The following recommendations relating to water and sanitation are largely based on the UNHCR Handbook for Emergencies (1) and Environmental Health Engineering in the Tropics (2).
Water. In general, the supply of adequate quantities of water to refugees in a camp setting has greater overall impact on health than a supply of small quantities of microbially pure water. The provision of adequate quantities of water is particularly effective in the prevention of bacillary dysentery. Nevertheless, whenever possible, sources of clean water should be sought or disinfection systems established. An additional health benefit derived from the provision of ample supplies of water, at a convenient distance from the camp, is the decrease in the daily workload of women, upon whom the burden of water collection usually falls.
Appropriate water sources should be identified before refugees arrive in an area. An adequate water supply is a crucial component of attempts to prevent disease and protect health and, as such, should be among the highest priorities for camp planners and administrators.
Standards. WHO has set standards for the microbiological quality of water supplies. These are as follows:
When surface water is used as a communal source, covered storage will allow suspended particles to settle on the bottom, improving the quality of the water. Longer standing times and higher temperatures will yield a greater improvement in water quality.
Filtration and chlorination may require considerable effort and resources, but should be considered if the situation warrants.
Although boiling is an effective means of removing water pathogens, it is not generally a practical solution in refugee camps where fuel supplies are limited.
As a short-term measure during an emergency (e.g., a cholera outbreak, and when treatment of all water sources is not feasible), purification agents (such as chlorine) may be distributed to each household. In this way, water can be treated in household storage containers. However, a massive education effort is required and such measures usually cannot be maintained for longer than a few weeks.
Water storage containers with narrow necks or covers that prevent people from introducing their hands into the container are likely to reduce further contamination of water once it is stored in the home. The use of separate containers to store water for drinking and water for washing is preferable.
Supply. The chosen water supply should be adequate to meet the needs of the camp year-round. Seasonal variations in rainfall and in camp population should be taken into consideration when selecting a water source.
The UNHCR recommends that a minimum quantity of 20 L of water/person/day be provided. Health clinics, feeding centers, and hospitals require 40-60 L/patient/day.
Ideally, no individual dwelling should be located greater than 150 m from a water source. At any greater distance, the use of water for hygiene is greatly diminished.
Sanitation. Camp sanitation plans should be drawn up before refugees arrive. Because of the crucial role it plays in disease prevention, sanitation should be an early priority for camp planners.
Community attitudes and cultural practices regarding sanitation and disposal of excreta are vital to the success of a sanitation project and should be taken into careful consideration.
All efforts should be made to separate garbage and human waste from water and food supplies. Excreta should be contained within a specific area. Defecation fields may be used as a short-term measure until a more appropriate sanitation system can be implemented. This is particularly suitable in hot, dry climates.
The design and installation of latrines should also take into consideration the attitudes and practices of the refugee population. Latrines should be located so as to remove the possibility of contamination of the water source.
Latrines that are poorly maintained will not be used. For this reason, personal or family latrines are the best solution. However, limitations on building supplies, money, and space may make this impossible. If communal latrines are to be used, no more than 20 people should share one latrine and responsibility for maintaining cleanliness should be clearly assigned.
Breast-feeding. Breast-feeding is an effective measure for preventing diarrheal illness among infants. Exclusive breast-feeding for the first 4-6 months of a baby's life, and continued breast-feeding until the child is 2 years of age, should be encouraged through educational campaigns targeted at pregnant and lactating women. Distribution of milk products should be restricted, and feeding bottles should never be distributed within a camp (see "Nutrition").
Personal hygiene. Community health education should reinforce the importance of handwashing with soap and of general domestic and personal hygiene, in particular safe food-handling practices. Soap should be made readily available by relief agencies.
Assessment of dehydration and fluid deficit through careful physical examination should receive particular attention. Fever, rapid breathing, and hypovolemic shock may accompany severe dehydration.
Careful monitoring of the patient's weight and the signs of dehydration throughout the course of therapy will help assess the adequacy of rehydration. Adults with acute, dehydrating diarrhea should be carefully assessed by a physician to rule out cholera.
Management of patients. In the camp setting, all patients with diarrhea should be encouraged to report to a clinic or health post for assessment, advice on feeding, fluid intake, and diarrhea prevention. The treatment of dehydration should always be initiated in the clinic. Ideally, a central clinic should be supplemented with several small ORT centers in the camp, staffed by trained community health workers.
Prevention of dehydration. Case management should focus on the prevention of dehydration under two sets of circumstances: a) when a patient with diarrhea shows no signs of dehydration, b) when a patient has already been treated for dehydration in the ORT corner and is being released from medical care. Management of patients in these situations includes the following.
ORS. Mothers should be shown how to mix and give ORS and initially be given a 2-day supply. The amount to be given at home is as follows.
Continued feeding. Infants who are breast-fed should continue to receive
breast milk. If an infant is receiving milk formula in a feeding center, the
milk should be diluted with an equal volume of clean water until the diarrhea
stops.
For children greater than 4-6 months of age:
For babies who are unable to drink but are not in shock, a nasogastric tube can be used to administer ORS solution at the rate of 15 mL/kg body weight/hour. For infants in shock, a nasogastric tube should be used only if IV equipment and fluids are not available.
Reassessment. The patient's hydration status should be reassessed after 3-4 hours, and treatment continued according to the degree of dehydration at that time. Note: If the child is still dehydrated, rehydration should continue in the center. The mother should offer the child small amounts of food.
If the child is less than 12 months of age, the mother should be advised to continue breast-feeding. If the child is not being breast-fed, 100-200 mL of clean, plain water should be given before continuing the ORS. Older children and adults should consume plain water as often as they wish throughout the course of rehydration with ORS solution.
Nutritional maintenance. Infants should resume feeding as outlined above. For children greater than 4-6 months old and adults, feeding should begin as soon as the appetite returns. Energy-rich, easily digestible foods will help maintain their nutritional status. There is no reason to delay feeding until the diarrhea stops and there is no justification for "resting" the bowel through fasting. Note: Children enrolled in SFPs or TFPs who develop diarrhea with dehydration should be fed HEM diluted with ORS in a ratio of 1:1, alternating with plain ORS. The overall volume of fluid should be calculated according to the child's weight and degree of dehydration.
Use of chemotherapy. Antimicrobial drugs are contraindicated for the routine treatment of uncomplicated, watery diarrhea. Specific indications for their use include:
Anti-diarrheal agents are contraindicated for the treatment of diarrheal disease. Stimulants, steroids, and purgatives are not indicated for treatment of diarrheal disease and may produce adverse effects.