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close this bookHandbook for Emergencies - Second Edition (UNHCR, 1999, 414 p.)
close this folder14. Health
View the document(introduction...)
View the documentOverview
View the documentIntroduction
View the documentHealth Assessment, Planning, Monitoring and Surveillance
View the documentMain Health Programmes
View the documentOrganization of Refugee Health Care
View the documentHuman Resources and Coordination
View the documentKey References
View the documentAnnexes

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;

· Experience 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 health.

3 Obstetrics: the branch of medicine concerned with childbirth and the treatment of women before and after childbirth.

Curative care

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.

Immunization

29. Measles has been documented as being responsible for excess loss of lives, particularly but not exclusively among children under five years of age.

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

· Emergency 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.);

· Communicable 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 emergencies are:

i. Measles,

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 Guidelines, 1995.

Diarrhoeal Diseases

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 breast-feeding;

iv. Reinforced home visiting and early case detection;

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 interventions.

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.

Measles

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).

Malaria

41. Malaria can also pose major problems. Its appropriate management and control is also a matter for experts and is based on the following:

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 sites;

iv. Vector control, including the distribution of insecticide-impregnated mosquito nets and periodic spraying, as indicated.

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 control.

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

Disease

Major contributing factors

Preventive measures

Diarrhoeal
diseases

Overcrowding, contamination of
water and food
Lack of hygiene

· adequate living space
· public health education
· distribution of soap
· good personal and food hygiene
· safe water supply and sanitation

Measles

Overcrowding
Low vaccination coverage

· minimum living space standards as defined in chapter
12 on site planning
· immunization of children with distribution of vitamin A.
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 conditions

Acute
respiratory
infections

Poor housing
Lack of blankets and clothing
Smoke in living area

· minimum living space standards and
· proper shelter, adequate clothing, sufficient
blankets

Malaria

New environment with a strain to
which the refugees are not immune
Stagnant water which
becomes a breeding area for
mosquitoes

· destroying mosquito breeding places, larvae and
adult mosquitoes by spraying. However the success
of vector control is dependent on particular mosquito
habits and local experts must be consulted
· provision of mosquito nets
· drug prophylaxis (e.g. pregnant women according to
national protocols)

Meningococcal
meningitis

Overcrowding in areas where
disease is endemic (often has local
seasonal pattern)

· minimum living space standards
· immunization only after expert advice when
surveys suggest necessity

Tuberculosis

Overcrowding
Malnutrition
High HIV prevalence

· minimum living space standards (but where it is en-
demic it will remain a problem)
· immunization

Typhoid

Overcrowding
Poor personal hygiene
Contaminated water supply
Inadequate sanitation

· minimum living space standards
· safe water, proper sanitation
· good personal, food and public hygiene and public
health education
WHO does not recommend vaccination as it offers only
low, short-term individual protection and little or no pro-
tection against the spread of the disease

Worms
especially
hookworms

Overcrowding
Poor sanitation

· minimum living space standards
· proper sanitation, good personal hygiene
· wearing shoes

Scabies6

Overcrowding
Poor personal hygiene

· minimum living space standards
· enough water and soap for washing

Xerophthalmia
Vitamin A
deficiency

Inadequate diet
Following acute prolonged
infections, measles and
diarrhoea

· adequate dietary intake of vitamin A. If not available,
provide vitamin A fortified food. If this is not possible,
vitamin A supplements
· immunization against measles. Systematic prophylaxis
for children, every 4-6 months

Anaemia

Malaria, hookworm, poor
absorption or insufficient intake of
iron and folate

· prevention/treatment of contributory disease
· correction of diet including food fortification

Tetanus

Injuries to unimmunized
population
Poor obstetrical practice causes
neo-natal tetanus

· good first aid
· immunization of pregnant women and subsequent
general immunization within EPI
· training of midwives and clean ligatures, scissors,
razors, etc.

Hepatitis

Lack of hygiene
Contamination of food and water

· safe water supply
· effective sanitation
· safe blood transfusions

STD's/HIV

Loss of social organization
Poor transfusion practices
Lack of information

· test syphilis during pregnancy
· test all blood before transfusion
· ensure adherence to universal precautions
· health
· availability of condoms
· treat partners

6 Scabies: skin disease caused by burrowing mites

Reproductive Health7

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 details.

45. Reproductive health care in refugee situations should be provided by adequately trained and supervised staff and should be guided by the following principle:

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 violence;

ii. Decrease HIV transmission by respecting universal precautions8 and guaranteeing the availability of free condoms;

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 possible;

v. Identify a person responsible to coordinate reproductive health activities under the responsibility of the overall health coordinator.

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 disease.

Safe Motherhood

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 HIV/AIDS9

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 Settings, 1996.

Family Planning

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.

Tuberculosis control11

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.

Mental Health13

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 powerlessness.

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 ensured.

13 World Health Organization and United Nations High Commissioner for Refugees. Manual of Mental Health of Refugees, 1996.

Capacity building

Health Education

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.

Training

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.

Medical supplies

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.

Laboratory Services

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 transfusion.