|Handbook for Emergencies - Second Edition (UNHCR, 1999, 414 p.)|
· An assessment of the health and nutritional status is an essential start to the provision of health services;
· This must be done by experts with experience of emergencies and, if possible, local knowledge;
· The factors affecting the health of the refugees must be identified and a surveillance and reporting system established.
4. First, information should be obtained on the number of refugees2 segregated by age (percentage of children under five years of age) and sex (male/female ratio). See chapter 11 on registration for more information on estimating the total number of refugees.
Age/sex breakdown can be estimated from:
i. Information collected during surveys;
ii. Information collected during mass immunization campaigns;
iii. Mass health screening on arrival;
iv. Information collected by community health workers.
5. The aim of the initial health assessment is to identify basic problems and needs and to establish priorities. It should be carried out by people with appropriate qualifications and relevant experience. There are obvious advantages in using national or locally-based personnel, but appropriate outside expertise can be made available quickly and should be requested through the Health and Community Development Section at Headquarters if necessary.
6. The priority should be to evaluate the incidence of the major causes of excess mortality and morbidity - measles, diarrhoeas, pneumonia, malaria and malnutrition.
7. Relevant information can be obtained from:
i. Direct observation;
ii. Reviewing baseline information regarding the country/areas of origin and asylum;
iii. Analyzing records at health facilities and interviewing health workers;
iv. Undertaking sample surveys (nutrition and mortality). These must be done by experts;
v. Population estimation and registration (see chapter 11 on population estimation and registration);
vi. Mass health and nutrition screening on arrival. This should focus on: (i) nutrition screening through visual inspection and measurement of the Mid Upper Arm Circumference ("MUAC"), (see chapter 15 on food and nutrition), (ii) checking for communicable diseases and vaccination coverage, and (iii) identifying patients in need of urgent referral. It is usually impractical to try to provide treatment in the screening line itself.
8. Figure 2 illustrates key management considerations for action in light of the initial assessment.
2 Health experts sometimes call this number "the denominator".
Figure 2 - Assessment and Response
Monitoring and Surveillance: The Health Information System
9. From the earliest stages of an emergency, a health information system should be put in place under the responsibility of the UNHCR Health Coordinator. The health information system should be simple, reliable, and action oriented, and its use will be essential to:
i. Quantify the health and nutritional status of the refugee population;
ii. Follow trends in health status and monitor the impact and outcomes of the relief programme;
iii. Detect epidemics;
iv. Evaluate programme effectiveness and service coverage;
v. Ensure that resources are targeted to the areas of greatest needs;
vi. Re-orient the programme as necessary.
10. Annex 1 sets out the tables and forms for collecting health-related information. However, to have a more comprehensive idea of the situation, information regarding water, food, sanitation, shelter and availability of soap should also be collected and analyzed (see the relevant chapters on water, nutrition, sanitation, and physical planning).
11. The health information system should be kept simple. The information to be collected should be adapted to suit the collectors' qualifications. Overly detailed or complex reporting requirements will result in non-compliance. In addition, only data that can and will be acted on should be collected. Communication and exchange of views among all the actors in the health information system are essential to secure the functioning of the system.
Only simple arrangements are effective in emergencies.
12. Health information in the initial stages of an emergency should concentrate on:
i. Demography (see chapter 11 on registration, also paragraph 4 above, and table 1 of Annex 1);
ii. Mortality and its causes (see tables 2.1 and 2.2 of Annex 1 and paragraph 14 below);
iii. Nutritional status (see Annexes 4 and 5 of chapter 15 on food and nutrition);
iv. Morbidity (see below, and table 3.1 of Annex 1).
13. Only when the situation stabilizes can the system be made more comprehensive. Information on mortality and morbidity should be collected as follows:
14. Each health facility should keep a log of all patient deaths with cause of death and relevant demographic information. This information should be summarized in tables 2.1 and 2.2 of Annex 1, reported centrally and consolidated with other data. Because many deaths occur outside the health-care system, a community-based mortality surveillance system should also be established. Such a system requires identifying sites which people are using as cemeteries, employing grave watchers on a 24 hours basis, routinely issuing burial shrouds, and using community informants. Deaths that occur outside hospitals with unknown causes should be validated through verbal autopsy by health workers specifically trained for this task.
15. Each health facility providing out-patient services (including clinics for under five's and selective feeding programmes) should keep daily records. These records should be in the form of a log book or tally sheets at least, and should at least record the patient's name, age, sex, clinical and laboratory diagnosis and treatment. This information should be summarized in the forms set out as tables 3.1. in Annex 1 and reported centrally.
16. Diseases recorded in the health information system must have a case definition (i.e. a standard description) which will guide health workers in their diagnosis and ensure the consistency and validity of data. Where possible, case definitions that rely on clinical signs and symptoms (e.g. malaria) should be checked against a laboratory standard test (e.g. blood test for malaria).
17. In addition, the patient should be issued a health record card (or "Road to Health" card) on which the date, diagnosis, and treatment are recorded. Every contact a patient has with the health-care system, whether for curative or preventive services, should be noted on the health record card retained by the patient.
18. The health information system should be periodically assessed to determine its accuracy, completeness, simplicity, flexibility, and timeliness. The way programme planners and key decision-makers use the information should also be assessed. The system should evolve as the need for information changes.
19. Camp and centrally controlled monitoring of health and nutritional status is essential if problems are to be identified in time to allow preventive and/or corrective actions to be taken and to adjust resource allocation. The refugees' health status should improve as public health services start to function adequately and the refugees adjust to their new environment.
20. However, a vigilant surveillance system must be maintained. Seasonal changes will affect health (for example temperature changes, and especially the rainy season) so seasonal variations in the incidence of disease will remain. The UNHCR Health Coordinator and her/his counterparts in the government and other partners will be responsible for the quality of this surveillance, the data required, who will interpret it and how to ensure action on the results and feed-back to all actors.
21. The most important and specific indicators of the overall status of the refugee population are the Crude Mortality Rate (CMR), for the whole population and Under-5 Mortality Rate (U-5MR) for children under five years of age. These indicators are of crucial importance to managers of the operation and are also of great interest to the media, donors and relief agencies. A priority for the health surveillance system is to produce reliable information on death rates.
22. During the emergency phase, mortality rates should be expressed as deaths/10,000 persons/day so that sudden changes can be detected.
Crude Mortality Rate is
This is calculated as follows:
23. The objective of the overall assistance programme in the emergency phase should be to achieve CMR of <1/10,000/day and U-5MR of <2/10,000/day as soon as possible. These rates still represent approximately twice the "normal" CMR and U-5MR for non-displaced populations in most developing nations and should not signal a relaxation of efforts.
24. Age and sex-specific mortality rates have to be collected systematically and may indicate the need for targeted interventions. Table 1 below shows some benchmarks against which the daily Crude Mortality Rate (CMR) can be compared. Under-5 Mortality Rate benchmarks are usually twice the CMR.
Table 1 - Crude Mortality Rate Benchmarks
Morbidity (incidence and types of disease)
25. Knowing the major causes of illness and the groups at greatest risk helps efficient planning of intervention strategies and the most effective use of resources. Morbidity incidence is the number of new cases of a given disease among the population over a certain period of time, usually expressed per 1,000. It is more useful to follow this than to keep a simple tally of cases, as trends can be followed over time, or compared with other situations. Morbidity incidence should be recorded as set out in Tables 3.1 and 3.2 in Annex 1.