Program-Specific Recommendations

• Rapid Health Assessment
• Health Information Systems
• Nutrition
• Control of Vaccine-Preventable Diseases
• Control of Diarrheal Diseases
• Malaria Control
• Tuberculosis Control
• Epidemic Investigations

Rapid Health Assessment

• Assess the magnitude of the displacement.
• Determine the major health and nutrition needs of the displaced population.
• Initiate a health and nutrition surveillance system.
• Assess the local response capacity and immediate needs.

Preparations

Before the field visit, relevant information relating to the status of the incoming refugees, as well as the available resources of the host community, should be obtained from local ministries or organizations based in the capital city. Any maps of the area where the refugees are arriving and settling should likewise be obtained. Aerial photographs will also be of value, but may be considered sensitive by the military of the host country. International organizations like UNICEF, WHO, and the Red Cross/Red Crescent may also have demographic and health data concerning the refugee population.

In preparation for the field visit, establish whether food, medical supplies (including vaccines), or other relief supplies have been ordered or procured by any of the relief agencies involved. Additionally, the following conditions should be included in a field assessment.

Field assessment

• Total refugee or displaced population
• Age-sex breakdown
• Identification of at-risk groups; e.g., children less than 5 years of age, pregnant and lactating women, disabled and wounded persons, and unaccompanied minors
• Average family or household size

Sources of information. Local government officials or camp authorities may be able to provide registration records. If no registration system is in effect, one should be established immediately. Information recorded should include the names of household heads, the number of family members by age and sex, former village and region of residence, and ethnic group, if applicable.

Refugee leaders may also have records, particularly if entire villages have fled together. In certain situations, political groups may have organized the exodus and may have detailed lists of refugee families.

A visual inspection of the settlement may provide a general impression of the demographic composition of the population. However, information obtained in this manner should be used judiciously as it is likely to provide a distorted view of the situation.

It may be necessary to conduct a limited survey on a convenience sample in order to obtain demographic information. Beginning at a randomly selected point, survey a sample (e.g., 50) of dwellings. Visit every fifth or 10th house until the predetermined number of houses have been surveyed. At each house, record the number of family members, the age and sex of each person, and the number of pregnant or lactating women. This process will establish an initial estimate of the demographic composition of the population. Estimate the number of persons in each house, as well as the total number of houses in the settlement, to gain a provisional estimate of the camp population. At the very least, this quick survey should give a rough estimate of the proportion of the total population made up of "vulnerable" groups; i.e., children less than 5 years of age and women of child bearing age. To determine the total population, a census may need to be conducted later.

Background health information

• Main health problems in country of origin.
• Previous sources of health care (e.g., traditional healers).
• Important health beliefs and traditions (e.g., food taboos during pregnancy).
• Social structure (e.g., whether the refugees are grouped in their traditional villages and what type of social or political organization exists).
• Strength and coverage of public health programs in country of origin (e.g., immunization).

Sources of information. Obtain documents and reports from the host government, international organizations, and nongovernment organizations pertaining to endemic diseases and public health programs in the displaced population's region of origin.

Interview refugee leaders, heads of households, women leaders (e.g., traditional midwives), and health workers among the refugee population.

Seek information from development agencies, private companies, missionaries, or other groups having experience with the displaced population.

Nutritional status

• Prevalence of protein-energy undernutrition in the population less than 5 years of age.
• Nutritional status before arrival in host country.
• Prevalence of micronutrient deficiencies in the population less than 5 years of age.

Sources of nutritional information. If refugees are still arriving at the site:

• Initiate nutritional screening of new arrivals immediately.
• Measure all children (or every third or fourth child, if insufficient trained personnel are available or the refugee influx is too great) for mid-upper arm circumference (MUAC) or, if time and personnel permit, WFH. Estimate the proportion of undernourished children using the methods described in the Rapid Nutrition Assessment Manual. (*) (*) Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.
• Look for clinical signs of severe anemia and vitamin A, B, and C deficiencies.
• If refugees are continuing to arrive, set up a permanent screening program for new arrivals. A screening program also can be used to administer measles vaccination and vitamin A supplements to new arrivals.

• Walk through the settlement, select houses randomly, and observe the nutritional status of the children less than 5 years of age. Visual assessment should only be done by persons who are experienced in the assessment of malnutrition. The observer should enter the homes as malnourished children are likely to be bedridden.
• Combine the visual inspection with a rapid assessment of nutritional status, using either MUAC or WFH measurements. This can be done during the demographic survey described above. (See "Rapid Health Assessment")
• Review the records of local hospitals treating members of the displaced population. Note admissions or consultations for undernutrition and deaths related to undernutrition.
• Interview refugee leaders to establish food availability before displacement and the duration of the journey from place of origin to their present location.

Mortality rates

Why this information is needed. In the initial stages of a population displacement, mortality rates, expressed as deaths/10,000/day, are a critical indicator of improving or deteriorating health status.

In many African countries, the daily CMR (extrapolated from published annual rates) is approximately 0.5/10,000/day during non-emergency conditions. In general, health workers should be extremely concerned when CMRs in a displaced population exceed 1/10,000/day, or when less than 5 years of age mortality rates exceed 4/10,000/day.

Sources of mortality information. Check local hospital records and the records of local burial contractors. Interview community leaders.

Establish a mortality surveillance system. One approach is to designate a single burial site for the camp, which should be monitored by 24-hour grave watchers. Grave watchers should be trained to interview families, using a standard questionnaire, and then to record the data to determine gender, approximate age, and probable cause of death.

Other methods of collecting mortality data include registering deaths, issuing burial shrouds to families of the deceased to ensure compliance, or employing volunteer community informants who report deaths for a defined section of the population.

Demographic data are absolutely essential for calculating mortality rates. These provide the denominator for estimating death rates in the entire population and within specific vulnerable groups, such as children less than 5 years of age.

The population needs to be assured that death registration will have no adverse consequences (e.g., ration reductions). Morbidity

The information required includes age- and sex-specific data regarding the incidence of common diseases of public health importance, i.e., measles, malaria, diarrheal diseases, and ARI, as well as diseases of epidemic potential such as hepatitis and meningitis. The data should be collected by all health facilities, including feeding centers.

Why this information is needed. Data on diseases of public health importance may help plan an effective preventive and curative health program for refugees. These data will also facilitate the procurement of appropriate medical supplies and the recruitment and training of appropriate medical personnel, as well as focus environmental sanitation efforts (e.g., toward mosquito control in areas of high malaria prevalence).

Sources of morbidity information. Review the records of local clinics and hospitals to which refugees have access.

Where a clinic, hospital, or feeding center has already been established within the camp, examine patient records or registers and tally common causes of morbidity. Interview refugee leaders and health workers within the refugee population.

A simple morbidity surveillance system should be established as soon as curative services are established in the camp. Feeding centers should be included in the surveillance system. Community health workers should be trained as soon as possible to report diseases at the community level.

The initiation of certain public health actions should not be delayed until the disease appears. For example, measles immunization should be implemented immediately. Do not wait for the appearance of measles in the camp. Also, oral rehydration centers should be routinely established in all situations.

Environmental conditions

• Climatic conditions (average temperatures and rainfall patterns).
• Geographic features (soil, slope, and drainage).
• Water sources (local wells, reservoirs, rivers, tanks).
• Local disease epidemiology (endemic infectious diseases, e.g., malaria, schistosomiasis).
• Local disease vectors (mosquitoes, flies, ticks), including breeding sites.
• Availability of local materials for shelter and fuel.
• Existing shelters.
• Existing sanitation arrangements (latrines and open areas).

Resources available

Efforts to evaluate food supplies should include:

• Attempting to assess the quantity and type of food currently available to the population.
• Calculating the average per capita caloric intake over the period of time for which records are available, if food is already being officially distributed.
• Inspecting any local markets for food availability and prices.
• Conducting a quick survey of dwellings and estimating the average food stores in each household. This should be done during the demographic survey (see "Rapid Health Assessment"). Look for obvious inequities between different families or different ethnic or regional groups.

Food logistics. Assess transport and fuel availability, storage facilities (size, security), and seasonal conditions of access roads.

Feeding programs. Follow these guidelines to evaluate feeding programs:

• Look for any established feeding programs (mass, supplementary, and therapeutic feedings). These may have been set up by local officials, PVOs, church groups, or local villagers.
• Assess enrollment and discharge criteria, enrollment and attendance figures, quantity and quality of food being provided, availability of water, managerial competence, utensils, and storage.
• Determine whether measles vaccine is being administered.

• Determine the ease of access by refugees (official attitudes, location, hours of operation).
• Evaluate the condition and size of facilities.
• Note the extent and appropriateness of medicines, equipment, and services.
• Determine the type and number of personnel.
• Review cold storage facilities, vaccine supplies, logistics, and communication systems.

• Note the type of facility (clinic, hospital, feeding center), as well as the size, capacity, and structure (tent, local materials).
• Determine the adequacy of health-facility water supply.
• Assess refrigeration facilities, fuel, and generator.
• Assess supplies of essential drugs (whether generic or brandname) and medical supplies.
• Determine the need for essential vaccines and immunization equipment.
• Note the type of health personnel (doctors, nurses, nutritionists, sanitarians) and their relevant experience and skills.
• Review storage facilities.
• Assess adequacy of transport, fuel, and communications.
• Locate health workers in refugee population (traditional healers, birth attendants, "modern" practitioners).
• Determine whether there is a need for interpreters.

• An itemized summary of the findings should be prepared, following the sequence of activities outlined in this document.
• Estimate and quantify the need for outside assistance, based on preliminary findings.
• Prepare and convey assessment findings to appropriate emergency health officials at the local, national, and international levels.

(*) Adapted from : WHO Emergency Relief Operations. Emergency Preparedness and Response: Rapid Health Assessment in Sudden Population Displacements. WHO, in collaboration with CDC and other WHO Collaborating Centers for Emergency Preparedness and Response. Geneva: January 1990.

Preparation

• Obtain available information regarding refugees and resources from host country ministries and organizations.
• Obtain available maps or aerial photographs.
• Obtain demographic and health data from international organizations.

• Determine total displaced population.
• Determine age and sex breakdown of population.
• Identify groups at increased risk.
• Determine average household size.

• Identify primary health problems in country of origin.
• Identify previous sources of health care.
• Ascertain important health beliefs and traditions.
• Determine the existing social structure.
• Determine the strength and coverage of public health programs in country of origin.

• Determine prevalence of PEM in population less than 5 years of age.
• Ascertain prior nutritional status.
• Determine prevalence of micronutrient deficiencies in the population less than 5 years of age.

• Calculate crude, age-, sex-, and cause-specific mortality rates.

• Determine age- and sex-specific incidence rates of diseases that have public health importance.

• Determine climatic conditions.
• Identify geographic features.
• Identify water sources.
• Ascertain local disease epidemiology.
• Identify local disease vectors.
• Assess availability of local materials for shelter and fuel.
• Assess existing shelters and sanitation arrangements.

• Assess food supplies and distribution systems.
• Identify and assess local, regional, and national food sources.
• Assess the logistics of food transport and storage.
• Assess feeding programs.
• Identify and assess local health services.
• Assess camp health services.

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