FETP Thailand June 2007 Dr. Augusto Pinto CDS/CSR Bangkok sub-unit - - PowerPoint PPT Presentation

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E P I D E M I C A L E R T A N D R E S P O N S E

Epidemiological surveillance and response in humanitarian crisis

• Dr. Augusto Pinto

CDS/CSR Bangkok sub-unit WHO-SEARO

FETP Thailand June 2007

E P I D E M I C A L E R T A N D R E S P O N S E

Cours objectives

To present the tools for epidemiological surveillance in humanitarian crisis

Rapid assessment of health conditions Surveillance/EWAR system Response thorugh practical examples

E P I D E M I C A L E R T A N D R E S P O N S E

Contents

A- Problem B- Initial assessment C- Surveillance/response in emergency phase D- Phase of consolidation E- Conclusion

E P I D E M I C A L E R T A N D R E S P O N S E

E P I D E M I C A L E R T A N D R E S P O N S E

Complex emergency situations

Poor countries Disruption of: Public health infrastructures and services Changes in: Supplies Housing Communication Transportation Political context Environment Security

E P I D E M I C A L E R T A N D R E S P O N S E

Complex emergency situations

Man made or natural War, forced migrations Drought, famine Hurricane, earthquakes, floods, etc. Population displacement Internally (IDPs), refugees Increased population density & size

Indonesia 2004-05 Darfur 2003-04 Tchechnia 2000 Kosovo / Albania 1999 Rwanda / Zaire 1994 Somalia 1979-81, 1992 Ethiopia / Sudan 1984-85 Cambodia / Thailand 1975

E P I D E M I C A L E R T A N D R E S P O N S E

The ten most deadly conflicts The ten most deadly conflicts

• riginating in the 1990s
• riginating in the 1990s

Conflict Years Estimated No

• f deaths (range)

Rwanda 1994 500,000 - 1,000,000 Angola 1992-94 100,000 - 500,000 Somalia 1991-99 48,000 - 300,000 Bosnia 1992-95 35,000 - 250,000 Liberia 1991-6 25,000 - 200,000 Burundi 1993 30,000 - 200,000 Chechnya 1994-6 30,000 - 90,000 Tajikistan 1992-9 20,000 - 120,000 Algeria 1992-99 30,000 - 100,000 Gulf war 1990-1 4,300 - 100,000

Source: Murray et. Al, 2002

Tsunami 2004-05: > 300000 deaths Darfur 2003-05: > 200000 deaths ?

E P I D E M I C A L E R T A N D R E S P O N S E

Exercise Exercise (10 minutes)

(10 minutes)

WHAT TO DO?

E P I D E M I C A L E R T A N D R E S P O N S E

The 10 priorities in emergency

• 1. Rapid assessment of health status
• 2. Mass immunization against measles
• 3. Environmental hygiene and water availability
• 4. Food availability
• 5. Shelter
• 6. Case management, therapeutic protocols
• 7. Prevention and control of epidemic prone diseases
• 8. Health information system (public health)
• 9. Human resources
• 10. Coordination of interventions

source : Refugee Health, MSF

E P I D E M I C A L E R T A N D R E S P O N S E

Contents

A- The problem B- Initial assessment (RHA) C- Surveillance in emergency phase D- Consolidation phase E- Conclusion

E P I D E M I C A L E R T A N D R E S P O N S E

RHA: what is it for? RHA: what is it for?

The rapid but structured collection of relevant information to:

– Confirm the emergency, and judge its relative severity by assessing its impact, – identify the basic needs of the population that require immediate response, – prioritize the required interventions and resources, – help mobilize additional, urgent resources, and – define the aspects and the areas for which there is the need for more detailed assessments and follow-up

adapted after Ockwell, 2002

E P I D E M I C A L E R T A N D R E S P O N S E

RHA: its core elements / features RHA: its core elements / features

• speed: a short interval between data collection and

presentation of results,

• combination of various methods and sources of data, and
• rientation towards decision / action

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E P I D E M I C A L E R T A N D R E S P O N S E

Rapid Health Assesment

Basic needs Denominators Health risks

E P I D E M I C A L E R T A N D R E S P O N S E

Exercise Exercise (5minutes

(5minutes)

)

What kind of NEEDS do you think they need?

E P I D E M I C A L E R T A N D R E S P O N S E

Basic needs

Definition of basic needs

• Water
• Sanitation
• Nutrition
• Shelter
• No food items
• Health care
• Others

How do you want to quantify/ To measure them? (5 minutes)

E P I D E M I C A L E R T A N D R E S P O N S E

Basic needs

Water

• Nb of liters water/person

Sanitation

• Nb persons or families/ latrine

Shelter

• Nb of person / shelter
• m2 habitable/person

No food items

• recurrent soap, fuel
• not recurrent blankets,

cook tools, jerricans… Nutrition

• Nb Kcalories / person / day
• Type of food
• contents in Fat, Protein, Carboidrats

Health care

• Accessibility to health centres (time,

cost, acceptability)

• Ratio personnel beds/patient

Others

E P I D E M I C A L E R T A N D R E S P O N S E

Some indicators of reference

Quantity of water

• 15-20 litres/p/day

(min 5 litres the first days) Latrines

• 1family/latrine (20 pers./latrine)

Access to water

• 1 hand pump / 500-750 pers.
• 250 persons / tap

Shelter Surface

• 30 m2 /pers. In the camp/area
• 3,5 m2 /pers. In the shelter

(source : Refugee Health, MSF)

Caloric ratio

• 1900 - 2100 kcal / pers / day

Measles coverage

• 100% of <15 years

Crude mortality rate

• <1 death / 10.000 / day

E P I D E M I C A L E R T A N D R E S P O N S E

HOW to know? HOW to know?

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E P I D E M I C A L E R T A N D R E S P O N S E

Rapid Health Assesment

Basic needs Denominators Health risks

E P I D E M I C A L E R T A N D R E S P O N S E

Denominators

Definitions of denominators

• Populations displaced/refugees in camps
• Populations displaced/refugees with local population
• Local Population

Nature of information

• Size and structure of population

E P I D E M I C A L E R T A N D R E S P O N S E

Kosovar refugees, in Albania, april 1999 tractors camp(Kukës) Kosovar refugees, in Albania, april 1999 tractors camp(Kukës)

E P I D E M I C A L E R T A N D R E S P O N S E

Kosovars refugees, Albania april 1999 : Tents shellter in organized camp Kosovars refugees, Albania april 1999 : Tents shellter in organized camp

E P I D E M I C A L E R T A N D R E S P O N S E

Kosovar refugees, Albania 1999 Hosted by local families Kosovar refugees, Albania 1999 Hosted by local families

E P I D E M I C A L E R T A N D R E S P O N S E

E P I D E M I C A L E R T A N D R E S P O N S E

Abushok camp, El Fasher town, North Darfur Sudan 2004 IDPs Camp

E P I D E M I C A L E R T A N D R E S P O N S E

IDPs settlement, Ryad village, El Geneina, West Darfur Sudan 2004 IDPs and Local population

E P I D E M I C A L E R T A N D R E S P O N S E

Kalma camp, Nyala, South Darfur, Sudan 2004 Spontaneus and self made shelters

E P I D E M I C A L E R T A N D R E S P O N S E

El Fasher town, North Darfur, Sudan 2004 IDP spontaneus concentration

E P I D E M I C A L E R T A N D R E S P O N S E

HOW MANY? HOW MANY?

How do you count them???????

10 minutes brain storming

E P I D E M I C A L E R T A N D R E S P O N S E

Denominators in a camp or open area

3 key indicators

• Total surface occupied
• Surface occupied by a shelter
• Shelter population density

4 steps Phase I Cartography – define the borders of the camp Phase II Topography – Spatial organisation of camp Phase III Density in one « surface sample »

• quadrats method
• T square method
• Interpolation

Phase IV Extrapolation to entire camp

E P I D E M I C A L E R T A N D R E S P O N S E

Phase I - Cartography

Classic method : with compass

• reliable in all situations
• Map paper
• biais linked with observer

Alternative method: Global Positionning System (GPS)

• faster
• Electronic map
• biais link with observer + instrument

E P I D E M I C A L E R T A N D R E S P O N S E

Utilization of GPS

a)

Starting from a corner

b)

Adjust the GPS

• In UTM
• in latitude / longitude

c)

Note the coordinates

d)

Move to the next corner

e)

Note the coordinates

f)

Repeat on all perimeter

Latitude 39º38'91" N Longitude 104º40'52"W

E P I D E M I C A L E R T A N D R E S P O N S E

Phase II - Topography

Ideal : air picture or satellite image

E P I D E M I C A L E R T A N D R E S P O N S E

Phase II - Topography

Family shelters Water pumps Collective shelters Health structures patways

Ideal : air picture or satellite image

E P I D E M I C A L E R T A N D R E S P O N S E

Phase II - Topography

Water pumps High density Collective shelters Health structures patways Low density

In practice: definition of zone of density

E P I D E M I C A L E R T A N D R E S P O N S E

Methods Methods

Quadrats T-Squared Interpolation (ongoing study)

E P I D E M I C A L E R T A N D R E S P O N S E

Utilisation of GPS with a GIS

Kalma camp South Darfur

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Random Random sampling sampling using using GIS GIS

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Quadrats Quadrats method method

The principle of the QUADRAT method is to count the average population living in a square blocks of known surface than obtain total population figures extrapolating the average population per block for the total surface

E P I D E M I C A L E R T A N D R E S P O N S E

Material and human resources

• 2 strings or plastic tape of 25 meters
• 4 wood piles
• 3 people
• 1 compass

25m 25m 25m 25m

Quadrats Quadrats method method

E P I D E M I C A L E R T A N D R E S P O N S E

Quadrats Quadrats method method Inclusion criteria Inclusion criteria

Inside Inside Outside Outside

E P I D E M I C A L E R T A N D R E S P O N S E

T T-

• Squared

Squared

Material and human resources

• 1 Deca-meter
• 3 people
• 1 tele meter

E P I D E M I C A L E R T A N D R E S P O N S E

T T-

• squared

squared

Is based on the estimation

• f household density which

is than extrapolate to the total surface

E P I D E M I C A L E R T A N D R E S P O N S E

Extrapolation to Extrapolation to the the total area total area

Quadrats method

(x) people/square (mean) X (n) squares in 1 area X refugees (y) Family shelter /square (mean) X (n) squares in 1 area Y families after add the estimation of each area

T-square method

) 2 1 ( 2

2 1 2 ^ i m i i T

z x m + =

∑

=

π γ

m SE

T T

2 ) (

^ ^

γ γ =

T

S N γ =

E P I D E M I C A L E R T A N D R E S P O N S E

Some results Some results appliying appliying Quadrat Quadrat and T square and T square

Golden standard: 9479 (Mozambique) Quadrat: 7681 (CI 95%: 6160-9203) T square: 9523 (100.4%)

Grais F. et Al. Disasters 2005

Homogeneity of population Quadrat : 15-17 points T square :45-50 points Quadrat: design the quadrat T square : intrusive,

structure Houses

E P I D E M I C A L E R T A N D R E S P O N S E

Interpolation Interpolation

Closer values have a higher probability to be more similar than more distant measurements.

Interpolation methods have been employed mostly for continuous data, as in the spatial distribution of temperature, rainfall, soil and groundwater chemistry pollution concentrations, lead poisoning, etc.

E P I D E M I C A L E R T A N D R E S P O N S E

Interpolation Interpolation

25m 25m

Material and human resources

• 1 strings or plastic tape of 25 meters
• 1 wood pile
• 2 people

E P I D E M I C A L E R T A N D R E S P O N S E

Count Count Households Households

25m 25m

Inside Inside Inside Outside Outside

E P I D E M I C A L E R T A N D R E S P O N S E

Comparing Comparing results results of

• f the

the three three methods methods

E P I D E M I C A L E R T A N D R E S P O N S E

Interpolation: Interpolation: Strenghts Strenghts/limits /limits

Easy to implement Not intrusive Few points 10-15 Quick Accept zero values

Still linked to expensive GIS Computation still laborious

E P I D E M I C A L E R T A N D R E S P O N S E

Running Ordinary Running Ordinary Kriging Kriging to interpolated surface to interpolated surface

Running Kriging on the shapefile by using the value of population density Generate the interpolated surface on the study area

The interpolated surface represent the population density in the study area

E P I D E M I C A L E R T A N D R E S P O N S E

Using the grid points to extract the population value from the i Using the grid points to extract the population value from the interpolated surface nterpolated surface

X Y Predicted StdError Error Stdd_Error 530211.87 1477944.04 0.00000000000 0.00250103099 0.00000000000 0.00000000000 530241.87 1477944.04 0.00000000000 0.00219448208 0.00000000000 0.00000000000 530211.87 1477974.04 0.00000000000 0.00222658854 0.00000000000 0.00000000000 530241.87 1477974.04 0.00006889087 0.00175459122 0.00006889087 0.03926320054 530271.87 1477974.04 0.00000000000 0.00127230458 0.00000000000 0.00000000000 530301.87 1477974.04 0.00008977212 0.00167010604 0.00008977212 0.05375234601

Each record represents a point that hold data

• n the predicted population density.

Calculate the population based the grid size (e.g. for 30m grid: Estimated population = sum of Predicted pop value * 30* 30) Predicted population density Using GIS to extract value from the interpolated surface

Create a point layer of 30 * 30 sq. meters over the study area

E P I D E M I C A L E R T A N D R E S P O N S E

Denominators: dynamic process

Recording flow

• Arrival (reception centre) and living (back home)
• Estimate the flow of population in and out

Monitoring the demography of the camp

• Number of daily deaths
• Number of births

E P I D E M I C A L E R T A N D R E S P O N S E

Recording the flow of refugees living Rwanda (Tanzanian border 1994) Recording the flow of refugees living Rwanda (Tanzanian border 1994)

E P I D E M I C A L E R T A N D R E S P O N S E

Pause Pause

E P I D E M I C A L E R T A N D R E S P O N S E

Contents

A- The problem B- Initial assessment C- Surveillance/response in emergency phase D- Consolidation phase E - Conclusion

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

What is surveillance? What is an Early WArning Response System?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Definition Definition of

• f Epidemilogical

Epidemilogical surveillance surveillance

Continue collection and systematic analysis and interpretation of health data for planning, implementation and evaluation of public health actions timely diffusion of this data to decision makers final step prevention and control of diseases and accidents

Thacker SB. Surveillance. In : Gregg MB, editor. Field Epidemiology. New York : Oxford University Press, 1996:16-32.

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Definition of EWAR Definition of EWAR

An EWAR can be defined as the functions of an integrated surveillance system aiming to detect any abnormal health event and to provide an adequate and timely response

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHEN implement Focus on WHAT?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Surveillance in Surveillance in humanitarian humanitarian crisis crisis situation situation

As soon as possible In emergency phase: to focus essentially on

• Major health problems
• Health events to whom we can implement a response

System flexible: to adapt to new needs

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHY? (Objectives)

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Objectives Objectives of

• f EWAR

EWAR

General

Control morbidity and mortality due to epidemic prone diseases

Specifics

• Detect unusual conditions(epidemics)

in need of intervention/response of public health

• Provide reliable data (indicators) to

WHO/MOH/Humanitarian partners to adjust public health intervention

• Evaluate the workload of health structures

to optimize the resource allocation

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHAT? ( prioritize, tsunami)

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Pre Pre-

• existing communicable disease risks in Sumatra

existing communicable disease risks in Sumatra 2005 2005

Cholera Diarrhoea Typhoid fever Leprosy Tetanus Dengue fever Diphtheria Measles AFP Filariasis Syphilis Gonorrhoea Pneumonia Neonatal tetanus Tuberculosis Aids Viral hepatitis Influenza Meningitis Malaria

E P I D E M I C A L E R T A N D R E S P O N S E

CD risk prioritization CD risk prioritization

Cholera Diarrhoea Typhoid fever Leprosy Tetanus Dengue fever Diphtheria Measles AFP Filariasis Syphilis Gonorrhoea Pneumonia Neonatal tetanus Tuberculosis Aids Viral hepatitis Influenza Meningitis Malaria

E P I D E M I C A L E R T A N D R E S P O N S E

Risk Risk assessment assessment

Pre-existing situation (country of origins/hosting)

• Normal morbidity
• Immunization status
• Recent or current epidemics (before living)

Risk linked to the specific situation

• War situation or natural disaster
• Precarious condition (water, food, care)
• Concentration of population
• Epidemic in the hosting region or country

E P I D E M I C A L E R T A N D R E S P O N S E

Darfur, Darfur, Sudan Sudan May 2004 May 2004

Epidemic prone diseases

• Polio,measles, cholera
• Malaria, yellow fever
• Meningitis

Diseases linked to precaroiuseness

• diarrhea, shigellosis (disentery)
• hepatitis
• Respiratory infections
• Malnutrition

Vector born diseases

• Malaria
• Visceral Leishmaniosis

E P I D E M I C A L E R T A N D R E S P O N S E

Hurricane Mitch, Central America, 1998

Epidemic prone diseases

• Cholera

Diseases linked to the precariouseness Diseases linked to the kind of disaster Other risks out of CD?

• Diarrhoea
• Respiratory infection
• Tetanus, skin diseases
• Leptospirosis (rats)
• Dengue, malaria (mosquitos)

Toxic/chemical risk (factory destruction)

E P I D E M I C A L E R T A N D R E S P O N S E

Kosovar refugees in Albania, 1999

Epidemic prone diseases

• polio, anthrax…
• measles, cholera

Diseases linked to the precariouseness

• diarrhea, shigellosis (disentery)
• hepatites
• Respiratory infections

Chronic diseaes

• hypertension
• Hearth insufficience
• diabetes

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

How standardize the case detection?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Health event Definition

Acute Watery Diarrhoea Acute watery diarrhoea with severe dehydration in a patients older than five years of age . Diarrhoea with blood (Dysentery) More than 3 loose stools per day (24 hours) with visible blood Acute respiratory infection Fever and at least one of the following : rhinitis, cough, redness or soreness of throat OR Fever and fast breath (> 50 breaths/min) and at least one of the following : cough, difficulty in breathing Suspected Measles Rash with fever and cough, runny nose or conjunctivitis Acute Jaundice syndrome Acute onset of yellows eyes or skin Suspected meningitis 12 months and over: sudden onset of fever (> 38° C) with stiff neck Under 12 months: fever with bulging fontanel AFP Acute flaccid paralysis in a child aged < 15 years, including Guillain Barré syndrome or any acute paralytic illness in a person of any age. Malaria Person with fever or history of fever >38°C within the last 48 hours with one or more of the following symptoms: such as nausea, vomiting and diarrhoea, headache, back joint pain, chills, myalgia) with positive laboratory test for malaria parasites blood film (thick or thin smear) or rapid diagnostic test . Neonatal tetanus Suspected case: Any neonatal death between 3 and 28 days of age in which the cause of death is unknown or any neonate reported as having suffered from neonatal tetanus between 3 and 28 days of age and not investigated Confirmed case: Any neonate with a normal ability to suck and cry during the first two days of life, and who between 3 and 28 days of age cannot suck normally, and becomes stiff or has convulsions or both Injuries Any person with traumas or wounds from any cause that require surgical treatment and hospitalisation Severe malnutrition Malnutrition: In children 6 to 59 months (65cm to 110cm in height): <70%Weight for height (W/H) index OR < –3z scores (on table of NCHS/WHO normalized reference values of weight-for-height by sex). OR MUAC < 11 cm Bilateral pitting oedema irrespective of W/H, in absence of other causes. Unexplained fever Fever (> 38°C) for more than 48 hours and not meeting the above case definitions Others All others medical conditions not meeting the above case definitions This category is used to compute Total Attendance

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

HOW? Design framework

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Detecting threatening health events Detecting threatening health events Surveillance components Surveillance components

Report Data Public health alert

Capture Filter Verify Collect Analyse Interpret Assess

Surveillance: Response Event-based Indicator-based Post-outbreak strengthening

Evaluate Investigate Control

Signal

Strengthen

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHAT should be the main attribute of the EWAR system?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Main attributes of EWAR in CE Main attributes of EWAR in CE

Simplicity Sensitivity Flexibility Acceptability Timeliness Feasibility

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHAT VARIABLES COLLECT?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Surveillance/EWAR record

Sensible: Syndroms Rumors detection Simple:

• Standard forms
• 12 syndroms
• 2 age groups
• Cases and deaths
• Data entry/analysis

Epidata/EpiInfo

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHERE to collect these VARIABLES? WHO should collect ?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Data Data flow flow

Define data and specimen flow, decentralization

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHICH frequency for data/information transmission?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Weekly epidemiological bulletin Weekly epidemiological bulletin

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

How to facilitate data transmission and standard data analysis?

5 minutes

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E P I D E M I C A L E R T A N D R E S P O N S E

E P I D E M I C A L E R T A N D R E S P O N S E

PC application for data management PC application for data management

• Simple
• Immediate understanding
• Ensure quality of data
• Facilitate the response

for outbreak control

E P I D E M I C A L E R T A N D R E S P O N S E

Phases in Phases in the the process process

PHASE 6 : Ensure prompt analysis and standard report production at state and federal level

– Simple computer application) at local and central level – Database files sent by e-mail from state to federal level every Saturday – Production of MMWR every Sunday for weekly health meeting with all partners at central level

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

WHAT indicators to produce?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

• Number of new cases and deaths for each health

event by week

• Total attendance per week
• Case Fatality Ratio for each health event
• Proportional morbidity by age groups (0-4

and 5+)

• Distribution of new cases by geographical

level

• Distribution of new cases by age groups and

geographical level

• Number of deaths by age and geographical

level,

• Number of health facilities reporting/number
• f health facilities expected to report
• Incidence of health events by week and

geographical level

• Under Five years Mortality rate per 10,000

population per week

• Crude Mortality rate per 10,000 population per

week

• Timeliness from camps to the state
• Timeliness from the state to the federal level
• Completeness of the reporting units
• State
• Administrative Unit
• Camp

Weekly

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Health Health structures structures reporting reporting Darfur, Darfur, weeks weeks 21 to 30, 2004 21 to 30, 2004

Number IDPs camps (129) Number of reporting units weeks

• Fig. 3: Weekly number of reporting units in Greater Darfur, from week 21 to 30, 2004

5 10 15 20 25 30 35 40 45 21 22 23 24 25 26 27 28 29 30 weeks reporting units

Phase 8: produce outputs

E P I D E M I C A L E R T A N D R E S P O N S E

Outbreak Outbreak detection detection/ / lab lab

F ig . 4 : N u m b e r o f c a s e s

• f B

lo

• d

y d ia rrh

• e

a in A b u S h

• a

k c a m p , N

• rth

D a rfu r, fro m w e e k 2 1 s t to 3 th , 2 4

.0 5 .0 1 .0 1 5 .0 2 .0 2 5 .0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 w e e k s

Fig 5: Number of cases of Acute Jaundice in Morni, West Darfur, from week 21 to week 30, 2004 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 21 22 23 24 25 26 27 28 29 30 weeks

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

HOW to trigger a signal?

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Case Case definiton definiton thresholds thresholds definition definition

Agreement on thresholds to trigger actions:

– 1 case of measles, – 1 case of AFP, – 1 case of severe malnutrition, – 1 case of NNT, – Doubling cases of meningitis in two weeks (minimum 2 cases) – Unusual deaths in patients older > 5 presenting watery diarrhoea – Any unexpected health event (e.g. cluster of severe diseases, cluster of deaths)

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

How to support laboratory diagnosis

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Laboratory Laboratory support support Selection and agreement with National PHL in Khartoum as reference laboratory (enrolled in Lyon programme) Strenghtening diagnosis capacities Positioning media transportation Selection of private carrier (Polio) Information to all partners Allocation of budget

E P I D E M I C A L E R T A N D R E S P O N S E

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

INTERPRETdata analysis

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Bloody diarrhoea by age group, Weeks 15-19, 1999, Albania

200 400 600 800 1000 1200 1400 15 16 17 18 19

< 5 ans 5 ans et + 10 20 30 15 16 17 18 19 < 5 ans 5 ans et + 1 2 15 16 17 18 19

Proportional morbidity Diarrheas / cardiovascular Number of reported cases

E P I D E M I C A L E R T A N D R E S P O N S E

Health structures notifying and consultations notified Albania, weeks 15 to 19, 1999

20 40 60 80 100 120 140 15 16 17 18 19 ONG

• Min. de la santé

5000 10000 15000 20000 25000 30000 15 16 17 18 19

Numbers of consultations Numbers of health structures Weeks Weeks

E P I D E M I C A L E R T A N D R E S P O N S E

Number of cases and deaths in Abushok weeks 21-27, North Darfur

20 40 60 80 100 120 140 160 180 200 220 240 21 22 23 24 25 26 27 weeks BLDIAR DEATHS

Laboratory Confirmed 3 cases Sh. Dys. 1 30 june 5 deaths Under five Increase population 26800 -> 35040

E P I D E M I C A L E R T A N D R E S P O N S E

Collection of mortality data

Kalma Camp (Pop. 73658), South Darfur, weeks 24-32, 2004

Prospective data collection Retrospective survey

deaths/10000/jour deaths/10000/jour

0.28 3.8 (IC 2.9 – 5.0)

E P I D E M I C A L E R T A N D R E S P O N S E

Public Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases EWAR EWAR system system

HOW to organize a response system

5 minutes

E P I D E M I C A L E R T A N D R E S P O N S E

Activate rumors verification and facilitate prompt response

– Participation of community leaders in camps – Definition of simple Thresholds to trigger actions at peripheral level – Definition of investigation and response teams – Allocation of specific budget for response

Phases in Phases in the the process process

E P I D E M I C A L E R T A N D R E S P O N S E

Protocol Protocol of

• f surveillance in emergency,

surveillance in emergency, document document the the system system

Population under surveillance Type of the system Case definition Threshold definition Data to be collected Indicators to be produced Reference laboratory Reporting system Specimen transport system Data quality control Feedback production

E P I D E M I C A L E R T A N D R E S P O N S E

Contents

A- The problem B- Initial assessment C- Surveillance/response in emergency phase D- Consolidation phase E - Conclusion

106

E P I D E M I C A L E R T A N D R E S P O N S E

Phase of consolidation

• Lessons learned
• Revision of objectives
• Training of actors
• Integration in the national system

E P I D E M I C A L E R T A N D R E S P O N S E

Training Training of

• f national cadres

national cadres

E P I D E M I C A L E R T A N D R E S P O N S E

Conclusion Conclusion

Based on a short list of priority diseases Minimum response capacity in place, including laboratory Mortality, whenever feasible Event-based as well as indicator-based Importance of feedback and coordination Integration as a mid-term perspective

E P I D E M I C A L E R T A N D R E S P O N S E

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« Setting up an early warning system for epidemic-prone diseases in Darfur: a participative approach » Disasters,2005, 29(4): 310-322