Main Health Programmes
· The main causes of
death and diseases in emergency situations are measles, diarrhoeas (including
cholera), acute respiratory infections, malnutrition and malaria (where
prevalent). Priority should be placed on programmes to reduce the negative
impact of these diseases;
· Other causes of
morbidity include tuberculosis, meningitis, vector-borne diseases, sexually
transmitted diseases including HIV/AIDS, pregnancy and obstetric3
complications, and childhood vaccine-preventable diseases;
· The emotional
stress of displacement, often compounded by harassment, violence and grief
suffered by the refugees will combine to deplete their physical and emotional
reserves and reduce their natural resistance to diseases;
underlines the importance of meeting the reproductive health needs of refugees,
and most particularly of women and adolescents;
· Early emphasis
should be placed on correcting environmental factors which adversely affect
3 Obstetrics: the branch of medicine
concerned with childbirth and the treatment of women before and after
26. The peak of curative medical care is at the early stage,
when refugees are most vulnerable to their new environment with the health
hazards it poses and before it has been possible to achieve any major public
health improvements. Even though curative care alone will not meet the objective
of reducing excess loss of lives, it will create confidence among the refugees
towards the health services.
27. Appropriate diagnosis and treatment protocols of major
diseases must be defined in accordance with national protocols, if they are
suitable to the refugee context. There may be some exceptions to this rule, but
implementation of refugee specific protocols should always be previously agreed
upon with national authorities.
28. Remember to take into account deaths occurring outside the
health care system. A commonly documented error, committed by even excellent
clinicians who have become absorbed in a health facility, is to fail to notice
that cemeteries are being filled by refugees dying in their shelters, without
having been identified or referred to receive appropriate curative services.
29. Measles has been documented as being responsible for excess
loss of lives, particularly but not exclusively among children under five years
Immunization against measles for young children is the only
essential immunization in the early stages of an emergency.
UNHCR advocates the immunization of children from 6 months up to
12 or even 15 years (rather than the more usual 5 years) because of the
increased risks from the living conditions in refugee emergencies.
30. The decision as to whether or not to undertake a measles
vaccination campaign at the onset of an emergency should be the responsibility
of an expert. The campaign should ideally be associated with, but not delayed
by, distribution of Vitamin A. The decision will be based on the vaccination
coverage reported in the country and area of origin and its reliability, and
whether there has been a recent epidemic or vaccination campaign. If there is a
need for a measles vaccination campaign, it should not be delayed until other
vaccines are available, and it should have appropriate mechanisms to ensure new
arrivals are vaccinated. The provision of vaccines should be discussed with
UNICEF (see the MOU between UNICEF and UNHCR, Appendix 3).
31. There are strong reasons, both medical and organizational,
not to have a mass immunization programme with all vaccines. The most common
causes of disease and death in the emergency phase cannot be cured or prevented
by immunizations (except measles). Mass immunization programmes require a large
number of workers, and vaccines need careful handling and controlled,
refrigerated conditions. Therefore undertaking such a campaign may represent a
misuse of time and resources in an emergency.
32. As soon as the emergency has stabilized there should be a
complete Expanded Programme of Immunization (EPI), which should form an integral
part of the ongoing long-term health programme. A standard EPI includes
diphtheria, pertusis and tetanus toxoid (DPT), oral polio (OPV), and BCG
(Bacille Calmette-Guerin) vaccines as well as measles. However, there should not
be a vaccination campaign against any of these (apart from measles), nor should
there be a complete EPI, unless the following criteria are met: the population
is expected to remain stable for at least 3 months; the operational capacity to
administer vaccine is adequate, and the programme can be integrated into the
national immunization programme within a reasonable length of time (see the MOU
between UNICEF and UNHCR, Appendix 3).
33. It is essential that adequate immunization records be kept.
At the very minimum, personal immunization (or "Road to Health") cards should be
issued. In addition, an independent central register of all immunizations is
desirable, to enable analysis of vaccination coverage.
Communicable Disease Control
conditions, particularly overcrowding, poor sanitation etc. will facilitate the
spread of communicable diseases;
· The aim is to
prevent, detect, control and treat diseases;
· Refugees are at
greatest risk if they are exposed to a disease against which they have not
acquired immunity (e.g. measles, malaria etc.);
disease outbreaks require an immediate on-the-spot expert investigation and
close coordination of the response with the national authorities, WHO and
partners as appropriate.
34. The main causes of death and morbidity among refugees in
ii. Diarrhoeal diseases,
iii. Acute respiratory infections,
iv. Malaria (where prevalent).
Moreover, the interaction between malnutrition and infection,
particularly among young children, contributes to increased rates of mortality.
Other communicable diseases - meningococcal
meningitis4, tuberculosis, sexually transmitted diseases (STDs),
hepatitis, typhoid fever, typhus and relapsing fever - have also been observed
among refugee populations. However, the contribution of these illnesses to the
overall burden of disease among refugees has been relatively small.
4 See World Health
Organization. Control of Epidemic Meningococcal Disease: WHO Practical
35. Diarrhoeal diseases represent a major public health problem
and acute epidemics of shigellosis (causing bloody diarrhoea dysentery) and
cholera, have become common in refugee emergencies and have resulted in excess
loss of lives. In risk areas, it is essential to set up appropriate preventive
measures as soon as possible. These measures include:
i. Adequate supply of potable water and an
appropriate sanitation system;
ii. Provision of soap and education on personal
hygiene and water management;
iii. Promotion of food safety and
iv. Reinforced home visiting and early case
v. Identification of an area ("cholera management
unit") to manage patients with cholera in case an epidemic occurs.
36. It is not possible to predict how a cholera outbreak will
develop. If proper preventive measures are taken less than 1% of the population
should be affected. Usually however, 1 to 3% are affected but in extreme cases
it can be more-even as much as 10%.
37. To be prepared to respond quickly to an outbreak, the above
preventive measures should be accompanied by the establishment of appropriate
protocols on case management. These protocols should be based on National or WHO
protocols and should be founded on rehydration therapy, continued feeding and
appropriate antibiotics (especially for shigellosis5). In addition,
there should be a reliable surveillance system for early detection of cholera
cases, to follow trends and determine the effectiveness of specific
38. A significant amount of material, financial and experienced
human resources are likely to be needed to respond to a cholera outbreak and
reduce the case fatality rate.
39. To facilitate an immediate response, cholera kits can be
obtained from the Supply and Transport Section at Headquarters at short notice.
Each kit can cover the overall management of some 500 cases. No efficient
vaccine to prevent cholera outbreaks is as yet available.
5 See World Health
Organization. Guidelines for the control of Epidemics due to Shigella
Dysenteriae Type 1, 1995.
40. WHO has classified refugees and displaced populations,
especially in camps, as groups at highest risk for measles outbreaks. Indeed,
this disease has been devastating in many refugee situations. Measles
vaccination coverage should be as close as possible to 100%, if not, measures
should be taken immediately to control the situation (see the MOU between UNICEF
and UNHCR, Appendix 3, and paragraphs on immunization above).
41. Malaria can also pose major problems. Its appropriate
management and control is also a matter for experts and is based on the
i. Early case detection and appropriate treatment.
It may be necessary to study drug resistance;
ii. Preventative treatment (chemoprophylaxis)
particularly for pregnant women;
iii. Elimination of vector breeding
iv. Vector control, including the distribution of
insecticide-impregnated mosquito nets and periodic spraying, as
42. Chemical control measures such as spraying, or impregnated
mosquito nets, may seem quite attractive but should only be taken upon expert
advice as several factors must be considered such as: the habits of the
refugees, seasonal variations, mosquito biting habits, transmission levels,
national protocols about chemicals and registered lists of chemicals, and cost.
Please see chapter 17 on environmental sanitation for guidance on vector
Acute Respiratory Infections
43. Pneumonia is the acute respiratory infection that has been
documented as a cause for excess mortality, most particularly in the under five
population. It is therefore essential to make sure that refugees are provided
with adequate shelter and blankets as soon as possible. Health staff must be
appropriately trained to diagnose and treat respiratory infections.
44. The more common diseases are outlined in table 2 below which
illustrates the environmental impact on disease and indicates those improvements
in living conditions which will bear directly on the health of the refugees.
Table 2 - Common diseases
Major contributing factors
Overcrowding, contamination of
water and food
· adequate living
· public health education
· distribution of soap
· good personal and food hygiene
· safe water supply and sanitation
Low vaccination coverage
· minimum living space standards
as defined in chapter
12 on site planning
· immunization of children with distribution of vitamin
Immunization from 6 months up to 12-15 years (rather
than the more
usual 5 years) is recommended because
of the increased risks from living
Lack of blankets and clothing
Smoke in living
· minimum living space standards
· proper shelter, adequate clothing,
New environment with a strain to
which the refugees are not
Stagnant water which
becomes a breeding area for
· destroying mosquito breeding
places, larvae and
adult mosquitoes by spraying. However the success
vector control is dependent on particular mosquito
habits and local experts
must be consulted
· provision of mosquito
· drug prophylaxis (e.g. pregnant women
Overcrowding in areas where
disease is endemic (often has
· minimum living space
· immunization only after expert
surveys suggest necessity
High HIV prevalence
· minimum living space standards
(but where it is en-
demic it will remain a problem)
Poor personal hygiene
· minimum living space
· safe water, proper
· good personal, food and public
hygiene and public
WHO does not recommend vaccination as
it offers only
low, short-term individual protection and little or no
tection against the spread of the disease
· minimum living space
· proper sanitation, good personal
· wearing shoes
Poor personal hygiene
· minimum living space
· enough water and soap for washing
Following acute prolonged
· adequate dietary intake of
vitamin A. If not available,
provide vitamin A fortified food. If this is not
vitamin A supplements
immunization against measles. Systematic prophylaxis
for children, every 4-6
Malaria, hookworm, poor
absorption or insufficient intake
iron and folate
· prevention/treatment of
· correction of diet
including food fortification
Injuries to unimmunized
· good first aid
· immunization of pregnant women and
general immunization within EPI
· training of midwives and clean ligatures,
Lack of hygiene
Contamination of food and water
· safe water supply
· effective sanitation
· safe blood transfusions
Loss of social organization
Lack of information
· test syphilis during
· test all blood before
· ensure adherence to universal
· availability of condoms
· treat partners
6 Scabies: skin disease caused by
7 See: United Nations High
Commissioner for Refugees. An Inter-agency Field Manual on Reproductive Health
in Refugee Situations, 1995.
UNFPA have developed a set of
reproductive health kits which can be used as part of a programme to deal with
reproductive health problems and the Health and Nutrition Unit or the Supplies
and Transport Section at Headquarters should be contacted for
45. Reproductive health care in refugee situations should be
provided by adequately trained and supervised staff and should be guided by the
Reproductive health care should be available in all
Situations and be based on refugee, particularly women's, needs and expressed
demands. The various religious, ethical values and cultural backgrounds of the
refugees should be respected, in conformity with universally recognized
international human rights.
46. The provision of quality reproductive health services
requires a collaborative effort by a number of sectors (health, community
services, protection, education) and organizations, which should provide
reproductive health services based on their mandates.
47. While resources should not be diverted from addressing the
problems of the major killers (measles, diarrhoeal diseases, acute respiratory
infections and malaria), there are some aspects of reproductive health which
must also be dealt with in the initial phase of an emergency. The major
objectives of reproductive health care in an emergency are to:
i. Prevent and manage the consequences of sexual
ii. Decrease HIV transmission by respecting
universal precautions8 and guaranteeing the availability of free
iii. Prevent excess neonatal and maternal morbidity
and mortality by providing clean home delivery kits, ensuring clean and safe
deliveries at health facilities and managing emergency obstetric complications
by establishing a referral system;
iv. Plan for provision of comprehensive reproductive
health services, integrated into Primary Health Care, as soon as
v. Identify a person responsible to coordinate
reproductive health activities under the responsibility of the overall health
48. As soon as feasible, when the situation has stabilized,
comprehensive reproductive health services based on the needs of refugees should
be put in place. These services should be integrated within the primary health
care system and should address the following aspects:
8 "Universal precautions" means
procedures and practices by health workers to limit transmission of
49. This should cover antenatal care, delivery care and
postnatal care. All pregnant women should receive antenatal care services during
pregnancy. All deliveries should be accompanied by a trained health care
provider. A referral system to manage obstetric emergencies should be put in
place. Within the first 4-6 weeks, mothers and their new babies should visit the
health services and receive nutritional supplements, counselling on child
spacing, and education about breast-feeding and infant care.
Prevention and Response to Sexual Violence
Please refer to chapter 10 on community services.
Sexually Transmitted Diseases including
50. Experience shows that HIV spreads fastest in
conditions of poverty and social instability - conditions which typify refugee
emergencies. The priority should be on preventing HIV transmission: ensure there
is respect for universal precautions and work closely with the community to
promote HIV prevention strategies including condom education and distribution.
Where blood transfusions are provided, ensure they are safe. Treatment of
sexually transmitted diseases should be a routine part of the health services
and should include appropriate follow up of partners.
Mandatory HIV testing in refugee circumstances, with the
single exception of testing blood for transfusion, is not justified, and WHO has
determined that, as a matter of policy, such testing should not be pursued.
9 United Nations High Commissioner for
Refugees, UNAIDS and WHO. Guidelines for HIV Interventions in Emergency
51. Family planning services should be initiated as soon as
feasible. Ensure that the refugees are informed and understand their free choice
in the matter.
Other Reproductive Health Concerns
52. Women who have complications such as spontaneous or unsafe
abortion should be cared for by the referral system.
53. Programmes to eradicate harmful traditional practices
including female genital mutilation should be implemented once the situation has
stabilized. It is crucial to work closely with the refugee community in tackling
this issue10. Culturally appropriate sanitary supplies should be
distributed to women as soon as possible. Inadequate sanitary protection may
prevent women from collecting material assistance.
10 See IOM/FOM (83/97: 90/97),
Policies on Harmful Traditional Practices, UNHCR, 1997.
Reproductive Health and Young People
54. Health workers should pay particular attention to meeting
the reproductive health needs of young people as they may be at greater risk and
have more limited access to appropriate services.
55. It is important to ensure that sufficient female health
workers are trained in reproductive health in order to provide culturally
appropriate health services including education in the community and at the
health facilities. At least some of these health workers should be recruited
from among the refugee community.
56. The prevalence of Tuberculosis (TB) has significantly
increased in recent years worldwide, but a TB control programme is not a
priority in the early stages of an emergency when mortality and malnutrition
rates are very high.
57. Expert advice and involvement of the National TB control
programme (often supported by WHO) are needed before starting a TB programme.
Bad planning and poor implementation could result in more harm than good.
58. To increase the chances of success, TB programmes should
only be started in stable situations, when Directly Observed Therapy12
can be implemented, when funds, drugs, reliable laboratory services and
trained staff are available.
11 World Health Organization and
United Nations High Commissioner for Refugees. Guidelines for Tuberculosis
Control in Refugees and Displaced Populations, 1996.
12 Directly Observed Therapy is where
the health worker is able to observe the treatment including that the medication
is taken correctly.
59. The psychosocial needs of refugees have often been neglected
or even forgotten. However, health services should aim to promote the highest
standard of both physical and mental health. It is easy to recognize that there
is a heavy burden placed upon refugees from, for example, physical violence,
grief and bereavement, fear and stress, an uncertain future and a sense of
60. Experience in identifying and dealing with the psychosocial
problems of refugees (including Post Traumatic Stress Disorders) is limited,
even so the following general guidance can be given. Any programme dealing with
mental health must be community-based with the refugees themselves playing a
major role. The programme must be based on a solid knowledge and understanding
of the refugees' cultural background and integrated with the other services
provided to refugees, and, from the outset, its long term sustainability must be
13 World Health Organization and
United Nations High Commissioner for Refugees. Manual of Mental Health of
61. The importance of health education is widely recognized.
However, there are significant difficulties in persuading those most at risk to
change long-established habits.
In the emergency phase, the priority topics should be those
directly related to the immediate public health problems.
62. Health education should therefore focus on the disposal of
human excreta and refuse, water management and personal hygiene. Many
governments and organizations produce simple health education materials that may
be useful. Trained refugee teachers and respected elders are likely to be more
effective than outsiders in communicating the basic principles and practices of
health to their own people. At a later stage, information, education and
communication should also be a major tool for the prevention and reduction of
sexually transmitted diseases including HIV.
63. As suggested by the definition of "emergency", extraordinary
mobilization of resources, including human, will be needed to cope with the
situation. Annex 2 sets out a suggested structure of the health service and
numbers and qualifications of staff needed. Full staff support including
community health workers, and health workers, doctors and nurses at health
centres, health posts and clinics, with the necessary qualifications and
experience, will not be instantly available.
Training will therefore be a cornerstone of an effective
health and relief programme.
64. Training activities must be well targeted to meet the
objective of the programme, and this is dependent on definition of roles and
responsibilities among various levels of health care and identifying the
necessary qualifications. Training must be part of the main health programme.
65. There must be a policy on essential drugs. The aim of the
policy will be to ensure a supply of safe, effective and affordable drugs to
meet priority needs of the refugees. The Health and Community Development
Section and the Supply and Transport Section at Headquarters issued an essential
drugs list which is used to order drugs for UNHCR operations.
66. In order to foster the appropriate use of drugs, standard
treatment protocols should be established. This will help rationalize
prescription habits among the various partners and organize training activities.
Protocols are usually based on national standards.
67. In the early stage of an emergency, it is often useful to
resort to pre-packaged emergency health kits. The best known is the New
Emergency Health Kit which has been developed through collaboration among many
agencies (WHO, UNICEF, MSF, ICRC, UNHCR and others). The contents of the kit are
intended to cover the needs of 10,000 people for 3 months during an emergency.
The kit can be obtained at short notice through the Supply and Transport Section
at Headquarters and can be used at the community level of health care and at
health centres. The emergency health kit should only be used in the early stage
of an emergency and not relied on for longer term needs.
68. As soon as possible, arrangements should be made for a
regular supply of appropriate quantities of essential drugs from the UNHCR
essential drugs list. The requests should be based on epidemiological
surveillance and disease patterns. The Supply and Transport Section can also
provide support for the purchase of drugs and their transport to the field.
69. It is of utmost importance to establish a system to monitor
drug consumption. In major operations, a full time pharmacist may be needed to
work with UNHCR. Over-prescription of medicines by health workers following
pressure by refugees is not uncommon in refugee emergencies.
70. Donations of unsolicited drugs are often a problem during
emergencies. A number of agencies (UNDP, UNHCR UNICEF, WHO, MSF and others) have
jointly developed guidelines on drug donations14 that provide donors
and users with a list of drugs and supplies which can be sent to emergency
situations. This is to help ensure that personnel in the field do not waste time
sorting out "useless" donations (small quantities of mixed drugs, free samples,
expired medicines, inappropriate vaccines, and drugs identified only by brand
names or in an unfamiliar language). UNHCR's policy is that overseas medical
supplies should be sent only in response to a specific request or after expert
clearance. The WHO Representative, local diplomatic missions and all others
concerned should be briefed accordingly.
14 WHO, Guidelines for Drug
Donations, May 1996.
71. Refugees are often remote from laboratory facilities.
However, very simple laboratory services at the site level are usually adequate.
72. Reference laboratory services are required for epidemic
management and control, (e.g., meningitis, shigellosis, cholera, hemoragic and
relapsing fevers, high malarial endemicity, hepatitis etc.) to confirm/clarify
diagnosis and perform antibiotic sensitivity. This should be discussed with the
national authorities and WHO. Where blood transfusions are provided, laboratory
services will be absolutely essential to test all blood for HIV before