Student Guide Module 2: Preventive Medicine in Humanitarian Emergencies Flood Scenario Problem based learning exercise objectives Identify the key elements for the assessment of a population following a disaster. Determine the needs of the affected population. Use the surveillance cycle. Identify the main modes of disease transmission for the displaced. Establish the intervention priorities in a disaster situation. Develop intervention strategies according to the disaster situation Case: Hurricane and flood in a coastal country A hurricane with excessive rainfall five times the normal volume caused considerable flooding in rural and urban coastal plains. More than 70,000 people living in the regional capital have been severely affected by the floods, along with an additional 100,000 people living in rural areas as estimated by flights over the region. The government has declared this region a disaster area. People living within the coastal strip are caught between the sea and the sea wall to the north and the conservancy in the south. The conservancies are huge flood plains surrounded by 12 flood dikes which retain water for agricultural purposes in the dry season. The dikes are now overflowing with water and although the military has been attempting to reinforce the dikes with sand bags, there is concern that a breach in the dikes could result in an additional four feet of water emptying into the flooded coastal zone. Most health centers in the regional capital are closed because they are flooded. The status of health centers in the rural areas is not accurately known. A large tent camp has been established on high ground with at least 10,000 people. Mostly families with children have sought refuge in the camp. People in the camp are currently surviving only on immediately available supplies. Two out of five water treatment plants were out of service. The pumping stations are pumping water 24 hours per day. Delivery trucks are in short supply. The water is being chlorinated, but the dosage is very low and the stock of chlorine is nearly depleted.
All the pit latrines, septic tanks and drainage canals are flooded. People are now commonly using buckets and emptying the contents into the flood water. Raw sewage in the flooded waters as well as rodents and snakes are major problems. The government has declared a humanitarian emergency and a Health Emergency Operations Center (HEOC) has been established in the Ministry of Health (MoH), which is led by the Disaster Coordinator. You have been asked by the coordinator to organize a team to fly to the area by helicopter, visit the camp and carry out a rapid assessment to determine how best to respond to the situation. 1) What type of personnel need to be a part of this assessment team? (2 min) Scenario continued: On arrival at the camp you note several NGOs who have been working the country have responded by bringing in tents and food. There are now over 10,000 people in the camp. There is 1 clinic that has been set up by an NGO Cases of malaria are being diagnosed at the clinic. People are defecating in a nearby flood water, which most people are also using for drinking water. There is almost no security in the camp and many families are frightened. You have a satellite phone and file your first report to the disaster coordinator even before beginning your structured assessment. 2) What are the most immediate needs? (3 min) Scenario continued: You assign members of your team to carry out a rapid population assessment and emergency needs assessment. For each they need to complete a chart that has been developed as a tool for these assessments. The emergency (rapid) need assessment helps determine basic population needs and resources in order to meet those needs. It also helps identify gaps between needs and available resources, which are outlined below. 3) What are the major areas and their key elements that need to be included in the population assessment chart? (5 min)
4) What are the major areas and their key elements that need to be included in the emergency (rapid) needs assessment chart? (10 min) Scenario continued: (5 min) 2 weeks after your rapid assessment report was filed you return to the area with a mobile health assessment team to conduct a rapid, two-hour assessment. You visit the camp and a clinic. The area of the camp is 200 square meters. In the camp families and friends seem to be arranged together and share cooking fires. The fuel source appears to be wood from furniture recovered from the flood water. It is extremely smoky because of the large number of open fires. You first meet with an aid worker who is helping to organize the camp and the 2 doctors and 4 nurses who provide care at the medical clinic. You find that they have conducted a census and gathered the following demographic data: Total Population 0-4 years 5-15 years >15 years Total Male Fem Total Male Fem Total Male Fem Total Male Fem 10090 4830 5260 1720 820 900 3440 1650 1790 4930 2360 2570 There are 360 known pregnant women; an unknown number of unaccompanied children, and a total of 630 people older than 60 years 440 of these are women and 190 are men. Injured people are mostly children with burns or minor trauma. There is neither electricity nor running water. The nurses have a small stock of basic medications and clinic supplies as well as a centrifuge for measuring hemoglobin and a microscope. The nurses report that they have primarily now been seeing children with diarrhea, fever, skin infections, cough and other respiratory symptoms.including asthma. They see lacerations and minor trauma from people going in to the flood waters. There have been a number of deaths reported, 20 victims (10 elderly, 10 children including 1 newborn with respiratory symptoms). They are recording patients and the presumed diagnosis or chief complaints on paper. The people in the camp were rural small farmers, laborers and herdsmen with limited access to health care. Childhood malnutrition rates were quite high. Immunization rates were less than 60%.
Access to maternity care is also limited and a higher than expected number of pregnancies have stress related complications such as preeclampsia and premature delivery.. Water is supplied by carrying water from the flood waters in buckets and other containers. Boiling is the only safe and available water treatment, but most people are not doing this because of the difficulty and fuel scarcity. Not enough latrines have been built and women complain that they do not feel safe going to the latrines. As a result many defecate in the flood waters. Garbage is either burned or dumped outside the tents. Food is mostly boiled rice or wheat mush prepared from emergency stores that have arrived irregularly by helicopter. Food is supplemented by supplies families brought with them. There is no consistent food distribution system, with people grabbing whatever they can when a supply arrives. The nurses suspect that the elderly and single mothers are particularly at risk for not getting food from the emergency supplies. Food is prepared by individual family groups using available water and cooking over open fires. Some people do not have access to a fire or equipment to cook and are eating uncooked mush. There is little or no soap. Despite the smoke, flies and mosquitoes are present. Children going into the flood waters to fish risk snake bites. There is no particular order in the tent city with families and friends banding together to protect each other, but no security forces or organized leadership. 5) What modes of disease transmission are potentially the most important in this camp? Case progression: Conducting surveillance and making quick decisions After completing your assessment of the camp and health care center you suggest that the nurses and community health workers (CHW) establish a surveillance system by keeping a log of all patient encounters, births, deaths, arrivals and departures in the camp. You would like to review it after 1 week. During that week the rains have continued and some additional bulk food supplies were delivered to the camp, but little else has changed. One week later you collect the log and use it to complete the Weekly Surveillance Reporting Form you intend to submit to the Ministry of Health (MoH) regional disaster coordinator.
Divide into 2 groups and review either log A or B 6) Identify the 4-5 most significant public health concerns based on the information in the weekly surveillance reporting form (log A or B). (10 min + 5 min discussion) 7) Prioritize these concerns according to which are most likely to result in the greatest amount of preventable mortality if not immediately addressed. (10 min) 8) What are the most feasible intervention strategies to address the most significant health concerns you identified in the exercise? (10 min)
Handout 1 Based on the acquired knowledge, identify the key elements of the population assessment. Demographics - Total number of people in population - Population Structure: Age groups (0-4, 5-15, >15 years) and sex - Vulnerable Groups: Pregnant and Lactating Mothers, children <5years,unaccompanied children, elderly and injured Pre-disaster health conditions - Prevalence of chronic diseases, malnutrition rates, prevalence of infectious diseases, vaccination coverage and access to health care
Healthcare system evaluation - Physical condition of buildings and durable medical equipment - Numbers and types of health workers - Non-durable supplies and medications - Condition of electricity, clean water and sewerage at healthcare facilities - Is surgical or in-patient care possible? - Condition of cold chain and vaccines - Is a system of disease surveillance functioning? Condition of other community resources - Physical condition of buildings and durable medical equipment - Numbers and types of health workers - Non-durable supplies and medications - Condition of electricity, clean water and sewerage at healthcare facilities - Is surgical or in-patient care possible? - Condition of cold chain and vaccines - Is a system of disease surveillance functioning?
Handout 2 Carry out the emergency (rapid) needs assessment. Water Quantity Where are the primary sources? Stability Quality? Water cleaned and purified? Distribution system Nutrition Quantity Food sources, security, storage, distribution system and acceptability Malnutrition rates in sentinel population (under 5 years) Shelter Covered floor space Total Sanitation System for disposal of human waste
Number of latrines or toilets per person; condition and acceptability Water and soap for personal hygiene Food preparation Environmental conditions Risks: Slope, water drainage; smoke, unsafe buildings Presence of pollution/ contaminants in water or air Garbage disposal methods Insect vectors and other dangerous animal / plant life Health needs Crude mortality rates Under 5 years mortality rates Morbidity