" 'ur'ura and s"oc%& s"oc% s"ould be
treated by restoring blood (olume.
C"emo'ro'"yla:is of contacts is not recommended in emergency situations.
,u''orti(e t"era'y s"ould be gi(en to maintain "ydration and adeJuate
nutrition.
Con(ulsions s"ould be treated ;it" dia8e'am& intra(enously or rectally.
9"e 'atient s"ould be nursed in a s"aded and ;ell-(entilated area. 9"e
unconscious or semiconscious 'atient s"ould be nursed on "is5"er sideN turning
e(ery #!$ "ours can 're(ent 'ressure sores.
Table -#"- Antimicrobials to treat bacterial meningitis
Agent oute Dail, dose>
adults
Dail, dose>
c)ildren
Duration
8da,s9
-en8yl'enicillin *E $!) M? four!
si: times
)33 333 ?5%g S )
Am'icillin5
amo:icillin
*E #!$ g t;ice #03 mg5%g S )
Amo:icillin Oral #!$ g t;ice #03 mg5%g S )
C"loram'"enicol *E g t;ice!
t"ree times
33 mg5%g S )
C"loram'"enicol
2oily4
*M $ g single dose 33 mg5%g !#
Cefota:ime *E # g t;ice #03 mg5%g S )
Ceftria:one *E !# g once!
t;ice
03!A3 mg5%g S )
Ceftria:one *M !# g single
dose
03!A3 mg5%g !#
Co-trimo:a8ole *E5 *M # g ,MG t;ice 33 mg5%g S )
a
Co-trimo:a8ole Oral # g ,MG t;ice
a
33 mg5%g S )
,ulfadia8ine *E g si: times #33 mg5%g S )
a
25Q= sulfametho+azole
$re'ention and control measures
,ee ,ection ).#.# for detecting an outbrea% of meningococcal meningitis 2alert
and e'idemic t"res"olds4. ,ee ,ection #.1.0 for im'lementing a mass (accination
cam'aign.
0urt)er reading
<onduite I tenir en cas dJKpidKmie de mKningite I mKningocoque L5anagement
of a meningococcal meningitis outbrea6M. Paris& MKdecins ,ans =ronti_res& //1.
<ontrol of epidemic meningococcal diseases: ,89 practical guidelines& #nd ed.
@ene(a& World Healt" Organi8ation& //A 2document WHO5EMC5-AC5/A.$4.
Detecting meningococcal meningitis e'idemics in "ig"ly-endemic African
countries: WHO recommendation. ,ee6ly Cpidemiological :ecord& #333& *3D$31!
$3/.
Cmergence of ,>? meningococcal disease" :eport of a ,89 <onsultation*
Eeneva* )!& 2eptember 2%%. @ene(a& World Healt" Organi8ation& #33
2document WHO5CD,5C,B5@AB5#33#.4.
;aboratory methods for the diagnosis of meningitis caused by Neisseria
meningitidis* 2treptococcus pneumoniae* and 8aemophilus influenzae. @ene(a&
World Healt" Organi8ation& /// 2document WHO5CD,5C,B5EDC5//.64.
-#"- ela(sing fe'er 8louse<borne9
7asic facts
Bela'sing fe(er is a se(ere febrile disease& usually lasting #!$ ;ee%s.
E'idemic rela'sing fe(er is caused by 7orrelia recurrentis& a bacterium t"at is
transmitted by body lice.
Alt"oug" it is 'resent s'oradically in almost all continents 2e:ce't Oceania4&
rela'sing fe(er is endemic in ,udan and in t"e "ig"lands of Et"io'ia.
Periods of fe(er usually last )!1 days and alternate ;it" afebrile 'eriods.
Eac" febrile 'eriod is terminated by a crisis.
9"e incubation 'eriod is about a ;ee%.
?' to #3Q of untreated 'atients die.
Diagnosis
*n endemic areas& under conditions of o(ercro;ding and (ery 'oor sanitation&
a "ealt" ;or%er s"ould sus'ect rela'sing fe(er in a 'atient ;it" "ig" fe(er and
t;o of t"e follo;ing four sym'toms:
se(ere Foint 'ain&
c"ills&
Faundice&
nose or ot"er bleeding&
or in a 'atient ;it" "ig" fe(er ;"o is res'onding 'oorly to antimalarial drugs.
*n areas ;"ere t"ere "a(e been no cases for a number of mont"s& it is
ad(isable to confirm t"e initial cases in t"e laboratory by microsco'y.
9"e diagnosis of rela'sing fe(er can be confirmed by ta%ing blood from
'atients sus'ected of "a(ing t"e disease ;"ile t"ey "a(e acute "ig" fe(er& and
sending to a laboratory ;"ere testing can be carried out. 9y'ical 7orrelia
s'iroc"aetes can be seen directly t"roug" blood-smear microsco'y.
9"e seams of clot"ing s"ould be e:amined for lice and t"eir eggs. Eery often
t"e c"ildren of t"e "ouse"old ;ill easily be able to identify lice in t"e clot"ing
if 'resent. -lan%ets and any c"anges of clot"ing s"ould be c"ec%ed.
Case management
Effecti(e treatment is a(ailable& com'rising a single dose of a common
antimicrobial 2e.g. eryt"romycin& tetracycline or do:ycycline4& as follo;s:
do:ycycline: single dose of 33 mg in adults&
tetracycline: single dose of 033 mg in adults&
eryt"romycin: single dose of 033 mg in adults and c"ildren o(er 0 years&
eryt"romycin: single dose of #03 mg in c"ildren u' to 0 years.
IM$OTANT# Do:ycycline and tetracycline must not be gi(en to 'regnant
;omen.
$re'ention and control measures
Detect and treat all t"ose sus'ected of "a(ing rela'sing fe(er and t"eir close
contacts.
Carry out a 'o'ulation-based delousing 'rogramme in affected areas.
Promote im'ro(ed 'ersonal "ygiene.
Pre(ent furt"er outbrea%s t"roug" community 're(ention 'rogrammes.
Control body louse infestation 2see ,ections #.). and 0.#4.
-#". Scabies
7asic facts
,cabies is a 'arasitic disease of t"e s%in caused by t"e mite 2arcoptes scabiei"
*t is transmitted by direct s%in-to-s%in contact or se:ual contact.
9ransfer from bedclot"es can occur only if clot"ing "as been contaminated by
an infested 'erson immediately before"and.
9"e infestation 'resents as 'a'ules& (esicles or burro;s containing t"e mites
and t"eir eggs.
Lesions are most common around finger ;ebs& ;rists and elbo;s and t"e
abdomen.
9"e "ead& nec%& 'alms and soles may be affected in infants.
9"e disease "as ;ides'read distribution.
9"e largest e'idemics "a(e occurred in conditions of 'oor sanitation and
o(ercro;ding follo;ing dis'lacement.
,cabies is endemic in most de(elo'ing countries.
Clinical features
*n 'eo'le ;it"out 're(ious e:'osure& t"e incubation 'eriod is #!1 ;ee%s
before t"e onset of itc"ing.
*n 're(iously infested 'eo'le& sym'toms occur !) days after re-e:'osure.
*ntense itc"ing occurs es'ecially at nig"t.
,cratc"ing can be se(ere in c"ildren& and result in secondary bacterial
infection of t"e 'a'ules.
*nfestation can be se(ere and debilitating in malnouris"ed 'eo'le.
Diagnosis
Clinical diagnosis is made by t"e identification of c"aracteristic lesions.
Mites reco(ered from burro;s can be identified microsco'ically.
Case management
9reatment of t"e ;"ole grou' is necessary& as some members maybe asym'-
tomatic.
=ormulations of insecticides 2belo;4 can be a''lied as creams& lotions or
aJueous emulsions for use against scabies. 9"e formulation must be a''lied to
all 'arts of t"e body belo; t"e nec%& not only to t"e 'laces ;"ere itc"ing is
felt. *t s"ould not be ;as"ed off until t"e ne:t day. 9reated 'ersons can dress
after t"e a''lication "as been allo;ed to dry for about 0 minutes.
Malat"ion 2Q4 aJueous emulsion or 'ermet"rin 20Q4 cream s"ould be
a''lied to t"e body belo; t"e nec% and left for #) "ours before ;as"ing.
@amma ben8ene "e:ac"loride cream 2Q4 may also be used.
-en8yl ben8oate 2#0Q4 emulsion may be used but may reJuire re'eated
a''lications. Half- and Juarter-strengt" solutions s"ould be used for c"ildren
aged A!# and )!6 years& res'ecti(ely.
-en8yl ben8oate is irritating and s"ould be a(oided in malnouris"ed c"ildren
;"ere 'ossible. -en8yl ben8oate s"ould also be a(oided if 'ossible if t"e
'atient "as o'en lesions due to scratc"ing.
Clot"ing and bedclot"es s"ould be ;as"ed if 'ossible.
*(ermectin& used for filariasis and onc"ocerciasis& is also effecti(e in treating
scabies infections in a single oral dose of 33!#33 mg5%g body ;eig"t. *t can
be 'articularly useful in outbrea%s& in H*E-infected indi(iduals and in crusted
scabies.
-#"1 Se=uall, transmitted infections
7asic facts
9"e four main syndromes of se:ually transmitted infections 2,9*s4 are:
uret"ral disc"arge&
(aginal disc"arge&
genital ulcer disease&
lo;er abdominal 'ain.
,yndromic management of ,9*s is 'articularly rele(ant in resource-'oor settings
and in emergency situations& ;"ere laboratory bac%-u' of clinical diagnosis is seldom
a(ailable. A number of algorit"ms 2flo; c"arts4 "a(e been 'ro'osed for t"e four
syndromes listed abo(e. 9"eir 'erformance is better for uret"ral disc"arge and genital
ulcer disease. Current algorit"ms for (aginal disc"arge are not "ig"ly effecti(e in
detecting gonorr"oea and c"lamydial infection in ;omen& or in discriminating
bet;een (aginal infections and (aginal 'lus cer(ical infections. WHO algorit"ms for
uret"ral disc"arge& genital ulcers and (aginal disc"arge are described in Anne: $.
Pre(ention of ,9*s is an im'ortant control measure and consists of:
early diagnosis and treatment of ;omen and men and management of 'artnersN
"ealt" education: safe se:ual be"a(iour messages in "ealt" education
acti(ities and 'romotion of a''ro'riate "ealt"-care-see%ing be"a(iourN
condom distribution.
S(ecific diagnosis and case management
Genital ulcer
@enital ulcers may be due to sy'"ilis& c"ancroid& granuloma inguinale or "er'es
sim'le:. Clinical differential diagnosis of genital ulcers is inaccurate& 'arti-cularly in
settings ;"ere se(eral etiologies are common. Clinical manifestations may be furt"er
altered in t"e 'resence of H*E infection.
9"e 'atient s"ould be e:amined to confirm t"e 'resence of genital ulceration.
9reatment a''ro'riate to local etiologies and antimicrobial sensiti(ity 'atterns s"ould
be gi(en. =or e:am'le& in areas ;"ere more t"an one cause is %no;n to be 'resent&
'atients ;it" genital ulcers s"ould be treated for all rele(ant conditions at t"e time of
t"eir initial 'resentation to ensure adeJuate t"era'y in case of loss to follo;-u'.
Laboratory-assisted differential diagnosis is rarely "el'ful at t"e initial (isit& and
mi:ed infections are common. =or instance& in areas of "ig" sy'"ilis incidence& a
reacti(e serological test may reflect a 're(ious infection and gi(e a misleading 'icture
of t"e 'atient<s 'resent condition.
:ecommended regimens:
treatment for sy'"ilis
(lus
treatment for c"ancroid or treatment for granuloma inguinale
Genital ulcer and HI infection
*n H*E-infected 'atients& 'rolonged courses of treatment may be necessary for
c"ancroid. Moreo(er& ;"ere H*E infection is 're(alent& a significant 'ro'ortion of
'atients ;it" genital ulcer may also carry "er'es sim'le: (irus. Her'etic ulcers may
be aty'ical and 'ersist for long 'eriods in H*E-infected 'atients. Patients ;it" genital
ulcers s"ould be follo;ed u' ;ee%ly until t"e ulceration s"o;s signs of "ealing.
!rethral discharge
Male 'atients ;it" uret"ral disc"arge and5or dysuria s"ould be e:amine for
e(idence of disc"arge.
*f microsco'y is a(ailable& a uret"ral s'ecimen s"ould be ta%en and a uret"ral
smear stained ;it" @ram stain. A count of more t"an 0 'olymor'"onuclear leu%o-
cytes 'er field 2V 3334 confirms a diagnosis of uret"ritis.
9"e maFor 'at"ogens causing uret"ral disc"arge are Neisseria gonorrhoeae and
<hlamydia trachomatis. ?nless a diagnosis of gonorr"oea can be definiti(ely
e:cluded by laboratory tests& t"e treatment of t"e 'atient ;it" uret"ral disc"arge
s"ould 'ro(ide adeJuate co(erage of t"ese t;o organisms.
:ecommended regimens:
treat as for uncom'licated gonorr"oea
(lus
do:ycycline& 33 mg orally& t;ice daily for 6 days
or tetracycline& 033 mg orally& four times daily for 6 days
Note: 9etracyclines are contraindicated in 'regnancy.
4lternative regimen /here single(dose therapy for gonorrhoea is not available:
trimet"o'rim 2A3 mg4 ] sulfamet"o:a8ole 2)33 mg4& 3 tablets orally& daily
for $ days
(lus
do:ycycline& 33 mg orally& t;ice daily for 6 days
or tetracycline& 033 mg orally& four times daily for 6 days
Note: 9"is regimen s"ould be used only in areas ;"ere trimet"o'rim!sulfame-
t"o:a8ole "as been s"o;n to be effecti(e against uncom'licated gonorr"oea.
4lternative if tetracyclines are contraindicated or not tolerated:
treat as for uncom'licated gonorr"oea
(lus
eryt"romycin& 033 mg orally& four times daily for 6 days
As follo;-u'& 'atients s"ould be ad(ised to return if sym'toms 'ersist 6 days after
t"e start of t"era'y.
aginal discharge
Eaginal disc"arge is most commonly caused by (aginitis& but may also be t"e
result of cer(icitis. Eaginitis may be caused by Trichomonas vaginalis& <andida
albicans and a combination of Eardnerella s''. and anaerobic bacterial infection
2bacterial (aginosis4.
Cer(icitis may be due to N" gonorrhoeae or <hlamydia trachomatis infection.
Management is more im'ortant t"an t"at of (aginitis& from a 'ublic "ealt" 'oint of
(ie;& as cer(icitis may "a(e serious seJuelae. Ho;e(er& clinical differentiation
bet;een t"e t;o conditions is difficult and ideally reJuires s'eculum e:ami-nation by
a s%illed '"ysician.
<ervicitis
:ecommended regimens:
treat as for uncom'licated gonorr"oea
(lus
do:ycycline& 33 mg orally& t;ice daily for 6 days
or tetracycline& 033 mg orally& four times daily for 6 days
Note: 9etracyclines are contraindicated in 'regnancy.
4lternative if tetracyclines are contraindicated or not tolerated:
treat as for uncom'licated gonorr"oea
(lus
eryt"romycin& 033 mg orally& four times daily for 6 days
4lternative regimen /here single(dose therapy for gonorrhoea is not available:
trimet"o'rim 2A3 mg4 ] sulfamet"o:a8ole 2)33 mg4& 3 tablets orally& daily
for $ days
(lus
do:ycycline& 33 mg orally& t;ice daily for 6 days
or tetracycline& 033 mg orally& four times daily for 6 days
Note" 9"is regimen s"ould be used only in areas ;"ere trimet"o'rim!
sulfamet"o:a8ole "as been s"o;n to be effecti(e against uncom'licated gonorr"oea.
Faginitis
:ecommended regimens:
treat ;it" metronida8ole& # g orally as a single dose
or metronida8ole& )33!033 mg orally& t;ice daily for 6 days
(lus
nystatin& 33 333 *? intra(aginally& once daily for ) days
or micona8ole or clotrima8ole& #33 mg intra(aginally& once daily for $ days
or clotrima8ole& 033 mg intra(aginally& as a single dose
Note: Patients ta%ing metronida8ole s"ould be cautioned to a(oid alco"ol.
Lo@er abdominal (ain
All se:ually acti(e ;omen 'resenting ;it" lo;er abdominal 'ain s"ould be
carefully e(aluated for t"e 'resence of sal'ingitis and5or endometritis!'el(ic
inflammatory disease 2P*D4. *n addition& routine bimanual and abdominal
e:aminations s"ould be carried out on all ;omen ;it" a 'resum'ti(e ,9*& since some
;omen ;it" P*D or endometritis ;ill not com'lain of lo;er abdominal 'ain. Women
;it" endometritis may 'resent ;it" com'laints of (aginal disc"arge and5or bleeding
and5or uterine tenderness on 'el(ic e:amination. ,ym'toms suggesti(e of P*D include
abdominal 'ain& dys'areunia& (aginal disc"arge& menometrorr"agia& dysuria& 'ain
associated ;it" menses& fe(er& and sometimes nausea and (omiting.
P*D is generally caused by N" gonorrhoeae& <" trachomatis and anaerobic bacteria
27acteroides s''. and @ram-'ositi(e cocci4. *t is difficult to diagnose because clinical
manifestations are (aried. P*D becomes "ig"ly 'robable ;"en one or more of t"e
abo(e sym'toms are seen in a ;oman ;it" adne:al tenderness& e(idence of lo;er
genital tract infection and cer(ical motion tenderness. Enlargement or induration of
one or bot" fallo'ian tubes& tender 'el(ic mass& and direct or rebound tenderness may
also be 'resent. 9"e 'atient<s tem'erature may be ele(ated but is normal in many
cases. *n general& clinicians s"ould err on t"e side of o(er-diagnosing and treating
milder cases.
Patients ;it" acute P*D s"ould be admitted to "os'ital if:
t"e diagnosis is uncertain&
surgical emergencies suc" as a''endicitis and ecto'ic 'regnancy need to be
e:cluded&
a 'el(ic abscess is sus'ected&
se(ere illness 'recludes management on an out'atient basis& O t"e 'atient is
'regnant&
t"e 'atient is unable to follo; or tolerate an out'atient regimen&
t"e 'atient "as failed to res'ond to out'atient t"era'y&
clinical follo;-u' 6# "ours after t"e start of antimicrobial treatment cannot be
guaranteed.
,ee recommended regimens for lo;er abdominal 'ain related to se:ually
transmitted diseases belo;.
0urt)er reading
Euidelines for the management of se+ually transmitted infections. @ene(a& World
Healt" Organi8ation& #33 2document WHO5H*EbA*D,5#33.34.
Dallabetta @A& Laga M& Lam'tey PB. <ontrol of se+ually transmitted diseases: a
handboo6 for the design and management of programs. Arlington& EA& A*D,CAP
ProFect& =amily Healt" *nternational& //6.
;o/er abdominal pain
IN$ATIENT T2EA$?D recommended s,ndromic treatment 8* alternati'e
regimens9
. ceftria:one& #03 mg intramuscularly& once daily
(lus do:ycycline& 33 mg orally or intra(enously& t;ice daily
or tetracycline& 033 mg orally& ) times daily
#. clindamycin& /33 mg intra(enously& e(ery A "ours
(lus gentamicin& .0 mg5%g intra(enously e(ery A "ours
$. ci'roflo:acin& 033 mg orally& t;ice daily& or s'ectinomycin g
intramuscularly& ) times daily
(lus metronida8ole& )33!033 mg orally or intra(enously& t;ice daily
or c"loram'"enicol& 033 mg orally or intra(enously& ) times daily
Note: =or all t"ree regimens& continue treatment for at least # days after t"e 'atient
"as im'ro(ed and follo; ;it":
do:ycycline& 33 mg orally& t;ice daily for ) days
or tetracycline& 033 mg orally& four times daily for ) days
Note: Patients ta%ing metronida8ole s"ould be cautioned to a(oid alco"ol.
9etracyclines are contraindicated in 'regnancy.
O!T$ATIENT T2EA$?D recommended s,ndromic treatment
single-dose t"era'y for uncom'licated gonorr"oea (lus
do:ycycline& 33 mg orally& t;ice daily for ) days
or tetracycline& 033 mg orally& four times daily for ) days
(lus
metronida8ole& )33!033 mg orally& t;ice daily for ) days
Note: Patients ta%ing metronida8ole s"ould be cautioned to a(oid alco"ol.
9etracyclines are contraindicated in 'regnancy.
Out'atients ;it" P*D s"ould be follo;ed u' at 6# "ours and admitted if t"eir
condition "as not im'ro(ed.
O!T$ATIENT T2EA$?D alternati'e s,ndromic treatment @)ere single<
dose t)era(, for gonorr)oea is not a'ailableD
trimet"o'rim 2A3 mg4 ] sulfamet"o:a8ole 2)33 mg4& 3 tablets orally once
daily for $ days and t"en # tablets orally t;ice daily for 3 days
(lus
do:ycycline 33 mg orally& t;ice daily
or tetracycline 033 mg orally& ) times daily for ) days
(lus
metronida8ole )33!033 mg orally& t;ice daily for ) days
Note: 9"is regimen s"ould be used only in areas ;"ere trimet"o'rim!
sulfamet"o:a8ole "as been s"o;n to be effecti(e in t"e treatment of uncom'licated
gonorr"oea. Patients ta%ing metronida8ole s"ould be cautioned to a(oid alco"ol.
9etracyclines are contraindicated in 'regnancy.
Out'atients ;it" P*D s"ould be follo;ed u' at 6# "ours and admitted if t"eir
condition "as not im'ro(ed.
-#"3 Tr,(anosomiasis> African 8African slee(ing sic4ness9
.
7asic facts
African try'anosomiasis is found uniJuely in sub-,a"aran Africa. *n e'idemic
situations& as in t"e Democratic Be'ublic of t"e Congo& t"e 're(alence of t"e
disease can be as "ig" as 63Q in some areas.
An im'ortant feature of African try'anosomiasis is its focal nature. *t tends to
occur in circumscribed 8ones. Obser(ed 're(alence ratios (ary greatly from
one geogra'"ical area to anot"er& and e(en bet;een one (illage and anot"er
;it"in t"e same area.
War and dis'lacement are not directly in(ol(ed in t"e s'read of t"e disease&
but t"ey 'lay a maFor role in causing t"e brea%do;n of sur(eillance&
casedetection and treatment.
9"e causal agents are:
Trypanosoma brucei gambiense 2tro'ical forest& central and ;est Africa4N
T" b" rhodesiense 2sa(anna"& east and sout"ern Africa4.
Endemic countries can be classified into four maFor le(els of endemicity
de'ending on t"eir le(el of disease 're(alence 2see ma' belo;. E(en ;it"in
eac" country t"e s'acial distribution is "ig"ly "eterogeneous and occurs in
foci and micro-foci.
Humans are t"e maFor reser(oir in t"e T" b" gambiense formN ;ild ruminants
and domestic cattle are t"e maFor reser(oir for T" b" rhodesiense. Outbrea%s
occur ;"en "uman!fly contact is intensified or t"roug" mo(ements of "osts or
infected flies.
*nfection occurs after an infected tsetse fly 2Elossina s''.4 bites t"e (ictim and
transmits t"e try'anosome. 9"e 'arasite t"en multi'lies in t"e blood and
lym'" glands and& after a (ariable delay& crosses t"e blood!brain barrier and
'ro(o%es maFor& often irre(ersible& neurological disorders t"at lead to deat".
9"e incubation 'eriod is s"ort for T" b" rhodesiense 2$ days to a fe; ;ee%s4N it
can be years for T" b" gambiense.
Clinical features
*n t"e early stages& a 'ainful c"ancre 2rare in T" b" gambiense infection4& ;"ic"
originates as a 'a'ule and e(ol(es into a nodule& may be found at t"e 'rimary site of a
tsetse fly bite. 9"ere may be fe(er& intense "eadac"e& insomnia& 'ainless
lym'"adeno'at"y& anaemia& local oedema and ras". *n t"e later stage t"ere is
cac"e:ia& slee' disturbance and signs of central ner(ous system im'airment. 9"e
disease may run a 'rotracted course of se(eral years in t"e case of T" b" gambiense. *n
t"e case of T" b" rhodesiense& t"e disease "as a ra'id and acute e(olution. -ot"
diseases are al;ays fatal in t"e absence of treatment.
Diagnosis
Presum'ti(e: serological: card agglutination try'anosomiasis test 2CA994: for
T" b" gambiense only or immunofluorescent assay for T" b" rhodesiense mainly
and 'ossibly for T" b" gambiense"
Confirmati(e: 'arasitological: detection 2microsco'y4 of try'anosomes in
blood& lym'" node as'irates or C,=.
Case management
Early screening and diagnosis are essential& as treatment is easier in t"e first stage
of t"e disease 2fe;er inFections reJuired& no 'syc"iatric disorders4& carries a lo;er ris%
and can be administered on an out'atient basis. Diagnosis and treatment reJuire
trained 'ersonnel& and self-treatment is not 'ossible. Most a(ailable drugs are old&
difficult to administer ;"ere resources are limited& and by no means al;ays
successful.
T" b" gambiense
:ecommended regimens
0irst stage of t)e disease 8@it)out cerebros(inal fluid in'ol'ement9
Dentamidine 2) mg5%g body ;eig"t 'er day4 intramuscularly for 6 consecuti(e
days on an out'atient basis.
Second stage 8@it) cerebros(inal fluid in'ol'ement9
5elarsoprol B Hos'itali8ation ;it" $ series of daily inFections administered ;it" a
rest 'eriod of A to 3 days bet;een eac" series. A series consists of one inFection of
$.1 mg5%g5daily melarso'rol intra(enously for $ consecuti(e days.
*n case of melarso'rol treatment failure& use eflornithine )33 mg5%g 'er day
administered in four daily slo; infusions 2lasting a''ro:imately # "ours4. *nfusions
are gi(en e(ery 1 "ours& ;"ic" re'resents a dose of 33 mg5%g 'er infusion.
T" b" rhodesiense
:ecommended regimens
0irst stage of t)e disease 8@it)out cerebros(inal fluid in'ol'ement9
2uramin B 9"e recommended dosage is #3 mg5%g 'er day ;it" a ma:imum dose
of g 'er inFection. 9"e drug is administered intra(enously at t"e rate of one inFection
'er ;ee%. 9"e treatment course is 0 ;ee%s for a total of 0 inFections.
Second stage of t)e disease 8@it) cerebros(inal fluid in'ol'ement9
5elarsoprol B Hos'itali8ation ;it" $ series of daily inFections administered ;it" a
rest 'eriod of A ! 3 days bet;een eac" series. A series consists of one inFection of
$.1 mg5%g 'er day melarso'rol intra(enously for $ consecuti(e days.
Note: Melarso'rol causes reacti(e ence'"alo'at"y in 0!3Q of 'atients& ;it" fatal
outcome in about "alf t"e cases. 9"e treatment "as a 3!$3Q rate of treatment failure&
'robably due to '"armacological resistance.
*ncreasing rates of resistance to melarsoprol 2as "ig" as #0Q4 "a(e been re'orted
from (arious African countries& suc" as ,udan and ?ganda& leading to greater use of
eflornithine.
$rocurement of eFui(ment and drugs
,ince #33& a 'ublic-'ri(ate 'artners"i' agreement signed by WHO "as made all
t"ese drugs ;idely a(ailable. 9"e drugs are donated to WHO. BeJuests for su''lies
are made to WHO by go(ernments of disease-endemic countries and organi8ations
;or%ing in associations ;it" t"ese go(ernments. ,toc% control and deli(ery of t"e
drugs are underta%en by MKdecins ,ans =ronti_res in accordance ;it" WHO
guidelines. All t"e drugs are 'ro(ided free of c"arge: reci'ient countries 'ay only for
trans'ort costs and customs c"arges.
$re'ention
Human reser(oirs s"ould be contained t"roug" 'eriodic 'o'ulation screening
and c"emot"era'y.
9setse fly control 'rogrammes s"ould be conducted& using tra's and screens
2may be im'regnated ;it" insecticide4.
Public education s"ould be underta%en on 'ersonal 'rotection against t"e bites
of t"e tsetse fly.
Donation of blood by t"ose ;"o li(e or "a(e stayed in endemic areas s"ould
be 'ro"ibited.
Control measures in e(idemic situations
Control measures com'rise sur(eys to identify affected areasN early identi-fication
of infection in t"e community& follo;ed by treatmentN and urgent im'lementation of
tsetse fly control measures.
Drug resistance monitoring
Melarso'rol treatment failure can be as "ig" as $3Q in some areas. A melarso'rol
resistance sur(eillance net;or% "as been establis"ed by WHO.
0urt)er reading
,89 report on global surveillance of epidemic(prone infectious diseases:
4frican trypanosomiasis. @ene(a& WHO& #333 2 WHO5CD,5C,B5*,B5#333.4.
8uman trypanosomiasis: a guide for drug supply. @ene(a& World Healt"
Organi8ation& #33 2document WHO5CD,5C,B5EPH5#33.$4.
Programme against African try'anosomiasis 2PAA94& #33). *,,. A#:#))#.
-#"5 Tuberculosis
7asic facts
9uberculosis 29-4 is a disease most commonly affecting t"e lungs& but also
ot"er organs.
*t is caused by t"e bacterium 5ycobacterium tuberculosis" 9"e 5"
tuberculosis com'le: includes 5"tuberculosis and 5"africanum* 'rimarily
from "umans& and 5"bovis & 'rimarily from cattle.
5" tuberculosis and 5" africanum are transmitted by e:'osure to t"e bacilli in
airborne dro'let nuclei 'roduced by 'eo'le ;it" 'ulmonary or laryngeal
tuberculosis during e:'iratory efforts& suc" as coug"ing and snee8ing.
-o(ine 9- results from e:'osure to tuberculous cattle& usually by ingestion of
un'asteuri8ed mil% or dairy 'roducts& and sometimes by airborne s'read to
farmers and animal "andlers.
9"e incubation 'eriod is about #!3 ;ee%sN latent infections may 'ersist
t"roug"out a 'erson<s life.
*n t"e acute '"ase of an emergency& ;"en mortality rates are "ig" o;ing to
acute res'iratory infections& malnutrition& diarr"oeal diseases and malaria
2;"ere 're(alent4& 9- control is not a 'riority. A 9- control 'rogramme
s"ould not be im'lemented until crude mortality rates are belo; 'er 3 333
'o'ulation 'er day. *t is crucial t"at t"ere is some stability in t"e 'o'ulation& as
all 'atients commencing 9- treatment must com'lete t"e full 1- or A-mont"
treatment course. *f t"ere are "ig" rates of treatment defaulters& t"ere is a "ig"
ris% of de(elo'ment of multidrug-resistant 9-.
.e(ert"eless& 9- is a 'articularly im'ortant disease in long-term emer-gencies
;"ere refugees or internally dis'laced 'ersons are in cam's or o(ercro;ded
communities for long 'eriods. *n t"ese conditions& 'eo'le are at 'articularly
"ig" ris% of de(elo'ing 9- o;ing to o(ercro;ding& malnutrition and "ig" H*E
sero're(alence. *n Denya in //$& t"e incidence of ne; infectious 9- 'atients
in cam's ;as four times t"e rate in t"e local 'o'ulation. *n t;o cam's in
,udan in //3& o(er one-t"ird of all adult deat"s ;ere due to 9-.
Diagnosis
9"e most im'ortant sym'toms of 9- are:
'roducti(e coug" of long duration 2 S $ ;ee%s4&
"aemo'tysis&
significant ;eig"t loss.
9- 'atients may also "a(e fe(er& nig"t s;eats& breat"lessness& c"est 'ain and loss
of a''etite.
9"e full case definitions for 9- are gi(en in Anne: 0.
Patients ;it" sus'ected 9- s"ould "a(e t"ree s'utum sam'les e:amined by lig"t
microsco'y for acid-fast bacilli& using t"e Gie"l-.eelsen stain.
Criteria for establis)ing a T7 control (rogramme in emergenc,
situations
DO9, is t"e 9- control strategy recommended by WHO. *t is im'ortant t"at t"e
9- 'rogramme im'lements t"e DO9, strategy and& ;"ere 'ossible& coordinates t"is
;it" t"e national 9- 'rogramme of t"e "ost country. 9"e same treatment 'rotocols
s"ould be used& and data on case-finding and treatment outcome s"ould be re'orted to
t"e rele(ant district 9- coordinator of t"e national 9- 'rogramme. *m'lementation of
a DO9, 'rogramme reJuires t"at t"e follo;ing criteria are met:
case detection t"roug" s'utum-smear microsco'yN t"is im'lies t"e e:istence of
a laboratory system ca'able of underta%ing s'utum-smear microsco'y to an
acce'table standardN
standardi8ed s"ort-course c"emot"era'y a(ailable to at least all smear-'ositi(e
'atients under direct obser(ation of treatment& at least during t"e initial '"ase
of treatmentN
a secure and regular su''ly of a''ro'riate anti-9- drugsN
a monitoring system for 'rogramme su'er(ision and e(aluationN
'olitical ;illingness on t"e 'art of t"e rele(ant go(ernment2s4 aut"orities to
im'lement t"e 'rogramme.
9"e follo;ing criteria are essential before a 9- 'rogramme is im'lemented:
sur(eillance data indicate t"at 9- is an im'ortant "ealt" 'roblemN
t"e acute emergency '"ase is o(erN
t"e basic needs of ;ater& adeJuate food& s"elter and sanitation are metN
essential clinical ser(ices and drugs are a(ailableN
security in and stability of t"e affected 'o'ulation is en(isaged for at least 1
mont"sN
sufficient funding is a(ailable to su''ort t"e 'rogramme for at least #
mont"sN
laboratory ser(ices for s'utum-smear microsco'y are a(ailable.
Once t"e decision to im'lement a DO9, 'rogramme is made& t"e follo;ing
information s"ould be collected:
a(ailable funding and duration of su''ortN
annual 9- incidence in t"e country of originN
9- control 'olicies in t"e country of origin and t"e "ost countryN
e:'ertise among t"e national 9- 'rogramme or nongo(ernmental
organi8ations in im'lementing 9- control 'rogrammes.
Drug 'rocurement& establis"ment of laboratory ser(ices and training may ta%e u'
to $ mont"s& so t"e decision to im'lement a 9- control 'rogramme s"ould be made as
soon as 'ossible after t"e acute emergency '"ase is o(er.
9"e %ey ste's in setting u' a 9- control 'rogramme using t"e DO9, strategy are:
lead agency identified& e.g. national 9- 'rogramme& nongo(ernmental
organi8ationN
funding identifiedN
;or% 'lan& resource needs and budget 're'aredN
9- coordinator2s4 2if 'ossible 'er 03 333 'o'ulation4 a''ointedN
agreement ;it" national 9- 'rogramme of "ost country on:
integration of refugee5internally dis'laced 'erson 9- control 'rogramme
;it" national 9- 'rogramme&
drug regimens to be used&
co(erage of t"e local 'o'ulation by t"e 9- control 'rogramme&
referral of seriously ill 'atients to local "os'itals&
laboratories suitable for Juality control of smear e:amination&
'rocurement of drug stoc%s and reagents&
'rocedures for follo;-u' of cases in t"e re'atriation '"ase&
'rogramme e(aluationN
staff needs assessed& Fob descri'tions de(elo'ed and staff recruitedN
secure storage facilities identifiedN
'roduction of local 9- control 'rotocolN
re'orting system establis"ed.
Case management
9"e 'riority is t"e diagnosis and treatment of smear-'ositi(e infectious cases of
9-. 9o ensure t"e a''ro'riate treatment and cure of 9- 'atients& strict
im'lementation of t"e DO9, strategy is im'ortant.
9"ere are 'rimarily t"ree ty'es of regimen:
category for ne; smear-'ositi(e 2infectious4 'ulmonary cases&
category # for re-treatment cases&
category $ for smear-negati(e 'ulmonary or e:tra-'ulmonary cases.
9"e c"emot"era'eutic regimens are based on standardi8ed combinations of fi(e
essential drugs: rifam'icin 2B4& isonia8id 2H4& 'yra8inamide 2P4& et"ambutol 2E4 and
stre'tomycin 2,4.
Eac" of t"e standardi8ed c"emot"era'eutic regimens consist of t;o '"ases:
t"e initial 2intensi(e4 '"ase: #!$ mont"s& ;it" $!0 drugs gi(en daily under
direct obser(ationN
t"e continuation '"ase: )!1 mont"s& ;it" #!$ drugs gi(en t"ree times a ;ee%
under direct obser(ation& or in some cases 2e.g. during re'atriation of refugees4
t;o drugs for 1 mont"s gi(en daily unsu'er(ised& but in fi:ed-dose
combination form.
All doses of rifam'icin-containing regimens s"ould be obser(ed by staff. Actual
s;allo;ing of medication s"ould be su'er(ised.
Multidrug<resistant T7
MDB-9- is a s'ecific form of drug-resistant 9- due to a bacillus resistant to
at least isonia8id and rifam'icin& t"e t;o most 'o;erful anti-9- drugs.
DO9,-Plus is designed to cure MDB-9- using second-line anti-9- drugs.
DO9,-Plus is needed in areas ;"ere MDB-9- "as emerged due to 're(ious
inadeJuate 9- control 'rogrammes.
DO9,-Plus 'ilot 'roFects are recommended onl, in settings @)ere t)e
DOTS strateg, is full, in (lace to (rotect against t)e creation of furt)er
drug resistance#
*t is (ital t"at WHO is consulted before DO9,-Plus 'ilot 'roFects are launc"ed
in order to minimi8e t"e ris% of creating drug resistance to secondline anti-9-
drugs.
0urt)er reading
Harries AD& Ma"er D. T7/8-F: a clinical manual. @ene(a& World Healt"
Organi8ation& //1 2document WHO59-5/1.#334.
Treatment of tuberculosis: guidelines for national programmes& #nd ed. @ene(a&
World Healt" Organi8ation& //6 2document WHO59-5/6.##34.
Tuberculosis control in refugee situations: an inter(agency field manual. @ene(a&
World Healt" Organi8ation& //6 2document WHO59-5/6.##4.
-#%6 T,()oid fe'er
7asic facts
9y'"oid fe(er is caused by 2almonella 9y'"i* a @ram-negati(e bacterium. A
(ery similar but often less se(ere disease is caused by t"e 2almonella seroty'e
Paraty'"i A" *n most countries in ;"ic" t"ese diseases "a(e been studied& t"e
ratio of disease caused by 2" 9y'"i to t"at caused by 2" Paraty'"i is about
3:.
9y'"oid fe(er remains a global "ealt" 'roblem. *t is difficult to estimate t"e
real burden of ty'"oid fe(er in t"e ;orld because t"e clinical 'icture is
confused ;it" many ot"er febrile infections because of t"e lac% of a''ro-'riate
laboratory resources in most areas in de(elo'ing countries. Many cases remain
under-diagnosed. *n bot" endemic areas and in large outbrea%s& most cases of
ty'"oid fe(er are seen in t"ose aged $!/ years.
Humans are t"e only natural "ost and reser(oir. 9"e infection is transmitted by
ingestion of faecally contaminated food or ;ater. 9"e "ig"est incidence occurs
;"ere ;ater su''lies ser(ing a large 'o'ulation are faecally contaminated.
9"e incubation 'eriod is usually A!) days& but may e:tend from $ days u' to
# mont"s.
,ome #!0Q of infected 'eo'le become c"ronic carriers ;"o "arbour 2" 9y'"i
in t"e gall bladder. C"ronic carriers are greatly in(ol(ed in t"e s'read of t"e
disease.
Patients infected ;it" H*E are at a significantly increased ris% of se(ere
disease due to 2" 9y'"i and 2" Paraty'"i.
Clinical features
9"e clinical 'resentation of ty'"oid fe(er (aries from a mild illness ;it" lo;-
grade fe(er& malaise and dry coug" to a se(ere clinical 'icture ;it" abdominal
discomfort& altered mental status and multi'le com'lications.
Clinical diagnosis is difficult. *n t"e absence of laboratory confirmation& any case
of fe(er of at least $A `C for $ or more days is considered sus'ect if t"e
e'idemiological conte:t is conduci(e.
De'ending on t"e clinical setting and Juality of a(ailable medical care& some 0!
3Q of ty'"oid 'atients may de(elo' serious com'lications& t"e most freJuent being
intestinal "aemorr"age or 'eritonitis due to intestinal 'erforation.
Clinical case definitions are gi(en in 9able 0.1.
Table -#". Clinical case definitions
Confirmed case of ty'"oid fe(er A 'atient ;it" fe(er 2$A `C or more4
lasting $ or more days& ;it" laboratory-
confirmed 2" 9y'"i organisms 2blood&
bone marro;& bo;el fluid4
Probable case of ty'"oid fe(er A 'atient ;it" fe(er 2$A `C or more4
lasting $ or more days& ;it" a 'ositi(e
serodiagnosis or antigen detection test but
no 2" 9y'"i isolation
C"ronic carrier An indi(idual e:creting 2" 9y'"i in t"e
stool or urine for longer t"an one year
after t"e onset of acute ty'"oid fe(erN
s"ort-term carriers also e:ist& but t"eir
e'idemiological role is not as im'ortant
as t"at of c"ronic carriers
Diagnosis
9"e definiti(e diagnosis of ty'"oid fe(er de'ends on t"e isolation of 2" 9y'"i
organisms from t"e blood or bone marro; or bo;ed fluid. -lood culture
bottles s"ould be trans'orted to t"e referral laboratory at ambient tem'erature.
9"e classical Widal test measuring agglutinating antibody titres against 2"
9y'"i in serum "as only moderate sensiti(ity and s'ecificity. *t can be
negati(e in u' to $3Q of culture-'ro(en cases of ty'"oid fe(er and can be
falsely 'ositi(e in many circumstances. .e;er diagnostic tests based on
detection of serum antibodies "ig"ly s'ecific to 2" 9y'"i are currently being
de(elo'ed and some "a(e already been mar%eted. 9"ey are ra'id& (ery
accurate and easy to 'erform. Alt"oug" t"ey "a(e not yet been e(aluated
e:tensi(ely in t"e field& t"ey are li%ely to become standard 'oint-of-care tests
for t"e diagnosis of ty'"oid fe(er& 'articularly in emergencies ;"ere access to
blood culture facilities is com'romised.
Case management
More t"an /3Q of 'atients can be managed at "ome ;it" oral antimicrobial&
minimal nursing care& and close medical follo;-u' for com'lications or failure
to res'ond to t"era'y. Ho;e(er& t"e emergence of multidrug-resistant strains
in many 'arts of t"e ;orld "as reduced t"e c"oice of effecti(e anti-microbial
a(ailable in many areas. W"en feasible& antimicrobial susce'tibility testing is
crucial as a guide to clinical management.
9"e a(ailable e(idence suggests t"at t"e fluoroJuinolones
6
are t"e o'timal
c"oice for t"e treatment of ty'"oid fe(er at all ages. Ho;e(er& in areas of t"e
;orld ;"ere t"e bacterium is still fully sensiti(e to traditional first-line drugs
2c"loram'"enicol& am'icillin& amo:icillin or trimet"o'rim!sulfamet"o:a8ole4
and fluoroJuinolones are not a(ailable or affordable& t"ese drugs do remain
a''ro'riate for t"e treatment of ty'"oid fe(er. C"loram'"enicol& des'ite t"e
ris% of agranulocytosis 2 'er 3 333 'atients4& is still ;idely 'rescribed in
de(elo'ing countries to treat ty'"oid fe(er. 2" 9y'"i strains from many areas
of t"e ;orld& suc" as *ndonesia and most countries in Africa& remain sensiti(e
to t"is drug.
,u''orti(e measures are im'ortant in t"e management of ty'"oid fe(er& suc"
as oral or intra(enous "ydration& anti'yretics& and a''ro'riate nutrition and
blood transfusions& if indicated.
9y'"oid fe(er 'atients ;it" c"anges in mental status c"aracteri8ed by
delirium& obtundation or stu'or s"ould be immediately e(aluated for
meningitis by e:amination of t"e cerebros'inal fluid. *f t"e findings are
normal and ty'"oid fe(er is sus'ected& adults and c"ildren s"ould imme-
diately be treated ;it" "ig"-dose intra(enous de:amet"asone in addition to
antimicrobials. De:amet"asone& gi(en in an initial dose of $ mg5%g body
;eig"t by slo; intra(enous infusion o(er $3 minutes& follo;ed 1 "ours later
by mg 'er %g body ;eig"t e(ery 1 "ours for a total of eig"t times& can
reduce mortality by a''ro:imately A3!/3Q in t"ese "ig"-ris% 'atients.
De:amet"asone& gi(en in a lo;er dose& is not effecti(e. Hig"-dose steroid
treatment need not a;ait t"e results of ty'"oid blood cultures if ot"er causes
of se(ere disease are unli%ely.
$re'ention and control measures
Healt" education& clean ;ater& food ins'ection& 'ro'er food "andling and
'ro'er se;age dis'osal are essential in 're(enting ty'"oid fe(er outbrea%s.
Early detection and containment of t"e cases are 'aramount in reducing
dissemination. 9"e "ealt" aut"orities must be informed if one or more
sus'ected cases are identified. 9"e outbrea% s"ould be confirmed follo;ing
WHO guidelines& and a referral laboratory s"ould be consulted ;"ene(er
'ossible to Juic%ly obtain an antimicrobial sensiti(ity 'attern of t"e outbrea%
strain.
/accination
9"e old 'arenteral& %illed& ;"ole-cell (accine ;as effecti(e but 'roduced an
unacce'table rate of side-effects. .o;adays& a 'arenteral (accine containing
t"e 'olysacc"aride Ei antigen is t"e (accine of c"oice in dis'laced
'o'ulations. A li(e oral (accine using 2" 9y'"i strain 9y#a is also a(ailable.
.eit"er t"e 'olysacc"aride (accine nor t"e 9y#a (accine is licensed for
c"ildren under # years of age. 9"e 9y#a (accine s"ould not be used in
'atients recei(ing antimicrobials.
Mass (accination may be an adFunct for t"e control of ty'"oid fe(er during a
sustained& "ig"-incidence e'idemic. 9"is is es'ecially true ;"en access to ;ell
functioning medical ser(ices is not 'ossible or in t"e case of a multidrug-
resistant strain. *f t"e in(ol(ed community cannot be fully (accinated& c"ildren
aged #!/ years s"ould be gi(en 'riority.
-#%" T,()us 8e(idemic louse<borne9
7asic facts
9y'"us is a ric%ettsial disease caused by t"e 'at"ogen :ic6ettsia pro/aze6i"
*t is transmitted by t"e "uman body louse& ;"ic" is infected by feeding on t"e
blood of a 'atient ;it" acute ty'"us. *nfected lice e:crete ric%ettsiae in t"eir
faeces& and "umans are infected by rubbing faeces or crus"ed lice into t"e bite.
9"e disease is endemic in t"e "ig"lands and cold areas of Africa& Asia and
,out" America. Cases occurred in t"e 'ast in t"e -al%ans and 'arts of t"e
former ,o(iet ?nion& and cases of -rill-Ginsser disease 2recrudescent ty'"us4
are still re'orted from t"ese regions.
Befugees and dis'laced 'ersons in affected areas are at a "ig" ris% of
e'idemics if t"ere are o(ercro;ding& 'oor ;as"ing facilities and body lice.
Large outbrea%s "a(e been re'orted among refugees in -urundi& Et"io'ia and
B;anda.
9"e crude mortality rate ranges from 3Q to )3Q ;it"out treatment& and can
rise to 03Q in t"e elderly.
9"e crude mortality rate is around 63Q among t"ose ;"o de(elo'
com'lications.
Clinical features
9"e incubation 'eriod is !# ;ee%s& commonly # days.
9"ere is a sudden onset of fe(er& c"ills& "eadac"e and generali8ed 'ain.
A macular ras" s'reads o(er t"e trun% and limbs after 0!1 days of t"e illness.
*n se(ere cases& com'lications suc" as (ascular colla'se& gangrene& acute
res'iratory distress syndrome and coma can occur.
Diagnosis
9y'"us "as a nons'ecific clinical 'resentation& so laboratory testing is usually
needed to confirm t"e diagnosis for t"e first cases in a sus'ected e'idemic.
,erological tec"niJues are used& t"e most common being t"e indirect
fluorescent antibody test.
Ot"er tests are t"e en8yme-lin%ed immunosorbent assay and com'lement
fi:ation.
Only initial cases s"ould be confirmedN after confirmation of an e'idemic t"e
diagnosis s"ould be clinical.
Case management
*n areas ;"ere ty'"us is %no;n to 'resent a ris%& all ne;ly arri(ed refugees or
internally dis'laced 'ersons in a cam' or community s"ould be screened and&
if body lice are found& mass delousing s"ould be carried out.
Prom't treatment of 'atients ;it" antimicrobials is essential.
9"e treatment of first c"oice is a single oral dose of do:ycycline 20 mg5%g
body ;eig"t4.
9y'"us can also be treated ;it" tetracycline or c"loram'"enicol orally ;it" a
loading dose of #!$ g 2in c"ildren& tetracycline at #0!03 mg5%g body ;eig"t&
c"loram'"enicol 03 mg5%g body ;eig"t4& follo;ed by daily doses of !#
g5day in four di(ided doses at 1-"our inter(als until t"e 'atient becomes
afebrile 2usually $!6 days4 'lus one day.
*n se(ere cases& 'atients s"ould be admitted to "os'ital and gi(en intra-(enous
tetracycline or c"loram'"enicol.
$re'ention and control measures
Once an e'idemic is confirmed& all 'atients and contacts s"ould be deloused
using 'ermet"rin 'o;der 3.0Q. Permet"rin is a''lied to all clot"es and
bedding using a s"a%er-to' container or a s'ecial "and-"eld 'o;der duster.
9"e 'o;der is blo;n into t"e clot"ing t"roug" t"e nec% o'enings& u' t"e
slee(es& u' t"e legs and from all sides of t"e loosened ;aist. *f t"is is not
a(ailable a #0Q solution of ben8yl ben8oate 2found in all essential drug %its4
can be a''lied and ;as"ed off #) "ours later.
Clot"ing and bedding t"at "a(e not been used s"ould also be treated. One easy
met"od is to 'lace all clot"ing and bedclot"es in a blan%et& add dusting 'o;der
and s"a%e. Alternati(ely& suc" items can be im'regnated ;it" 'ermet"rin by
t"e same met"ods as are used for im'regnating mosJuito nets. Clot"ing t"us
treated ;ill retain its insecticidal 'ro'erties for se(eral ;as"es and ;ill resist
re-infestation by lice.
-#%% /iral )aemorr)agic fe'ers 8/209
7asic facts
Eiruses causing "aemorr"agic fe(ers 2H=4 belong to different ta:onomic grou's
and are c"aracteri8ed by different modes of transmission& geogra'"ical distribution&
disease se(erity and different 'ro'ensity to cause "aemorr"agic signs in t"ose ;"o are
infected 29able 0.64. H= (iruses include some of t"e most freJuently let"al infectious
agents& and some of t"em can be "ig"ly transmissible by direct contact from 'erson to
'erson& resulting in community outbrea%s or nosocomial transmission.
9"e incubation 'eriod is usually 0!3 days 2range #!# days4& ;it" t"e e:ce'tion
of "aemorr"agic fe(er ;it" renal syndrome 2H=B,& caused by Hantaan (irus4 in
;"ic" sym'toms a''ear on a(erage #!$ ;ee%s after infection.
De'ending on t"e area at ris% and t"e infectious agent in(ol(ed& disasters and ;ar
conditions may increase t"e ris% of H= occurrence t"roug" different circumstances:
contact ;it" rodents 2H=B,& Lassa fe(er& .e; World EH=4& contact ;it" carcasses of
;ild infected animals 2Ebola H=& Crimean-Congo H=4 or brea%do;n of mosJuito
control 'rogrammes 2yello; fe(er& dengue& Bift Ealley fe(er4. Moreo(er& t"e 'oor
condition of many "ealt" care facilities freJuently seen in emergency-affected
countries increases t"e ris% of nosocomial outbrea%s of EH= agents transmitted by
blood or fomites& 'articularly ;it" t"e lac% of minimal barrier nursing 'rocedures& t"e
lac% of safe dis'osal of s"ar's and t"e reuse of infected needles and syringes.
Table -#"1 Some features of t)e main agents of 'iral )aemorr)agic
fe'ers
0amil, Disease /ector
in
nature
Geogra()ica
l distribution
Mortalit
,
is4 of
(erson<to<
(erson
transmissio
n and
nosocomial
outbrea4s
=ilo(iridae Ebola H=& ?n%no;
n
a
EJuatorial
Africa
03!/3Q
2Ebola
H=4& #$!
63Q
2Marburg
H=4
Hes
Marburg H=
Arena(iridae Lassa fe(er Boden West Africa 0!#3Q Hes
.e; World
EH=
b
Bodent Americas 0!$3Q Hes
-unya(irida
e
Crimean-
Congo
9ic% Africa&
central Asia&
eastern
Euro'e&
Middle East
#3!03Q Hes
H=
Bift Ealley
fe(er
MosJuito Africa& UQ .o
Arabic
'eninsula
Haemorr"agi
c fe(er ;it"
renal
syndrome
Bodent Asia&
-al%ans&
!0Q .o
Euro'e&
Eurasia
Dengue fe(er&
dengue H=&
dengue s"oc%
syndrome
.see 2ection
?"?0
MosJuito Asia& Africa& UQ .o
Pacific&
Americas
Hello; fe(er
.see 2ection
?"2>0
MosJuito Africa&
tro'ical
Americas
#3Q .o
a
<ontact /ith infected apes through hunting activities or consumption of ape
meat has been the origin of several outbrea6s"
b
4rgentine* 7olivian* 7razilian and Fenezuelan haemorrhagic fevers"
Clinical features
*nitial sym'toms of EH= are not s'ecific and o(erla' ;it" t"e clinical
'resentation of more common infectious diseases seen in endemic areas: fe(er&
"eadac"e& bac% 'ain& myalgias& nausea& (omiting& diarr"oea& 'rostration and
conFuncti(al inFection.
More s'ecific signs 2maculo'a'ular ras" ;it" filo(iruses& se(ere '"aryngitis ;it"
Lassa fe(er& Faundice ;it" Bift Ealley fe(er4 are inconsistent or difficult to assess
under field conditions.
Haemorr"ages 2'etec"iae& nosebleeds& bleeding gums& ecc"ymosis& melaena&
"aematemesis& bloody diarr"oea4 are by definition t"e distinguis"ing feature of EH=&
but t"ey are not al;ays 'resent& e(en in t"e late stages of t"e disease. 9"e
combination of com'atible clinical sym'toms& endemic area and clustered cases is
essential to sus'ect an outbrea% of EH= 2see WHO case definition& Anne: 04.
W"en isolated 'atients 'resent ;it" fe(er and "aemorr"agic signs outside of an
outbrea% situation& standard barrier nursing 'rocedures must be reinforced.
.e(ert"eless& more common diseases are li%ely to be t"e cause 2e.g. malaria or
ty'"oid fe(er com'licated ;it" disseminated intra(ascular coagulation4.
Diagnosis
De'ending on t"e circumstances of sam'ling and on t"e causal agent& laboratory
confirmation of EH= can be based on:
antigen or antibody detection in serum&
'olymerase c"ain reaction from any infected sam'le&
(irus isolation& or
immuno"istoc"emical staining of auto'sy material.
9"is last met"od "as been s"o;n to allo; t"e retros'ecti(e diagnosis of filo-(irus
infection from dead bodies& and a relati(ely safe 'rocedure "as been de(el-o'ed for
sam'ling and s"i'ment of diagnostic s%in sni's in fi:ati(e solution.
Any ot"er met"od in(ol(ing t"e mani'ulation& s"i'ment and analysis of material
'otentially infected ;it" EH= agents s"ould follo; strict biosafety 'rocedures. As
soon as one case of EH= is sus'ected& contact s"ould be made ;it" 'ublic "ealt"
officers& and ultimately ;it" WHO re'resentati(es& in order to organi8e an a''ro'riate
outbrea% res'onse& including collection5s"i'ment of diagnostic material under safe
conditions to a reference laboratory.
Case management
*n most cases of EH= t"ere is no s'ecific treatment& but some general 'rinci'les
of case management must be follo;ed.
As long as diagnosis of EH= is not confirmed& consider and treat for more
common and 'otentially confounding diseases& in 'articular malaria& ty'"oid
fe(er& louse-borne ty'"us& rela'sing fe(er or le'tos'irosis.
A(oid nosocomial transmission by strict im'lementation of barrier nursing. f
barrier nursing material is not a(ailable and a "ig"ly transmissible form f EH=
is li%ely& a(oid any in(asi(e 'rocedure 2e.g. blood sam'ling& inFections&
lacement of infusion lines or nasogastric tubes4 and 'ut on at least one ayer of
glo(es for any direct contact ;it" t"e 'atient.
,u''orti(e treatment ! analgesic drugs 2e:cluding as'irin and non-steroidal
nti-inflammatories4& fluid re'lacement or antimicrobial t"era'y if secondary
nfection is sus'ected ! can ma%e a difference& at least in t"e comfort of t"e
atient. *n t"e case of H=B,& dengue H= and dengue s"oc% syndrome& ro'er
management of fluid and electrolyte balance can be life-sa(ing.
Biba(irin 2ideally gi(en intra(enously4 im'ro(es t"e 'rognosis dramatically f
gi(en early in Lassa fe(er e'isodes& and 'robably also in cases of Crimean-
ongo H=& H=B, and some .e; World H=.
$re'ention and control measures
W"ere outbrea%s of EH= are %no;n to occur& routine 're(ention measures "ould
include reinforced sanitation& "os'ital infection control& case detection nd "ealt"
education. *n addition& t"ere are s'ecific inter(entions t"at can be m'lemented eit"er
to 're(ent outbrea%s or to limit t"e e:tension of an stablis"ed outbrea% 29able 0.A4.
Commercial (accines against EH= are not (ailable e:ce't for yello; fe(er& ;"ere
mass (accination is t"e mainstay of 'idemic control 2see ,ection 0.04.
*n t"e case of an outbrea%& 'o'ulation mo(ements can contribute to t"e s'read f
infection to non-affected areas. Contacts under daily follo;-u' s"ould be ncouraged
to limit t"eir mo(ements.
Table -#"3 S(ecific inter'entions to (re'ent or limit
disease outbrea4s
Disease S(ecific (re'enti'e
measures
Control
measures:outbrea4
Ebola H=& Marburg H=
Lassa fe(er Bodent control ,trict barrier nursing in
us'ected5confirmed cases .e; World EH= Bodent control
Crimean-Congo H= A(oidance of contact ;it"
ic%-infested animals
Bift Ealley fe(er MosJuito control MosJuito control
Haemorr"agic fe(er ;it"
renal yndrome
A(oidance of contact ;it"
odents
Bodent control
Dengue fe(er& dengue H=&
and engue s"oc% syndrome
MosJuito control .see
2ections 2"'" and 2"'"20
MosJuito control
see 2ection ?"$0
Hello; fe(er MosJuito control Mass (accination 'lus
mosJuito control .see 2ection ?"2>0 .see 2ections 2"'" and
2"'"20
7arrier nursing
9o 're(ent secondary infections& contact ;it" t"e 'atient<s lesions and body fluids
s"ould be minimi8ed using standard isolation 'recautions:
isolation of 'atients&
restriction of access to 'atients< ;ards&
use of 'rotecti(e clot"ing&
safe dis'osal of ;aste&
disinfection of reusable su''lies and eJui'ment&
safe funeral 'ractices.
,im'le guidelines "a(e been de(elo'ed 2see selected reading belo;4 on "o; to
im'lement t"ese 'rinci'les& e(en ;"ere resources are limited.
0urt)er reading
-nfection control for viral haemorrhagic fevers in the 4frican health care setting.
@ene(a& World Healt" Organi8ation& //A 2document WHO5EMC5E,B5/A.#4.
-#%* ?ello@ fe'er
7asic facts
Hello; fe(er is an acute infectious disease caused by a fla(i(irus.
Mild cases are clinically indeterminate but se(ere cases are c"aracteri8ed by
Faundice.
O(erall case-fatality rates are around 0Q& but among t"ose ;it" Faundice t"ey
are #3!03Q.
9"e disease is found in Africa and ,out" America.
9"ere "as been a dramatic increase in t"e incidence of t"e disease in t"e 'ast
0 years.
Hello; fe(er "as t;o ty'es of transmission cycle: Fungle and urban. *n t"e
Fungle cycle& t"e (irus is transmitted among non-"uman 'rimates by different
mosJuito (ectorsN "umans are only incidentally infected. *n t"e urban cycle&
t"e (irus is transmitted from infected "umans to susce'tible "umans by 4edes
aegypti mosJuitoes& ;"ic" breed in "ouse"old containers and refuse.
Clinical features
9"e incubation 'eriod is usually $!1 days.
An acute phase lasting for # to 0 days ;it":
a sudden onset of fe(er&
"eadac"e or bac%ac"e&
muscle 'ain&
nausea&
(omiting&
red eyes 2inFected conFuncti(a4.
9"is '"ase of yello; fe(er can be confused ;it" ot"er diseases t"at also 'resent
;it" fe(er& "eadac"e& nausea and (omiting because Faundice may not be 'resent in
less se(ere 2or mild4 cases of yello; fe(er. 9"e less se(ere cases are often non-fatal.
A tem'orary period of remission follo;s t"e acute '"ase in 0!#3Q of cases.
After t"is brief remission& a to+ic phase can follo; ;it" Faundice ;it"in #
;ee%s of onset of first sym'toms. Haemorr"agic manifestations 2bleeding
from t"e gums& nose or in t"e stool& (omiting blood4 and signs of renal failure
may occur.
W2O case definition for ,ello@ fe'er sur'eillanceD
Sus(ected caseD An illness c"aracteri8ed by an acute onset of fe(er follo;ed by
Faundice ;it"in # ;ee%s of onset of t"e first sym'toms A.D one of t"e follo;ing:
bleeding from t"e nose& gums& s%in& or gastrointestinal tract OB deat" ;it"in $ ;ee%s
of t"e onset of illness.
Confirmed caseD A sus'ected case t"at is confirmed by laboratory results or
lin%ed to anot"er confirmed case or outbrea%.
Outbrea4D An outbrea% of yello; fe(er is at least one confirmed case.
Diagnosis
Diagnosis of t"e disease is t"roug" serology. 9;o blood sam'les must be sent
to a reference laboratory for confirmation.
Case management
,u''orti(e treatment s"ould be gi(en ! no s'ecific treatment is a(ailable for
yello; fe(er.
*n t"e to:ic '"ase& su''orti(e treatment includes t"era'ies for de"ydration and
fe(er. *n se(ere cases& deat" can occur bet;een t"e 6t" and 3t" day after
onset of t"e first sym'toms.
=or fe(er: gi(e 'aracetamol.
=or de"ydration: gi(e oral re"ydration salts or *E fluids de'ending on t"e
assessment of de"ydration.
=or restlessness: gi(e dia8e'am.
=or malaria: gi(e an antimalarial recommended for your area.
=or bacterial infections: gi(e antibacterials recommended for your area.
Access by daytime-biting mosJuitoes s"ould be 're(ented by screening t"e
'atient or using a bednet.
$re'ention and control measures
E:'osure to mosJuitoes s"ould be a(oided& including t"e use of 'rotecti(e
clot"ing and re'ellents.
,lee'ing and li(ing Juarters s"ould be screened.
A (ery effecti(e (accine is a(ailable& and mass (accination is a %ey
inter(ention for outbrea% control 2see ,ection #.1.64.
*n urban areas& mosJuito breeding sites s"ould be destroyed.
0urt)er reading
1istrict guidelines for yello/ fever surveillance. @ene(a& World "ealt"
Organi8ation& //A 2document WHO5EP*5@E.5/A.3/4.
Eainio C& Cutts =. Nello/ fever. @ene(a& World "ealt" Organi8ation& //A
2document WHO5EP*5@E.5/A.4.
,89 report on global surveillance of epidemic(prone infectious diseases"
<hapter 2" Nello/ fever. @ene(a& World Healt" Organi8ation& #333 2document
WHO5CD,5C,B5 *,B5#333.4.
Nello/ fever ! Technical <onsensus 5eeting* Eeneva* 2!> 5arch ##&. @ene(a&
World "ealt" Organi8ation& //A. 2document WHO5EP*5@E.5/A.3A4.
ANNEAES
"# W2O reference 'alues for emergencies
Table A"#" Cut<off 'alues for emergenc,
@arning
2ealt) status More t)an
Daily crude mortality rate 'er 3 333 'o'ulation
Daily under-0 mortality rate # 'er 3 333 c"ildren under 0
Table A"#% 7asic needs
Water A'erage reFuirements
\uantity #3 litres 'er 'erson 'er day
\uality #03 'eo'le 'er ;ater 'oint
not more than ?% metres from housing
Sanitation
Latrine *deally 'er family
Minimum seat 'er #3 'eo'le
>% metres from housing
Befuse dis'osal communal 'it 'er 033 'eo'le
2 + ? + 2 metres
S)elter
*ndi(idual reJuirements $.0 sJuare metres 'er 'erson
Collecti(e reJuirements $3 sJuare metres 'er 'erson
including shelter* sanitation* services*
/arehousing* access
2ouse)old fuel
=ire;ood 0 %g 'er "ouse"old 'er day /ith one
economic stove per family* the needs may
be reduced to ? 6g per stove per day
Table A"#* 2ealt) care needs
$redicted morbidit, E=(ected attac4 rate in emergenc,
situations
Acute res'iratory infections& U 0 years 3Q 'er mont" in cold ;eat"er
Diarr"oeal diseases& U 0 years 03Q 'er mont"
Malaria& non-immune 'o'ulation 03Q 'er mont"
Essential (rimar, )ealt) care acti'ities Target
?nder-0 clinic and gro;t" monitoring all c"ildren aged 3!0/ mont"s
Antenatal clinic all 'regnancies
Assisted deli(eries all deli(eries
/accination Target
9etanus to:oid all deli(eries
-C@ all ne;borns
DP9-99 all c"ildren aged 3! year
DP9#-99# all c"ildren aged 3! year
DP9$ all c"ildren aged 3! year
Measles all c"ildren aged /!# mont"s
Table A"#+ 2ealt) (ersonnel reFuirements
Acti'it, Out(ut of " (erson (er )our
Eaccination $3 (accinations
?nder-0 clinic and gro;t" monitoring 3 c"ildren
Antenatal clinic 1 ;omen
Assisted deli(ery deli(ery
OPD
a
consultation 1 consultations
OPD
a
treatments& e.g. dressings 1 treatments
Healt" ;or%er reJuirements 13 staff 'er 3 333 'o'ulation
a
9D1: outpatient department
Note: person per day = ) hours of field /or6"
Table A"#- 2ealt) su((l, reFuirements
Essential drugs and medical eFui(ment
WHO -asic Emergency Dit %it for 3 333 'o'ulation for $ mont"s
WHO ,u''lementary Emergency Dit %it for 3 333 'o'ulation for $ mont"s
Safe @ater
Pre'aring litre of stoc% solution Calcium "y'oc"lorite 63Q: 0 g5litre
;ater
or bleac"ing 'o;der $3Q: $$ g5litre
;ater
or sodium "y'oc"lorite 0Q: #03 ml5litre
;ater
or sodium "y'oc"lorite 3Q: 3 ml5litre
;ater
?sing t"e stoc% solution 3.1 ml or t"ree dro's5litre ;ater
13 ml533 litres ;ater
Note: allo/ the chlorinated /ater to stand at least >% minutes before using"
%# 2ealt) assessment B sam(le sur'e, forms
%A A$ID 2EALT2 ASSESSMENT
Date of (isit:bbbbbdbbbbbd
bbbbbb
Com'iled by: Organi8ation:
2 dd mm yyyy 4
.ame of location: ?rban 5 Bural 2circle one4 Pro(ince5@o(ernorate:
District5Area and .ame of to;n or city: \uarter5.eig"bour"ood:
subdistrict:
Beference code: Ot"er location information:
" Access
Boutes to location: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb Distance from
nearest airfield^ bbbbbbbbbb %m
Distance from "ard surface road^ bbbbbbbbbb %m Boutes 'assable ;it" lorry: Hes
5 .o
Are t"ere security 'roblems^ Hes 5 .o ! *f yes& s'ecify& 'ro(iding t"e source:
bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Ot"er information about access: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
9ele'"ones ;or%ing^ Hes 5 .o ! *f yes& can call: locally 5 ca'ital 5 international
% $o(ulation
2ource of information: .ame: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9itle: b
9otal 'o'ulation 2a''ro:imate or estimate4: bbbbbbbbbbbbbb .umber of
dis'laced 'eo'le: bbbbbbbbbbbbbb
Estimated se: ratio of current adult 'o'ulation: bbbbbbbbbbbb Q ;omen
Estimated number of c"ildren U 0 years: bbbbbbbbb O estimated Q of total
'o'ulation U 0 years bbbbbbb
Estimated number of 'regnant ;omen: bbbbbbbbbbb
Are t"ere ot"er es'ecially (ulnerable 'o'ulation grou's in t"e area 2for e:am'le&
in institutions4:
* Main )ealt) concerns
W"at are t"e main "ealt" concerns currently^
As re'orted by t"e 'o'ulation: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
As re'orted by "ealt" staff: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
+ Deat) rates in recent time (eriod 8da,s> @ee4s or mont)s9
2ource of information: .ame: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9itle: b
O(erall mortality rate 2all ages4: bbbbbbbbb deat"s 'er bbbbbbbbb 'ersons 'er
bbbbbbbbbb 2recent time 'eriod4
Mortality rate in c"ildren U0: bbbbbbbb deat"s 'er bbbbbbbb c"ildren U0 years
'er bbbbbbbb 2recent time 'eriod4
- 2ealt) facilities
2ource of information: .ame: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9itle: b
.o. of "os'itals in t"is area: bbbbbbbbbbbbbb .o. of 'rimary "ealt" centers 2;it"
doctor4bbbbbbbbbbbbbbbbbb
.o. of 'rimary "ealt" centres 2;it"out doctor4:bbbbbbbbbbbbbbbbbbbb .o. of
'ri(ate clinics: bbbbbbbbbbbbbbb
.o. of ot"er "ealt" facilities in t"is area: bbbbbbbbbbb
2fill out tables belo; ;it" descri'tion of indi(idual "ealt" facilities4
*f no "os'itals in t"e area& ;"ere are 'atients referred for s'eciali8ed
medical5surgical care^
*s t"ere an ambulance ser(ice: Hes 5 .o
*f yes& "o; many ;or%ing ambulances^ bbbbbbbbb
Ha(e t"e "ealt" facilities been looted^ Hes 5 .o
*f yes& ;"at medical eJui'ment "as been stolen5destroyed^ bbbbbbbbbbbbbbbbbb
. Maternal and c)ild )ealt) and nutrition
2ource of information: .ame: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9itle: b
*s t"ere access to an emergency obstetric care centre in t"e area assessed^ Hes 5
.o
*f yes& ;"ic"^ bbbbbbbbbbbbbbbbbbbbbbbbb
*f no& ;"ere is t"e closest one^ bbbbbbbbbbbbbbbbbbbbbbbbb
W"at Q of c"ildren !) years of age "a(e been (accinated for measles:
bbbbbbbbbb Q
*s t"ere a community c"ild care unit in t"is location: Hes 2.o.bbbbbbbbbb4 5 .o
*f yes& "o; many c"ildren are enrolled in all units^ bbbbbbbbbb
*s t"ere a t"era'eutic feeding centre^ Hes 2.o.bbbbbbbbbb4 5 .o
*f yes& "o; many c"ildren enrolled^ bbbbbbbbbb
Has t"ere been a recent assessment of malnutrition in t"is location^ Hes 5 .o
*f yes& 're(alence of acute malnutrition:bbbbbbbbbbb Q
Ho; measured^ Weig"t-for-age 5 Weig"t-for-"eig"t 5 M?AC 5
Ot"erbbbbbbbbbbbbb
1 Outbrea4s of disease
Ha(e t"ere been any infectious disease outbrea%s 2unusual numbers of cases4 in
recent days5;ee%s^
*f yes& describe sym'toms& 'lace& number of 'eo'le affected: bbbbbbbbbbbbbbbbb
3 Mine:!AO in&uries
Ha(e t"ere been any inFuries in recent mont"s from mines or une:'loded
ordnance: Hes 5 .o
*f yes& describe and identify location: 8Do not 'isit t)e locationR9 bbbbbbbbbbbbb
5 Ot)er )ealt) (roblems:issues
"6 7asic descri(tion of )ealt) facilities# .ame of contact and
contact information: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
.
o
.
.a
me
of
"e
alt
"
fac
ilit
y
9y'
e of
facil
ity
MoH
or
ot"er
2s'eci
fy4^
=unct
ionin
g
2fully
&
'artia
lly&
not at
all4
Le
(el
of
da
ma
ge
2us
e
H*
C
cod
es
on
ne:
t
'ag
e4
.o. total
beds
A(erage
.o.
out'atient
s seen 'er
day
.o.
maternity
beds
A(erage
.o.
deli(eries
attended
during
one ;ee%
9ot
al
Occ
u'ie
d
toda
y
1
mon
t"s
ago
9o
da
y
1
mon
t"s
ago
9o
da
y
1
mon
t"s
ago
9o
da
y

#
$
)
0
.o. .am
e of
"ealt
"
.o. doctors .o. nurses .o. ot"er
'rofessional staff
1 mont"s
ago
9oday 1 mont"s
ago
9oday 1 mont"s
ago
Today
facili
ty

#
$
)
0
"" A'ailabilit, of drugs> eFui(ment> and utilities
.
o.
Amo
:icilli
n Co-
trimo
:.
Am'i
cillin
O
B
,
Antim
alarial
drugs
*E
flu
ids
Ot
"e
r
=ood
for
'atient
s or
malno
uris"e
d
Elect
ricity
Wat
er
su''
ly
9oil
et
.o.
o'er
atin
g
t"eat
res
Eac
cine
col
d
c"ai
n
Ot"e
r
e:'r
essed
need
s
2atta
c"
list if
nece
ssary
4
2if
no&
;"at
is
lac%i
ng^4
2if
no&
;"a
t is
lac%
ing^
4
2if
no&
;"a
t is
lac%
ing^
4

#
$
)
0
2see 9able A belo; for more details on drugs and eJui'ment4
Codes for infrastructure damage assessmentD
"% e'ie@ of out(atient register
Healt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9y'e of facility: bbbbbbbbb
9ime 'eriod 2collect data of a recent 'eriod& 'referably of t"e ;ee% 'receding t"e
(isit4
-eginning date: bbbbbbbbbbbbbbbbbbbbbbbbb Ending date: bbbbbbbbbbbbbbbb
Diagnosis of
out'atients
U 0 years 0] years 9otal
Acute lo;er
res'iratory
infection
Acute ;atery
diarr"oea
2including c"olera4
-loody diarr"oea
2dysentery4
Measles
Meningitis
Malaria
Acute Faundice
syndrome
Acute
"aemorr"agic fe(er
syndrome
War inFury
*nFury 2not ;ar-
related4
Malnutrition
9- ne; cases
2;it"5;it"out lab.
confirmation4
Diabetes
Cardio(ascular
disease
Ot"er5un%no;n
9otal consultations
during time 'eriod
"* e'ie@ of deat) register
Healt" facility or data source: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
9ime 'eriod 2collect data of a recent 'eriod& 'referably of t"e t;o ;ee%s& or more&
'receding t"e (isit4
-eginning date: bbbbbbbbbbbbbbbbbbbbbbbbb Ending date: bbbbbbbbbbbbbbbb
Cause of deat" U 0 years 0] years 9otal
Acute lo;er
res'iratory
infection
Acute ;atery
diarr"oea
2including c"olera4
-loody diarr"oea
2dysentery4
Measles
Meningitis
Malaria
Cause of deat" U 0 years 0] years 9otal
Acute Faundice
syndrome
Acute
"aemorr"agic fe(er
syndrome
War inFury
*nFury 2not ;ar-
related4
Cardio(ascular
Bes'iratory
Cancer
Maternal deat"
Ot"er5un%no;n
9otal deat"s
"+ ecommendations for immediate (ublic )ealt) action
W"at must be 'ut in 'lace immediately to reduce a(oidable mortality and
morbidity^
W"ic" acti(ities must be im'lemented for t"is to "a''en^
W"at are t"e ris%s to be monitored^
Ho; can ;e monitor t"em^
W"ic" in'uts are needed to im'lement all t"is^
Table A" More detailed list of drugs and
eFui(ment
List of %ey drugs and eJui'ment for CL*.*C,N if 'ossible try to (erify stoc%
Juantity and duration of a(ailability
.ame of "ealt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9y'e of facility:
2ealt) facilit,
Disease Selected drugs " % * + -
Diarr"oea Oral re"ydration salts
Co-trimo:a8ole
tablets
AB* Co-trimo:a8ole
tablets
Procaine 'enicillin
inFection
Paediatric
'aracetamol tablets
Malaria C"loroJuine tablets
,P
\uinine
Artesunate
AmodiaJuine
Anaemia =errous salt ] folic
acid tablets
Worm
infestations
Mebenda8ole tablets
Albenda8ole
ConFuncti(itis 9etracycline eye
ointment
,%in
infections
*odine& gentian (iolet
or local
alternati(e
=ungal s%in
infections
-en8oic acid ]
salicylic acid
ointment
,cabies and
ot"ers
-en8yl ben8oate
lotion
,oa'
Ginc o:ide ointment
Permet"rin5malat"ion
Pain Acetylsalicylic acid
or 'aracetamol
tablets
Pro'"ylactic
drugs
Betinol 2(itamin A4
=errous salt ] folic
acid tablets
Eaccine-
're(entable
diseases
*ntact cold c"ain
,yringes and needles
-C@
(accine5adFu(ant
Measles (accine
DP9 (accine
Polio (accine
.utrition Heig"t board
,cale
Hig"-'rotein biscuits
Ot"er su''lemental
feeding food
9"era'eutic mil% 2=-
60 > =-334
List of additional %ey drugs and eJui'ment for =*B,9-LEEEL HO,P*9ALN if
'ossible try to (erify stoc% Juantity and duration of a(ailability
.ame of "ealt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9y'e of facility:
2ealt) facilit,
Disease Selected drugs " % * + -
@eneral anaest"etics 2%etamine&
t"io'ental4
Local anaest"etics
Preo'erati(e medication and
sedation for s"ort-term
'rocedures 2atro'ine& dia8e'am4
9rauma5
surgery
Parenteral solutions for
re"ydration ] gi(ing set ]
canulae:
! ringer<s lactate
! glucose 0Q
-lood substitutes5transfusions
Muscle rela:ants&
c"olinesterase in"ibitors
.on-o'ioids 2A,,& ibu'rofen&
'aracetamol4
Pain O'ioid analgesicss 2mor'"ine&
'et"idine4
Allergies&
ana'"ylactic
reactions
Adrenaline 2e'ine'"rine4 inF.
Hydrocortisone 'o;der for inF.
Prednisolone tablets
Con(ulsions P"enobarbital tablets
P"enytoin tablets
Amo:icillin tablets
Am'icillin 'o;der for inF.
-en8yl'enicillin 'o;der inF.
Clo:acillin 'o;der *nF.
Co-trimo:a8ole tablets
P"eno:ymet"yl'enicillin tablets
Procaine ben8yl'enicillin
tablets
*nfections C"loram'"enicol ca'sules
Do:ycycline ca'sules& tablets
Eryt"romycin tablets
@entamicin inFection
Metronida8ole tablet
9rimet"o'rim ]
sulfamet"o:a8ole
9etracycline eye ointment
@entamicin eye dro's
2ealt) facilit,
Disease Selected drugs " % * + -
Atenolol tablets
Hydrala8ine 'o;der
for inFection
Hy'ertension&
coronary
"eart disease
Met"yldo'a tablets
.itroglycerin tablets
=urosemide inFection
Hydroc"lorot"ia8ide
tablet
C"lor"e:idine
solution
Disinfectant&
antise'tics
Poly(idone iodine
solution
,il(er sulfa8idine
cream
C"lorine-based
com'ound
Diabetes Oral antidiabetics
*nsulins
Caesarian eJui'ment
EJui'ment for
assisted deli(ery
Obstetrics Ergometrine tablets&
inFection
O:ytocin inFection
Psyc"otic
disorders
C"lor'roma8ine
tablets&
inFections
Amino'"ylline
inFection
,albutamol
tablet5aerosol
Ast"ma -eclometasone
aerosol
*'ratro'ium bromine
aerosol
Adrenaline inFection
Et"inylestradiol ]
le(onorgestrel tablet
Hormonal
contrace'ti(es
Le(onorgestrel tablet
Medro:y'rogesterone
acetate de'ot
inFection
E:'ressed needs for s'ecific drugs and eJui'ment
,ource of information: .ame: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9itle: bbb
Drugs and eJui'ment needed:
Table A% To be considered if t)e )ealt)
assessment relates to
ID$s:refugees in a cam( or
)oused in (ublic buildings
.ote t"at t"is is not intended to be a full assessment of t"e facilities a(ailable for
t"e *DPs5refugees. 9"is s"ould be carried out by t"e a''ro'riate res'onsible agencies
2see ,ection / of Anne: #-!Healt" sur(ey4. *f t"e *DPs5refugees are already under
t"e care of suc" an entity t"e follo;ing table s"ould be filled in consultation ;it"
t"em& if considered necessary.
Are t"e follo;ing
adeJuate:
Hes .o *mmediate
reJuirements
Water su''ly^
=ood distribution^
,ource^
E:creta dis'osal^
,"elter^
,oa'& buc%ets& etc.
for ;as"ing^
=uel and coo%ing
utensils^
Ot"er (ital needs^
W"ic"
agency5organi8ation
is res'onsible for:
! management of
t"e cam'
2location4^
! 'ro(ision of
"ealt" care^
%7 2EALT2 S!/E?
"# 7asic data
%# Member information list
Main res(ondentD Wife of "ead of "ouse"old and mot"er of t"e c"ildren 2if
t"ere are any c"ildren4 ot"er 2s'ecify4 bbbbbbbbbbbbbbbbbbbbbbb
2ead of t)e )ouse)oldD male female refugee status no refugee status
List belo; all indi(iduals ;"o since onset of crisis& are or "a(e been li(ing for at
least one mont" in t"e "ouse"old& including t"ose ;"o died or are missing
House
"old
memb
er
numbe
r
Main
res'on
dent
2=4
Head
of
"ouse
"old
2=4
Ag
e in
,ea
rs
2if
2
yea
rs
or
old
er4
Age
in
mon
t)s
2if
unde
r 2
year
s4
,e:
2M5
=4
Presen
t at
inter(i
e;^
2Hes5
.o4
House
"old
memb
er is:
House"old
member is
today:
*f
dead
or
missi
ng&
since
;"en
^
2date
:
dd5m
m4
- Core
family
. Ali(e&
al;ays
li(ed in t"is
"ouse"old
-
E:tend
ed
family
#. Ali(e&
mo(ed in&
still 'resent
- Ot"er
2s'ecif
y4
$. Ali(e&
mo(ed out
). Ali(e in
'rison
0. Died&
"ad al;ays
li(ed in t"is
"ouse"old
1. Died&
mo(ed
in5out
6.
Missing5un
%no;n
5
# 5
BECOBD .?M-EB: eeeeeeeeeeee
. Date of study 2dd5mm5yyyy4: eee 5 eee5 eee
#. ,ection number: eeeeeeeeeeee
$. .ame of (illage5cam'5site: eeeeeeeeeeee
). Date of arri(al in area5site 2dd5mm5yyyy4: eee 5 eee5 eee
0. .ame of "ead of "ouse"old: eeeeeeeeeeee
1. Male- or female-"eaded "ouse"old: Male =emale
6. 9otal number of 'eo'le in "ouse"old: eeeeeeeeeeee
A. 9otal number of c"ildren under 0 years: eeeeeeeeeeee
/. 9otal number of 'regnant or lactating ;omen: eeeeeeeeeee
3. 9otal number of elderly 'ersons 2o(er 10 years4:
eeeeeeeeeee
$ 5
) 5
0 5
1 5
6 5
A 5
/ 5
3 5
5
# 5
*# etros(ecti'e mortalit,
9otal number of deat"s since start of crisis bbbbbbbbbbbbbbbbbbbbbbbbbb
Deat"
number
Age in
,ears .if
2 years
or older0
Age in
mont)s
.2 to 2>
months 0
Age in
mont)s
.under 2
months0
,e: Mont" of
deat":
Cause of
deat":
2M5=4 # P =eb
#33$
P ;atery
diarr"oea
$ P Mar
#33$
# P bloody
diarr"oea
) P A'r
#33$
$ P measles
0 P May
#33$
) P coug" R
difficulty
breat"ing
1 P Cun
#33$ etc.
0 P fe(er of
un%no;n
origin
1 P
trauma5inFury
i.e.
12a4Pmine5
?fOZ&
12b4P;ar-
related ot"er
t"an
mine5?fO&
12c4Proad
traffic
accident& or
12d4Pot"er
6 P deat"
during or
rig"t after
c"ildbirt"
A P ot"er
2s'ecify4

#
$
)
0
1
6
A
/
3

#
T
Bne+ploded ordnance
+ Nutritional status and 'accination co'erage of c)ildren under -
,ears
House"
old
member
number
,e: Age Weig"
t
Lengt"
or
"eig"t
Presen
ce of
bilater
al
'itting
oedem
a
Date of
measles
(accinati
on
2card4
OPE 2all
) doses
at
a''ro'ri
ate time
inter(als
4
(accinati
on
2card4
DP9 2all
) doses
at
a''ro'ri
ate time
inter(als
4 or D9
(accinati
on 2card4
2M5
=4
2in
mont"
s4
2in %g&
'recisi
on to
33 g4
2in cm&
'recisi
on to
3.0
cm4
2Hes5.
o4
2Hes5.o
4
2Hes5.o
4
2Hes5.o
4

#
$
)
0
1
6
A
/
3

#
+# Communicable diseases in c)ildren under fi'e ,ears 8ALI>
diarr)oea> measles9
*n t"e last # ;ee%s& "as any c"ild under 0 years of age in t"e "ouse"old suffered
from a coug" or cold& diarr"oea or any fe(er^ Hes .o
If ?es> com(lete table B If No> cross out table
House"
old
number
.umber of e'isodes of: Did
you
access
medic
al
*f
accesse
d
medical
assistan
Did you
recei(e
medicati
ons^
2Hes5.o4
*f recei(ed
medication
s& ;"at
;ere t"ey^
assista
nce
during
any
e'isod
e^
2Hes5
.o4
ce& at
;"at
le(el^
=e(er
2e.g.
sus'ec
ted
malari
a4
Coug"
;it"
fe(er
2R
difficu
lt
breat"i
ng4
Ba
s"
;it
"
fe(
er
Diarr"
oea
.
9raditio
nal
"ealer
.
Antimicro
bial
#.
Commu
nity
"ealt"
;or%er
#. OB,
$.
Healt"
centre
).
Hos'ita
l .5ar6
option
/ith
cross0
$.
Ot"er5un%
no;n
.5ar6
option
/ith
cross0
. #. $.
).
. #. $.
# . #. $.
).
. #. $.
$ . #. $.
).
. #. $.
) . #. $.
).
. #. $.
0 . #. $.
).
. #. $.
1 . #. $.
).
. #. $.
6 . #. $.
).
. #. $.
A . #. $.
).
. #. $.
/ . #. $.
).
. #. $.
3 . #. $.
).
. #. $.
. #. $.
).
. #. $.
# . #. $.
).
. #. $.
-# Noncommunicable diseases 8),(ertension> diabetes mellitus>
)eart disease and cancer9
2ince crisis: ! "as t"ere been anyone in t"e "ouse"old ;it" )ig) blood (ressure
.diagnosed by a physician0O Hes .o
! anyone in t"e "ouse"old ;it" diabetes 2diagnosed by a physician0^ Hes .o
! anyone in t"e "ouse"old ;it" )eart disease 2diagnosed by a physician0^ Hes
.o
! anyone in t"e "ouse"old ;it" cancer 2diagnosed by a physician0^ Hes .o
If ?es> com(lete table 8one line (er (erson and disease> same (erson can )a'e
more t)an one disease9 B If No> cross out table
House"
old
membe
r
number
Disease: *nforma
tion
source
Has
been
or is
under
regula
r
medic
al
follo;
-u'^
2Hes5
.o4
Any
sc"eduled
a''ointme
nt missed^
Has
been5is
on
regular
drug
treatme
nt^
2Hes5.
o4
*nterru'tio
n in drug
treatment
of any
lengt"^
As of
today&
is
"e5s"e:
.
Hy'erten
sion
.
Healt"
card
2Hes5.o4 2Hes5.o4 .
Ali(e&
"ome
#.
Diabetes
#. ,elf-
re'orted
#.
Ali(e&
in
"os'ita
l
$. Heart
disease
$.
House"
old
$.
Ali(e&
else;"
ere
). Cancer member
2ot"er
t"an t"e
'atient4
).
Died&
at
"ome
.one line
per
person
and
disease0
2list all
sources
belo/4
0.
Died&
in
"os'ita
l
*n
t"e
last
mon
t"
,in
ce
2dat
e4
*n
t"e
last
mon
t"
,in
ce
2dat
e4
1.
Died&
else;"
ere

#
$
)
0
1
6
A
/
3

#
.# Maternal )ealt) 8antenatal care9
2ince crisis& "as t"ere been anybody 'regnant or become 'regnant^ Hes .o
If ?es> com(lete table B If No> cross out table
Hous
e"old
mem
ber
num
ber
Eue
ss
ho/
man
y
mon
ths
sinc
e
day
conc
eive
d
*nfor
matio
n
sourc
e:
Ho
;
man
y
time
s
gon
e for
ante
nata
l
care
^
Anti-
tetan
us
(acci
natio
n
gi(en
^
As%
ed
to
atte
nd
mor
e
t"an
one
c"ec
%
'er
mon
t"^
*f
Nes&
al;
ays
gon
e^
*f
No&
ran
%
u'
to $
rea
son
s
Adm
itted
to
"os'i
tal
durin
g
'reg
nanc
y to
ensur
e
adeJ
uate
follo
;-
u'^
Any
medi
cine
'resc
ribed
durin
g
'regn
ancy^
*f
Nes&
;as5i
s it
'ossi
ble
to
com
'lete
t"e
treat
ment
^
*f
No&
ran
%
u'
to $
rea
son
s
.
Anten
atal
card
,rit
e
@zer
oA
if
nev
er
gon
e0
] H-
]urin
e
c"ec%
2Hes
5.o4
2He
s5.
o
2Hes5
.o4
2Hes5
.o4
2Hes5
.o4
#.
,elf-
re'ort
ed
$.
Hous
e"old
mem
ber
ot"er
t"an
t"e
one
'regn
ant
.list
all
sourc
es
belo/
0
..o
#.Hes
&
(erifi
ed by
card
$.Hes
&
re'ort
ed
orally
. .
#. #.
$. $.
. .
# #. #.
$. $.
. .
$ #. #.
$. $.
. .
) #. #.
$. $.
. .
0 #. #.
$. $.
1# Maternal )ealt) 8deli'er, : stillbirt) : abortion : (ost<natal
care9
2ince crisis& "as any ;oman in t"e "ouse"old gi(en birt" or lost a c"ild during
'regnancy5immediately after c"ildbirt"^ Hes .o
If ?es> com(lete table B If No> cross out table
House
"oldm
ember
numbe
r
-a
by
bor
n:
Date
conce
i(ed
2dd/
mm4
Date
of
deli
(ery
or
loss
of
baby
2dd/
mm4
-aby
born
t"rou
g":
W"ere
did
t"e
de-
li(ery
2or
loss of
baby4
ta%e
'lace^
*f at
5<
8*
D8<
or
8os
pital&
"o;
long
did it
ta%e
to
get
t"ere
^
*f
hom
e
deliv
ery
;as
it
o;n
c"oic
e^
*f
No&
ran
% u'
to $
reas
ons
*f home
deliver
y&
assisted
by
;"om^
@one
for
any
'ost-
natal
care
(isit
^
.
Ali
(e&
;ei
g"t
mo
re
t"a
n
#03
3 g
.if
not
6no/
n
e+act
ly*
ma6e
best
guess
0
.if
not
6no
/n
e+ac
tly*
ma6
e
best
gues
s0
.
.orm
al
2(agi
nal4
deli(
ery or
abort
.
Home
.
"our
or
less
2Hes5
.o4
.
.obody
2Hes5
.o4
#.
Ali
(e&
;ei
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t"a
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#.
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n
#.
MCH
#. -
#
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s
#.
=amily5
friend
#03
3 g
$.
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g"t
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$.
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$. #-
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s
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lost
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0. On
t"e
;ay to
"os'it
al
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Doctor
1.
Ot"er
2s'eci
fy4
1. 9-A
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ambul
ance*
privat
e
transp
ort
.
#.
$.
.
# #.
$.
.
$ #.
$.
.
) #.
$.
.
0 #.
$.
5# En'ironment
S)elte
. 9y'e of "abitation 2circle4: # $ ) 2s'ecify4 bbbbbbbbbbbbbbbbbbbbbbbbbbbb
P 'lastic roof onlyN # P sim'le "utN $ P tentN ) P ot"er
Sanitation
#. Latrines 2circle4: # $ ) 0 1 2s'ecify4 bbbbbbbbbbbbbbbbbbbbbbbbbbbb
P one latrine5toilet 'er "ouse"oldN # P collecti(e latrinesN $ P trenc"N ) P defecation
fieldN 0 P no s'ecific areaN 1 P ot"er
Water
$. Distance from 'ublic ta'5;ater 'oint: bbbbbbbbbbbbbbbbbbbbbbbbbbbbm
). Head of "ouse"old "as %no;ledge
about use of disinfected ;ater:
Hes .o
0. .umber of ;ater containers 2#3 litres4
'er "ouse"old 2e.g. ^ for 3 litres4:
bbbbbbbbbbbbbbbbbbbbbbbbbbbb
1. .umber of times ;ater containers
filled 'er day:
bbbbbbbbbbbbbbbbbbbbbbbbbbbb
6. A(ailability of ;as"ing and bat"ing
facilities:
Hes .o
A. Presence of stagnant ;ater near "ouse: Hes .o
Non<food items
/. .umber of blan%ets in "ouse"old: bbbbbbbbbbbbbbbbbbbbbbbbbbbb
3. AdeJuate clot"ing 2at least one
c"ange of clot"es& ada'ted to climate4:
Hes .o
. AdeJuate amount of fuel and coo%ing
'ots:
Hes .o
efuse
#. Befuse dis'osal met"od 2circle4: # $ ) 0 2s'ecify4
bbbbbbbbbbbbbbbbbbbbbbbbbbbb
P designated communal 'itsN # P "a'"a8ard 'ilingN $ P "ouse"old 'itN ) P no
s'ecific areaN 0 P ot"er
* NC2S:W2O normaliCed reference 'alues for @eig)t
for )eig)t b, se=
Weig)t<for<lengt) 8+5B3+ cm9 and @eig)t<for<)eig)t 83-B""6 cm9
7o,sS @eig)t 84g9 GirlsS @eig)t 84g9
B+
SD
B*
SD
B%
SD
B"
SD
Median Lengt) Media
n
B"
SD
B%
SD
B*
SD
B+
SD
.6
E
16
E
36
E
56
E
8cm9 56
E
36
E
16
E
.6
E
.A #. #.0 #.A $. )/ $.$ #./ #.1 #.# .A
.A #.# #.0 #./ $.$ 03 $.) $ #.1 #.$ ./
.A #.# #.1 $. $.0 0 $.0 $. #.6 #.$ ./
./ #.$ #.A $.# $.6 0# $.6 $.$ #.A #.) #
./ #.) #./ $.) $./ 0$ $./ $.) $ #.0 #.
# #.1 $. $.1 ). 0) ). $.1 $. #.6 #.#
#.# #.6 $.$ $.A ).$ 00 ).$ $.A $.$ #.A #.$
#.$ #./ $.0 ) ).1 01 ).0 ) $.0 $ #.)
#.0 $. $.6 ).$ ).A 06 ).A ).# $.6 $. #.1
#.6 $.$ $./ ).0 0. 0A 0.) ) $./ $.$ #.6
#./ $.0 ). ).A 0.) 0/ 0.$ ).6 ). $.0 #./
$. $.6 ).) 0 0.6 13 0.0 )./ ).$ $.6 $.
$.$ ) ).1 0.$ 0./ 1 0.A 0.# ).1 $./ $.$
$.0 ).# )./ 0.1 1.# 1# 1. 0.) ).A ). $.0
$.A ).0 0.# 0.A 1.0 1$ 1.) 0.6 0 ).) $.6
) ).6 0.) 1. 1.A 1) 1.6 1 0.$ ).1 $./
).$ 0 0.6 1.) 6. 10 6 1.$ 0.0 ).A ).
).0 0.$ 1 1.6 6.) 11 6.$ 1.0 0.A 0. ).$
).A 0.0 1.# 6 6.6 16 6.0 1.A 1 0.$ ).0
0. 0.A 1.0 6.$ A 1A 6.A 6. 1.$ 0.0 ).A
0.$ 1 1.A 6.0 A.$ 1/ A. 6.$ 1.0 0.A 0
0.0 1.$ 6 6.A A.0 63 A.) 6.1 1.A 1 0.#
0.A 1.0 6.$ A. A.A 6 A.1 6.A 6 1.# 0.)
1 1.A 6.0 A.$ /. 6# A./ A. 6.# 1.) 0.1
1.# 6 6.A A.1 /.$ 6$ /. A.$ 6.0 1.1 0.A
1.) 6.# A A.A /.1 6) /.) A.0 6.6 1.A 1
1.1 6.) A.# / /.A 60 /.1 A.6 6./ 6 1.#
1.A 6.1 A.) /.# 3 61 /.A A./ A. 6.# 1.)
6 6.A A.1 /.) 3.$ 66 3 /. A.$ 6.) 1.1
6. A A.A /.6 3.0 6A 3.# /.$ A.0 6.1 1.6
6.$ A.# / /./ 3.6 6/ 3.) /.0 A.6 6.A 1./
6.0 A.$ /.# 3. 3./ A3 3.1 /.6 A.A A 6.
6.1 A.0 /.) 3.# . A 3.A /./ / A. 6.#
6.A A.6 /.1 3.) .$ A# 3. /.# A.$ 6.)
7o,sS @eig)t 84g9 GirlsS @eig)t 84g9
B+ SD B*
SD
B%
SD
B"
SD
Median Len
gt)
Media
n
B"
SD
B%
SD
B*
SD
B+ SD
.6E 16
E
36
E
56
E
8cm9 56
E
36
E
16
E
.6E
6./ A.A /.6 3.1 .0 A$ .# 3.$ /.) A.0 6.1
A. / /./ 3.A .6 A) .) 3.0 /.1 A.6 6.6
6.A A./ /./ #. A0 .A 3.A /.6 A.1 6.1
6./ / 3. .# #.$ A1 # /./ A.A 6.6
A. /.# 3.$ .0 #.1 A6 #.$ .# 3. / 6./
A.$ /.) 3.0 .6 #.A AA #.0 .) 3.$ /.# A.
A.) /.1 3.6 ./ $ A/ #.6 .1 3.0 /.$ A.#
A.1 /.A 3./ #. $.$ /3 #./ .A 3.6 /.0 A.)
A.A /./ . #.$ $.0 / $.# # 3.A /.6 A.0
A./ 3. .$ #.0 $.6 /# $.) #.# /./ A.6
/. 3.$ .0 #.A ) /$ $.1 #.) .# 3 A.A
/.# 3.0 .6 $ ).# /) $./ #.1 .) 3.# /
/.) 3.6 ./ $.# ).0 /0 ). #./ .1 3.) /.
/.1 3./ #. $.) ).6 /1 ).$ $. .A 3.1 /.$
/.6 #.) $.6 0 /6 ).1 $.$ # 3.6 /.0
/./ .# #.1 $./ 0.# /A )./ $.0 #.# 3./ /.1
3. .) #.A ). 0.0 // 0. $.A #.) . /.A
3.$ .1 $ ).) 0.6 33 0.) ) #.6 .$ /./
3.) .A $.# ).1 1 3 0.1 ).$ #./ .0 3.
3.1 # $.) )./ 1.$ 3# 0./ ).0 $. .6 3.$
3.A #.# $.6 0. 1.1 3$ 1.# ).6 $.$ ./ 3.0
#.) $./ 0.) 1./ 3) 1.0 0 $.0 #. 3.1
.# #.6 ).# 0.1 6. 30 1.6 0.$ $.A #.$ 3.A
.) #./ ).) 0./ 6.) 31 6 0.0 ) #.0
.1 $. ).6 1.# 6.6 36 6.$ 0.A ).$ #.6 .#
.A $.) )./ 1.0 A 3A 6.1 1. ).0 $ .)
# $.1 0.# 1.A A.$ 3/ 6./ 1.) ).A $.# .1
#.# $.A 0.) 6. A.6 3 A.A 1.1 0 $.) ./
.otes:
. Lengt" is generally measured in c"ildren belo; A0 cm& and "eig"t in c"ildren
A0 cm and abo(e. Becumbent lengt" is on a(erage 3.0 cm greater t"an
standing "eig"tN alt"oug" t"e difference is of no im'ortance to t"e indi(idual
c"ild& a correction may be made by deducting 3.0 cm from all lengt"s abo(e
A)./ cm if standing "eig"t cannot be measured.
#. ,D P standard de(iation score 2or G-score4. 9"e relations"i' bet;een t"e
'ercentage of median (alue and t"e ,D-score or G-score (aries ;it" age and
"eig"t& 'articularly in t"e first year of life& and beyond 0 years. -et;een and
0 years median ! ,D and median !# ,D corres'ond to a''ro:imately /3Q
and A3Q of median 2;eig"t-for-lengt"5"eig"t& and ;eig"t-for-age4&
res'ecti(ely. -eyond 0 years of age or 3 cm 2or 33 cm in stunted c"ildren4
t"is eJui(alence is not maintainedN median !# ,D is muc" belo; A3Q of
median. Hence t"e use of L'ercentage-of-medianM is not recommended&
'articularly in c"ildren of sc"ool age. ,ome;"ere beyond 3 years or $6 cm&
t"e adolescent gro;t" s'urt begins and t"e time of its onset is (ariable. 9"e
correct inter'retation of ;eig"t-for-"eig"t data beyond t"is 'oint is t"erefore
difficult.
+# Wee4l, sur'eillance re(ort
Guidelines for filling sur'eillance forms
*n eac" "ealt" facility& a daily register of consultations s"ould be %e't.
,uggested lay out of register in "ealt" facility:
O$D
No#
Date Name Location Se= Date
of
birt)
Ne@
case:
follo@<
u(
Diagnosis Treatment
One 'erson in eac" "ealt" facility s"ould be identified as res'onsible for data
collection and notification of 'otential e'idemics to t"e Healt" Coordinator. *n
eac" Agency5.@O& one 'erson s"ould be res'onsible for com'iling t"e data
from t"e daily register for t"e ;ee%ly "ealt" re'ort.
9"e ;ee%ly form s"ould be filled out from Monday to ,unday and com'iled
by t"e agency5.@O Healt" Coordinator as soon as 'ossible.
2o@ to fill in t)e @ee4l, morbidit, form
Data s"ould be recorded in t;o age categories: under 0 years and 0 years and
o(er.
.e; cases5consultations reJuested for communicable and noncommu-nicable
diseases.
All cases attending t"e "ealt" facility s"ould be recorded on t"e Wee%ly
Morbidity =orm& including t"ose ;"o are subseJuently referred to "os'ital.
Only t"e first consultation s"ould be re'ortedN follo;-u' (isits for t"e same
disease s"ould not be re'orted.
At t"e end of eac" ;ee%& t"e re'orting officer must count u' all t"e cases and
deat"s from eac" disease as recorded in t"e out'atient and in'atient records.
9"e "ealt" ;or%er must select t"e main cause for t"e consultation& i.e. one
disease5syndrome for eac" case.
*f one of t"e diseases "as e'idemic 'otential mar%ed ;it" an asteris% in t"e
form& record t"is disease as t"e main cause of consultation.
LOt"er communicable diseasesM include all cases of communicable diseases
not mentioned in t"e list of diseases eg s%in infections
LOt"er noncommunicable diseasesM include all cases of noncommunicable
diseases not mentioned in t"e list of diseases e.g. gastrointestinal 'roblems&
"eart disease& diabetes.
Diseases of outbrea% 'otential are mar%ed ;it" an asteris%
Z
on t"e morbidity
form. 9"ey must be re'orted to your "ealt" coordinator using t"e outbrea6
alert formif t"e ;ee%ly alert t"res"olds belo; are 'assed 2see bo: on alert
t"res"olds belo;4.
*n t"e e(ent of an increase in t"e number of cases of a disease5syndrome&
sur(eillance acti(ities may need to be en"anced. =or e:am'le& acti(e case-
finding and case definitions may need to be re(ised& suc" as in t"e e(ent of an
outbrea% of meningitis.
Becord total number of consultations in t"e "ealt" facility in a ;ee%.
2o@ to fill in t)e @ee4l, mortalit, formD
9"is form is a line-listing of all deat"s.
=ill in all t"e details as reJuired for eac" case including names& age& se:& date
and location of deat" and laboratory sam'les ta%en& and record a main cause of
deat" for eac" entry e(en if Lun%no;nM.
Calculations of mortality rates can be 'erformed as follo;s:
Crude mortalit, rate 8CM9 : .umber of deat"s for t"e ;ee%5'o'ulation at t"e
end of t"e ;ee% V 3 333 'ersons56 days P deat"s53 333 'ersons5day. 2Alert
t"res"old or A9 is 53 3335day.4
!nder<- mortalit, rate 8!-M9 : .umber of deat"s among c"ildren U0 years
for t"e ;ee%5under 0 year 'o'ulation at t"e end of t"e ;ee% V 3 333 'ersons5 6 days
P deat"s53 333 'ersons5day 2A9 is #53 3335day4.
SAM$LE ALET T2ES2OLDS 8ma, need to be ada(ted for
(articular conte=t9
Acute ;atery diarr"oea: 0 cases in t"e 0 years and o(er age grou'
-loody diarr"oea: 0 cases
Measles: case
Meningitis ! sus'ected: 0 cases or .0 times t"e baseline
Acute "aemorr"agic fe(er syndrome: case
Acute Faundice syndrome: 0 cases or .0 times t"e baseline
Malaria: 0 cases or .0 times t"e baseline
Acute flaccid 'aralysis 2sus'ected 'oliomyelitis4:
case
.eonatal tetanus: case
=e(er of un%no;n origin: .0 times t"e baseline
Ot"er communicable diseases: .0 times t"e baseline
?n%no;n disease occurring as a cluster: re'ort any cluster
,e(ere malnutrition: # cases
-aseline P a(erage ;ee%ly number of cases of t"e disease calculated o(er t"e 'ast
$ ;ee%s.
"# SAM$LE WEEKL? MO7IDIT? 0OM
Pro(ince5@o(ernorate: bbbbbbbbbbbbbbbbbbbbbbbbbbbbb District5Area: bbbbbb
9o;n5Eillage5,ettlement5Cam': bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Healt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbb Agency: bbbbbbbbbbbbbbbbb
Be'orting 'eriod: from Monday bbbbbb5bbbbbb5bbbbbbbb to ,unday bbb5bbbbbb
Po'ulation co(ered: bbbbbbbbbbbbbbbbbbbbbbbbbbbb ?nder-0 'o'ulation: bbbb
.ame of sur(eillance officer: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
DISEASE : S?NDOME NEW CASES
!nder - ,ears - ,ears and o'er
Z
Acute ;atery diarr"oea
Z
-loody diarr"oea
Z
Measles
Z
Meningitis ! sus'ected
Z
Acute flaccid 'aralysis
2sus'ected 'oliomyelitis4
Z
Acute "aemorr"agic
fe(er syndrome
Z
Acute Faundice syndrome
Z
Malaria ! sus'ected
?''er res'iratory tract
infection
Acute lo;er res'iratory
tract infection5'neumonia
.eonatal tetanus
=e(er of un%no;n origin
Ot"er communicable
diseases
Z
?n%no;n disease
occurring as a cluster
9rauma5inFury:
Landmine 5 ?fO
ZZ
inFury
War-related ot"er t"an
mine5?fO
ZZ
Boad traffic accident
Ot"er
,e(ere malnutrition
Mental "ealt"5stress-
related 'roblems
Ot"er non-communicable
diseases
9O9AL CL*.*C
A99E.DA.CE
Z
Diseases ;it" outbrea% 'otential ! re'ort as soon as 'ossible to your "ealt"
coordinator using outbrea% alert form. ,ee alert t"res"olds under Lguidelines for
use of sur(eillance formsM.
ZZ
?ne:'loded ordnance
%# WEEKL?:MONT2L? DEMOGA$2? 0OM
Pro(ince5@o(ernorate: bbbbbbbbbbbbbbbbbbbbbbbbbbbbb District5Area: bbbbbb
9o;n5Eillage5,ettlement5Cam': bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Healt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbb Agency: bbbbbbbbbbbbbbbbb
Be'orting 'eriod: from Monday bbbbbb5bbbbbb5bbbbbbbb to ,unday bbb5bbbbbb
.ame of sur(eillance officer: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
C)ildren C)ildren Total (o(ulation
under - ,ears 8a9 o'er - ,ears 8b9 8a Kb9
$o(ulation at t)e
end of last
@ee4:mont) 8"9
7irt)s t)is
@ee4:mont) 8%9
Arri'als t)is
@ee4:mont) 8*9
Deat)s t)is
@ee4:mont) 8+9
De(artures t)is
@ee4:mont) 8-9
End of
@ee4:mont)
(o(ulation G
8 " K % K * B + B - 9
*# WEEKL? MOTALIT? 0OM
Pro(ince5@o(ernorate: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbb District5Area:
bbbbbbbbbbbbbbbbbbbbbbbbbbbbbb 9o;n5Eillage5,ettlement5Cam': bbbbbbbbbbbb
Healt" facility 2"os'ital5"ealt" centre4: bbbbbbbbbbbbbbbbbbbbbbbbbbbb
Be'orting 'eriod: from Monday bbbbbb5bbbbbb5bbbbbbbb to ,unday bbb5bbbbbbbbb
Po'ulation at t"e end of t"e ;ee%: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbb ?nder 0
'o'ulation at t"e end of t"e ;ee%: bbbbbbbbbbbbbbbbbbbbbbbbb
.ame of sur(eillance officer: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Direct causes of deat) !nderl,i
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causes of
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3
g ,ee case definitions list.
T
*f t"is bo: is tic%ed& also s'ecify cause in t"e Lspecify causeM column. E:am'le&
if c"olera is sus'ected as t"e cause of t"e acute ;atery diarr"oea deat"& tic% t"e acute
;atery diarr"oea column and ;rite c"oleraM in Lspecify causeA column. =or
Trauma:in&ur, deat"s: Lspecify causeA column s"ould indicate P mine5 ?fO& # P
;ar-related ot"er t"an mine5?fO& $ P B9A 2road traffic accident4& or ) P ot"er
-# Case definitions
AC!TE WATE? DIA2OEA
9"ree or more abnormally loose or fluid stools in t"e 'ast #) "ours ;it" or
;it"out de"ydration.
To sus(ect case of c)oleraD
Person aged o(er 0 years ;it" se(ere de"ydration or deat" from acute ;atery
diarr"oea ;it" or ;it"out (omiting.
Person aged o(er # years ;it" acute ;atery diarr"oea in an area /here there is a
cholera outbrea6"
To confirm case of c)oleraD
*solation of Fibrio cholera O or O$/ from diarr"oeal stool sam'le.
AC!TE 2AEMO2AGIC 0E/E S?NDOME
Acute onset of fe(er of less t"an $ ;ee%s< duration in a se(erely ill 'atient and
any t;o of t"e follo;ing:
"aemorr"agic or 'ur'uric ras"&
e'ista:is&
"aematemesis&
"aemo'tysis&
blood in stools&
ot"er "aemorr"agic sym'tom and no %no;n 'redis'osing "ost factors for
"aemorr"agic manifestations.
AC!TE ;A!NDICE S?NDOME
Acute onset of Faundice and se(ere illness and absence of any %no;n
'reci'itating factors.
AC!TE LOWE ES$IATO? TACT
IN0ECTION:$NE!MONIA IN C2ILDEN O- ?EAS
Coug" or difficult breat"ingN
and
-reat"ing 03 or more times 'er minute for infants aged # mont"s to yearN
-reat"ing )3 or more times 'er minute for c"ildren aged to 0 yearsN
and
.o c"est indra;ing& no stridor& no general danger signs.
Note: Se'ere (neumonia = Coug" or difficult breat"ing K any general danger
sign 2unable to drin% or breastfeed& (omits e(eryt"ing& con(ulsions& let"argic or
unconscious4 or c"est indra;ing or stridor in a calm c"ild.
AC!TE 0LACCID $AAL?SIS 8S!S$ECTED
$OLIOM?ELITIS9
Acute flaccid 'aralysis in a c"ild aged U 0 years& including @uillain--arrK
syndrome or any 'aralytic illness in a 'erson of any age.
To confirm caseD
Laboratory-confirmed ;ild 'olio(irus in stool sam'le.
7LOOD? DIA2OEA
Acute diarr"oea ;it" (isible blood in t"e stool.
To confirm case of e(idemic bacillar, d,senter,D
9a%e stool s'ecimen for culture and blood for serology. *solation of 2higella
dysenteriae.
MALAIA B S!S$ECTED
Bncomplicated malaria
Patient ;it" fe(er or "istory of fe(er ;it"in t"e 'ast )A "ours 2;it" or ;it"out
ot"er sym'toms suc" as nausea& (omiting and diarr"oea& "eadac"e& bac% 'ain& c"ills&
myalgia4 in ;"om ot"er ob(ious causes of fe(er "a(e been e:cluded.
2evere malaria
Patient ;it" sym'toms as for uncom'licated malaria& as ;ell as dro;siness ;it"
e:treme ;ea%ness and associated signs and sym'toms related to organ failure suc" as
disorientation& loss of consciousness& con(ulsions& se(ere anaemia& Faundice&
"aemoglobinuria& s'ontaneous bleeding& 'ulmonary oedema and s"oc%.
To confirm caseD
Demonstration of malaria 'arasites in blood film by e:amining t"ic% or t"in
smears& or by ra'id diagnostic test %it for Dlasmodium falciparum"
MEASLES
=e(er and maculo'a'ular ras" 2i.e. non-(esicular4 and coug"& cory8a 2i.e. runny
nose4 or conFuncti(itis 2i.e. red eyes4N
or
Any 'erson in ;"om a clinical "ealt" ;or%er sus'ects measles infection.
To confirm caseD
At least a fourfold increase in antibody titre or isolation of measles (irus or
'resence of measles-s'ecific *gM antibodies.
MENINGITIS B S!S$ECTED
,udden onset of fe(er 2S $A.3 `C a:illary4 and one of t"e follo;ing:
nec% stiffness&
altered consciousness&
ot"er meningeal sign or 'etec"ial5'ur'ural ras".
*n c"ildren U year meningitis is sus'ected ;"en fe(er is accom'anied by a
bulging fontanelle.
To confirm caseD
Positi(e cerebros'inal fluid antigen detection or 'ositi(e cerebros'inal fluid
culture or 'ositi(e blood culture.
NEONATAL TETAN!S
Sus(ected caseD
Any neonatal deat" bet;een $ and #A days of age in ;"ic" t"e cause of deat" is
un%no;n or any neonate re'orted as "a(ing suffered from neonatal tetanus bet;een $
and #A days of age and not in(estigated.
To confirm caseD
Any neonate ;it" normal ability to suc% and cry during t"e first # days of life& and
;"o bet;een $ and #A days of age cannot suc% normally and becomes stiff or "as
con(ulsions 2i.e. Fer%ing of t"e muscles4 or bot".
Hos'ital-re'orted cases are considered confirmed.
T)e diagnosis is entirel, clinical and does not de(end on bacteriological
confirmation.
OT2E COMM!NICA7LE DISEASES
9"ese include some ot"er communicable diseases not line-listed on t"e
sur(eillance forms. 9"e list belo; is non-e:"austi(e and details t;o outbrea%-'rone
diseases in t"is category.
;C-2854N-42-2
isceral leishmaniasis "L#
Person ;it" clinical signs of 'rolonged 2S# ;ee%s4 irregular fe(er& s'lenomegaly
and ;eig"t loss& ;it" serological 2at 'eri'"eral geogra'"ical le(el4 and5or 2;"en
feasible at central le(el4 'arasitological confirmation of t"e diagnosis.
Note: *n endemic malarious areas& (isceral leis"maniasis must be sus'ected ;"en
fe(er not res'onding to anti-malarial drugs 'ersists for more t"an # ;ee%s 2assuming
drug-resistant malaria "as also been considered4.
To confirm caseD
Positi(e 'arasitology
stained smears from bone marro;& s'leen& li(er& lym'" node& blood
or
culture of t"e organism from a bio'sy or as'irated material
Positi(e serology 2immunofluorescent assay& EL*,A& Direct Agglutination 9est4
$utaneous leishmaniasis "$L#
Person ;it" clinical signs and 'arasitological confirmation of t"e diagnosis.
Clinical signs: A''earance of one or more s%in lesions& ty'ically on unco(ered 'arts
of t"e body. 9"e face& nec%& arms and legs are most common sites. A nodule may
a''ear at t"e site of inoculation and may enlarge to become an indolent ulcer. 9"e
sore may remain in t"is stage for a (ariable time before "ealing ! it ty'ically lea(es a
de'ressed scar.
To confirm caseD
Positi(e 'arasitology 2stained smear or culture from t"e lesion4.
TND89-1 FCFC:
Person ;it" fe(er of at least $A hC for $ or more days is considered sus'ect if t"e
e'idemiological conte:t is conduci(e.
Clinical diagnosis is difficult as it may (ary from a mild illness ;it" lo; grade
fe(er and malaise to a se(ere 'icture of sustained fe(er& diarr"oea or consti'ation&
anore:ia& se(ere "eadac"e and intestinal 'erforation may occur.
To confirm caseD
*solation of 2" 9y'"i from blood or stool cultures.
0E/E O0 !NKNOWN OIGIN
Person ;it" fe(er in ;"om all ob(ious causes of fe(er "a(e been e:cluded.
!NKNOWN DISEASE OCC!ING AS A CL!STE
An aggregation of cases ;it" related sym'toms and signs of un%no;n cause t"at
are closely grou'ed in time and5or 'lace.
SEA!ALL? TANSMITTED DISEASES
ECN-T4; B;<C: 2NN1:95C
?lcer on 'enis or scrotum in men and on labia& (agina or cer(i: in ;omen ;it" or
;it"out inguinal adeno'at"y.
B:CT8:4; 1-2<84:EC 2NN1:95C
?ret"ral disc"arge in men ;it" or ;it"out dysuria.
F4E-N4; 1-2<84:EC 2NN1:95C
Abnormal (aginal disc"arge 2amount& colour and odour4 ;it" or ;it"out lo;er
abdominal 'ain or s'ecific sym'toms or s'ecific ris% factors.
;9,C: 47195-N4; D4-N
,ym'toms of lo;er abdominal 'ain and 'ain during se:ual relations& ;it"
e:amination s"o;ing (aginal disc"arge& lo;er abdominal tenderness on 'al'ation or
tem'erature S$A `C.
S!S$ECTED $!LMONA? T!7EC!LOSIS
Any 'erson ;"o 'resents ;it" sym'toms or signs suggesti(e of 'ulmonary
tuberculosis& in 'articular coug" of long duration. May also "a(e "aemo'tysis& c"est
'ain& breat"lessness& fe(er5nig"t s;eats& tiredness& loss of a''etite and significant
;eig"t loss.
All 9- sus'ects s"ould "a(e t"ree s'utum sam'les e:amined by lig"t microsco'yN
early morning sam'les are more li%ely to contain t"e tuberculosis organism t"an a
sam'le later in t"e day.
25C4:(D92-T-FC DB;59N4:N TB7C:<B;92-2 .DT7U0
Diagnostic criteria s"ould include at least t;o s'utum smear s'ecimens 'ositi(e
for acid-fast bacilli 2A=-4N
or
One s'utum smear s'ecimen 'ositi(e for A=- and radiogra'"ic abnormalities
consistent ;it" acti(e 'ulmonary tuberculosisN
or
One s'utum smear s'ecimen 'ositi(e for A=- and a culture 'ositi(e for 5"
tuberculosis"
25C4:(NCE4T-FC DB;59N4:N TB7C:<B;92-2 .DT7!0
A case of 'ulmonary tuberculosis t"at does not meet t"e abo(e definition for
smear-'ositi(e tuberculosis. Diagnostic criteria s"ould include at least t"ree s'utum
smear s'ecimens negati(e for A=-N
and
Badiogra'"ic abnormalities consistent ;it" acti(e 'ulmonary tuberculosisN
and
.o res'onse to a course of broad-s'ectrum antimicrobialN
and
Decision by a clinician to treat ;it" a full course of antituberculosis
c"emot"era'y.
MALN!TITION
,e(ere malnutrition:
*n c"ildren 1 to 0/ mont"s 210 to 3 cm in "eig"t4:
;eig"t-for-"eig"t 2W5H4 inde: U !$ G scores 2on table of .CH,5WHO
normali8ed reference (alues of ;eig"t-for-"eig"t by se:4N
bilateral 'itting oedema irres'ecti(e of W5H& in absence of ot"er causes.
TA!MA: IN;!?
-nGury .intentional0
A bodily lesion at t"e organic le(el& resulting from an intentionally inflicted acute
e:'osure to energy in amounts t"at e:ceed t"e t"res"old of '"ysiological tolerance.
-nGury .non(intentional0
A bodily lesion at t"e organic le(el& resulting from a non-intentionally 2i.e.
LaccidentallyM4 inflicted acute e:'osure to energy in amounts t"at e:ceed t"e
t"res"old of '"ysiological tolerance.
;andmine/BP9 inGury
A 'erson ;"o "as sustained& eit"er directly or indirectly& a fatal or non-fatal inFury
caused by t"e e:'losion of a landmine or ot"er une:'loded ordnance 2?fO4.
.ote: Landmine inFuries relate to buried mines 2e.g. anti'ersonnel and5or
anti(e"icle mines4.
?fO inFuries arise from e:'losi(e obFects5de(ices t"at are ty'ically abo(e ground
at time of detonation& suc" as cluster munitions t"at did not detonate on im'act.
E:am'les of ot"er categories of trauma5inFury t"at may be used for sur(eillance:
Trauma/inGury other than landmine/BP9 inGury
:oad traffic accident
9ther
MATENAL DEAT2
Deat" of a ;oman ;"ile 'regnant or ;it"in )# days of termination of 'regnancy&
regardless of t"e site or duration of 'regnancy& from any cause related to or
aggra(ated by t"e 'regnancy or its management.
NEONATAL DEAT2
Deat" of a li(e-born infant in its first #A days of life.
*t is a classification by age not cause.
.# Outbrea4 in'estigation 4it
SAM$LE O!T7EAK ALET 0OM
Pro(ince5@o(ernorate: bbbbbbbbbbbbbbbbbbbbbbbbbbbbb District5Area: bbbbbb
9o;n5Eillage5,ettlement5Cam': bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Healt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbb Agency: bbbbbbbbbbbbbbbbb
Date: bbbbbb5bbbbbb5bbbbbbbb
.ame of re'orting officer: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
S,m(toms and signsD Sus(ected disease:s,ndromeD
,ou can tic4 se'eral bo=es tic4 ONE bo= onl,
Acute ;atery diarr"oea Acute ;atery diarr"oea
-loody diarr"oea -acillary dysentery5s"igellosis
=e(er C"olera
Bas" Measles
Coug" Meningitis
Eomiting Malaria
.ec% stiffness Acute flaccid 'aralysis 2sus'ected 'oliomyelitis4
Caundice Acute "aemorr"agic fe(er syndrome
-leeding Acute Faundice syndrome
Acute 'aralysis or ;ea%ness Cutaneous leis"maniasis
*ncreased secretions 2e.g.
s;eating& drooling4
Eisceral leis"maniasis
Ot"er: bbbbbbbbbbbbbbbbb 9y'"oid fe(er
?n%no;n disease occurring in a cluste
Total number of cases
re(ortedD
Ot"er: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Seria
l No#
Ag
e
Se
=
Locatio
n
Date
of
onse
t
Laborator
, s(ecimen
ta4en
8,es:no9
Treatmen
t gi'en
Outcom
e
a
0inal
classi<
fication
b
a
Outcome: * P currently illN B P reco(ering or reco(eredN D P died.
b
=inal classification: , P sus'ected case ;it" clinical diagnosisN C P confirmed
case ;it" laboratory diagnosis.
SAM$LE CASE IN/ESTIGATION 0OM
Pro(ince5@o(ernorate: bbbbbbbbbbbbbbbbbbbbbbbbbbbbb District5Area: bbbbbb
9o;n5Eillage5,ettlement5Cam': bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Healt" facility: bbbbbbbbbbbbbbbbbbbbbbbbbbbb Agency: bbbbbbbbbbbbbbbbb
Date: bbbbbb5bbbbbb5bbbbbbbb
NOTED ONE 0OM $E CASE IN/ESTIGATED
" $ATIENT IDENTI0ICATION
Case .o.: bbbbbbbbbbbbbbbbbbbbbbbbbbbb .ame: bbbbbbbbbbbbbbbbbbbbb
Location:bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Date of birt": bbbbbb5bbbbbb5bbbbbbbb Age: bbbbbbbbbbbbb ,e:: M 0
% CLINICAL DATA
Date of onset of illness: bbbbbb5bbbbbb5bbbbbbbb
Acute ;atery diarr"oea
-loody diarr"oea
=e(er
Bas"
Coug"
Eomiting
.ec% stiffness
Caundice
-leeding
Acute 'aralysis or ;ea%ness
*ncreased secretions 2e.g. s;eating& drooling4
Ot"er: bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
* LA7OATO? DATA
,am'le: bbbbbbbbbbbbbbbbb Date ta%en: bbbbbb5bbbbbb5bbbbbbb Lab.
recei(ed: bbbbbb5bbbbbb5bbbbbbbb
.ame of laboratory: bbbbbbbbbbbbbbbbbbbbbbbbbbbb
9y'e of test: bbbbbbbbbbbbbbbbbbbbbb Date of results: bbbbbb5bbbbbb5bbbbbbb
Besult: $os# Neg
+ 0INAL CLASSI0ICATION
Confirmed: Laboratory Date of final diagnosis: bbbbbb5bbbbbb5bbbbb
Clinical case
Discarded final diagnosis: bbbbbbbbbbbbbbbb
-# 0IELD IN/ESTIGATO
.ame: bbbbbbbbbbbbbbbbbbbbbbbbbbbb
Position: bbbbbbbbbbbbbbbbbbbbbbbbbbbb ,ignature: bbbbbbbbbbbbbbbbbb
O!T7EAK IN/ESTIGATION KIT
Item !nit Iuantit,:4it
"# 7asic consumables
module
. Cotton ;ool& -P&
33Q& surgical Juality
roll of 033 g 0
.# -all'oint 'en 0
.$ Pencil 0
.) Eraser 0
.0 =elt-ti' 'en
2;ater'roof4
0
.1 Mar%ing 'en& ;ater-
resistant in%& blac% and
blue
0
.6 .oteboo% 2A)& "ard
co(er& sJuared 'a'er4
0
.A Labels 2blan%& self-
ad"esi(e4
series 0
./ Buler 0
.3 Calculator 0
. ,cissors 0
.# 9"ermometer 23 !
33`4
0
.$ 9orc" 2] D-ty'e s'are
batteries4
0
.) ,ealing ta'e roll 0
.0 .ormal saline 23./Q4 033 ml 0
033 ml 0
.1 ,"ar's container for
dis'osal of needles and
syringes& min. # litres
0
.6 C"lorine granules 033
mg5containers
0
%# Common consumables
for collection of all
s(ecimens
#. @au8e s;abs& 3 : 3
cm& 33Q cotton& #-'ly&
6-t"r& sterile
3 : 3 'cs5bo: 0
#.# Disinfecting s;abs&
im'regnated ;it" 63Q
iso'ro'yl alco"ol
335bo: 0
#.$ Microsco'e slides& 61
: #1 mm& cut edges
035bo: 0
#.) Co(er glasses& ## : ##
mm
3335bo: 0
#.0 ,toring bo: for
microslides& ;ooden
frame& for #0 'ieces eac"
35'ac% 0
#.1 ?ni(ersal container& 63
ml& 00 : )) mm& reliable
sealing and PE ca'&
mac"ine-sterile ;it"
standard label
3335'ac% 0
#.6 -raunoderm
2alco"ol]PEP-*OD4 for
surgical scrub& against
bacteria& fungi& (iruses
including H-E and H*E4
litre5contain 0
#.A Po(idone iodine
solution
033 ml5contain 0
#./ Alco"olic "and rub
2]'um' dis'enser4
0
*# 7lood module
$. -lood lancets& sterile&
dis'osable
'ac% of #33 0
$.# Mono(ettes 2orange
ca'& 3 ml4
'ac% of 33
$.$ Mono(ettes 2red ca'&
ED9A& $ ml4
'ac% of 33
$.) .eedles for
Mono(ettes #@
'ac% of 33
$.0 .eedles for
Mono(ettes #$@
'ac% of 33
$.1 -utterfly needles for
blood culture #@
'ac% of 33
$.6 Dis'osable soft
transfer 'i'ettes

$.A Bac%s for blood tubes 0

$./ -and aids 2small4 'ac% 0
$.3 -lood culture bottles
2Hemoline 'erformance
D?O& c"ildren4
# (ials5'ac% 0
$. -lood culture bottles
2Hemoline 'erformance
di'"asic4
# (ials5'ac% 0
$.# 9ourniJuets ;it" cli' 0
Item !nit Iuantit,:4it
+# es(irator, module
). 9ongue de'ressor 335'ac% 0
).# =le:ible ;ire calcium
alginate ti''ed s;ab 2for
'ertussis4
335'ac%
).$ ,yringe for suction&
03513 ml ;it" cat"eter ti'
135'ac% #
).) 9rans'ort s;abs ;it"
9rans Amies trans'ort
medium
3335'ac%
).0 Eirus trans'ort
medium 2Cellmatics4
035'ac%
-# !rine module
0. ?rine container ;it"
boric acid& P, ;5scre;
ca'& $3 ml 2sterile4
)335'ac%
.# Stool module
1. Bectal s;abs for adults #0
1.# Bectal s;abs for
infants
#0
1.$ ,tool collection tubes
;it" s'oon
)335'ac%
1.) 9ubes ;it" Cary--lair
trans'ort medium
33
1# CS0 module
6. ,terile cotton s;ab 335'ac% 0
6.# -ottle ;it" 9rans
*solate media
33
6.$ ,'inal needle& #0@ :
$.0
#05bo 0
6.) ,'inal needles& #$@ :
$.0
#05bo 0
6.0 .eedle for transfer into
medium& #@
^5bo:
6.1 Microtube #.3 ml& PP&
;it" mout" scre; ca' and
s%irted base
035bag
6.6 Local anaest"etics
2lidocaine #Q #ml4& #0@
needle& 0-ml syringe
33
3# Self<(rotection module
A. Dis'osable surgical
go;ns
3
A.# Dis'osable surgical
face mas%s
03 'cs5bo: 0
A.$ Dis'osable glo(es:
si8es ,& M& L
33 'cs5bo: 0
A.) @oggles 3
A.0 =ace-mas% ty'e
==P$,L $M brand
3
A.1 Dis'osable surgical
ca's& si8e M
03 'cs5bo: 0
A.6 Bubber surgical boots 'air& si8e )# 0
A.A Dis'osable
im'ermeable s"oe co(er&
lengt" $A cm
33 'cs5bag 0
A./ *m'ermeable a'rons&
/3 : # cm
0
A.3 Eisors5face-s"ield 0
5# S(ecimen trans(ort
module
/. ,'ecimen carrier 2cool
bo:4
0
/.# *ce'ac%s set of #) 0 set of #) 0
/.$ Microcentrifuge tube
rac%
0
/.) Com'lete combination
'ac%aging for infectious
substances& -*OPACD #
;it" .0-litre -*OCAB
0
/.0 CL-) t"ermal control
unit& 'olystyrene bo: set in
fibreboard case ;it" all
labels and instructions
0
1 OrganiCation of an isolation centre and calculation of
treatment su((lies
0our se(arate s(acesD
Admission and obser(ation unit
.eutral 'art: staff office and staff rest room& "os'ital %itc"en& store rooms
Hos'italisation unit: reser(ed for se(ere 'atients ;it" *E fluids
Beco(ery unit: oral re"ydration s'ace
*n eac" s'ace& ensure e:clusi(e latrines& ;as"ing areas& large Juantities of ;ater
and safe dis'osal of ;aste
0igure A1#" OrganiCation of an emergenc, treatment centre and (atient<flo@
Table A1#" Essential rules in c)olera treatment centre
Mode of transmission Essential rules in t)e
CTC
Additional recommended
rules
Peo'le O Access limited to 'atient
] one family member ]
staff
O *deally one carer 'er
'atient only
O One-;ay flo; of 'eo'le O $ se'arate s'aces ;it"in
t"e centre
2see bo: 4
Water O ,afe ;ater 2c"lorination
concentration according to
s'ecific useN see 9able
A6.#4
O *deally 03 litres 'er
'atient and 'er day
O Large Juantity needed
2minimum 3
litres5'erson5day4
Hands O Hand-;as"ing stations
;it" safe ;ater and soa' in
sufficient Juantities
O Cut and clean nails
O Was" "ands ;it" ;ater
and soa'
O before and after ta%ing
care of 'atients
O after going to t"e latrines
O before coo%ing or eating
after lea(ing t"e admission
;ard
=ood O Coo%ed food O =ood 'ro(ided by t"e
C9C 2'referably not by
families4
O Healt" care ;or%ers
s"ould not "andle food or
;ater
O Large stoc%s of food may
be Ltem'tingM and may
lead to security 'roblems
En(ironmental
contamination 2faeces and
;aste4
O Ensure e:clusi(e latrines
for t"e unit
O Latrines at least 33
metres a;ay from ;ells or
surface sources
O Disinfect buc%ets& soiled
surfaces and latrines
regularly ;it" t"e
a''ro'riate c"lorine
solution 2see 9able A6.#4
O ,'ecial c"olera beds
O *ncinerator for medical
;aste
Cor'ses O ,e'arate morgue O ,afe funeral 'ractices
O Disinfect cor'ses 2see
9able A6.#4
O Dis'ose of cor'ses as
soon as 'ossible
Table A1#% $re(aration and use of disinfectants
Starting @it)D %E SOL!TION 6#%E SOL!TION 6#6-E
SOL!TION
Calcium
),(oc)lorite
at 63Q acti(e
c"lorine
$3 g5litre or $3 g53 litres or 6 g53 litres or
2L"ig"-test
"y'oc"loriteM&
LH9HM4
# tables'oons5litre # tables'oons53
litres
5# tables'oon53
litres
C)lorinated lime
at $3Q acti(e
c"lorine
11 g5litre or 11 g53 litres or 1 g53 litres or
2Lbleac"ing
'o;derM4
) tables'oons5litre ) tables'oons53
litres

tables'oon53litres
Sodium
),(oc)lorite
solution at 1Q
acti(ec"lorine
$$$ ml5litre or $$$ ml53 litres or A$ ml53 litres or
2L"ouse"old
bleac"M4
## tables'oons5litre ## tables'oons53
litres
0 tables'oons53
litres
!SE 0O
DISIN0ECTION
O0
E:creta =loor Hands
Cor'ses ?tensils ,%in
,"oes -eds Clot"es
Measurements used: teas'oon P 0 mlN tables'oon P 0 mlN cu' P #33 ml. Do
not use metallic buc%et for 're'aration and storage of c"lorinated solutions
Table A1#* C)olera treatment su((lies for an
outbrea4
Ho% to estimate the initial amount of supplies needed for a cholera
outbrea&
23.#Q of t"e 'o'ulation e:'ected to fall ill initially4
9"e table belo; gi(es you an estimate of t"e amount of su''lies you ;ill need
according to t"e number of 'eo'le in your area. 9o find t"e amounts needed for eac"
item& loo% in t"e column under t"e a''ro:imate 'o'ulation of your catc"ment area to
t"e nearest 0333. Hou may add se(eral columns 2e.g. if your "ealt" facility ser(es $0
333 'eo'le& add t"e amounts in t"e 3 333 and 0333 columns to t"ose in t"e #3 333
column4. Write t"e amount needed at your "ealt" facility in t"e em'ty column on t"e
rig"t.
$o(ulation 2] numbers e+pected to fall ill0 Hour
area
0 333 3333 0333 #3333 03333 33333
ITEM 234 2#34 2$34 2)34 2334 2#334
e),dration su((lies
OB, 'ac%ets
2for litre
eac"4
10 $3 /0 #13 103 $33
.asogastric
tubes 2adults4
0.$5$.0 mm
21 =lac%4 03
cm
# $ 1
.asogastric
tubes
2c"ildren4
# $ 1
Binger<s
lactate bags&
litre&
;it" gi(ing
sets
# #) $1 )A #3 #)3
,cal' (ein
sets
# $ ) 0 3 #3
Antimicrobial
Do:ycycline&
33 mg
2adults4
1 # A #) 13 #3
Eryt"romycin&
#03 mg
#) )A 6# /1 #)3 )A3
2c"ildren4
Ot)er treatment su((lies
Large ;ater
dis'ensers
;it" ta'
2mar%ed at 0!
3 litres4
# # )
-litre bottles
for OB,
solution
# ) 1 # #3 )3
3.0-litre
bottles for
OB, solution
# ) 1 # #3 )3
9umblers&
#33 ml
) A # 1 )3 A3
9eas'oons # ) 1 A #3 )3
Cotton ;ool&
%g
5#
5#
# 0 3
Ad"esi(e
ta'e& reels
# $ 1
1eveloped by ,89 Elobal Tas6 Force on <holera <ontrol
Table A1#+ D,senter, treatment su((lies (er
(o(ulation
Ho% to estimate the amount of supplies needed for a dysentery
outbrea&
23.#Q of t"e 'o'ulation e:'ected to fall ill initially4
9"e table belo; gi(es you an estimate of t"e amount of su''lies you ;ill need
according to t"e number of 'eo'le in your area. 9o find t"e amounts needed for eac"
item& loo% in t"e column under t"e a''ro:imate 'o'ulation of your catc"ment area to
t"e nearest 0333. Hou may add se(eral columns 2e.g. if your "ealt" facility ser(es $0
333 'eo'le& add t"e amounts in t"e 3 333 and 0333 columns to t"ose in t"e #3 333
column4. Write t"e amount needed at your "ealt" facility in t"e em'ty column on t"e
rig"t.
$o(ulation 2] numbers e+pected to fall ill0 Hour
area
0 333 3333 0333 #3333 03333 33333
ITEM 234 2#34 2$34 2)34 2334 2#334
e),dration su((lies
OB, 'ac%ets
2for litre
eac"4
3 #3 $3 )3 33 #33
Binger<s
lactate bags&
litre& ;it"
gi(ing sets
# ) 1 A #3 )3
,cal' (ein
sets
# # 0 3
Antimicrobial
Ci'roflo:acin&
033 mg
33 #33 $33 )33 333 #333
Ot)er treatment su((lies
Large ;ater
dis'ensers
;it" ta'
2mar%ed at 0!
3 litres4
#
-litre bottles
for OB,
solution
# # 0 3
3.0-litre
bottles for
OB, solution
# # 0 3
9umblers&
#33 ml
# $ ) 3 #3
9eas'oons # # 0 3
Cotton ;ool&
%g
5#
5#
# 0 3
Ad"esi(e
ta'e& reels
# $ 1
Hand soa'& %g # ) 1 A #3 )3
-o:es of soa'
for ;as"ing
clot"es
$ 1 / # $3 13
-litre bottle
of cleaning
solution 2#Q
c"lorine or !
#Q '"enol4
# )
1eveloped by ,89 Elobal Tas6 Force on <holera <ontrol
Table A1#- T,()oid fe'er treatment su((lies
(er (o(ulation
Ho% to estimate the amount of supplies needed for a typhoid outbrea&
23.#Q of t"e 'o'ulation e:'ected to fall ill initially4
9"e table belo; gi(es you an estimate of t"e amount of su''lies you ;ill need
according to t"e number of 'eo'le in your area. 9o find t"e amounts needed for eac"
item& loo% in t"e column under t"e a''ro:imate 'o'ulation of your catc"ment area to
t"e nearest 0333. Hou may add se(eral columns 2e.g. if your "ealt" facility ser(es $0
333 'eo'le& add t"e amounts in t"e 3 333 and 0333 columns to t"ose in t"e #3 333
column4. Write t"e amount needed at your "ealt" facility in t"e em'ty column on t"e
rig"t. On t"e basis of drug resistance in your area& c"oose only one of t"e
antimicrobial.
$o(ulation 2] numbers e+pected to fall ill0 Hour
area
0 333 3333 0333 #3333 03333 33333
ITEM 234 2#34 2$34 2)34 2334 2#334
e),dration su((lies
OB, 'ac%ets 2for
litre eac"4
3 #3 $3 )3 33 #33
Binger<s lactate
bags
Z
litre& ;it"
gi(ing sets
# $ ) 3 #3
,cal' (ein sets # # 0 3
Antimicrobial
C"loram'"enicol&
#03 mg
#033 0333 6033 3333 #0333 03333
Amo:icillin& 033
mg
1A3 $$13 03)3 16#3 1A33 $$133
Co-trimo:a8ole& A)3 1A3 #0#3 $$13 A)33 1A33
2,Mf )33
mg]9MP A3
mg 4
Cefi:ime& #33mg
ZZ
A)3 1A3 #0#3 $$13 A)33 1A33
Ot)er treatment su((lies
Large ;ater
dis'ensers ;it"
ta' 2mar%ed at 0!
3 litres4
#
3.0-litre bottles
for OB, solution
# # 0 3
-litre bottles for
OB, solution
# # 0 3
9umblers& #33 ml # $ ) 3 #3
9eas'oons # # 0 3
Cotton ;ool& %g 5#
5#
# 0 3
Ad"esi(e ta'e&
reels
# $ 1
Hand soa'& %g # ) 1 A #3 )3
-o: of soa' for
;as"ing clot"es
$ 1 / # $3 13
-litre bottle of
cleaning solution
2#Q c"lorine or
!#Q '"enol4
# )
T
<onsidering that less than ?%V of the patients need -F rehydration"
TT
-n case of multidrug resistance to above antimicrobial* choose <efi+ime"
1eveloped by ,89 Elobal Tas6 Force on <holera <ontrol
3 Collection of s(ecimens for laborator, anal,sis
A3#" 7LOOD S$ECIMEN COLLECTION
-lood and se'arated serum are t"e most common s'ecimens ta%en in outbrea%s of
communicable disease. Eenous blood can be used for direct isolation of t"e 'at"ogen&
or se'arated into serum for t"e detection of genetic material 2e.g. by 'olymerase c"ain
reaction4& s'ecific antibodies 2by serology4& antigens or to:ins 2e.g. by
immunofluorescence4. ,erum is 'referable to unse'arated blood for t"e 'rocessing of
most s'ecimens for diagnosis of (iral 'at"ogens& e:ce't ;"ere ot"er;ise directed.
W"en s'ecific antibodies are being assayed& it is often "el'ful to collect 'aired sera&
i.e. an acute sam'le at t"e onset of illness and a con(alescent sam'le !) ;ee%s later.
-lood can also collected by finger 'ric% for t"e 're'aration of slides for microsco'y
or for absor'tion on to s'ecial filter 'a'er discs for analysis. W"ene(er 'ossible&
blood s'ecimens for culture s"ould be ta%en before antimicrobial are administered to
t"e 'atient.
Materials for collection of 'enous blood sam(les
,%in disinfection: 63Q alco"ol 2iso'ro'anol4 or 3Q 'o(idone iodine& s;abs&
gau8e 'ads& band-aids.
Dis'osable late: or (inyl glo(es.
9ourniJuet& Eacutainerc or similar (acuum blood collection de(ices& or
dis'osable syringes and needles.
,terile scre;-ca' tubes 2or cryotubes if indicated4& blood culture bottles 203 ml
for adults& #0 ml for c"ildren4 ;it" a''ro'riate media.
Labels and indelible mar%er 'en.
Met)od of collection
Place a tourniJuet abo(e t"e (ene'uncture site. Disinfect t"e to's of blood
culture bottles.
Pal'ate and locate t"e (ein. *t is critical to disinfect t"e (ene'uncture site
meticulously ;it" 3Q 'oly(idone iodine or 63Q iso'ro'anol by s;abbing
t"e s%in concentrically from t"e centre of t"e (ene'uncture site out;ards. Let
t"e disinfectant e(a'orate. Do not re'al'ate t"e (ein. Perform (ene'uncture.
*f ;it"dra;ing ;it" con(entional dis'osable syringes& ;it"dra; 0!3 ml of
;"ole blood from adults& #!0 ml from c"ildren and 3.0!# ml from infants.
?nder ase'sis& transfer t"e s'ecimen to a''ro'riate trans'ort tubes and culture
bottles. ,ecure ca's tig"tly.
*f ;it"dra;ing ;it" (acuum systems& ;it"dra; t"e desired amount of blood
directly into eac" trans'ort tube and culture bottle.
Bemo(e t"e tourniJuet. A''ly 'ressure to site until bleeding sto's and a''ly
ad"esi(e dressing.
Label t"e tubes& including t"e uniJue 'atient identification number& using an
indelible mar%er 'en.
Do not reca' used s"ar's. Discard directly into t"e s"ar's dis'osal container.
Com'lete t"e case in(estigation and t"e laboratory reJuest forms using t"e
same identification number.
2andling and trans(ort
-lood s'ecimen bottles and tubes s"ould be trans'orted u'rig"t and secured in a
scre; ca' container or in a rac% in a trans'ort bo:. 9"ey s"ould "a(e enoug"
absorbent 'a'er around t"em to soa% u' all t"e liJuid in case of s'illage.
*f t"e s'ecimen ;ill reac" t"e laboratory ;it"in #) "ours& most 'at"ogens can be
reco(ered from blood cultures trans'orted at ambient tem'erature. Dee' at )!A `C for
longer transit 'eriods& unless a cold-sensiti(e bacterial 'at"ogen is sus'ected suc" as
meningococcus& 'neumococcus& 2higella s''.
A3#% 7LOOD S$ECIMEN COLLECTION 0O /20
IN/ESTIGATION
All in(asi(e 'rocedures and in(estigations s"ould be minimi8ed until t"e
diagnosis of EH= is confirmed or e:cluded. Only t"e s'ecific diagnostic sam'les
needed s"ould be obtained from acutely ill 'atients. Ot"er routine blood sam'les
s"ould be a(oided ;"en in(estigating a case of (iral "aemorr"agic fe(er.
9"e blood sam'les s"ould be %e't in t"eir original tube 2sealed sterile dry tubes&
Mono(ettes or Eacutainer
c
ty'e 4.
Do not attem't to se'arate serum or 'lasma from blood clots in t"e field& t"is may
be "ig"ly ris%y in case of EH=s. 9"ese 'rocedures s"ould be 'erformed at t"e
reference laboratory.
Eac" collected sam'le must be identified as LHig" ris%M& and labels 're'ared in
ad(ance for bot" s'ecimens collected including laboratory reJuest forms. Labels
s"ould include name& date of collection and a code for t"e lin% ;it" t"e corres'onding
case record.
$recautions for sam(ling
W"en in(estigating cases of EH=s& strict basic safety 'recautions must be ta%en.
,ome additional s'ecific 'recautions and safety eJui'ment are reJuired to 'rotect s%in
and mucous membranes against t"ese 'at"ogens.
-lood s'ecimens s"ould be ta%en by a doctor or nurse e:'erienced in t"e
'rocedure. ?rine sam'les also s"ould be "andled carefullyN a #3-ml syringe may be
used to transfer urine from a bed'an to t"e s'ecified container.
'l%ays %ear protective clothing %hen handling specimens from suspected H(
cases)
a 'rotecti(e go;n&
a ;ater'roof 'rotecti(e a'ron&
t;o 'airs of late: glo(es&
'articulate filter face mas%&
goggles&
rubber boots.
Met)od of collection
Obser(e all t"e basic safety 'recautions ;"en obtaining s'ecimens sam'les
from sus'ected EH= cases.
=or ta%ing blood sam'les& it is ad(isable t"e use of a (acuum blood sam'ling
system 2Mono(ette or Eacutainerc4. Ho;e(er& you may use t"e most familiar
eJui'ment and 'rocedure to a(oid t"e ris% of accidents or s'ills.
Wit"dra; 0!3 ml of ;"ole blood from adults& #!0 ml from c"ildren and 3.0!
# ml from infants& directly in t"e trans'ort tube 2blood sam'le tube4.
A(oid t"e use of dis'osable alco"ol s;abs to a''ly 'ressure to (eno'ucture
;ounds. *t is ad(isable to use dry cotton ;ool balls or gau8e s;abs.
After ta%ing t"e sam'le& disinfect t"e blood sam'le tube e:ternally by ;i'ing
;it" "y'oc"lorite solution of 3.0Q 2see AA.64.
Ta4ing off (rotecti'e clot)ing
W"en finis"ed& remo(e t"e a'ronN before remo(ing t"e outer 'air of glo(es&
;as" your "ands ;it" soa' and ;ater and rinse t"em in "y'oc"lorite solution
3.0Q 2see AA.64 for one minute.
Dee' t"e inner glo(es on ;"ile remo(ing goggles& mas%& anyt"ing used to
co(er t"e "ead&t"e e:ternal go;n and boots 2t"e boots s"ould also "a(e been
're(iously soa%ed in same "y'oc"lorite solution4.
=inally remo(e t"e glo(es and t"e inner go;n& ;as" your "ands ;ell ;it"
soa' and ;ater and disinfect t"em ;it" 63Q iso'ro'anol or 'o(idone iodine.
Dis'ose of all 'rotecti(e clot"ing& glo(es& and materials in a 'lastic bag and
incinerate e(eryt"ing. Bemember to ne(er reca' used s"ar's. Discard directly
into s"ar's dis'osal container for later incineration.
2andling and trans(ort
,'ecial care must be ta%en to 're(ent e:ternal contamination of s'ecimen
containers during s'ecimen collection.
9"ree 'ac%age system:
9"e blood sam'le tube s"ould be trans'orted u'rig"t and secured in a scre;-
ca'& lea%-'roof secondary container ;it" sufficient absorbent material to
absorb all t"e contents s"ould lea%age occur. -e sure t"e ca' is scre;ed tig"t
and t"e tube labelled 2s'ecimen record4. 9"e secondary container s"ould be
e:ternally disinfected by ;i'ing ;it" 3.0Q "y'oc"lorite solution 3.0Q 2see
AA.64.
,'ecimen data forms and information t"at identifies or describes t"e s'ecimen
and also identifies t"e s"i''er and recei(er s"ould be ta'ed to t"e outside of
t"e secondary rece'tacle.
9"e secondary container is finally 'laced into a t"ird container 2trans'ort bo:4.
9"e outer 'art of t"e trans'ort bo: s"ould be clearly and (isibly labeled ;it"
t"e bio"a8ard label and t"e address. *t must also clearly identify t"e ty'e of
s'ecimen& t"e s"i''er and t"e recei(er.
*f t"e blood sam'le cannot be 'rocessed t"e same day& ice-'ac%s must be
'laced into t"e trans'ort bo: in order to %ee' t"e sam'le cold 2around ) `C!A
`C4.
W)ole blood sam(le s)ould not be froCen#
A3#* CEE7OS$INAL 0L!ID 8CS09 S$ECIMEN
COLLECTION
9"e s'ecimen must be ta%en by a '"ysician or a 'erson e:'erienced in t"e
'rocedure. C,= is used in t"e diagnosis of (iral& bacterial& 'arasitic and fungal
meningitis5ence'"alitis.
Materials for collection
A lumbar 'uncture tray s"ould be used t"at includes:
sterile materials: glo(es& cotton ;ool& to;els or dra'es&
local anaest"etic& needle& syringe&
s%in disinfectant: 3Q 'oly(idone iodine or 63Q iso'ro'anol&
t;o lumbar 'uncture needles& small bore ;it" stylet&
si: small sterile scre;-ca' tubes and tube rac%&
;ater manometer 2o'tional4&
microsco'e slides and slide bo:es.
Met)od of collection
As only e:'erienced 'ersonnel s"ould be in(ol(ed in t"e collection of C,=
sam'les& t"e met"od is not described "ere. C,= is collected directly into t"e se'arate
scre;-ca' tubes. *f t"e sam'le is not to be 'rom'tly trans'orted& se'arate sam'les
s"ould be collected for bacterial and (iral 'rocessing.
2andling and trans(ort
*n general& s'ecimens s"ould be deli(ered to t"e laboratory and 'rocessed as soon
as 'ossible.
C,= s'ecimens for bacteriology are trans'orted at ambient tem'erature& generally
;it"out trans'ort media. 9"ey must ne(er be refrigerated& as t"ese 'at"ogens do not
sur(i(e ;ell at lo; tem'eratures.
C,= s'ecimens for (irology do not need a trans'ort medium. 9"ey may be
trans'orted at )!A `C for u' to )A "ours& or at !63 `C for longer 'eriods.
a(id diagnostic tests
,e(eral commercial %its are a(ailable& based on t"e direct detection of N"
meningitidis antigens in C,= by late: agglutination tests. =ollo; t"e manufacturer<s
instructions 'recisely ;"en using t"ese tests. =or best results& test t"e su'ernatant of
t"e centrifuged C,= sam'le as soon as 'ossible. *f immediate testing is not 'ossible&
t"e sam'le can be refrigerated 2bet;een # `C and A `C4 for u' to se(eral "ours& or
fro8en at !#3 `C for longer 'eriods. Beagents s"ould be %e't refrigerated bet;een #
`C and A `C ;"en not in use. Product deterioration occurs at "ig"er tem'eratures&
es'ecially in tro'ical climates& and test results may become unreliable before t"e
e:'iry date of t"e %it. Late: sus'ensions s"ould ne(er be fro8en. .ote t"at some %its
"a(e a ;or%ing tem'erature range and tro'ical tem'eratures may be abo(e t"e
recommended u''er limit.
A3#+ 0AECAL S$ECIMEN COLLECTION
,tool s'ecimens are most useful for microbiological diagnosis if collected soon
after onset of diarr"oea 2for (iruses U )A "ours and for bacteria U ) days4 and
'referably before t"e initiation of antimicrobial t"era'y. *f reJuired& t;o or t"ree
s'ecimens may be collected on se'arate days. ,tool is t"e 'referred s'ecimen for
culture of bacterial and (iral diarr"oeal 'at"ogens. Bectal s;abs from faeces of
infants may also be used for bacterial culture& but t"ey are not useful for t"e diagnosis
of (iruses and of little (alue for t"e diagnosis of 'arasites. ,ee figure AA. for
sam'ling and trans'ort 'rocedures for c"olera and 2higella s''.
Materials for collection
Clean& dry& lea%& 'roof-scre; ca' container and ad"esi(e ta'e.
A''ro'riate bacterial trans'ort media for trans'ort of rectal s;abs from
infants.
Parasitology trans'ort 'ac%: 3Q formalin in ;ater& 'oly(inyl iso'ro'yl
alco"ol 2PEA4.
Met)od of collecting a stool s(ecimen
Collect fres"ly 'assed stool& 0 ml liJuid or 0 g solid 2'ea-si8e4& in a container.
Label t"e container.
Met)od of collecting a rectal s@ab from infants
Moisten a s;ab in sterile saline.
*nsert t"e s;ab ti' Fust 'ast t"e anal s'"incter and rotate gently.
Wit"dra; t"e s;ab and e:amine to ensure t"at t"e cotton ti' is stained ;it"
faeces.
Place t"e s;ab in a sterile tube5container containing t"e a''ro'riate trans'ort
medium.
*f necessary& brea% off t"e to' 'art of t"e stic% ;it"out touc"ing t"e inside of
t"e tube and tig"ten t"e scre; ca' firmly.
Label t"e s'ecimen tube.
2andling and trans(ort
,tool s'ecimens s"ould be trans'orted at )!A`C. -acterial yields may fall
significantly if s'ecimens are not 'rocessed ;it"in !# days of collection. 2higella
s''. are 'articularly sensiti(e to ele(ated tem'eratures.
C"olera s'ecimens do not need refrigeration. Wit" Cary--lair trans'ort medium&
t"e sam'le needs to reac" t"e laboratory ;it"in 6 days. Wit"out a trans'ort medium&
t"e s'ecimen must be trans'orted to t"e laboratory ;it"in # "ours 2a cotton-ti''ed
rectal s;ab soa%ed in liJuid stool 'laced in sterile tube or bag5filter 'a'er soa%ed ;it"
liJuid stool ;it" # or $ dro's of normal saline .aCl /Q can be used.4
,'ecimens to be e:amined for 'arasites s"ould be mi:ed ;it" 3Q formalin or
PEA& t"ree 'arts stool to one 'art 'reser(ati(e. 9"ey s"ould be trans'orted at ambient
tem'erature in containers sealed in 'lastic bags.
0igure A3#" Stool sam(ling and trans(ort (rocedures for c)olera and Shigella s((#
A3#- ES$IATO? TACT S$ECIMEN COLLECTION
,'ecimens are collected from t"e u''er or lo;er res'iratory tract& de'ending on
t"e site of infection. ?''er res'iratory tract 'at"ogens 2(iral and bacterial4 are found
in t"roat and naso'"aryngeal s'ecimens. Lo;er res'iratory tract 'at"ogens are found
in s'utum s'ecimens. =or organisms suc" as ;egionella& culture is difficult& and
diagnosis is best based on t"e detection of antigen e:creted in t"e urine.
W"en acute e'iglottitis is sus'ected& no attem't s"ould be made to ta%e t"roat or
'"aryngeal s'ecimens since t"ese 'rocedures may 'reci'itate res'iratory obstruction.
E'iglottitis is generally confirmed by lateral nec% f-ray& but t"e etiological agent may
be isolated on blood culture.
Materials for collection
9rans'ort media ! bacterial and (iral.
Dacron and cotton s;abs.
9ongue de'ressor.
=le:ible ;ire calcium alginate ti''ed s;ab 2for sus'ected 'ertussis4.
.asal s'eculum 2for sus'ected 'ertussis ! not essential4.
,uction a''aratus or #3!03 ml syringe.
,terile scre;-ca' tubes and ;ide-mout"ed clean sterile Fars 2minimum (olume
#0 ml4.
BDDC: :C2D-:4T9:N T:4<T 2DC<-5CN2
Met)od of collecting a t)roat s@ab
Hold t"e tongue do;n ;it" t"e de'ressor. ?se a strong lig"t source to locate
areas of inflammation and e:udate in t"e 'osterior '"aryn: and t"e tonsillar
region of t"e t"roat be"ind t"e u(ula.
Bub t"e area bac% and fort" ;it" a dacron or calcium alginate s;ab. Wit"dra;
t"e s;ab ;it"out touc"ing t"e c"ee%s& teet" or gums and insert into a scre;-
ca' tube containing trans'ort medium.
*f necessary& brea% off t"e to' 'art of t"e stic% ;it"out touc"ing t"e inside of
t"e tube and tig"ten t"e scre; ca' firmly.
Label t"e s'ecimen containers.
Com'lete t"e laboratory reJuest form.
Met)od of collecting naso()ar,ngeal s@abs 8for sus(ected (ertussis9
,eat t"e 'atient comfortably& tilt t"e "ead bac% and insert t"e nasal s'eculum.
*nsert a fle:ible calcium alginate5dacron s;ab t"roug" t"e s'eculum 'arallel to
t"e floor of t"e nose ;it"out 'ointing u';ards. Alternati(ely& bend t"e s;ab
and insert it into t"e t"roat and mo(e t"e s;ab u';ards into t"e
naso'"aryngeal s'ace.
Botate t"e s;ab on t"e naso'"aryngeal membrane a fe; times& remo(e it
carefully and insert it into a scre;-ca' tube containing trans'ort medium.
*f necessary& brea% off t"e to' 'art of t"e s;ab ;it"out touc"ing t"e inside of
t"e tube and tig"ten t"e scre; ca' firmly.
Label t"e s'ecimen tube.
Com'lete t"e laboratory reJuest form.
;9,C: :C2D-:4T9:N T:4<T 2DC<-5CN2
Met)od of collecting s(utum
*nstruct t"e 'atient to ta%e a dee' breat" and coug" u' s'utum directly into a
;ide-mout" sterile container.
A(oid sali(a or 'ostnasal disc"arge. 9"e minimum (olume s"ould be about
ml. Label t"e s'ecimen containers.
Com'lete t"e laboratory reJuest form.
Al;ays label t"e Far& .O9 t"e lid.
2andling and trans(ort
All res'iratory s'ecimens& e:ce't s'utum& are trans'orted in a''ro'riate
bacterial5(iral media.
9rans'ort as Juic%ly as 'ossible to t"e laboratory to reduce o(ergro;t" by
commensal oral flora.
=or transit 'eriods u' to #) "ours& trans'ort bacterial s'ecimens at ambient
tem'erature and (iruses at )!A `C in a''ro'riate media.
A3#. !INE S$ECIMEN COLLECTION
Materials for collection
,terile 'lastic cu' ;it" lid 203 ml or more4.
Clean& scre;-to' s'ecimen trans'ort containers 2Luni(ersalM containers are
often used4.
@au8e 'ads.
,oa' and clean ;ater 2or normal saline4 if 'ossible.
Met)od of collection
@i(e t"e 'atient clear instructions to 'ass urine for a fe; seconds& and t"en to
"old t"e cu' in t"e urine stream for a fe; seconds to catc" a mid-stream urine
sam'le. 9"is s"ould decrease t"e ris% of contamination from organisms li(ing
in t"e uret"ra.
9o decrease t"e ris% of contamination from s%in organisms& t"e 'atient s"ould
be directed to a(oid touc"ing t"e inside or rim of t"e 'lastic cu' ;it" t"e s%in
of t"e "ands& legs or e:ternal genitalia. 9ig"ten t"e ca' firmly ;"en finis"ed.
=or "os'itali8ed or debilitated 'atients& it may be necessary to ;as" t"e
e:ternal genitalia ;it" soa'y ;ater to reduce t"e ris% of contamination. *f soa'
and clean ;ater are not a(ailable& t"e area may be rinsed ;it" normal saline.
Dry t"e area t"oroug"ly ;it" gau8e 'ads before collecting t"e urine.
?rine collection bags may be necessary for infants. *f used& transfer urine from
t"e urine bag to s'ecimen containers as soon as 'ossible to 're(ent
contamination ;it" s%in bacteria. ?se a dis'osable transfer 'i'ette to transfer
t"e urine.
Label t"e s'ecimen containers.
2andling and trans(ort
9rans'ort to t"e laboratory ;it"in #!$ "ours of collection. *f t"is is not 'ossible&
do not free8e but %ee' t"e s'ecimen refrigerated at )!A `C to reduce t"e ris% of
o(ergro;t" of contaminating organisms.
C"olera s'ecimens do not need refrigeration. Wit" Cary--lair trans'ort medium&
t"e sam'les need to reac" t"e laboratory ;it"in 6 days. Wit"out a trans'ort medium&
t"e s'ecimens must be trans'orted to t"e laboratory ;it"in # "ours 2a cotton-ti''ed
rectal s;ab soa%ed in liJuid stool 'laced in sterile tube or bagN or filter 'a'er soa%ed
;it" liJuid stool ;it" # or $ dro's of normal saline .cCl /Q can be used4.
Ensure t"at trans'ort containers are lea%-'roof and tig"tly sealed.
A3#1 C2EMICAL DISIN0ECTANTS
Disinfection
C"lorine is t"e recommended disinfectant for use in field laboratories. An
all'ur'ose disinfectant s"ould "a(e a ;or%ing concentration of 3.Q 2P g5litre P
333 ''m4 of a(ailable c"lorine. A stronger solution of 3.0Q 2P 0 g5litre P 0333 ''m4
a(ailable c"lorine s"ould be used in situations suc" as sus'ected (iral "aemorr"agic
fe(er outbrea%s.
*n 're'aring a''ro'riate dilutions& remember t"at different 'roducts "a(e different
concentrations of a(ailable c"lorine. 9o 're'are solutions ;it" t"e abo(e
concentrations& t"e manufacturer may 'ro(ide a''ro'riate instructions. Ot"er;ise& use
t"e guidelines 'ro(ided belo;. C"lorine solutions gradually lose strengt"& and fres"ly
diluted solutions must t"erefore be 're'ared daily. Clear ;ater s"ould be used
because organic matter destroys c"lorine.
Commonly used c"lorine-based disinfectants include:
sodium "y'oc"loriteN
commercial liJuid bleac"es suc" as "ouse"old bleac" 2e.g. C"loro:
c
& Eau-de-
Ca(el4& ;"ic" generally contain 0Q 203 g5litre or 03 333 ''m4 a(ailable
c"lorine.
Ho;e(er& t"e latter 're'arations lose a 'ro'ortion of t"eir c"lorine content o(er
time. 9"ic% bleac" solutions s"ould ne(er be used directly for disinfection 'ur'oses in
disasters as t"ey contain 'otentially 'oisonous additi(es.
9o 're'are a 3.Q c"lorine solution ;it" commercial bleac"& ma%e a in 03
dilution& i.e. 'art bleac" in )/ 'arts ;ater to gi(e final concentrations of a(ailable
c"lorine of 3.Q. 2=or e:am'le& t"is could entail adding #3 ml of bleac" to
a''ro:imately litre of ;ater.4
,imilarly& to ma%e a 3.0Q c"lorine solution& ma%e a in 3 dilution& i.e. 'art
bleac" in / 'arts ;ater to gi(e final concentrations of a(ailable c"lorine of 3.0Q 2e.g.
add 33 ml of bleac" to /33 ml ;ater.4
C)loramine (o@der
W"ile t"e abo(e-described bleac" solution may satisfy all disinfection needs&
c"loramine 'o;der may 'ro(e con(enient for t"e disinfection of s'ills of blood and
ot"er 'otentially infectious body fluids. *t may also 'ro(e useful under field
conditions because of ease of trans'ort. *t contains a''ro:imately #0Q a(ailable
c"lorine. *n addition to its use as a 'o;der on s'ills& c"loramine 'o;der may be used
to 're'are liJuid c"lorine solutions. 9"e recommended formula is #3 g of c"loramine
'o;der to litre of clean ;ater.
Decontamination of surfaces
Wear an a'ron& "ea(y-duty glo(es and ot"er barrier 'rotection if needed. Disinfect
surfaces by ;i'ing clean ;it" 3.Q c"lorine solution& t"en incinerate all absorbent
material in "ea(y-duty garbage bags.
Decontamination of blood or bod, fluid s(ills
=or s'ills& c"loramine granules s"ould be (ery liberally s'rin%led to absorb t"e
s'ill and left for at least $3 minutes. *f c"loramine 'o;der is not a(ailable& one may
use 3.0Q c"lorine solution to inacti(ate 'at"ogens before soa%ing u' t"e fluid ;it"
absorbent materials. 9"ese absorbent materials must t"en be incinerated.
SteriliCation and reuse of instruments and materials
*n field outbrea% situations& it is not ad(isable to consider sterili8ation and reuse of
any instruments or materials. ,terili8ation tec"niJues are t"erefore not reJuired and
are not described "ere
Disinfection of )ands
9"e 'rinci'al means for disinfecting "ands is by ;as"ing ;it" soa' and ;ater. *f
a(ailable& one may also use commercial "and disinfectants containing c"lor"e:idine
or 'oly(idone iodine.
5 Setting u( a diagnostic laborator,
A diagnostic laboratory s"ould com'ly ;it" a number of essential 'rinci'les.
*t must be able to underta%e t"e ty'es of test reJuired.
*t must be able to "andle t"e s'ecimen load.
*t must be safe and comfortable for t"e staff to ;or% in.
*f it is establis"ed in a community 2rat"er t"an in a tem'orary cam'4 it s"ould
be sustainable in t"e long term.
9o meet t"ese needs t"e laboratory s"ould "a(e:
A suitable building or room2s4 a''ro'riately laid out and furnis"ed.
AdeJuate numbers of staff ;"o "a(e been trained in t"e tests to be underta%en.
Defined standard o'erating 'rocedures co(ering t"e tests to be underta%en.
*nternal and e:ternal Juality control to ensure consistency and accuracy of
out'ut.
A safety 'olicy based on t"e tests underta%en and t"e ris%s 'osed by t"e
organisms 'resent in t"e area.
9"e a''ro'riate eJui'ment& reagents& media& glass;are and dis'osables.
9ec"nical& engineering and logistic su''ort.
@ood access and e:ternal communications.
Any de'arture from t"e most basic ty'e of laboratory im'lies a mar%ed increase in
com'le:ity and e:'ense& and a concomitant increase in t"e difficulties of maintaining
t"e unit and 'ro(iding suitable staff.
LA7OATO? $EMISES
Laboratories s"ould 'ro(ide an adeJuate le(el of secondary 2en(ironmental4
containment to allo; safe ;or%ing ;it"in and to 'rotect t"ose using t"e area around
t"e laboratory from microbiological ris%. *n acute emergencies& almost any
accommodation t"at can 'ro(ide co(er from t"e sun and rain "as at one time or
anot"er been used for laboratory ;or%. W"ile a tent or 'lastic s"eeting can be so used&
t"e ability of t"e staff to do useful ;or% is li%ely to be ra'idly degraded by 'oor
;or%ing conditions and 'ro'er accommodation s"ould be 'ro(ided as soon as
'ossible.
Any building or room t"at is to be used as a laboratory s"ould be structurally
sound. 9"is includes t"e ;alls& roofs& floors& ceilings& doors and ;indo;s. 9"e
internal surfaces s"ould be sealed ;it" oil 'aint or (arnis" so t"at t"ey can easily be
cleaned or disinfected and to 're(ent dust falling onto ;or% surfaces.
Windo;s s"ould fit& be able to o'en& and be 'ro(ided ;it" security grilles and
mosJuito screens ;"ere a''ro'riate. E:ternal doors s"ould be loc%able and not o'en
directly into t"e laboratory but into a ser(ice corridor. Entrances to staff rooms&
toilets& etc. s"ould also be off t"is corridor. *f only latrines are a(ailable t"ey s"ould
be of t"e E*P ty'e and reasonably close to t"e laboratory. AdeJuate "and-;as"ing
facilities must be 'ro(ided at t"e e:it to t"e laboratory room and for t"ose using t"e
toilet facilities5latrines. A s'ecimen rece'tion area s"ould be 'ro(ided t"at is outside
t"e main laboratory suite and off t"e ser(ice corridor.
*f t"e laboratory itself cannot be loc%ed ;"en it is em'ty& suitable security
measures 2e.g. loc%able cu'boards4 must be ta%en to 'rotect (aluable eJui'ment suc"
as microsco'es.
7enc)es
Laboratories must "a(e good stable ;or% surfaces. *deally& t"ese s"ould be totally
resistant to all li%ely disinfectants 2"y'oc"lorites& '"enolics& alde"ydes& alco"ols and
detergents4& acids& al%alis and sol(ents. 9"e best surfaces are s'ecial laminates t"at are
resistant to c"emical attac% and "eat& and sufficiently scratc"-resistant 2%itc"en ;or%
surfaces are rarely adeJuate4. Ho;e(er& in t"e basic laboratories used in emergencies
it is more common to find ;ooden tables or benc"es in use. Polis"ed surfaces do not
resist c"emicals and sol(ents ;ell and may tra' microorganisms. Any ga's in t"e
table surface s"ould be filled and le(elled before t"e surface is (arnis"ed.
-enc"es s"ould be of a suitable "eig"t 2/3 cm is commonly used4. Consideration
s"ould also be gi(en to t"e 'ossible need to 'ut small refrigerators& cu'boards and
dra;er units under benc"es ;"en benc" "eig"ts are selected. Laboratory seating
s"ould be of adeJuate "eig"t to allo; sustained comfortable ;or%ing at t"e benc"
2stools of some ty'e are ideal4 and s"ould also be able to be decontaminated ;it"out
damage ;it" t"e same range of disinfectants to be used on t"e benc"ing.
Laborator, ser'ices
A suitable building or room2s4 a''ro'riately laid out and furnis"ed.
AdeJuate ;ater su''lies are essential. 9"e laboratory may need its o;n ;ell.
Water tan%s s"ould be co(ered to %ee' out dust and ;ildlife. *f t"e su''ly is
contaminated& some form of 'urification system 2e.g. filtration and 'ossibly
c"emical disinfection4 may be needed. 9"e laboratory ;ill also need a still to
'ro(ide 'ure& mineral-free ;ater.
Hand-;as"ing facilities s"ould be 'ro(ided by t"e e:it door of eac"
laboratory.
A glass;are ;as"-u' and drying area ;ill be needed and t"is s"ould ideally be
in a se'arate room.
AdeJuate drainage must be 'ro(ided. Large soa%a;ays may be reJuired. *f
to;n drainage is used adeJuate tra''ing must be fitted to t"e laboratory ;aste
system to allo; for t"e tra''ing of any c"emical or biological s'ills before
t"ey contaminate t"e to;n system.
9"e laboratory s"ould be 'ro(ided ;it" an incinerator.
Com'le: autocla(es are generally not suitable for emergency laboratories.
Autocla(ing s"ould usually be limited to t"e sim'le domestic 'ressure coo%er
or basic benc" ty'e.
Dis(osal of laborator, @aste
A suitable building or room2s4 a''ro'riately laid out and furnis"ed.
LiJuid microbiological ;aste s"ould be eit"er "eat-treated or c"emically
treated before discard into t"e drainage system. *f c"emical decontamination is
used& any runoff from t"e drainage system must not be able to contaminate
'otable ;ater sources.
All solid ;aste containing infectious material or 'otentially infectious material
s"ould be incinerated.
Dis'osal bins must be 'ro(ided for s"ar's and t"e contents incinerated.
Electricit, and gas
AdeJuate electricity su''lies are li%ely to be needed. 9"e amount needed ;ill
de'end on t"e number of items of eJui'ment and ;"et"er t"ey need to be run
continuously.
*f local electricity su''lies are intermittent or inadeJuate a generator may be
needed. 9"e ca'acity of t"e generator ;ill be go(erned by t"e antici'ated load and
;"et"er it is needed for continuous or occasional use. *f all t"e labo-ratory electricity
comes from its o;n generator and some of t"e laboratory eJui'ment needs to run
continuously& a bac%u' generator is essential. *f intermittent to;n su''lies are used&
an automatic system to s;itc" on t"e generator if t"e to;n su''lies fail may be
needed. A battery reser(e 2;it" in(erters4 may be needed to co(er ga's in t"e su''ly.
-atteries may be %e't c"arged by a solar system and t"e need for suc" a system 2and
its sustainability4 s"ould be in(estigated.
@as 2'ro'ane5butane4 may be reJuired for -unsen burners and5or gas
refrigerators. 9"is ;ill de'end on t"e a(ailability of su''lies of bottled gas
and on t"e ability of engineering staff or local tradesmen to maintain suc" a
system.
En'ironmental controls 8'entilation> tem(erature> and )umidit,9
Eentilation and airflo; in basic laboratories 2e.g. microsco'y laboratories4 are
usually 'ro(ided (ia t"e ;indo;s and doors. All ;indo;s s"ould be fitted
;it" a means of s"ading t"em from t"e sun. 9"e ideal met"od is t"e use of
e:ternal s"utters "inged at t"e to' and ;it" a su''ort stay. Doors may "a(e a
grille fitted near floor le(el to allo; air entry.
*n laboratories ;"ere 'at"ogens are routinely "andled a 'redictable
unidirectional airflo; across and out of t"e laboratory s"ould be maintained
;"en t"e facility is in use so as to 'rotect t"e ;or%force. 9"is can be ac"ie(ed
by t"e use of e:traction fans situated on one side of t"e laboratory& 'referably
t"e o''osite side to o'ening ;indo;s and doors. Windo;s on t"e e:tractor
fan side of t"e laboratory s"ould not be ca'able of o'ening. Wor% ;it"
infectious ris% s"ould be conducted to;ards t"e e:traction fan side of t"e
room. .on-infectious ;or%5record %ee'ing s"ould be done on t"e o'ening
;indo;5door side.
W"en determining t"e layout of t"e laboratory account s"ould be ta%en of:
t"e 're(ailing ;ind direction&
t"e situation of ot"er buildings& 'at"s& etc. and t"e use made of t"e s'ace
around t"e laboratory building.
9"is is to ensure t"at t"e air from t"e laboratory is not (ented into areas ;"ere
'eo'le may be at ris% from contaminants. Ducted air e:traction may be needed.
Any diagnostic laboratory s"ould aim to ;or% ;it"in certain defined
tem'erature limits. *t s"ould be recognised t"at good laboratory 'ractice
2@LP4 for t"e 'rotection of ;or%ers 2i.e. ;earing of lab coats& glo(es& mas%s
for res'iratory 'rotection& eye 'rotection4 cannot be follo;ed easily in e:treme
tem'eratures 2S$3 oC4 or "ig" "umidity. *t s"ould also be noted t"at many
commercial diagnostic assays 'erform un'redictably& abo(e #A!$3 oC and t"at
eJui'ment 2es'ecially refrigerators4 usually ;or%s better ;"en it is not too
"ot. EJually& satisfactory ;or%ing becomes im'ossible ;"en it is too cold.
Control of tem'erature is e:tremely difficult in tented accommodation or in
laboratories built from 'lastic s"eeting ;"ic" is one reason ;"y suc"
accommodation s"ould be regarded as tem'orary.
9"e control of tem'erature and "umidity may reJuire an air conditioned5
cooled en(ironment. Becirculating air conditioning is not suited to micro-
biological laboratories since t"is may recirculate and concentrate infectious
ris%s to ;or%ers. C"iller systems are 'referred but must be sited ;it" regard
for cross-laboratory airflo;. =ans s"ould generally be a(oided as t"ey can
s'read infectious material around and blo; it into t"e faces of ;or%ers.
/ector:(est control
*nsects& rodents and any ot"er 'ests must be %e't out of t"e laboratory area. ,uc"
'ests may interfere ;it" t"e ;or% of t"e laboratory or contaminate media& etc. but in
addition also ris% t"e s'read of 'at"ogens from t"e laboratory to t"e outside t"us
com'romising secondary containment. Windo;s s"ould t"erefore be fitted ;it" insect
screens.
STA00
*n t"e early '"ases of a disaster only ;ell trained staff s"ould be em'loyed for
tec"nical ;or%. 9"ere ;ill not be sufficient time to train laboratory assistants. 9"e
tec"nical staff em'loyed s"ould be e:'erienced in t"e rele(ant fields 2'articularly
'arasitology and "aematology& alt"oug" some %no;ledge of bioc"emistry&
bacteriology and (irology may be needed4. At least one s"ould "a(e "ad e:'erience of
running a laboratory& 'referably in field conditions& and be able to underta%e
additional duties suc" as laboratory management& ordering stoc%& etc.
As t"e situation stabili8es& t"e o''ortunity to increase t"e numbers of staff and to
begin training or retraining local staff can begin.
T?$ES O0 TEST
*n t"e acute emergency '"ase it is li%ely t"at only basic laboratory facilities can be
establis"ed and "ence only a limited number of tests can be offered. As t"e situation
stabili8es it ;ill be 'ossible to establis" a more so'"isticated laboratory and "ence to
offer a ;ider range of tests.
" Acute emergenc, ()ase
Microorganisms:
malaria ! microsco'y and5or s'ot tests&
meningococcal meningitis ! s'ot tests&
stool e:aminations for o(a and 'arasites&
detection of bloodborne agents ot"er t"an malaria 2try'anosomes& leis"manias&
ric%ettsia4&
H*E and He'- 2if blood transfusions are being gi(en4.
*t is of (alue to "a(e a means of culturing and identifying 2higella dysenteriae and
Fibrio cholerae but t"is ;ill rarely be 'ossible in small basic laboratories. Lin%s ;it"
nearby laboratories ca'able of offering t"is ser(ice s"ould be considered.
-asic "aematology:
"aematocrit 2'ac%ed cell (olume4&
differential ;"ite cell counts&
sic%le-cell detection&
clotting time&
ty'ing and cross-matc"ing blood 2if blood transfusions are being underta%en4.
% $ost<emergenc, ()ase
At t"is stage& tests for less acute conditions can be included. =or e:am'le 9- is a
gro;ing 'roblem in many 'arts of t"e ;orld and can s'read readily in t"e cro;ded
conditions often found in refugee and *DP cam's. ,'utum microsco'y for t"e
diagnosis of 9- can easily be 'ractised in basic conditions but it is ;ort" doing only
if t"e condition can be treated and t"is s"ould only be done in t"e conte:t of a
'ro'erly designed and functioning DO9, 'rogramme.
STANDAD O$EATING $OCED!ES AND I!ALIT?
CONTOL
Merely meeting t"e basic design and safety criteria for diagnostic laboratories is
not enoug". 9"e staff must be able to underta%e t"e reJuired tests effecti(ely and
accurately. 9"e out'ut of t"e laboratory must be (alidated and a Juality control
system is essential. 9"e ;ay in ;"ic" all diagnostic 'rocedures underta%en in a
laboratory s"ould be 'erformed s"ould be laid do;n in L,tandard O'erating
ProceduresM 2,OPs4. 9"ese s"ould include reference to full ris% and "a8ard
assessments and safety 'rocedures. Protocols for internal and e:ternal Juality
assessment s"ould also be laid do;n in t"ese ,OPs.
*.9EB.AL \?AL*9H CO.9BOL
All 'rocedures underta%en in t"e laboratory must be measured against recogni8ed
standards. .e; batc"es of stains or reagents must be (alidated against t"e old. 9"e
;or% of t"e laboratory staff s"ould be (alidated regularly by t"e blind inclusion of
%no;n 'ositi(e and negati(e s'ecimens in t"e routine diagnostic ;or%.
Ef9EB.AL \?AL*9H CO.9BOL
A suitable body to underta%e e:ternal Juality control s"ould be identified as soon
as 'ossible after t"e establis"ment of t"e laboratory. 9"is agency s"ould 'ro(ide
%no;n 'ositi(e and negati(e s'ecimens for assessment of t"e ;or% of t"e laboratory.
DISEASE ISKS
Any agency intending to underta%e medical ;or% in an area s"ould obtain detailed
information as to t"e s'ectrum of diseases t"at it ;ill "a(e to deal ;it". 9"is is
essential bot" for t"e design of t"e laboratory L'ac%ageM reJuired and ;ill "el'
determine t"e microbiological ris%s t"at may face its staff 2all its staff& not Fust
laboratory staff members4. 9"e ris%s 'osed by any organism li%ely to be encountered
can be classified according to t"e follo;ing criteria:
'at"ogenicityN
mode of transmission and "ost range can be influenced by:
e:isting le(els of immunityion&
"ost 'o'ulation mo(ements&
(ectors and reser(oirs&
;eat"er&
en(ironmental factors 2to'ogra'"y& 'lant s'ecies and distribution& etc.4&
sanitation and en(ironmental "ygiene&
e:isting le(els of immunityN
A(ailability of effecti(e 're(enti(e measures& including:
immuni8ation5're(enti(e antisera&
sanitation&
(ector and reser(oir controlN
A(ailability of effecti(e treatment& including:
'assi(e immuni8ation&
'ost-e:'osure (accination&
antimicrobials5c"emot"era'eutic agents 2including any data on resistance
'atterns4.
SA0E WOKING $ACTICES
9"e safety of t"e staff must be a 'rime consideration ;"en a laboratory is set u'.
*t is ;"olly unet"ical to e:'ect staff to ;or% in conditions ;"ere safety is ignored.
9"e le(el of safety reJuired "as 'rofound im'lications for t"e design and ;or%ing of
t"e laboratory.
,afe ;or%ing in t"e laboratory de'ends on t"e obser(ance of basic safety
'recautions 29able A/.4 and on good training of staff bot" in safety and in good
benc" ;or%. 9"e le(el of t"e safety 'recautions t"at may need to be establis"ed o(er
and abo(e t"e general safety 'rinci'les ;ill de'end on:
t"e ty'es of tests to be done&
t"e ty'es of organism 'resent and t"e ris%s t"ey 'ose due to t"eir
'at"ogenicity& mode of transmission& etc.
;"et"er ;or% "ig"er ris% ;or% is a''ro'riate at t"e local le(el.
9"e safety le(els t"at can be ac"ie(ed in a laboratory 2and "ence t"e ty'es of test
t"at can be offered4 also de'end on t"e 'ossibility of maintaining and sustaining
safety eJui'ment.
*nfectious microorganisms can be classified into four ris% grou's 29able A/.#4 and
t"e le(el of safety needed to "andle t"em can t"en be determined 29able A/.$4.
Table A5#" General safet, (rinci(les
O 9"e laboratory s"ould "a(e a ;ritten manual of safe 'ractice and t"is s"ould be
follo;ed at all times.
O A first-aid bo: must be 'ro(ided and a staff member trained in first aid s"ould be
'resent at all times ;"en t"e laboratory is ;or%ing.
O Eye;as" facilities must be 'ro(ided.
O Only t"e laboratory staff s"ould be 'ermitted to enter t"e ;or%ing area of t"e
laboratory.
O Laboratory staff s"ould ;ear 'rotecti(e clot"ing& ;"ic" s"ould be remo(ed ;"en
t"ey lea(e t"e laboratory itself. *t s"ould not be ;orn in laboratory su''ort areas suc"
as offices& staff rooms& etc. Protecti(e clot"ing s"ould ne(er be stored in t"e same
loc%ers as street clot"ing.
O A''ro'riate s"oes s"ould be ;orn. O'en-toed s"oes 2sandals4 are not suitable for
;ear in t"e laboratory.
O =ace 'rotection 2goggles5mas%s5eyes"ields4 s"ould be 'ro(ided and ;orn ;"en
'rocedures t"at may 'roduce aerosols or s'las"es are underta%en.
O Bubber glo(es s"ould al;ays be ;orn ;"en "andling s'ecimens and t"ey or ot"er
a''ro'riate 'rotecti(e glo(es s"ould be ;orn for ot"er "a8ardous 'rocedures.
O Mout" 'i'etting s"ould be absolutely forbidden.
O Hy'odermic syringes and needles s"ould not be used as 'i'etting de(ices.
O All contaminated material 2s'ecimens& glass;are& s"ar's& etc4 s"ould be decon-
taminated before dis'osal or cleaning for re-use. 9o t"is end& a''ro'riate containers
2s"ar's bins& sealable 'lastic bags& disinfectant 'ots4 and disinfect-tants must be
'ro(ided.
O A 'redictable unidirectional airflo; across and out of t"e laboratory s"ould be
maintained ;"en t"e laboratory is in use 2see LEentilationM belo;4.
O Eating& drin%ing& smo%ing and a''lying cosmetics s"ould be forbidden in t"e
laboratory.
O Laboratory staff s"ould clean and disinfect all benc"es at t"e end of t"e ;or%ing day
or if infectious material is s'ilt.
O Laboratory staff s"ould al;ays ;as" t"eir "ands ;"en lea(ing t"e laboratory and
facilities must be 'ro(ided for t"is 'ur'ose.
O All s'ills& accidents& etc. s"ould be re'orted to t"e laboratory su'er(isor.
Table A5#% Infectious microorganisms classified b, ris4
grou(
@rou' Bis% Definition
.o or (ery lo; indi(idual
and community ris%
A microorganism t"at is
unli%ely to cause animal or
"uman disease
# Moderate ris% to
indi(iduals& lo; ris% to t"e
community
A 'at"ogen t"at can cause
"uman or animal disease
but is unli%ely to be a
serious "a8ard to
laboratory ;or%ers& t"e
community& li(estoc% or
t"e en(ironment.
Laboratory e:'osures may
cause serious infection but
effecti(e treatment and
're(enti(e measures are
a(ailable and t"e ris% of
s'read of infection is
limited
$ Hig" ris% to indi(iduals&
lo; ris% to t"e community
A 'at"ogen t"at usually
causes serious "uman or
animal disease but does
not ordinarily s'read from
one infected indi(idual to
anot"er. Effecti(e
treatment and 're(enti(e
measures are a(ailable.
) Hig" ris% to indi(iduals
and t"e community
A 'at"ogen t"at usually
causes serious "uman or
animal disease and t"at can
be readily transmitted from
one indi(idual to anot"er&
directly or indirectly.
Effecti(e treatment and
're(enti(e measures are
not usually a(ailable.
Table A5#* is4 grou(s> biosafet, le'els> laborator, (ractice and
safet, eFui(ment
Bis% grou' -iosafety le(el 9y'es of
laboratories
Laboratory
'ractice
,afety
eJui'ment
2basic4 -asic teac"ing @M-9
a
.one. O'en
benc" ;or%
# # 2basic4 Primary "ealt"
ser(ices&
'rimary le(el
"os'ital
diagnostic&
teac"ing and
'ublic "ealt"
ser(ices
@M-9 ] basic
'rotecti(e
clot"ingN
bio"a8ard
signs
O'en benc" ]
Class * or **
-,Cb for
'otential
aerosols
$ $ 2containment ,'ecial
diagnostic
As le(el # ]
s'ecial
'rotecti(e
clot"ing&
Class * or **
-,C and5or
controlled
access&
ot"er 'rimary
directional air
flo;
containment
for all ;or%
) ) 2ma:imum
containment4
Dangerous
'at"ogen
As le(el $ ]
airloc% entry&
s"o;er e:it&
s'ecial ;aste
dis'osal
Class *** -,C
or 'ositi(e
'ressure suits&
double ended
autocla(e&
filtered air
units
a
@M-9 P good microbiological benc" tec"niJue
b
-,C P biological safety cabinet
W"ere to:ic or corrosi(e c"emicals are in(ol(ed a suitable fume "ood ;it" an
e:tractor fan ;ill be reJuired. ,uc" eJui'ment is not safe for ;or% in(ol(ing
biological "a8ards. W"ere t"e ;or% in(ol(es dangerous 'at"ogens 2ris% grou' # and
"ig"er ! 9ables AA.# and AA.$4 'ro'erly designed safety cabinets ;ill be reJuired.
*n general t"e ty'e of laboratory t"at ;ill be set u' in t"e early stages of an
emergency ;ill be of basic le(el . Ho;e(er& in many areas ;"ere disasters occur
t"ere is a ris% of e:'osure to organisms in t"e "ig"er ris% grou's. 9"is must be ta%en
into account ;"en t"e laboratory is set u'. 9"e tests t"at can be done may be limited
by t"e 'otential ris%. *t is rare t"at "ig" biosafety le(els ;ill be a''ro'riate for a local
laboratory in an emergency but it may ;ell be t"at as a result some tests sim'ly
cannot be underta%en locally because safe ;or%ing cannot be guaranteed.
EI!I$$ING EMEGENC? LA7OATOIES
9"e ability of a laboratory to 'erform e(en t"e most basic tests de'ends on t"e
Juality of its eJui'ment. 9"e eJui'ment must not only be suitable for t"e tests
reJuired& it must also be safe. *t s"ould be designed ;it" certain general 'rinci'les in
mind:
*t s"ould 're(ent 2or at least limit4 contact bet;een t"e o'erator and infectious
material.
*t s"ould be made from materials t"at are corrosion resistant& im'ermeable to
liJuids and sufficiently strong.
*t must be free of s"ar' edges and mo(ing 'arts must be 'rotected.
*t must be sim'le to install& o'erate& maintain& decontaminate and clean.
*t must be electrically safe.
Microsco(es
9bGective lens" 9"is 'roduces t"e initial 2'rimary4 image& ;"ic" is t"en enlarged
and focused by t"e eye'iece. 9"e total magnification is t"e 'roduct of t"e
magnification of t"ese t;o lenses. 9"e ability of t"e obFecti(e lens to differentiate fine
detail is called its resol(ing 'o;er and is de'endent on:
. 9"e Lnumerical a'ertureM 2.A4 of t"e lens 2a factor of its diameter and focal
lengt"4. 9"e "ig"er t"e .A t"e greater t"e resol(ing 'o;er. 9"e .As of t"e
commonly used obFecti(es for microsco'es ;it" t"e normal 13 mm tube
lengt"s are: 3 : obFecti(e ! .A 3.#0
)3 : obFecti(e ! .A 3.10
33 : 2oil4 obFecti(e ! .A .#0
#. Correction for o'tical aberrations. 9"e best obFecti(es for general 'ur'oses are
Ac"romats. =lat field 2Plan4 Ac"romats are additionally corrected so t"at t"e
entire field is in focus but are more e:'ensi(e.
ObFecti(es s"ould ideally be 'arfocal so t"at ;"en t"e nose'iece of t"e
microsco'e is re(ol(ed to bring a ne; obFecti(e into t"e lig"t 'at" no refocusing is
needed. Modern obFecti(es are 'roduced to t"e D*. standard. 9"ese are longer t"an
older obFecti(es and s"ould not be mi:ed ;it" t"em& as t"ey ;ill not be 'arfocal. 9"e
use of suc" a mi:ture of lenses 'oses t"e ris% of damaging or brea%ing t"e slide. 9"e
)3: and 33: obFecti(es s"ould also be s'ring-loaded to a(oid damaging slides.
9il immersion lenses. ,ignificant loss of lig"t and detail at "ig" magnification can
be a(oided by filling t"e ga' bet;een t"e lens and t"e s'ecimen ;it" oil of t"e same
o'tical 'ro'erties as glass 2immersion oil4. 9"e use of synt"etic non-drying immersion
oil is recommended.
9"e eye'iece allo;s t"e detail collected by t"e obFecti(e lens to be seen. 9oo great
an eye'iece magnification can cause blurring of t"e image. Eye'ieces of 3 :
magnification are generally used but 6 : eye'ieces are (aluable for use ;it" oil
immersion lenses as t"e image& alt"oug" smaller& is s"ar'er. Microsco'es can "a(e
one eye'iece 2monocular4 or t;o 2binocular4. 9"e latter are more restful to use and
t"e standard of microsco'y is better.
-llumination. Microsco'es generally "a(e an integral controllable lig"t source.
Lo;-;attage "alogen sources are best and gi(e a consistent uniform lig"t. 2.-. 9"e
built-in illumination systems of c"ea'er microsco'es may not be made to acce'table
safety standards.4 W"ere electricity su''lies are li%ely to be intermittent 2or non-
e:istent4& a microsco'e t"at can also ta%e a mirror unit s"ould be su''lied.
2ubstage condenser. Allo;s t"e o'erator to mani'ulate t"e lig"t im'inging on t"e
obFect. *deally t"e lig"t beam s"ould be 'arallel to 'ro(ide an e(en intensity o(er t"e
;"ole image field. 9"e intensity of t"e lig"t beam can be altered ;it" an iris
dia'"ragm and focused by means of a focusing %nob. Condensers s"ould be of t"e
Abbe ty'e ;it" a dia'"ragm and a s;ing-out filter "older. 9"e condenser mount
s"ould allo; t"e condenser to be centred by use of adFustment scre;s unless it "as
been 're-centred by t"e manufacturer.
=ilters may be needed to reduce lig"t intensity& to alter lig"t colour 2to affect t"e
contrast of t"e image4 or to transmit lig"t of a 'articular ;a(elengt" 2e.g. for
fluorescence microsco'y4.
5echanical stage" 9"e microsco'e slide is su''orted on a 'latform called t"e
stage. *deally t"is s"ould allo; t"e slide to be mo(ed 2or t"e stage itself to be mo(ed4
by t"e use of t;o control ;"eels. A mec"anical stage s"ould "a(e smoot"-running
controls and s"ould be fitted ;it" (ernier scales so t"at s'ecimens can easily be
located. An integral mec"anical stage is better t"an a Lbolt onM (ersion as it ;ill be
more robust.
=ocusing controls must be smoot" in action 2es'ecially t"e fine focus4& robust and
must not be subFect to drift. ,'ecialist microsco'es may be needed for certain ty'es of
diagnostic test. =or e:am'le& some 'arasitological ;or% reJuires dar% ground
illumination ;it" a s'ecial sub-stage condenser.
Transporting microscopes. *f t"e microsco'e is to be trans'orted around for field
use at different sites& a s'ecial 'added trans'ort bo: ;ill be needed. 9"e bo:es in
;"ic" most microsco'es are su''lied Fust 'ro(ide for storage in t"e laboratory& not for
regular trans'ort. As an alternati(e t"ere are a number of com'act microsco'es t"at
"a(e been 'roduced for field use and one of t"ese may be suitable for t"e Fob !
"o;e(er& t"ese are rat"er e:'ensi(e and are less comfortable to use t"an t"e ordinary
laboratory instrument.
2torage. Pro(ide dust co(ers. *n t"e tro'ics& if at all 'ossible& store t"e micro-
sco'e in a bo: ;it" a lo;-;attage lig"t bulb in it t"at is on all t"e time and ;it" "oles
to allo; air circulation. 9"is ;ill ;arm and dry t"e air in t"e bo: and 're(ent t"e
gro;t" of fungus on t"e lenses.
;ocal purchase. W"en considering ;"ere to buy microsco'es& consider buying
locally if t"is does not com'romise Juality. *t could greatly ease su''ly of s'ares&
maintenance& etc.
Centrifuges
Centrifuges may be reJuired for:
measurement of "aematocrit ! 'ac%ed cell (olume 2PCE4&
se'aration of blood cells from 'lasma&
concentration of casts and cells in urine&
concentration of cells in C,=&
concentration of stool sam'les.
9;o ty'es of centrifuge are of (alue in t"e basic diagnostic laboratory. 9"ese are:
8aematocrit centrifuge. 9"ese small but fast-s'inning centrifuges are used for:
measurement of "aematocrit in t"e in(estigation of iron deficiency and
ot"er forms of anaemia&
t"e micro"aematocrit concentration tec"niJue for detecting motile
try'anosomes and microfilariae.
Eeneral purpose bench centrifuge" 9"ese are used for:
sedimenting cells& 'arasites and bacteria in body fluids for microsco'ical
e:amination&
to ;as" red cells& obtain serum and 'erform cross matc"ing&
to concentrate 'arasites&
to obtain 'lasma or serum for clinical c"emistry and antibody tests.
Colorimeters and )aemoglobinometers
Colorimeters are used for t"e Juantitati(e determination of substances 2suc" as
"aemoglobin and serum glucose4 t"at can alter in concentration during disease and
treatment. Haemoglobinometers can measure only "aemoglobin. ,im'le colorimeters
suc" as Lo(ibond com'arators 2'ortable colorimeters t"at reJuire no e:ternal 'o;er
source4 can be used for a number of basic bioc"emical tests. -attery-o'erated
instruments are a(ailable for more accurate and so'"isticated measurements.
Autocla'es and steriliCation
Many acti(ities in medical laboratories reJuire t"e use of sterile eJui'ment& media
or fluids. EJually& laboratories may 'roduce ;aste material t"at may need to be
sterili8ed before it can be discarded. Autocla(ing is a con(enient ;ay to sterilise items
in t"e laboratory. Essentially it in(ol(es "eating t"e items to u' to #3 `C abo(e t"e
boiling 'oint of ;ater in a 'ressure (essel. 9"is allo;s more ra'id sterili8ation t"an
sim'le boiling and also %ills organisms 2suc" as some bacterial s'ores4 t"at are not
%illed by boiling. Autocla(es are Juite so'"isticated 'ieces of eJui'ment and if only
small amounts of small items need to be sterili8ed an ordinary domestic 'ressure
coo%er is Juite adeJuate.
Hou ;ill need autocla(e indicator ta'e 2;it" stri'es t"at c"ange colour abo(e
boiling ;ater tem'erature4 to mar% items to ensure t"at t"e 'rocess is ;or%ing
satisfactorily.
-oiling ;ater sterili8ers are reasonably efficient but ;ill not %ill all 'at"ogenic
microorganisms 2e.g. some bacterial s'ores are resistant to boiling but are %illed by
autocla(ing4.
efrigerators
Befrigerators and free8ers t"at run on gas or %erosene are a(ailable and t"e
suitability of t"is ty'e of eJui'ment as com'ared ;it" electric mac"ines s"ould be
considered 2dual fuel gas5electric refrigerators are of es'ecial (alue in t"ese
situations4.
Befrigerators are essential 'ieces of laboratory eJui'ment in all but t"e most basic
laboratories. 9"ere are t;o main ty'es:
" Clectrical compression 29"e standard Euro'ean refrigerator. 9"ey "a(e a "eat
e:c"anger Xon t"e bac% usuallyY of t"in tubes ! ca 3.0 cm ! and a dum'y
com'ressor at t"e bottom4.
2" 4bsorption 2"a(e a "eat e:c"anger Xon t"e bac% usuallyY of t"ic% tubes4.
Com'ression refrigerators are electrical and reJuire less energy to run t"an t"e
absor'tion ty'e. Ho;e(er absor'tion refrigerators are a(ailable t"at can run off gas&
%erosene or electricity or dual fuels 2e.g. electricity5gas4. ,election s"ould be based on
a(ailable fuels. 2.-. ,olar refrigerators are a(ailable.4 *ce-lined refrigerators are
useful ;"ere electricity su''lies are intermittent& as t"ey remain cold for "ours e(en
;"en t"ere is no 'o;er. 9"e "oldo(er times of domestic refrigerators can be
im'ro(ed by 'utting some bottles filled ;it" ;ater near t"e to' and by im'ro(ing t"e
insulation of t"e door. O'en refrigerators as fe; times as 'ossible es'ecially if 'o;er
is off so t"at loss of cold air is %e't to a minimum.
Domestic refrigerators are not safe for t"e storage of flammable materials as t"ey
are not s'ar%-'rotected.
=ree8ers may be needed for storage of critical reagents. Consider a refrigerator
;it" a free8er com'artment unless a large free8er ca'acity is reJuired. Hou need to be
a;are t"at a refrigerator ;it" a free8er com'artment ;ill use muc" more fuel t"an one
;it"out.
Befrigerators t"at o'en from t"e to' are muc" more efficient t"an t"ose ;it" a
front door. Ho;e(er t"e latter are muc" more common and tend t"erefore to be
c"ea'er. *t is also usually easier to find t"ings in t"e latter.
Water (urification s,stems
Many laboratory tests 2e.g. 're'aring malaria slides4 reJuire 'ure ;ater. 9"ere are
a number of met"ods a(ailable for treating ;ater for laboratory use:
Filtration remo(es sus'ended solids and ot"er materials by 'assage t"roug"
material ;it" a small 'ore si8e. Ceramic filters ;ill remo(e all 'otential 'at"ogens
e:ce't (iruses. =ilters do not remo(e dissol(ed c"emicals.
1istillation remo(es non-(olatile materials& solids and all inorganics. ,tills reJuire
Juite a lot of energy to "eat t"em and a great deal of cool ;ater to condense t"e
distillate 2at least 03 litres5"our at a su''ly 'ressure of 3.$ %g5cm
#
4. Many stills are
made from glass and are fragile but stainless steel stills are a(ailable.
1emineralizers do not reJuire energy in'ut but t"ey do not 'roduce com'letely
'ure ;ater. 9"ey use ion-absorbing resins remo(e inorganic ions and some organic
materials from t"e ;ater. 9"ey can become contaminated ;it" bacteria and t"eir
ability to remo(e ions declines steadily unless t"ey are ;ell cared for and regenerated.
Portable deminerali8ers are a(ailable for small-scale use.
:everse osmosis 'roduces good-Juality ;ater but is energy-intensi(e and t"e
membranes used are easily damaged.
:emoval of suspended solids can be ac"ie(ed by settlement 2allo; t"e ;ater to
stand o(ernig"t and remo(e t"e su'ernatant4 or by adding aluminium sulfate to t"e
;ater at t"e rate of 0 g to 3 litres of ;ater& allo;ing to stand for #3 minutes and
'ouring off t"e clear su'ernatant. 9"is dose not 'roduce 'ure ;ater but does remo(e
many contaminants and is an essential 'rereJuisite for t"e use of eJui'ment suc" as
re(erse osmosis mac"ines and filters.
4dGustment of p8. Water for laboratory use s"ould "a(e a neutral 'H of 6.3.
Measure 'H ;it" a meter or ;it" 'H 'a'er stri's. Dilute "ydroc"loric acid can be
used to lo;er 'H and dilute sodium "ydro:ide to raise it.
=iltration and5or deminerali8ation is a good ;ay to 'ro(ide reasonable amounts of
adeJuately 'ure ;ater for laboratory use es'ecially in areas ;"ere ;ater su''lies
and5or electricity su''lies are unreliable.
Measurement of (2
Many basic laboratory 'rocesses reJuire buffered solutions or solutions of %no;n
'HN 'H can be measured sim'ly by means of s'ecial indicator 'a'ers but a more
satisfactory met"od is to use a 'H meter. 9"ese can be battery or mains o'erated.
C"ose a 'H meter t"at ;ill measure t"e ;"ole 'H range 23!)4 and t"at "as automatic
tem'erature com'ensation.
Incinerators
Plans for a basic incinerator suitable for emergency use can be found in "ealth
laboratory facilities in emergency and disaster situations. Plans for a more
so'"isticated 'lant are gi(en in Cngineering in emergencies"
E0EENCES
7asic ;aboratory 5ethods in 5edical Darasitology. @ene(a& World Healt"
Organi8ation& //.
7ench 4ids for the diagnosis of malaria infections" 2#nd Edition4. @ene(a& World
Healt" Organi8ation& #333.
7ench 4ids for the diagnosis of filarial infections" @ene(a& World Healt"
Organi8ation& //6.
7ench 4ids for the diagnosis of intestinal parasites" @ene(a& World Healt"
Organi8ation& //).
Euidelines for the <ollection of <linical 2pecimens during Field -nvestigation of
9utbrea6s" @ene(a& World Healt" Organi8ation& #333 2document WHO5CD,5C,B5
EDC5#333.)4.
8ealth laboratory facilities in emergency and disaster situations" Ale:andria&
World Healt" Organi8ation Begional Office for t"e Eastern Mediterranean& //)
2document WHO5EMBO .o. 14.
;aboratory 7iosafety 5anual. 2#
nd
Edition4. @ene(a& World Healt" Organi8ation&
//$.
5aintenance and repair of laboratory 1iagnostic* -maging and 8ospital
Cquipment. @ene(a& World Healt" Organi8ation& //).
2afety in 8ealth(<are ;aboratories. @ene(a& World Healt" Organi8ation& //6.
2election of 7asic ;aboratory Cquipment for ;aboratories /ith ;imited
:esources. Ale:andria& World Healt" Organi8ation Begional Office for t"e Eastern
Mediterranean& #333.
*ther relevant publications
C"eesbroug" M" ;aboratory practice in tropical countries" Dart . Cambridge&
Cambridge ?ni(ersity Press& //A.
C"eesbroug" M. ;aboratory practice in tropical countries" Dart 2 Cambridge&
Cambridge ?ni(ersity Press& #333.
MKdecins ,ans =ronti_res. :efugee health. London& Macmillan& //6.
"6# Treatment guidelines
9"ese treatment guidelines are intended to gi(e sim'le guidance for t"e training of
'rimary "ealt" care ;or%ers& using basic units of .e; Emergency Healt" Dits. *n t"e
dosage guidelines& fi(e age grou's "a(e been distinguis"ed& e:ce't for t"e treatment
of diarr"oea ;it" oral re"ydration fluid ;"ere si: age and ;eig"t categories are used#
W"en dosage is s"o;n as L tab V #M& one tablet s"ould be ta%en in t"e morning and
one before bedtime. W"en dosage is s"o;n as L# tab V $M& t;o tablets s"ould be ta%en
in t"e morning& t;o in t"e middle of t"e day and t;o before bedtime. 9"ese
guidelines "a(e been ada'ted from The ne/ emergency health 6it #& ;"ic" is
currently under re(ie;"
A
9"e treatment guidelines contain t"e follo;ing diagnostic5sym'tom grou's:
anaemia&
'ain&
diarr"oea&
fe(er&
're(enti(e care in 'regnancy&
measles&
res'iratory tract infections&
;orms&
s%in conditions&
eyes&
se:ually transmitted and urinary tract infections.
Anaemia
Weig"t 3 ) %g ) A %g A 0 %g 0 $0
%g
$0 %g ]
Diagnosis Age
3 #
# mont"s
0 0 0
0 years ]
,ym'tom mont"s
year
years years
,e(ere anaemia
2oedema& di88iness&
s"ortness of breat"4
efer
Moderate anaemia
2'allor and tiredness4
efer =errous
sulfate ]
folic acid&
tab
daily for
at least #
mont"s
=errous
sulfate ]
folic acid&
# tab
daily for
at least #
mont"s
=errous
sulfate ]
folic acid&
$ tab
daily for
at least #
mont"s
=errous
sulfate ]
folic acid&
$ tab
daily for
at least #
mont"s
$ain
Weig"
t
3 U )
%g
) A %g A 0 %g 0 $0 %g $0 %g ]
Diagnosi
s
,ym'tom
Age 3 #
mont"
s
# mont"s
year
0 years 0 0
years
0 years ]
Pain 2"eadac"e&
Foint 'ain&
toot"ac"e4
Paracetamol
& tablet 33
mg& 5# tab
V $
Paracetamol
& tablet 33
mg& tab V
$
A,A
&a*b
tab $33
mg&
tab V $
A,A&
tablet $33
mg& # tab V
$
,tomac"
'ain
efer Aluminiu
m
"ydro:ide&
5# tab V $
for $ days
Aluminiu
m
"ydro:ide&
tab V $
for $ days
a
424 = acetylsalicylic acid"
b
For children under 2 years* paracetamol is preferred because of the ris6 of
:eye syndrome"
Diarr)oea
Weig"t
3 0 %g
0!6./
%g
A!3./
%g
!0./
%g
1!#/./
%g
$3 %g ]
Diagnosis
,ym'tom
Age
a
U)
mont"s
)!
mont"s
#!#$
mont"s
#!)
years
0!)
years
0 years
]
Diarr"oea ;it" some
de"ydration 2WHO
9reatment Plan -4
b
A''ro:imate amount of OB, solution to gi(e in t"e first )
"ours 2in ml4
#33!
)33
)33!
133
133!
A33
A33!
#33
#33!
##33
##33!
)333
Diarr"oea lasting
more t"an t;o
;ee%s or in
malnouris"ed
'atient or 'atient in
'oor condition
@i(e OB, according to de"ydration stage and refer
-loody diarr"oea
c
2c"ec% 'resence of
blood in stools4
@i(e OB, according to de"ydration stage and refer
Diarr"oea ;it"
se(ere de"ydration
efer 'atient for nasogastric tube and5or intra(enous treatment
2WHO 9reatment
Plan C4
d
Diarr"oea ;it" no
de"ydration 2WHO
9reatment Plan A4
e
Continue to feed
Ad(ise t"e 'atient to return to t"e "ealt" ;or%er in case of
freJuent stools& increased t"irst& sun%en eyes or fe(erN or ;"en
t"e 'atient does not eat or drin% normallyN or does not get
better ;it"in t"ree daysN or de(elo's blood in t"e stool or
re'eated (omiting
a
?se t"e 'atient<s age only ;"en you do not %no; t"e ;eig"t. 9"e a''ro:imate
amount of OB, reJuired 2in ml4 can also be calculated by multi'lying t"e
'atient<s ;eig"t 2in grams4 times 3.360.
b
The ne/ emergency health 6it #&& Anne: #c.
c
Protocol to be establis"ed according to e'idemiological data.
d
The ne/ emergency health 6it #&& Anne: #d.
e
The ne/ emergency health 6it #&& Anne: #b.
!se of drugs for c)ildren @it) diarr)oea
Antimicrobial s"ould be used only for dysentery and for sus'ected cases of
c"olera ;it" se(ere de"ydration. Ot"er;ise t"ey are ineffecti(e and s"ould
not be gi(en.
Anti(arasitic drugs s"ould be used only for:
amoebiasis& after antimicrobial treatment of bloody diarr"oea for 2higella
"as failed& or tro'"o8oites of Cntamoeba histolytica containing red blood
cells are seen in t"e faecesN
giardiasis& ;"en diarr"oea "as lasted for at least ) days and cysts or
tro'"o8oites of Eiardia are seen in t"e faeces or small bo;el fluid.
Antidiarr)oeal drugs and anti<emetics s"ould never be used. .one "as any
'ro(en (alue and some are dangerous.
0e'er
Weig"t 3 ) %g ) A %g A 0 %g 0 $0
%g
$0 %g ]
Diagnosis
,ym'tom
Age
3 #
mont"s
# mont"s
b year
0 years 0 0
years
0 years
]
=e(er in
malnouris"ed 'atient
or 'atient in 'oor
condition& or ;"en in
doubt
efer
=e(er ;it" c"ills&
'resumed malaria efer C)ec4 national (rotocols and W2O
recommendations
=e(er ;it" coug" efer ,ee LBes'iratory tract infectionsM belo;
=e(er efer Paracetamol&
tab 33 mg&
5# tab V $
for to $
days
Paracetamol&
tab 33 mg&
tab V $ for
!$ days
A,A&
b*c
tab $33
mg& tab
V $ for
!$ days
A,A&
tab $33
mg& #
tab V $
for !$
days
2uns'ecified4
a
(irst-, second- and third-line therapies %ill vary according to resistance
patterns in the country + chec& national protocols and ,H*
recommendations .see 2ection ?"2 on malaria0"
b
424 = acetylsalicylic acid"
c
For children under 2 years* paracetamol is to be preferred because of the
ris6 of :eye syndrome"
$re'enti'e care in (regnanc,
Weig"t
3 ) %g ) A %g A 0 %g 0 $0
%g
$0 %g ]
Diagnosis
,ym'tom
Age 3 #
mont"s
# mont"s
year
0
years
0 0
years
0 years ]
Anaemia =errous
sulfate ]
folic acid&
tab daily
t"roug"out
'regnancy
2for treatment see
under Anaemia4
Malaria ,P: $ tab
t;ice at
least&
during
'regnancy:
once
during #nd
trimester
and one
during $
rd

trimester
a
2for treatment see
under =e(er4
a
2ee malaria 2ection ?"2 for recommendations on pregnancy and 8-F"
$onsult national protocols and ,H* recommendations"
Measles
Weig"t
3 ) %g ) A %g A 0 %g 0 $0
%g
$0 %g ]
Diagnosis
,ym'tom
Age 3 #
mont"s
# mont"s
year
0
years
0 0
years
0 years ]
Measles 9reat res'iratory tract disease
according to sym'toms
9reat conFuncti(itis as Lred eyesM
9reat diarr"oea according to
sym'toms
Continue 2breast4feeding& gi(e
retinol 2(itamin A4
es(irator, tract infections
Weig"
t
3 )
%g
) A %g A 0 %g 0 $0 %g
$0 %g ]
Diagnosi
s
,ym'tom
Age 3 #
mont"
s
# mont"s
year
0 years 0 0
years
0 years ]
,e(ere 'neumoniaa @i(e t"e first dose of co-trimo:a8ole 2see under Pneumonia4 and
refer
Pneumonia
a
efer Co-
trimo:a8ole
& tab )33
mg ,Mf
a
]
A3 mg
9MP&
b
5#
tab Vij# for
0 days
Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg
9MP& tab
Vij# for 0
days
Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg
9MP& tab
Vij# for 0
days
Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg
9MP& # tab
Vij# for 0
days
Beassess after # daysN continue 2breast4feeding& gi(e
fluids& clear t"e noseN return if breat"ing becomes faster
or more difficult& or not able to drin% or if t"e condition
deteriorates.
.o 'neumonia:
coug" or cold
a
efer Paracetamo
l
c
tab 33
mg 5# tab
Vij$ for !
$ days
Paracetamo
l tab 33
mg tab
Vij$ for !
$ days
A,A
d*e
tab
$33 mg
tab Vij$ for
!$ days
A,A tab
$33 mg #
tab Vij$ for
!$ days
,u''orti(e t"era'yN continue 2breast4feeding& gi(e
fluids& clear t"e noseN return if breat"ing becomes faster
or more difficult& or not able to drin% or if t"e condition
deteriorates.
Prolonged coug"
2$3 days4
efer
Acute ear 'ain
and5or ear
disc"arge for less
t"an # ;ee%s
efer Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg
9MP& 5#
tab Vi #
for 0 days
Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg 9MP
tab VV #
for 0 days
Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg 9MP
tab VV #
for 0 days
Co-
trimo:a8ole
& tab )33
mg ,Mf ]
A3 mg 9MP
# tab VV #
for 0 days
Ear disc"arge for
more t"an #
;ee%s& no 'ain or
fe(er
Clean t"e ear once daily by syringe ;it"out needle using
lu%e;arm clean ;ater.
Be'eat until t"e ;ater comes out clean. Dry re'eatedly ;it"
clean 'iece of clot".
a
25P = sulfametho+azole"
b
T5D = trimethoprim"
c
-f fever is present"
d
424 = acetylsalicylic acid"
e
For children under 2 years* paracetamol is to be preferred because of the
ris6 of :eye syndrome
Worms
a
Weig"
t
3 )
%g
) A
%g
A 0 %g 0 $0 %g
$0 %g ]
Diagnosis
,ym'tom
Age 3 #
mont"
s
#
mont"
s
0 years 0 0 years 0 years ]
year
Bound;or
m 'in;orm
Mebenda8ol
e& tab 33
mg& # tab
once
Mebenda8ol
e& tab 33
mg& # tab
once
Mebenda8ole
& tab 33 mg&
# tab once
Hoo%;orm Mebenda8ol
e& tab 33
mg& tab VV
# for $ days
Mebenda8ol
e& tab 33
mg& tab VV
# for $ days
Mebenda8ole
& tab 33 mg&
tab VV #
for $ days
a
Treatment of hoo6/orm in pregnancy /ith mebendazole is recommended in
endemic areasW mebendazole can safely be given in the second and third
trimesters of pregnancy"
S4in conditions
Wounds: e:tensi(e& dee' or
on face
efer
Wounds: limited and
su'erficial
Clean ;it" clean ;ater and soa' or diluted
c"lor"e:idine solutionN
a
gently a''ly gentian (iolet
solution
b
once a day
,e(ere burns 2on face or
e:tensi(e4
9reat as for mild burns and refer
Mild to moderate burns *mmerse immediatel, in cold ;ater& or use a cold ;et
clot"N continue until 'ain eases& t"en treat as for
;ounds
,e(ere bacterial infection
2;it" fe(er4
efer
Mild bacterial infection Clean ;it" clean ;ater and soa' or diluted
c"lor"e:idine solution
A''ly gentian (iolet solution t;ice a day
*f not im'ro(ed after 3 days& refer
=ungal infection A''ly gentian (iolet solution once a day for 0 days
*nfected scabies -acterial infection: clean ;it" clean ;ater and soa' or
diluted c"lor"e:idine solution A''ly gentian (iolet
solution t;ice a day
;"en infection is cured:
c"ildren U # years:
c"ildren # years and
adults:
a''ly diluted ben8yl
ben8oate
c
once a day for
$ days
a''ly non<diluted ben8yl
ben8oate 2#0Q4 once a day
for $ days
.on-infected scabies c"ildren U # years: c"ildren # years and
adults:
a''ly diluted ben8yl
ben8oate
c
once a day for
$ days
a''ly non<diluted ben8yl
ben8oate 2#0Q4 once a day
for $ days
a
<hlorhe+idine ?V must al/ays be diluted before use: 2% ml made up to litre
/ith /ater" Ta6e the (litre plastic bottle supplied /ith the 6itW put 2% ml of
chlorhe+idine solution into the bottle using the %(ml syringe supplied and fill
up the bottle /ith boiled or clean /ater" <hlorhe+idine "?V U cetrimide ?V
solution should be used in the same dilution"
b
Eentian violet %"?V concentration = teaspoon of gentian violet po/der per
litre of boiled/clean /ater" 2ha6e /ell* or use /arm /ater to dissolve all the
po/der"
c
<hildren !2 years*at half strength .2"?V0: dilute by mi+ing %"? litre benzyl
benzoate 2?V /ith %"? litre clean /ater in the (litre bottle supplied /ith the
6it" -nfants .%!2 months0*at quarter strength .$"2?V0: dilute by mi+ing %"?
litre benzyl benzoate 2"?V /ith %"? litre clean /ater"
E,es
Bed eyes 2conFuncti(itis4 A''ly tetracycline eye ointment $ times a
day for 6 days.
*f not im'ro(ed after $ days or in doubt&
refer.
Se=uall, transmitted and urinar, tract infections
,us'icion of se:ually transmitted or
urinary tract infection
efer
""# Management of t)e c)ild @it) coug) or difficult,
in breat)ing
5
" ASSESS T2E C2ILD
As4
Ho; old is t"e c"ild^
*s t"e c"ild coug"ing^ =or "o; long^
*s t"e c"ild able to drin% 2for c"ildren age # mont"s u' to 0 years4^
Has t"e young infant sto''ed feeding ;ell 2for c"ildren less t"an # mont"s4^
Has t"e c"ild "ad fe(er^ =or "o; long^
Has t"e c"ild "ad con(ulsions^
Loo4 and listen 8t)e c)ild must be calm9
Count t"e breat"s in a minute.
Loo% for c"est indra;ing.
Loo% and listen for stridor.
Loo% and listen for ;"ee8e. *s it recurrent^
,ee ;"et"er t"e c"ild is abnormally slee'y& or difficult to ;a%e.
=eel for fe(er& or lo; body tem'erature 2or measure tem'erature4.
Loo% for se(ere undernutrition.
% DECIDE 2OW TO TEAT T2E C2ILD
9"e c"ild aged less t"an # mont"s: see -able '....
9"e c"ild aged # mont"s u' to 0 years:
;"o is not ;"ee8ing: see -able '.../
;"o is ;"ee8ing: refer
9reatment instructions: see -able '...0
gi(e an antimicrobial
ad(ise mot"er to gi(e "ome care
treat fe(er
Table A""#" C)ild under % mont)s of age
,igns .o fast breat"ing =ast breat"ing .ot able to drin%
2less t"an 13 'er
minute4
213 'er minute or
more4
Con(ulsions
and or Abnormally slee'y
or difficult to ;a%e
.o se(ere c"est
indra;ing
,e(ere c"est
indra;ing
,tridor in calm
c"ild
W"ee8ing
or
=e(er or lo; body
tem'erature
Classification .o 'neumonia !
coug" or cold
,e(ere 'neumonia Eery se(ere disease
9reatment Ad(ise mot"er to
gi(e follo;ing
"ome care:
Befer urgently to
"os'ital
Befer urgently to
"os'ital
- %ee' infant ;arm @i(e first dose of
an antimicrobial
@i(e first dose of
an antimicrobial
breastfeed
freJuently
Dee' infant ;arm
2*f referral is not
feasible& treat ;it"
an antimicrobial
and follo; closely
Dee' infant ;arm
2*f referral is not
feasible& treat ;it"
an antimicrobial
and follo; closely
clear nose if it
interferes ;it"
feeding
Ad(ise mot"er to
return Juic%ly if:
- illness ;orsens
- breat"ing is
difficult
- breat"ing
becomes fast
- feeding becomes
a 'roblem
Table A""#% C)ild % mont)s to - ,ears of age
,igns .o c"est
indra;ing
.o c"est
indra;ing
C"est
indra;ing
.ot able to
drin%
and and Con(ulsions
.o fast
breat"ing 2less
t"an 03 'er
minute if c"ild
#! # mont"s
of age
=ast breat"ing
203 'er minute
or more if
c"ild #! #
mont"s of age
Abnormally
slee'y or
difficult to
;a%e ,tridor in
calm c"ild
or or or
)3 'er minute
if c"ild !0
years4
)3 'er minute
if c"ild !0
years4
,e(ere
undernutrition
Classification .o 'neumonia
! coug" or
cold
Pneumonia ,e(ere
'neumonia
Eery se(ere
disease
9reatment *f coug"ing
more t"an $3
days& refer for
Ad(ise mot"er
to gi(e "ome
care
efer urgently
to "os'ital
efer urgently
to "os'ital
assessment
Assess and
treat ear
'roblem or
sore t"roat if
'resent
@i(e an
antimicrobial
@i(e first dose
of
antimicrobial
@i(e first dose
of
antimicrobial
Assess and
treat ot"er
'roblems
9reat fe(er if
'resent
9reat fe(er if
'resent
9reat fe(er if
'resent
Ad(ise mot"er
to gi(e "ome
care
Ad(ise mot"er
to return in #
days for
reassessment&
or if t"e c"ild
is getting
;orse
*f referral is
not 'ossible&
treat ;it" an
antimicrobial
and follo;
closely4
*f cerebral
malaria is
'ossible& gi(e
an antimalarial
drug
9reat fe(er if
'resent

eassess in % da,s a c)ild @)o is ta4ing an antimicrobial for (neumonia

Signs Im(ro'ing T)e same Worse
O Less fe(er O .ot able to drin%
O Eating better O Has c"est
indra;ing
O -reat"ing slo;er O Has ot"er danger
signs
9reatment =inis" 0 days of
antimicrobial
C"ange
antimicrobial
efer urgently to
"os'ital
or
efer
Table A""#* Treatment instructions
@i(e an antimicrobial.
@i(e first dose of antimicrobial in t"e clinic.
*nstruct mot"er on "o; to gi(e t"e antimicrobial for 0 days at "ome 2or to
return to clinic for daily 'rocaine 'enicillin inFection4:
Co<trimo=aColeD trimet)o(rim
8TM$9 K sulfamet)o=aCole
8SMA9
Amo=icillin $rocaine
(enicillin
9;ice daily for 0 days 9"ree times daily for
0 days
Once daily
for 0 days
Adult
tablet
single
strengt"
Paediatric
tablet
,yru'
2)3 mg
9MP ]
#33 mg
,Mf4
9ablet
2#03 mg4
,yru'
2#0 mg
in 0 ml4
*ntramuscular
inFection
Age or
@eig)t
2A3 mg
9MP ]
)33 mg
,Mf4
2#3 mg
9MP ]
33 mg
,Mf4
?nder #
mont"s
5) b b #.0 ml b 5) #.0 ml #33 333 units
2U 1 %g4a
# mont"s
! #
mont"s
5# # 0.3 ml 5# 0.3 ml )33 333 units
21!/ %g4
#
mont"s !
0 years
$ 6.0 ml 3 ml A33 333 units
23!/
%g4
a
Eive oral antimicrobial for five days at home if referral is not feasible"
b
-f the child is less than one month old* give /2 paediatric tablet or "2? ml
syrup t/ice daily" 4void co(trimo+azole in infants under one month of age
/ho are premature or Gaundiced" 2yrups and paediatric tablets are mentioned
here for the sa6e of completenessW they are not available in the 6it"
Ad(ise mot"er to gi(e "ome care 2for c"ild aged # mont"s to 0 years4:
=eed t"e c"ild:
feed t"e c"ild during illness
increase feeding during illness
clear t"e nose if it interferes ;it" feeding
*ncrease fluids:
offer t"e c"ild e:tra to drin%
increase breastfeeding
soot"e t"e t"roat and relie(e coug" ;it" a safe remedy
Most im(ortant: for t"e c"ild classified as "a(ing no 'neumonia& coug" or
cold& ;atc" for t"e follo;ing signs and return Juic%ly if t"ey occur:

breat"ing becomes difficult

breat"ing becomes fast T)is c)ild ma, )a'e (neumonia

c"ild not able to drin%

c"ild becomes sic%er

9reat fe(er:
=e(er is
"ig"2S $/
`C4
=e(er is
not 2$A!$/
`C4 "ig"
*n falci'arum
malarious area:
any fe(er or
"istory of fe(er

@i(e
'aracetamol
Ad(ise
mot"er to
gi(e more
fluids
@i(e an
antimalarial 2or
treat according to
your national
malaria
'rogramme
recommendations4
$aracetamol dose e'er, . )ours =e(er for more
t"an 0 days
Age or @eig)t "66< mg tablet -66< mg tablet
# mont"s to #
mont"s 21!/
%g4
5) efer for
assessment
# mont"s to $
years 23!)
%g4
5)
$ years to 0
years 20!/
%g4

5#
5
"%# Assessment and treatment of diarr)ea
Table A"%#" Assessment of diarr)oeal (atients for de),dration
0irst assess ,our (atient for de),dration
$LAN $LAN 7 $LAN C
"# Loo4 atD Well& alert
T
estless> irritable
T
Let)argic or
unconsciousU
flo((,
@eneral condition
Eyes
a
.ormal ,un%en Eery sun%en and
dry
Mout" and tongue
b
Moist Dry Eery dry
9ears Present Absent Absent
9"irst Drin%s normally&
not t"irsty
T
T)irst,> drin4s
eagerl,
T
Drin4s (oorl, or
not able to drin4
%# 0eelD @oes bac% Juic%ly
T
Goes bac4 slo@l,
T
Goes bac4 'er,
slo@l, ,%in 'inc" c
*# Decide 9"e 'atient "as no
signs of
dehydration
*f t"e 'atient "as
t;o or more signs&
including at least
one
Z
sign t"ere is
some dehydration
*f t"e 'atient "as
t;o or more signs&
including at least
one
Z
sign t"ere is
severe dehydration
+# Treat ?se 9reatment Plan
A
Weig" t"e 'atient if
'ossible and use
9reatment Plan -
Weig" t"e 'atient
and use 9reatment
Plan C
!GENTL?
a
-n some infants and children the eyes normally appear some/hat sun6en" -t is
helpful to as6 the mother if the childJs eyes are normal or more sun6en than
usual"
b
1ryness of the mouth and tongue can also be palpated /ith a clean finger"
The mouth may al/ays be dry in a child /ho habitually breathes through the
mouth" The mouth may be /et in a dehydrated patient o/ing to recent
vomiting or drin6ing"
c
The s6in pinch is less useful in infants or children /ith marasmus .severe
/asting0 or 6/ashior6or .severe undernutrition /ith oedema0 or in obese
children"
,ource: The treatment of diarrhoea: a manual for physicians and other senior
health /or6ers" @ene(a& World Healt" Organi8ation& //0 2document
WHO5CDB5/0.$4.
TEATMENT $LAN AD TO TEAT DIA2OEA AT 2OME
?se t"is 'lan to teac" t"e mot"er to:
continue to treat at "ome "er c"ild<s current e'isode of diarr"oea&
gi(e early treatment for future e'isodes of diarr"oea.
E:'lain t"e t"ree rules for treating diarr"oea at "ome.
" Gi'e t)e c)ild more fluids t)an usual to (re'ent de),dration
V ?se recommended "ome fluids. 9"ese include: OB, solution& food-based
fluids 2suc" as sou'& rice ;ater and yog"urt drin%s4 and 'lain ;ater. ?se
OB, solution as described in t"e bo: belo;. .Note: if the child is under $
months of age and not yet ta6ing solid food* give 9:2 solution or /ater
rather than food(based fluid"0
V @i(e as muc" of t"ese fluids as t"e c"ild ;ill ta%e. ?se t"e amounts s"o;n
belo; for OB, as a guide.
V Continue gi(ing t"ese fluids until t"e diarr"oea sto's.
% Gi'e t)e c)ild (lent, of food to (re'ent undernutrition
V Continue to breastfeed freJuently.
V *f t"e c"ild is not breastfed& gi(e t"e usual mil%.
V *f t"e c"ild is 1 mont"s or older& or already ta%ing solid food:
also gi(e cereal or anot"er starc"y food mi:ed& if 'ossible& ;it"
'ulses&(egetables and meat or fis"N add one or t;o teas'oonfuls of
(egetable oil to eac" ser(ingN
gi(e fres" fruit Fuice or mas"ed banana to 'ro(ide 'otassiumN
gi(e fres"ly 're'ared foodsN coo% and mas" or grind food ;ellN
encourage t"e c"ild to eat: offer food at least si: times a dayN
gi(e t"e same food after diarr"oea sto's& and gi(e an e:tra meal eac"
day for # ;ee%s.
* Ta4e t)e c)ild to t)e )ealt) @or4er if )e:s)e does not get better
in * da,s or de'elo(s an, of t)e follo@ingD
V many ;atery stools
V re'eated (omiting
V mar%ed t"irst
V eating or drin%ing 'oorly
V fe(er
V blood in t"e stool
C)ildren s)ould be gi'en OS solutions at )ome ifD
t"ey "a(e been on 9reatment Plan - or CN
t"ey cannot return to t"e "ealt" ;or%er if t"e diarr"oea gets ;orseN or
if it is national 'olicy to gi(e OB, to all c"ildren ;"o see a "ealt" ;or%er for
diarr"oea.
If t)e c)ild is to be gi'en OS solution at )ome> s)o@ t)e mot)er )o@ muc)
OS to gi'e after eac) loose stool and gi'e )er enoug) (ac4ets for % da,s#
Age Amount of OS to be
gi'en after eac) loose
stool
Amount of OS to
(ro'ide for use at )ome
?nder #) mont"s 03!33 ml 033 ml5day
#!3 years 33!#33 ml 333 ml5day
3 years or more as muc" as ;anted #333 ml5day
Describe and s"o; t"e amount to be gi(en after eac" stool& using a local
measure.
S)o@ t)e mot)er )o@ to mi= and to gi'e OS
@i(e a teas'oonful e(ery !# minutes for a c"ild under # years.
@i(e freJuent si's from a cu' for older c"ildren.
*f t"e c"ild (omits& ;ait 3 minutes. 9"en gi(e t"e solution more slo;ly 2for
e:am'le& a s'oonful e(ery #!$ minutes4.
*f diarr"oea continues after t"e OB, 'ac%ets are used u'& tell t"e mot"er to
gi(e ot"er fluids as described in t"e first rule abo(e or return for more OB,.

TEATMENT $LAN 7D TO TEAT DE2?DATION

Table
A"%#%
A((ro=imate amount of OS solution to gi'e in t)e first +
)ours
Agea
O +
mont)s
+B""
mont)s
"%B%*
mont)s
%B+ ,ears -B"+
,ears
"- ,ears
K
Weig)t
3 0 %g
0!6./ %g A!3./ %g !0./
%g
1!#/./
%g
$3 %g ]
in ml #33!)33 )33!133 133!A33 A33!#33 #33!
##33
##33!
)333
in local
measure
a
DatientJs age* only /hen you do not 6no/ the /eight" The appro+imate
amount of 9:2 required .in ml0 can also be calculated by multiplying the
patientJs /eight .in grams0 times %"%)?"
*f t"e c"ild ;ants more OB, t"an s"o;n& gi(e more.
Encourage t"e mot"er to continue breastfeeding.
=or infants under 1 mont"s ;"o are not breastfed& also gi(e 33!#33 ml clean
;ater during t"is 'eriod.
Obser'e t)e c)ild carefull, and )el( t)e mot)er gi'e OS solution#
,"o; "er "o; muc" solution to gi(e t"e c"ild.
,"o; "er "o; to gi(e it ! a teas'oonful e(ery !# minutes for a c"ild under #
years& freJuent si's from a cu' for an older c"ild.
C"ec% from time to time to see if t"ere are 'roblems.
*f t"e c"ild (omits& ;ait 3 minutes and t"en continue gi(ing OB,& but more
slo;ly& for e:am'le& a s'oonful e(ery #!$ minutes.
*f t"e c"ild<s eyelids become 'uffy& sto' t"e OB, and gi(e 'lain ;ater or
breast mil%. @i(e OB, according to Plan A ;"en t"e 'uffiness is gone.
After + )ours> reassess t)e c)ild using t)e assessment c)art> t)en
select $lan A> 7 or C to continue treatment
*f t"ere are no signs of de"ydration& s"ift to Plan A. W"en de"ydration "as
been corrected& t"e c"ild usually 'asses urine and may also be tired and fall
aslee'.
*f signs indicating some de"ydration are still 'resent& re'eat Plan - but start to
offer food& mil% and Fuice as described in Plan A.
*f signs indicating se(ere de"ydration "a(e a''eared& s"ift to Plan C.
If t)e mot)er must lea'e before com(leting Treatment $lan 7D
,"o; "er "o; muc" OB, to gi(e to finis" t"e )-"our treatment at "ome.
@i(e "er enoug" OB, 'ac%ets to com'lete re"ydration& and for # more days as
s"o;n in Plan A.
,"o; "er "o; to 're'are OB, solution.
E:'lain to "er t"e t"ree rules in Plan A for treating "er c"ild at "ome:
to gi(e OB, or ot"er fluids until diarr"oea sto's&
to feed t"e c"ild&
to bring t"e c"ild bac% to t"e "ealt" ;or%er& if necessary.
TEATMENT $LAN CD TO TEAT SE/EE DE2?DATION
I!ICKL?
=ollo; t"e arro;s. *f t"e ans;er is LyesM go across. *f LnoM go do;n.
"*# 0lo@c)arts for s,ndromic management of
se=uall, transmitted infections
A !ET2AL DISC2AGE
2ource: Euidelines for the management of se+ually transmitted infections"
@ene(a& World Healt" Organi8ation& #33 2document WHO5BHB53.34.
7 GENITAL !LCES
2ource: Euidelines for the management of se+ually transmitted infections"
@ene(a& World Healt" Organi8ation& #33 2document WHO5BHB53.34.
C /AGINAL DISC2AGE
2ource: Euidelines for the management of se+ually transmitted infections"
@ene(a& World Healt" Organi8ation& #33 2document WHO5BHB53.34.
"+# 2ealt) card
2EALT2 CAD $'1-E 2E S'N-3 Card .o
<arte N
X
Date of
registration
1ate
dJenregistrement
*f 'ossible& obser(e t"e 'atient for at least 1 "ours after re"ydration to be sure t"e
mot"er can maintain "ydration gi(ing OB, solution by mout". *f t"e 'atient is older
t"an # years and t"ere isc"olera in t"e area& gi(e an a''ro'riate oral antimicrobial
after t"e 'atient "as become alert.
,ite ,ection5House .o. Date of arri(al at
site
;ieu 2ection /8abitation
N
X
1ate dJarrivKe
sur le lieu
=amily name @i(en names
Nom de famille DrKnoms
Date of birt" or age or
Hears
,e: M
5
=
.ame commonly %no;n by
1ate de naissance ou Yge ou 4ns 2e+e Nom dJusage habituel
C2ILD
EN
EN('N
-S
Mot"er<s name =at"er<s name
Nom de la mZre Nom du pZre
Heig"t cm Weig"t %
g
Percentage ;eig"t5"eig"t
Taille Doids Dourcentage poids/taille
=eeding 'rogramme
Programme d<alimentation
Me
asle
s
Date # -C@ Ot"ers
:o
uge
ole
Date 4utres
Eacci
nation
DP
9
Poli
o
1T
<
Doli
o
# $
Polio Date Date
WOME
N
(E44
ES
Pregn
ant
Hes5.o .o. of
'regnancies
.o. of c"ildren Lactati
n
Hes5
.o
Cncei
nte
9ui/Non NX de
grossesses
NX dJenfants 4llaita
nte
9ui/
Non
9etan
us
Dat
e
# $ ) 0
TKtan
os
=eeding 'rogramme
Drogramme dJalimentation
COMM
ENTS
*5SE1
'-I*
NS
@eneral 2=amily circumstances&
li(ing conditions& etc.4
Healt" 2-rief "istory& 'resent
condition4
EKnKrales .<irconstances familiales*
conditions de vie* etc"0
5Kdicales .:KsumK de lJKtat
actuel0
DATE CONDITION TEATM
ENT
CO!SES O7SE
/ATIO
NS
8Signs:s,m(tom
s:diagnosis9
8Medicatio
n:dose
8Medicatio
n
C)ange
in
time9 due:gi'en9 conditio
n9
Name of
)ealt)
@or4er
ETAT
Signes:s,m(tW
mes:diagnostic9
TAITEM
ENT
8MXdicatio
n:durXe de
la dose9
A$$LICA
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8MXdicatio
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reFuise:eff
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8C)ange
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dSXtat9
Nom de
lSagent
de santX
2ource: The Ne/ Cmergency 8ealth [it #&" @ene(a& World Healt" Organi8ation&
//A 2document WHO5DAP5/A.3
".# List of W2O guidelines on communicable
diseases
0ACT S2EETS
Title $ublication No#:Date
Ant"ra: =act ,"eet .o. #1) October #33
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#1)5en5
C"olera =act ,"eet .o. 36 Be(ised Marc" #333
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs365en
Dengue and
dengue
"aemorr"agic
fe(er
=act ,"eet .o. 6 Be(ised A'ril #33#
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs65en5
Di'"t"eria =act ,"eet .o. A/ Be(ised December #333
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs3A/5en5
=ood safety and
foodborne illness
=act ,"eet .o. #$6 re(ised Canuary #33#
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#$65en5
He'atitis - =act ,"eet .o. #3) Be(ised October #333
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#3)5en5
He'atitis C =act ,"eet .o. 1) Be(ised October #333
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs1)5en5
*nfluen8a =act ,"eet .o. # Marc" #33$
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#5en5
*nFection safety:
bac%ground
=act ,"eet .o. #$ Be(ised A'ril #33#
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#$5en5
Malaria =act ,"eet .o. /)
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs3/)5en5
Measles =act s"eet .`#A1 Marc" #330
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#A15en5
Plague =act ,"eet .o. #16 =ebruary #330
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs#165en5
Poliomyelitis =act ,"eet .o. ) Be(ised A'ril #33$
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs)5en5
Babies =act ,"eet .o. // Be(ised Cune #33
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs3//5en5
,almonella =act ,"eet .o. $/ A'ril #330
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs$/5en5inde:."tml
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs$/5en5inde:."tml
,mall'o: ,mall'o:
"tt':55;;;.;"o.int5mediacentre5facts"eets5small'o:5en5
9uberculosis =act ,"eet .o. 3) Be(ised Marc" #330
"tt':55;;;.;"o.int5mediacentre5facts"eets5fs3)5en5
9y'"oid fe(er and
Paraty'"oid fe(er
Water related diseases
"tt':55;;;.;"o.int5;aterbsanitationb"ealt"5diseases5ty'"oid5en5
9"e World Healt"
Organi8ation
About WHO
"tt':55;;;.;"o.int5about5en5
G!IDELINES : $!7LICATIONS : E$OTS
Communicable diseases control in emergencies - A field
manual
WHO5CD,5#330.#6
"tt':55;;;.;"o.int5infectious-disease
ne;s5*Ddocs5;"ocds#330#65
"ocds#330#6c"a'ters5inde:."tm
*,-. /# ) 0)11 1
Protocol for t"e assessment of national communicable
disease sur(eillance nd res'onse systems. @uidelines for
assessment teams
WHO5CD,5C,B**,B5
#33.#
"tt':55;;;.;"o.int5emc-
documents5sur(eillance5;"ocdscsrisr#33#c. "tm*
Englis" only
,trengt"ening im'lementation of t"e @lobal ,trategy for
Dengue =e(er5 engue Haemorr"agic =e(er Pre(ention and
Control
WHO5CD,5
2DE.45*C5#333.
"tt':55;;;.;"o.int5csr5resources5'ublications5dengue5en5;"
ocdsdenic 333.'df
Englis" only
WHO re'ort on global sur(eillance of e'idemic-'rone
infectious diseases
WHO5CD,5C,B5*,B5
#3335
"tt':55;;;.;"o.int5csr5resources5'ublications5sur(eillance5
WHObCD,bC, b*,Bb#333b5en5
Englis" only
@uidelines for t"e collection of clinical s'ecimens during
field in(estigation f outbrea%s
WHO5CD,5C,B5ED
C5#333.)
"tt':55;;;.;"o.int5emc-
documents5sur(eillance5;"ocdscsredc#33)c.
Englis" only
He'atitis A WHO5CD,5EDC5#33
3.6
"tt':55;;;.;"o.int5emc-
documents5"e'atitis5;"ocdscsredc#3336c."tm*
Englis" only
@uidelines for e'idemic 're'aredness and res'onse to
measles outbrea%s
WHO5CD,5C,B5*,B5
//5
"tt':55;;;.;"o.int5emc-
documents5measles5;"ocdscsrisr//c."tml
Englis" only
*nfluen8a 'andemic 're'aredness 'lan. 9"e role of WHO and
guidelines for ational and regional 'lanning
WHO5CD,5C,B5ED
C5//5
"tt':55;;;.;"o.int5csr5resources5'ublications5influen8a5WH Englis" only
ObCD,bC,Bb DCb//b5en5
Plague manual: e'idemiology& distribution& sur(eillance and
control
WHO5CD,5C,B5ED
C5//.#
"tt':55;;;.;"o.int5emc-
documents5'lague5;"ocdscsredc//#c."tml
Englis" and =renc"
Laboratory met"ods for t"e diagnosis of meningitis caused
by Neisseria eningitidis* 2treptococcus pneumoniae* and
8aemophilus influenzae
WHO5CD,5C,B5ED
C5//.6
"tt':55;;;.;"o.int5emc-
documents5meningitis5;"ocdscsredc//6c."tm*
Englis" and =renc"
Laboratory met"ods for t"e diagnosis of e'idemic dysentery
and c"olera& ///
WHO5CD,5C,B5ED
C55//.A
"tt':55;;;.cdc.go(5ncidod5dbmd5diseaseinfo5c"olera5to'.'df Englis" and =renc"
Control of e'idemic meningococcal disease. WHO 'ractical
guidelines. #nd ed.
WHO5EMC5D*,5/A.$
"tt':55;;;.;"o.intlemc-
documents5meningitis5;"oemcbac/A$c."tml
@uidelines for t"e sur(eillance and control of ant"ra: in
"uman and animals. $rd ed.
WHO5EMC5GD*5/A.1
C"olera and ot"er e'idemic diarr"oeal diseases control.
9ec"nical cards on en(ironmental sanitation& //6
WHO5EMC5D*,5/6.1
"tt':55;;;.;"o.int5csr5resources5'ublications5c"olera5WHO
bEMCbD*,b/6b15en5
E'idemic diarr"oeal disease 're'aredness and res'onse.
9raining and 'ractice& //A 2Partici'ant<s manual4
WHO5EMC5/6.$
Be(.
"tt':55;;;.;"o.int5emc-
documents5c"olera5;"oemcdis/6$c."tml
Englis"& =renc" and
,'anis"
E'idemic diarr"oeal disease 're'aredness and res'onse.
9raining and 'ractice& //A 2=acilitator<s guide4
WHO5EMC5/6.)
Be(.
"tt':55;;;.;"o.int5emc-
documents5c"olera5;"oemcdis/6)c."tml
Englis"& =renc" and
,'anis"
Dengue "aemorr"agic fe(er: diagnosis& treatment& 're(ention
and control. #nd ed.
Englis" only
"tt':55;;;.;"o.int5csr5resources5'ublications5dengue5en5ito
(iii.'df
@uidelines for t"e control of e'idemics due to ,"igella
dysenteriae ty'e
Draft& #330
"tt':55;;;.;"o.int5c"ild-adolescent-
"ealt"5Emergencies5,"igellosisb guidelines.'df
/IDEOS
Protecting oursel(es and our communities from
c"olera 2) min4.
#333
"tt':55;;;.;"o.int5emc5diseases5c"olera5(ideos."tml Englis" and =renc"
WE7 SITES
WHO ! "tt':55;;;.;"o.int5
WHO5C"olera ! "tt':55;;;.;"o.int5to'ics5c"olera5en5inde:."tml
WHO Communicable Diseases and ,ur(eillance ! "tt':55;;;.;"o.int5csr5en5
WHO Communicable Diseases ,ur(eillance and Bes'onse !
"tt':55;;;.;"o.int5csr5
WHO *nfectious Diseases ne;s& documents and Communicable disease tool%its !
"tt':55;;;.;"o.int5infectious-disease-ne;s5
WHO Boll -ac% Malaria 'artners"i' ! "tt':55;;;.rbm.;"o.int5
WHO Boll -ac% Malaria de'artment ! "tt':55;;;.;"o.int5malaria and
"tt':55;;;.;"o.int5malaria5com'le: emergencies
WHO5,to' 9- ! "tt':55;;;.sto'tb.org5
WHO5Water and ,anitation! "tt':55;;;.;"o.int5;aterbsanitationb"ealt"5en5
"1# List of (ublis)ers
9"e boo%s and documents mentioned in t"is manual may be obtained from t"e
follo;ing addresses. ,ome are a(ailable free of c"arge.
,H* 6ublications. Mar%eting and Dissemination& #3& a(enue A''ia& #
@ene(a #6& ,;it8erland ! 9el. ]) 234## 6/ #)61& =a:: ]) 234## 6/ )A06& E-mail:
'ublicationsk;"o.int& Web site: "tt':55;;;.;"o.int
7umarian 6ress, Inc., #/) -lue Hills A(enue& -loomfield& C9 3133#& ?,A 9el.
] 2A334 #A/ #11)& =a:: ] 2A134 #)$ #A16& E-mail: %'boo%skaol.com
,ater, Engineering and 2evelopment $entre, Loug"boroug" ?ni(ersity&
Leicesters"ire& LE $9?& England ! 9el. ])) 03/ ###AA0& =a:: ]))03/ #36/&
E-mail: WEDCklboro.ac.u%
48decins Sans (ronti9res
International *ffice) MKdecins ,ans =ronti_res& $/ rue de la 9ourelle& 3)3
-russels& -elgium ! 9el: ]$# # #A3AA& =a:: ]$# # #A336$
5elgium) MKdecins ,ans =ronti_res& Du'rKstreet /)& 3/3 -russels Cette 9el. ]$#
# )6) 6)6)& =a:: ]$# # )6) 6060
(rance) MKdecins ,ans =ronti_res& A& rue ,abin& 600)) Paris Cede: 9el. ]$$
)3 ##/#/& =a:: ]$$ )A 311A1A
Lu:embourg) MKdecins ,ans =ronti_res& 63& route de Lu:embourg& 6#)3
-Kreldange ! 9el. ]$0# $$ #00& =a: : ]$0# $$ 0$$
Netherlands) Artsen Gonder @ren8en& Ma: Eu;e'lein )3& Postbus 33)& 33
EA Amsterdam ! 9el. ]$ #3 0#3A633& =a:: ]$ #3 1#3063
Spain) MKdicos ,in =ronteras& .ou de la Bambla #1& 3A33 -arcelona 9el. ]$) /
$ $3)133& =a:: ]$) / $ $3)13#
S%it;erland) MKdecins ,ans =ronti_res& 6A rue de Lausanne& case 'ostale 1&
# @ene(a 1 ! 9el. ]) ## A)/ A)A)& =a:: ]) ## A)/ A)AA
-'L$ "-eaching-aids 't Lo% $ost#, P.O. -o: )/& ,t Albans& Hertford"ire AL
09& England ! 9el. ])) 6#6 A0$A1/& =a:: ])) 6#6 A)1A0#& E-mail: talcktalcu%.org
!NH$1 Head<uarters, case 'ostale #033& # @ene(a DK'lt #& ,;it8erland
9el. ]) 234## 6$/ A& =a:: ]) 234## 6$/ 6$66
"1# General references
Drugs and drug management
,89 model formulary. @ene(a& World Healt" Organi8ation& #33#.
1rugs used in parasitic diseases& #nd ed. @ene(a& World Healt" Organi8ation&
//0.
1rugs used in se+ually transmitted diseases and 8-F infection. @ene(a& World
Healt" Organi8ation& //0.
1rugs used in s6in diseases" @ene(a& World Healt" Organi8ation& //6.
Management ,ciences for Healt"& in collaboration ;it" t"e World Healt"
Organi8ation. 5anaging drug supply: the selection* procurement* distribution* and
use of pharmaceuticals& #nd ed. -loomfield& C9& Dumarian Press& //6.
8o/ to manage a health centre store. London& A''ro'riate Healt" Besources and
9ec"nologies Action @rou'& //).
<linical guidelines* diagnostic and treatment manual. Paris& MKdecins ,ans
=ronti_res& #33$.
Cssential drugs. Paris& MKdecins ,ans =ronti_res& #33#.
The Ne/ Cmergency 8ealth [it #&. @ene(a& World Healt" Organi8ation& //A.
Materials
Cmergency relief items: compendium of basic specifications" Fol" 2" 5edical
supplies and equipment* selected essential drugs* guidelines for drug donations. .e;
Hor%& ?nited .ations De(elo'ment Programme& //1.
General medicine
@regg M-. Field epidemiology" O:ford& O:ford ?ni(ersity Press& //1.
Lumley C,P et al. 8andboo6 of the medical care of catastrophes" London& Boyal
,ociety of Medicine //1.
,tric%land @9. 8unterJs tropical medicine& 6t" ed. P"iladel'"ia& W- ,aunders
Com'any& //.
5ansonJs tropical diseases. London& W.-. ,aunders& //1.
Eddleston M& Pierini ,. 9+ford handboo6 of tropical medicine" O:ford& O:ford
?ni(ersity Press& ///.
General D disasters and emergencies
:efugee health: an approach to emergency situations. MKdecins ,ans =ronti_res&
//6.
8andboo6 for emergencies #nd edition. @ene(a& Office of t"e ?nited .ations
Hig" Commissioner for Befugees& ///.
Perrin P. 8andboo6 on /ar and public health. @ene(a& *nternational Committee
of t"e Bed Cross& //1.
-r_s PLC. Dublic health action in emergencies caused by epidemics" @ene(a&
World Healt" Organi8ation& /A1.
<ommunity emergency preparedness: a manual for managers and policyma6ers.
@ene(a& World "ealt" Organi8ation& ///.
.oFi ED ed. The public health consequences of disasters. .e; Hor%& O:ford
?ni(ersity Press& //6.
:apid health assessment protocols for emergencies. @ene(a& World Healt"
Organi8ation& ///.