Infectiouos Disease Control in a Long-Term Refugee Camp_The Role of Epidemiologic Surveillance and...

Infectious Disease Control i n Long-term Refugee Camp: T h e Role o f Epidemiologic Surveillance a n d Investigation CHRISTOPHER J . ELIAS, M D , BRUCE H. ALEXANDER, M S , AN D T A N SOKLY Abstract: This report demonstrates t h e role of epidemiologic surveillance a n d investigation in t h e control o f infectious diseases in a long-term refugee camp. T h e applications o f simple methods i n a refugee camp o n t h e Thai-Cambodian border a r e described f o r a one-year period. T h e development o f a Health Information Office facilitated t h e collection o f demographic and vital statistics data, administration o f a disease surveillance system, regular monitoring o f hospital a n d outpatient discharge diagnoses, Introduction There are currently more than 1 2 million refugees throughout t h e world.' Disease and famine often accompany the movements o f refugees, ashealth a n d nutritional systems a r e disrupted b y strife. Refugee camps a re generally per- ceived a s temporary structures requiring immediate, short- term assistance. Unfortunately, persistent w a r i n the Middle- East, Afghanistan, Sub-Saharan Africa, and Southeast Asia has created refugee camps that require long-term assistance. These camps have become permanent settlements a n d a r e n o w home forthe majority o f t he world's refugees. T h e health care problems of long-term camps differ from those of short-term camps; t h e primary tasks arehealth maintenance, nutritional support, community development, a n d training of refugee health workers.2 These tasks a r e often more difficult than t h e highly publicized crisis management necessary during th e emergency phase o f refugee relief operations. T h e permanence of these camps, combined with t h e difficulty i n obtaining ongoing support, demands innovative planning t o effectively allocate scarce health resources. T h e importance o f epidemiologic assessment f o r public health planning a n d resource allocation h a s been emphasized i n emergency assistance situations.3,4 T h e successful us e of simple epidemiologic methods has been demonstrated i n t h e emergency phase o f th e Cambodian a n d Ethiopian refugee crises.5,6 Epidemiologic assessment i s equally important fo r dealing with t h e health concerns o f long-term camps.7 Effec- tive disease surveillance a n outbreak investigation c a n help direct public health interventions. Analysis of mortality trends and nutritional status c a n b e used t o evaluate th e effectiveness o f assistance programs.8.9 Knowledge of disease patterns c a n inform clinical practice a n d guide resource allocation decisions. Finally, this information m a y b e useful i n designing training programs a n d orienting expatriate per- sonnel. This paper reports o u r experience with epidemiologic surveillance o f infectious diseases i n t h e Site 2 South e n - campment f o r Cambodian refugees o n t h e Thai-Cambodian border. From t h e American Refugee Committee, Aranyaprathet, Thailand. A d - dress reprint requests to Christopher J . Elias, M D, Clinical Scholars Program, University o f Washington, HQ-18, 3747 15th Avenue N E , Seattle, WA 98105. This paper, submitted t o the Journal August 2 5 , 1989, w a s revised a n d accepted f o r publication December 1 9 , 1989. C 1990 American Journal o f Public Health 0090-0036/90$1.50 a n d investigation o f disease outbreaks. This office also organized community health education campaigns and disease control efforts. Examples o f specific disease investigations a r e provided t o demon- strate t h e utility o f epidemiologic surveillance i n t h e control of infectious disease. W e conclude that simple epidemiologic methods play a n important role in health planning in long-term refugee camps. ( A m J Public Health 1990: 80:824-828.) Methods Following t h e Vietnamese invasion o f Cambodia i n 1979, there w a s a large influx o f Cambodian refugees into camps i n Thailand. These refugees were physically, mentally, a n d nutritionally exhausted after nearly a decade o f w a r a n d four years o f hardship under the Khmer Rouge. Several reports have described t h e health conditions i n these early camps.' 1 ' 2 T e n years later there ar e still approximately 350,000 refugees i n eight camps along t h e Thai-Cambodian border. Site 2 , home t o over half these refugees, is divided into North a n d South. Site 2 South h a s a population o f approximately 70,000, or roughly 20 percent o f th e border refugee population. Th e a g e distribution o f Site 2 Southis skewed toward t he very young. Twenty-three percent o f the population i s under 5 years o f age, a n d 4 3 percent is under 15.13 T h e camp is severely overcrowded, with only 3 3 sq.m./person including public lands.'4 There is n o ground water i n Site 2 , requiring that waterbebrought long distances b y truck a t considerable expense a n d resulting i n a chronic shortage o f water f o r personal hygiene. Th e average water ration i s only 20 liters/person/day, significantly below the ideal o f 1 0 0 liters/ person/day recommended b y the Health Organiza- tion.15 There is n o running water, a n d the sewer system consists o f open ditches between rows o f houses. Inthe d r y season these sewers a r e stagnant pools o f waste. Inthe rainy season they quickly overflow, flooding nearby houses. Th e population i s totally dependent o n external food supplies. T h e acute malnutrition rates in children under a g e 5 years, which were very high (>13 percent) i n t h e acute phase o f t h e refugee crisis, h a d stabilized a t approximately 5 percent b y 1985.'5 T h e prevalence o f chronic malnutrition (stunting), however, remains high.'3 Th e diet consists pri- marily o f rice a n d canned fish. T h e United Nations World Food Program supplies a food basket calculated to supply sufficient protein a n d calories. It is common, however, f o r camp residents t o barter away some o f their food a i d o n t h e black market, gaining variety a t the cost o f nutritional value. Th e persistence o f significant malnutrition despite t he pro- vision o f adequate protein a n d calories arises i n part from this u s e o f rice a s the primary market exchange commodity; a phenomenon exacerbated b y severe under-employment. Humanitarian assistance f o r these refugees i s provided through t he UN Border Relief Operation (UNBRO), which supports a n d coordinates several voluntary agency health service programs i n the camps. T h e American Refugee Committee h a s t h e responsibility f o r providing curative health services f o r Site 2 South; their hospital a nd t w o A8JPH July 1990, Vol. 8 0 , N o. 7 24

Infectiouos Disease Control in a Long-Term Refugee Camp_The Role of Epidemiologic Surveillance and...

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