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KOSI FLOOD 2008KOSI FLOOD 2008

A NATIONAL DISASTERA NATIONAL DISASTER

Objectives of the session

1. Apply principles of epidemiology in Disaster Management

2. Apply surveillance tools as an early warning system to detect major outbreaks and epidemics

3. Know Measurements/Indicators/Triggers in Emergencies

4. Preparedness for Medical Relief (mobile medical teams and fixed site teams) and services render

• Immunization• Newborn minimal package of care• Maternal Health services (ANC/PNC)• Referral Services (Sick Newborn- NSU & SAM-MTC)(Sick Newborn- NSU & SAM-MTC)

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SHELTER…..

4Rescue……

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THE SUFFERING

FOOD…….

6DISPLACED POPULATION IN MEGA CAMPS

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CAMPS OTHER THAN MEGA CAMPS

8TAKING SHELTER IN GOVERNMENT BUILDINGS

Epidemiology Epidemiology and and

SurveillanceSurveillance

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Driving without looking at the traffic?

Is like making public health Is like making public health decisions in the absence of datadecisions in the absence of data

Surveillance: A role of the public health system

The systematic process of collection, transmission, analysis and feedback of public health data for

decision making

Surveillance

Information collected by the surveillance system

• How many get them?

• Who get the disease?

• Where they get them?

• When they get them?

• Why they get them?

• What needs to be done as response?

Surveillance

A dynamic vision of surveillance

Collect and transmit data

Analyzedata

Feedbackinformation

Make decisions

All levels use information to make decisions

Surveillance

The private sector can treat patients butonly the public sector can coordinate surveillance

Syndromes under surveillance

• Fever

• Cough

• Diarrhea

• Acute flaccid paralysis

• Jaundice

• Unusual syndrome causing

death/ hospitalization

Fever

1. Fever less than 7 days with:– Rash and cough or coryza or conjunctivitis (suspected

measles) – Altered sensorium (suspected Japanese encephalitis or

malaria)– Convulsions (suspected Japanese encephalitis )– Bleeding from skin, mucus membrane, vomiting blood or

passing fresh blood or black motion (suspected Dengue) – With none of the above (suspected malaria)

2. Fever > 7 days – Suspected typhoid

• Triggers– More than 2 similar case in the village (1000 Population)/ Camp

site

Cough

• Short duration (Cough < 2 weeks)– Suspected acute respiratory tract infection

• Longer duration (Cough of > 2 weeks)– Suspected tuberculosis

Diarrhea• Any new case of watery diarrhea

– Passage of 3 or more loose / watery stools in 24 hours

– With or without dehydration – Total duration of illness < 14 days

• Dysentery : Presence of visible blood in stool

• Trigger– More than 10 houses with diarrhea in a village

or urban ward or a single case of severe dehydration or death in a patient > than 5 years with diarrhea

Jaundice

• A new patient with an acute illness (<4 weeks) and following symptoms:– Jaundice, dark urine– Anorexia, malaise, fatigue– Pain in abdomen (right upper quadrant)

• Trigger – More than two cases of jaundice in different

houses irrespective of age in a village or 1000 population

Acute flaccid paralysis

• A case of acute flaccid paralysis is defined as any child:– Aged <15 years – Has acute onset of flaccid paralysis for which

no obvious cause is found

• Trigger– Single case of AFP

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Phases Anticipated health problems

Possible Interventions

Days 1-3 Injury/drowning and deaths Safe disposal of dead bodies

Injury management

Needs assessment for health

Days 3-5 Diarrhoeal diseases

Acute respiratory infections Psychosocial problems

Health promotion– Sanitation, environment– Water purification– Personal hygiene– Immunization (measles)–ORS & Zinc

Emerging disease surveillance (morbidity/ mortality)

5-10 days Above plus: Dehydration, Pneumonia, conjunctivitis, and skin infections

Above plus;

Antibiotics for pneumonia ; IV Fluids

Drugs for skin infections and conjunctivitis

>10 days Above plus: Vector-borne diseases (malaria, DF), Typhoid fever, Measles, and Malnutrition

Ongoing surveillance

Health education, measures for vector control, antimalarial

Supplementary feeding program

Rebuilding health infrastructure

Anticipated health problems and Anticipated health problems and interventionsinterventions

Mortality

• Measured as number of deaths per 10000 population per day

• Crude mortality rate (CMR) is for entire population and under 5 mortality rate (U5MR) is for children under 5 years of age

CMR = No. of deaths X 10000 Population X Period

Benchmark Mortality Rates in Emergencies

Crude Mortality Rate CMR (deaths/10,000/day)– Baseline 0.5 – Serious 1.0-2.0 – Crisis >2.0

U5MR – Baseline 0.8-1.2 – Serious >2.0-4.0

Morbidity• Morbidity is the number of NEW cases of a GIVEN DISEASE among the population

over a certain period of TIME• Measured per 10000 population per day

AR and CFR

• Attack rate (outbreaks): The cumulative incidence of cases (persons meeting case definition since onset of outbreak) in a group observed over a period during an outbreak.

• Case-fatality ratio (CFR): the percentage of persons diagnosed as having a specified disease who die as a result of that disease within a given period, usually expressed as a percentage (cases per 100).

Case study

• The first onset of Measles occurred in Madhepura on the 2nd of September 2008.

• The total population affected is estimated to be 10,000 .

• The Measles outbreak had a cumulative admission total of 145 males child and 155 female child.

• The daily admission rate is approx 35 patients. • This outbreak claimed 6 lives

Calculate AR and CFR. What do they tell you?

Attack Rate = number of cases x 100 population at risk

 Attack Rate = (145+155) = .030 ;

10,000

.03 x 100 = 3.0% There was a 3.0% attack rate. Based on the population, what does this attack rate indicate? (The attack rate is very high.This is a crisis situation. Response activities should be re-evaluated.) 

Case Fatality Ratio (CFR)= number of deaths x 100 number of cases

= 6 = .02 (145+155) 

= .02 x 100 = 2.0%  There was a 2.0% CFR. Based on the standards for Measles treatment, what does this CFR indicate? (This exceeds the standard of 1%. Serious action needs to be taken to improve health seeking behaviour and response activities).

Mortality in Refugee and Displaced Populations

• Major causes of death in the emergency phase– Measles– Diarrheal disease– Acute respiratory infections

• 50% - 90% of deaths in some refugee settings due to these 3 diseases

PROLONGED STRESS- NOT/ ENOUGH FOOD- ZERO HYGIENE- OVERCROWDED POPULATION

DISEASE DETERMINANTS IN CAMPS

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Intervention Age group

Routine immunization Pregnant women and children as per EPI schedule

Catch-up immunization(Measles Vaccination) 6 months to 14 years

Catch–up Vitamin A doses 9 months to 5 years

IFA supplementation 6months to 5 years

De-worming tablets 2 years to 5 years

Low osmolarity ORS All children affected with diarrhea; 6 months to 5 years

Zinc Along with ORS

Catch-up Health and Nutrition Round :Catch-up Health and Nutrition Round :

• Manpower support for Micro planning, Orientation and Monitoring

• Supplies• IEC (Session site banners, banners, posters, handouts etc)

Prevent or detect the outbreakVaccination

- Timely, high quality mass campaigns in emergencies- Routine childhood vaccination

Appropriate treatment of illness- Vitamin A

Infants <6m 50,000 IU – repeat next dayInfants 6-11m 100,000 IU – repeat next dayChildren 1y+ 200,000 IU – repeat next day

- Antibiotics for bacterial secondary infections- Treat dehydration

Preventing Measles Illness and Death in Emergencies

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Measles and Vitamin A Campaign

Objective

• To prevent outbreaks in flood affected areas

Target Populations

• Congregated populations displaced by flood, living in relief camps.

Target Age Group

• Measles immunization: Children from 6 months through 14 years age.

• Vitamin A: Children from 9 months to 5 years age

Microplan: Essential Background Information: Infrastructure and Manpower

• Existing cold chain equipment

– Cold boxes, vaccine carriers, ice packs

– Functioning freezers and ILR

• Electricity sources

• Functioning facilities

• # trained vaccinators, supervisors

• Available vehicles/motorcycles

• Vehicles/motorcycles for hire

CALCULATING SUPPLY NEEDS: VACCINE & INJECTION MATERIALS

• Doses of measles vaccine and diluent-

– # doses = target population + wastage + reserve

– Doses needed = target X 1.17 + 20% reserve

• Number of vials = doses needed / 5

• Diluent = number of vials

• Syringes and needles for dilution = # vials

• AD syringes = Doses needed

• Safety boxes = AD syringes + syringes for dilution

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• Vit A- 10 % reserve

CALCULATING COLD CHAIN NEEDS:

• Vaccine carriers: at least 2 per team

– 1 for vaccine 1 for extra icepacks

• Cold boxes: 1 for each storage depot

• Icepacks: = vaccine carriers X 4 + large cold boxes X 50

• Fuel for generator (icepacks need to be frozen 3-5 days before campaign)

• ILR, freezers?

Calculating Transport Needs

• Transport for supplies

• Transport for teams, supervisors, coordinators, monitors

• Fuel for vehicles & Hiring cost of vehicles

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ASHA for Floods• ASHA workers need to be mobilized • Minimal package for Newborn, child and maternal health care: Training of

ASHAs, PNC visit for maternal and newborn care, Breast feeding training for early initiation and exclusive Breastfeeding, ORS and Zinc for the management of Diarrhoea

• ASHAs to be equipped with counseling materials, ASHA kits

• The ASHA worker will be responsible for Ensuring chlorination of hand pumps, Testing water quality, PNC visits for mother and newborns and

Referral services.

HOME VISIT FOR PNC BY ASHA WORKER COUNSELLING FOR BREASTFEEDING

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ENSURING POST NATAL CARE FOR MOTHER AND CHILD IN EMERGENCY

ASHA THE REFERRAL LINKASHA THE REFERRAL LINK

FROM VILLAGES TO DISTRICT HOSPITAL NSU

REFERRAL LINKAGE:

ASHA WORKER PROVIDING POST NATAL CARE AND REFERRAL IN VILLAGES

To reduce the threat of epidemics regarding acute watery To reduce the threat of epidemics regarding acute watery diarrhea & malaria/dengue following steps are to be takendiarrhea & malaria/dengue following steps are to be taken

a.      Sustained & continuous provision of safe drinking water throughi. Water purification plants.

ii. Provision of Aqua Pure tablets for household.

iii. Provision of chlorinated water through tankers.

b.      Provision of L-ORS & Zinc.

c.      Provision of soap for hand washing before meals and after defecation.

d.      Health Education and awareness campaign through Banners, leaflets & electronic media.

e.      Fogging in all already covered as well as un-covered areas.

f.       Continuous indoor residual spray

g.      Continuous and sustained supply of Anti-diarrhoea & Anti malarial drugs.

h.      Early diagnosis through rapid diagnostic kits.

i.        Quick epidemic response through regional & district epidemic response team.

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Government of BiharFlood Response 2007

Daily IDSP Morbidity Reporting for the Facility / PHC / Mobile Clinic/Camp   Name of PHC / GH / Municipal Health post:      

Team leader of the Mobile team:         Date of reporting          Syndrome Cases Reported Total  (To put the total no. against each syndrome at the end of the day)    Under 5 years 5 years and over    No. of cases No. of deaths No. of cases No. of deaths  

1. Fever         

2. Fever with rash         

3. Acute Diarrheal Diseases

(including cholera)          

4. Acute Jaundice         

5. Acute Respiratory Infections         

6. Others         

Total         

      

Total patients seen at the facility / Mobile Clinic: :     Reporting Person (MO / I / C / Heath Officer) :        Instructions:  

a) Each Mobile team to report consolidated figures for all sites visited at PHC level on a daily basis.b) The PHC to send compiled report of PHC and all other activities to District Data Cell and State Data Cell daily.          

Government of BiharFlood Response 2007   

COMPILATION of Daily IDSP Morbidity Reporting for the PHC Area   Name of PHC (District)          Population under PHC          Date of reporting          

 PHC Mobile Clinics

Other Fixed Sites under

PHCTOTAL

Syndrome No. of clinics / sites       

FeverUnder 5 years        

5 years and over        

Fever with RashUnder 5 years        

5 years and over        Acute Diarrheal Diseases

(Including Cholera)

Under 5 years        

5 years and over        

Acute JaundiceUnder 5 years        

5 years and over        

Acute Respiratory InfectionsUnder 5 years        

5 years and over        

OthersUnder 5 years        

5 years and over        

Total CASESUnder 5 years        

5 years and over        

TOTAL DEATHSUnder 5 years        

5 years and over           Other Remarks / Comments:          Reporting Person (MO / I / C / Health Officer) :        Instructions:  a) Each Mobile team to report consolidated figures for all sites visited at PHC level on a daily basis.b) The PHC to send compiled report of PHC and all other activities to District Data Cell and State Data Cell daily.           

Mobile MedialTeam

Fixed Clinic(Camp, Private,

others)

Camp /Village

Camp /Village

Camp /Village

Mobile MedialTeam

Fixed Clinic(Camp, Private,

others)

Camp /Village

Camp /Village

Camp /Village

PHCMOIC

Supported by Data Cell

PHC Out-patientClinic

Submit compilation by phone(end of each day)

CMOSupported by

IDSP, District Data Cell

Submit compilation,formats

(within 2 days)

Director Public Health

Supported by State DataCell

Submit compilation,formats

within 4 days

Directors NICD, EMR

DRAFTFlow of Daily Disease Surveillance Data, Bihar Flood 2007

Based on MOHFW / WHO IDCP

Submitcompilation

Note:If PHC non-functional

or unreachable,mobile teams to submit to

District level forcompilation of the

PHC activities

DISTRICT HEALTH SOCIETY

Daily Immunization Report Date-

S No- Name of Block OPV Vit A MeaslesPregent woman

TTAny Adverse

ReportedNo of team

    .           

               

Name of PHC Reg. No. of Ambulance

No. of Health Camp

Visited by Mobile Team

No. of Patients

(Treated by Mobile Team)

Medicines (Distributed by Mobile Team)

Others Services

provided by Mobile

Team (if any)

Name & No. of Contact Person

of concerned PHC (Where

Mobile team is deployed)

Name Quantity

DISTRICT HEALTH SOCIETY

Mobile Team Activity Chart: -

Date:

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GROUP Work

Contingency/Preparedness Planning

Following Components :–1) Logistics – Inventory of resources (existing +

required), prepositioning

2) Human Resources

3) Transportation

4) Technical – Capacity building, Investigations, treatment protocol, control…

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Resources required• Budgetary provision• Personnel• Medical care• Laboratory support• Field teams• Immunization• Vector control• Environmental sanitation• Supplies (Bleaching Powder; IFA; Vitamin A; ASHA kits;

Halogen tablets; ORS & Zn; Medicine Kits ; Midwifery Kits; Baby Blankets; Cholera Kit etc)

• Transport• Communication

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