scripps clinic/scripps green hospital grand roundssep 09, 2009 · xerophthalmia: permanent...

Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009

Kristian R Olson MD, MPH, DTM&HSeptember 9, 2009

[email protected] Educator Unit, MGH Dept of MedicineCIMIT, Global Health Initiative Program Leader

Harvard Humanitarian Initiative

When Zebras Really Are Zebras:Global Health in Crises

• The presenter has no potential conflicts of interest to disclose.

When Zebras are Zebras:Global Health in Crises

CONFLICT OF INTEREST STATEMENT

Objectives:

1) To understand the definition and mortality cycle of Complex Humanitarian Emergencies (CHE’s)

2) To describe the four leading causes of death worldwide of children under five

3) To describe priorities and resources useful in these setting

Meanwhile, during this hour…

4) More than 1200 children under the age of 5 will die.

5) More than 60 women will die in and around childbirth

• 6.8 billion People*

• More than one half live on <$2 per day**

•Life expectancy in the 38 poorest countries is 48 yrs****US Census Bureau, World Population Clock, 9/2/09**Population Reference Bureau, prb.org*** Skolnik 2007 www.worldmapper.org Map 228

Tuberculosis

Territory size is proportional to worldwide cases of…

Scripps Conference Services & CME www.scripps.org/conferenceservices

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www.worldmapper.org Map 219

Physicians Working

Public Health

Health Care Politics

The Humanitarian Health Worker

You are here

Burmese Refugees- A Camp of 17,000

110, 000 People- Kalma Camp in South Darfur

Even more vulnerable?

CMR’s in Camp and Non-Camp Situations*

*Salama et al. Lancet 2004

While Camp-based Mortality improved, it remains high in non-camp settings


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Hasanea

Definitions:Definitions:1)1) Complex Humanitarian Emergency (CHE):Complex Humanitarian Emergency (CHE):

Situations in which mortality among the civilian population Situations in which mortality among the civilian population substantially increases above baseline, either as a result of thsubstantially increases above baseline, either as a result of the e direct effects of war or indirectly through increased prevalencedirect effects of war or indirectly through increased prevalenceof malnutrition and/or transmission of communicable diseases, of malnutrition and/or transmission of communicable diseases, particularly if the latter result from deliberate political and particularly if the latter result from deliberate political and military policies and strategies*military policies and strategies*

OrOr(Quantitative Definition) Crude Mortality Rate > 1 death per (Quantitative Definition) Crude Mortality Rate > 1 death per 10,000 per day**10,000 per day**……later qualified as a doubling of the baseline later qualified as a doubling of the baseline CMR where known.**CMR where known.**

2)2) Disaster:Disaster: ““an occurrence, either natural or man made, that an occurrence, either natural or man made, that causes human suffering and creates human needs that victims causes human suffering and creates human needs that victims cannot alleviate without assistance.cannot alleviate without assistance.””******

*Salama et al. 2004

** Toole and Waldman. 1990

***Skolnik. 2008

The Disease of DisplacementThe Disease of Displacement

1)1) 42 million Refugees and 42 million Refugees and IDPsIDPsworldwide.*worldwide.*

2)2) Once Once ““afflictedafflicted””, mortality , mortality increases 2 to 60 times above increases 2 to 60 times above baseline.baseline.

*www.unhcr.org Global Trends, 2008

What kills crowded, displaced people?What kills crowded, displaced people?

•• What kills vulnerable (U5M) in lowWhat kills vulnerable (U5M) in low--income countries in general?income countries in general?


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Worldwide, 79 Children Die Before Their 5th Birthday for Every 1000 Born

• 87/1000 in developing countries

• 6/1000 in developed countries

• 200/1000 in the poorest countries

*State of the World’s Children, 2006, Unicef

*Coglan. Lancet, 2006

Time in Months

CNN Leaves

The CHE Mortality Cycle

CMR

12

0.5

1.0

Emergency Phase

Post-emergency Phase

Baseline

Crude Mortality in Selected CHE’s*

*Salama et al. Lancet 2004

““Vital Signs of Displaced PersonsVital Signs of Displaced Persons””

•• Crude Mortality Rate (CMR)Crude Mortality Rate (CMR)-- Deaths per 10,000 people per dayDeaths per 10,000 people per day

(0.44 Africa, 0.25 Industrialized Nations)(0.44 Africa, 0.25 Industrialized Nations)

•• Under 5 Mortality Rate (U5MR) Under 5 Mortality Rate (U5MR) -- Deaths per 10000 Children<5 per dayDeaths per 10000 Children<5 per day

(1.14 in Africa, 0.04 Industrialized Nations)(1.14 in Africa, 0.04 Industrialized Nations)

•• Neonatal Mortality Rate (NMR)Neonatal Mortality Rate (NMR)--Deaths per 1000 live births in the 1Deaths per 1000 live births in the 1stst 28 28 days of lifedays of life

•• Case Fatality Rate (CFR)Case Fatality Rate (CFR)-- % of people dying of all people with a % of people dying of all people with a diseasedisease


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““Why has this person, fallen ill in Why has this person, fallen ill in this way, in this place, at this this way, in this place, at this time?time?””

-- EldrydEldryd ParryParry

Screening for MeaslesVaccine Coverage Has Decreased Resultant Deaths in Camps

(Resulted in >10% of Child Deaths in 1970’s and 80’s.)

Mumps in Darfur

Insecurity often disrupts Public Health


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Vitamin A Campaign-Deficiency affects 40% of the world’s children and leads to approximately one million deaths per year*

* Skolnik, 2008

MeaslesMeasles

Can account for 10% of child deathsCan account for 10% of child deaths

Exacerbated by Vitamin A DeficiencyExacerbated by Vitamin A Deficiency

Case fatality rates: 2 to 33%Case fatality rates: 2 to 33%

Vaccination Priority 6moVaccination Priority 6mo--59mo (up to 15 years when 59mo (up to 15 years when resources)resources)

Repeat as soon after child reaches 9 mo as possible (after Repeat as soon after child reaches 9 mo as possible (after interval of 30 days)interval of 30 days)

Case Case DefDef’’nn: Generalized rash>3 days AND Fever AND : Generalized rash>3 days AND Fever AND cough, runny nose, or Red Eyescough, runny nose, or Red Eyes

Diarrheal Disease:

•Oral Rehydrations Solution (ORS)

•Integrated Management of Childhood Illness (IMCI)

Oral Rehydrations Solution (ORS)

-Integrated Management of Childhood Illness (IMCI)


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Integrated Management of Integrated Management of Childhood Illness (IMCI)Childhood Illness (IMCI)

Includes three main Includes three main components:components:

1)1) Improving case management Improving case management skills of healthskills of health--care staff care staff

2)2) Improving overall health Improving overall health systemssystems

3)3) Improving family and Improving family and community health practicescommunity health practices

DiarrheaDiarrhea

ShigellaShigella = principal causes of epidemics= principal causes of epidemics•• Low infective dose (10Low infective dose (10--100 Organisms while cholera is counted in 100 Organisms while cholera is counted in

the millions the millions •• Sphere Standard: CFR<1%Sphere Standard: CFR<1%•• Case Definition: Any case of diarrhea with visible blood in stooCase Definition: Any case of diarrhea with visible blood in stoolsls•• Soap: great evidenceSoap: great evidence

Cholera = Acute Water DiarrheaCholera = Acute Water Diarrhea•• VibrioVibrio choleraecholerae O1 (classical and El Tor) and 1:139O1 (classical and El Tor) and 1:139•• Suspect an outbreak when: pts >5 develop severe dehydration or Suspect an outbreak when: pts >5 develop severe dehydration or

dies from acute watery diarrheadies from acute watery diarrhea•• Any adult death due to dehydration is highly suspectAny adult death due to dehydration is highly suspect•• Attack Rate Typically 1Attack Rate Typically 1--2% in 2% in ““open settingsopen settings”” but can be 5% in but can be 5% in

campscamps

•• MSF Case Definition: any patient developing acute water diarrheaMSF Case Definition: any patient developing acute water diarrhea(usually with vomiting), resulting in severe dehydration(usually with vomiting), resulting in severe dehydration

•• 8080--90% of cases can be treated effectively with ORS90% of cases can be treated effectively with ORS

•• EgEg. Preparation: 50,000 people might expect 2500 (5%) cases and . Preparation: 50,000 people might expect 2500 (5%) cases and up to 1875 (75%) requiring up to 1875 (75%) requiring IVfIVf

15 L per person per day and no fecal coliforms VIP Latrine being made: Ventilation Improved Pits

Soap Distribution

Referral Capability?Referral Capability?


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3 year old Burmese Refugee dying of Cerebral Malaria

MalariaMalariaPREVENTION:PREVENTION:

Individual Prevention (Individual Prevention (bednetsbednets)) Community Prevention (spraying, water Community Prevention (spraying, water

drainage)drainage) Consider prophylaxis for pregnant womenConsider prophylaxis for pregnant women Surveillance (No clear threshold for an epidemic)Surveillance (No clear threshold for an epidemic)

TREATMENT:TREATMENT: Strive for laboratory Strive for laboratory dxdx over case over case defdef’’nn ASAP.ASAP.

•• egeg Case Case DefDef’’nn: T>38.5 and absence of another infection: T>38.5 and absence of another infection

Learn local resistanceLearn local resistance Base treatments on WHO/MOH standards where Base treatments on WHO/MOH standards where

ableable ArtemesinArtemesin combination therapy!combination therapy! Hospitalize Hospitalize ““severesevere”” cases cases

((Artemether/Quinine/SzArtemether/Quinine/Sz Rx/ Rx/ Hypoglycemia/Hydration)Hypoglycemia/Hydration)

Meningococcal Meningitis

-Surveillance, prevention, and response to diseases of epidemic potential is crucial

His CSF


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MeningitisMeningitis

Large Outbreaks exclusively due to Large Outbreaks exclusively due to NeisseriaNeisseriameningitidismeningitidis

Traditional Periodic outbreaks in subTraditional Periodic outbreaks in sub--Saharan Saharan ““Meningitis BeltMeningitis Belt”” is changingis changing•• (Q 8(Q 8--10 years and stop at the onset of the rainy season)10 years and stop at the onset of the rainy season)

A and C A and C SerogroupsSerogroups = principal causes of outbreaks = principal causes of outbreaks •• (W(W--135 more recently)135 more recently)

Routine vaccination during nonRoutine vaccination during non--epidemic periods not epidemic periods not (yet) cost(yet) cost--effective. (Perhaps change with effective. (Perhaps change with MenactraMenactra?)?)

Attack rate varies widely (10Attack rate varies widely (10--1000 per 100,000)1000 per 100,000) Case Fatality Rates: 70% without Rx, 5Case Fatality Rates: 70% without Rx, 5--15% with Rx15% with Rx WHO no longer recommends chemoprophylaxis for WHO no longer recommends chemoprophylaxis for

contactscontacts

Case Definition for Bacterial MeningitisCase Definition for Bacterial MeningitisSuspected CaseSuspected Case <12 mo:<12 mo:

--Fever ANDFever AND--Bulging Bulging FontanelleFontanelle

>12mo to adults: >12mo to adults: --Sudden Onset Sudden Onset FeverFeverANDAND--Stiff NeckStiff NeckAND/ORAND/OR--PetechiaePetechiae or or purpurapurpura

Probable CaseProbable Case --Suspected CaseSuspected CaseANDAND--Turbid CSFTurbid CSFOROR--Ongoing OutbreakOngoing Outbreak

Confirmed CaseConfirmed Case --Suspected or Probable CaseSuspected or Probable CaseANDAND--Either positive CSF AgEither positive CSF AgOROR--Positive CulturePositive Culture

*Source: Refugee Health MSF 1997

Meningitis OutbreakMeningitis Outbreak

No universal epidemic threshold:No universal epidemic threshold:

•• PopPop’’nn >30,000: >30,000: 15 cases/100,000/week (for 2 consecutive 15 cases/100,000/week (for 2 consecutive weeks)weeks)

•• PopPop’’nn <30,000:<30,000: 2 consecutive doubling of cases over three weeks2 consecutive doubling of cases over three weeks

•• Next to declared epidemic or urban area:Next to declared epidemic or urban area: 5/100,000/week5/100,000/week

Once Outbreak Declared:Once Outbreak Declared:

•• Mass Immunization CampaignMass Immunization Campaign

•• Mass Campaign is not recommended if already Mass Campaign is not recommended if already ““too latetoo late”” and and decreasing (consider when rains come)decreasing (consider when rains come)

•• Consider Immunizing only 6mo to 30 yrs if limited suppliesConsider Immunizing only 6mo to 30 yrs if limited supplies

•• Prompt ID and Treatment (Single IM Oily Prompt ID and Treatment (Single IM Oily ChloramphenicolChloramphenicol (3g (3g single dose or 100mg/kg); IV single dose or 100mg/kg); IV CeftriaxoneCeftriaxone))

Addressing Malnutrition and Food Security


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Infant in Infant in AwassaAwassa Ethiopia, February 2009Ethiopia, February 2009

Xerophthalmia: Permanent blindness due to Vitamin A deficiency and measles

In long-established camps, mortality rates are lower than in the surrounding host population.*

*Spiegel et al. 2002

7 day old female initially breast fed well, now failing to suck and irritable


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1st Time Mother with Post-Partum Hemorrhage in DarfurMISP: Minimal Initial Services Package

*http://www.unfpa.org/emergencies/manual/2.htm

Midwife Resuscitation Training in Aceh, Indonesia

Not Just Device Delivery - Training and Re-training are Essential

ResuscitationResuscitation


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EvaluationEvaluation

Intervention

Control

1) Focus Group (adapted from World Health Organization (WHO) Verbal Autopsy for Infant Death)

• 5-7 people in each group; 6 groups in intervention and 2 groups in control

2) Survey with 44 questions

• 350 Total (244 in intervention; 106 in control)

3) Ventilation Device Assessment

• 211 device evaluations

Preliminary Findings Continued

Device EvaluationsIntervention Control Total Total

244 106 350 211

Intervention Control119 (out of 1840 births) 42 (out of 1268 births)

6.5% resuscitated 3.3% resuscitated

Capture:

Midwives Confident in Treating AsphyxiaIntervention Control

Outcomes:

Births3126

Of Babies Given Breathe Alive After 1 Day

Midwives Surveyed Total Births Assisted:

201 out of 244 35 out of 10682% confidant 33% confidant

* Olson, KR: Data not yet published.

Healthy 57 Day Old Infant Post‐Resuscitation

Top 10 Health PrioritiesTop 10 Health Priorities

AssessmentAssessment Measles immunizationMeasles immunization Water and SanitationWater and Sanitation Food and NutritionFood and Nutrition Shelter and site planningShelter and site planning Health CareHealth Care Control of EpidemicsControl of Epidemics Public Health SurveillancePublic Health Surveillance Human Resources and TrainingHuman Resources and Training CoordinationCoordination

Field References• MSF Clinical Guidelines; 7th Revised Ed. 2007

• Oxford Handbook of Tropical Medicine; M Eddleston and S Pierini; Oxford University Press, 2nd Ed. 2004

• Refugee Health: An approach to emergency situations; MSF; MacMillan Education; 1997.

• The Sphere Project Handbook: 2004 Ed

• Topics In International Health; CD ROM Series (www.talcuk.org)

• WHO: Communicable disease control in emergencies(www.who.int)

References:References:1)1) CoglanCoglan, B et al. Mortality in the Democratic Republic of Congo: a nati, B et al. Mortality in the Democratic Republic of Congo: a nationwide onwide

survey. Lancet 2006; 367:44survey. Lancet 2006; 367:44--51.51.

2)2) SalamaSalama P et al. Lessons learned from complex emergencies over past decP et al. Lessons learned from complex emergencies over past decade. ade. Lancet 2004; 364: 1801Lancet 2004; 364: 1801--13.13.

3)3) SkolnikSkolnik R. R. Essentials of Global Health.Essentials of Global Health. Boston: Jones and Bartlett; 2008.Boston: Jones and Bartlett; 2008.

4)4) Toole MJ, Waldman R. Prevention of excess mortality in refugee aToole MJ, Waldman R. Prevention of excess mortality in refugee and nd displaced populations in developing countries. JAMA 1990; 263: 3displaced populations in developing countries. JAMA 1990; 263: 3296296--302.302.

5) 5) Spiegel P et al. Health Spiegel P et al. Health programmesprogrammes and and policeispoliceis associated with decreased associated with decreased mortality in displaced persons in postmortality in displaced persons in post--emergency phase camps: a emergency phase camps: a retrospective study. Lancet 2002; 360: 1927retrospective study. Lancet 2002; 360: 1927--3434

6)6) 1951 Convention Relating to the Status of Refugees. Available at1951 Convention Relating to the Status of Refugees. Available athttp://http://www.ohchr.org/english/law/refugees.htmwww.ohchr.org/english/law/refugees.htm. Accessed October 21, . Accessed October 21, 2007.2007.


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