Roles and Responsibilities
The Camp Management Agency is the overall coordinating and monitoring body in the camp, but generally a health service provider coordinates the health sector. This health service provider is therefore primarily responsible for the planning, implementation, management and monitoring of health services. If there are several health service providers, including governmental, non-governmental and/or privately-run health facilities operating within the camp, the Camp Management Agency should work with relevant national authorities and the Health Cluster/Sector Lead Agency to establish a lead health agency in the camp.
The primary roles and responsibilities of the Camp Management Agency are:
- understanding key terminologies and strategies of health services in camp situations in order to interpret results of reports from health services providers
- disseminating information updates on health issues and alerting relevant coordination bodies about any gaps and duplications
- using this information to advocate for appropriate responses to health issues in the camp
- supporting and coordinating with the lead health agency on any matters which may require additional assistance
- addressing and referring urgent health care requests to health care providers.
The primary roles and responsibilities of the lead health agency in camps are:
- coordinating with national health authorities in all aspects of the health services within the camp
- facilitating cooperation among all health service providers to ensure appropriate implementation and monitoring of health services agreed in coordination meetings
- collecting age and gender disaggregated information from the health service providers and generating reports on relevant health issues
- disseminating information on health issues to other relevant sectors and agencies
- coordinating with the Camp Management Agency.
Both agencies are responsible for ensuring that the level and quality of health services provided by all health agencies adhere to locally or internationally accepted standards and medical ethics.
Cooperation With National Health Authorities
National health authorities must be contacted and involved from the outset of health planning and programmes in a camp. Their cooperation in establishing or supporting health structures is key to successful and sustainable programmes.
World Health Organization (WHO)
WHO is the global lead for health and works in close collaboration with national health authorities. This agency is consulted for advice and supplementary expertise.
Health care information management is an important aspect of the role of coordination that can be facilitated by the Camp Management Agency. It should be clear how information is shared while at the same time assuring confidentiality and protection of data to the extent possible. Generally, information from the camp population feeds directly to the health service providers. When a camp has multiple health service providers the information flow can be complex. Not only do the lead health agency and Camp Management Agency need to have all relevant information for planning and decision-making, but other health service providers should also be provided with information.
In these situations, health coordination meetings should occur on a regular basis and be managed by the lead health agency. These meetings should collect and disseminate health information between providers and generate important information to feed to camp coordination meetings convened by the Camp Management Agency. Health meetings should happen on a weekly or monthly basis, sometimes daily during epidemic outbreaks. Communication channels should also enable the health agencies providing services within the camp to share information or concerns with the lead health agency when needed for emergency issues.
Health Coordination Meetings
It is advantageous to hold health coordination meetings a few days before general coordination meetings so that key points can be raised in a timely fashion with all sectors and the Camp Management Agency.
The following sections of this chapter will highlight key terminology and aspects of health strategies and services in a camp and explain important points for supervising and coordinating health services. Additional roles and responsibilities of the Camp Management Agency and the lead health agency are included.
Voice From the Field - Coordination Between National Health Authorities and Health Relief Agencies
National health officials resist assessment findings or health interventions which reflect poorly on the government or the nation. The Camp Management Agency should advocate for necessary interventions and appropriate standards, always seeking to maintain a functional working relationship with the authorities.
An initial assessment coordinated by the lead health agency in cooperation with the Camp Management Agency and the national health authorities will identify health needs, services available and gaps. The results of the assessment will establish priority and evidence-based interventions and inform about implementation strategies, including whether to support established services or if new services are required.
It is important that the assessment team is experienced, as objective as possible and independent of political or other influences. Ideally, the initial assessment, whenever possible included within a multi-sectoral assessment, should be completed within three days of forming a camp or within three days of arrival at an already established camp. If there is time to plan for a camp set-up, and people arrive in a moderate and manageable stream, then health screening for each person can constitute an initial assessment.
Elements of a Health Assessment
Key information includes background of the displacement, population size disaggregated by age and gender and availability of health services, food and water. Accurate population figures are important for meaningful health statistics.
Identification of Priority Health Issues
Information collected includes an estimation of mortality rates and causes of mortality, morbidity data on the most common diseases, presence of diseases with epidemic potential (such as cholera, shigellosis, measles and meningitis), prevalence of acute malnutrition and data on vaccine coverage. Mortality rates offer the best indicator for assessing the severity of a situation and understanding the causes of mortality. They are key to guiding initial interventions.
The Presence and Activities of UN, Government and Non- Governmental Actors in the Health Sector
The initial assessment should give an overview of who is present in the camp, which services are offered or planned to be offered by each organisation, what is their operational capacity and what areas their services will cover. In very large camps health agencies may offer the same services in different zones of the camp. This overview is essential in order to maximise resources available and prevent overlapping services.
Existing health services within or outside the camp should be explored and their ability to provide health care to the camp population identified. This includes identifying and ensuring access to a referral hospital, a referral laboratory for specimen analysis and already established medical services. The team should identify the qualified health personnel available from the national health authorities and health relief agencies already present within the camp, as well as camp residents with health qualifications. Their level of training should also be assessed.
The Camp Management Agency facilitates and coordinates with other cluster/sector partners in conducting rapid or specific needs assessments especially at the onset of the crisis. For example, the lead health agency will usually initiate mapping of available health services and specific health resources using the Global Health Cluster and WHO's Health Resources Analysis and Mapping System (HeRAMS) tool and the 3Ws (Who is doing What and Where). The 2012 Inter-Agency Standing Committee (IASC) Multi-Cluster/Sector Initial Rapid Needs Assessment (MIRA) tool has also been used by various clusters in recent emergencies.
The data should be collected quickly and simply in the initial assessment in order to produce a reliable snapshot of the population. Examples of assessment methods are interviews with the national health authorities, interviews with the camp population, collection of morbidity and mortality data from medical facilities, interviews with informal health providers, like traditional birth attendants, and direct observation, such as counting graves to determine mortality rates and visiting existing health facilities.
Collect the Right Information
Often less information is more useful. Remember that all information collected should be useful and resist the urge to collect volumes of detailed information with no immediate application.
☞ For an example of an initial rapid health assessment, see the Tools section.
Initial assessments are done rapidly to measure the impact of the disaster or crisis and are used to inform emergency action. A follow-up assessment is required within one to three weeks and will provide more detailed information to maintain an organised, coordinated health response to the needs of the camp population. In addition, thematic assessments can be conducted at this time, such as assessing the prevalence of micronutrient deficiencies or immunisation rates among children. Surveys using a representative sample methodology should be implemented at this stage. Relief activities in the initial days, such as measles vaccination, food and water interventions, should not wait for a comprehensive assessment. These follow-up assessments can be carried out in coordination with the below activities.
Selection of Key Informants
Take care when choosing key informants. The most accessible, such as camp elders and leaders, may overlook health concerns of important health service users, particularly women. Child mortality is a key concern. Women and adolescents are usually children’s primary caregivers and main users of health care services. They should be consulted in assessments. Further, persons with specific needs and groups at risk, such as minorities, and persons with disabilities, may have challenges in accessing health care and should be included as key informants.
Mass Measles Vaccination Campaign
Measles is a highly infectious disease that has been regularly reported by the WHO as the leading cause of mortality in children in many recent emergencies. Population movement and high population densities are risk factors that facilitate transmission of the virus and may contribute to outbreaks even in areas with high immunisation coverage. In addition, poor health and poor nutritional status of measles-infected persons are associated with high rates of mortality. For these reasons, even if the initial assessment finds no measles cases, mass immunisation for measles is a top priority.
Measles outbreaks can still occur in a population with high levels of vaccine coverage. The current measles vaccine, under normal conditions, covers 85 per cent of children when administered at nine months of age. A significant number of people are still susceptible to measles and vulnerable to further outbreaks due to the extreme infectiousness of the disease. The aim is to ensure coverage of all children aged six months to 14 years of age.
National health authorities maintaining an Expanded Programme of Immunisation (EPI) should be involved in the coordination and implementation of a mass vaccination campaign from the outset. A mass immunisation campaign is principally a logistics exercise. It is the Camp Management Agency and the lead health agency’s responsibility to ensure that all systems coordinate in order to reach the goal of close to universal coverage. United Nations Children's Fund (UNICEF) and WHO usually support national authorities and other partners to ensure that all children are immunised against measles in emergency situations.
Ideally, all children from six months to 14 years of age should be vaccinated, regardless of previous vaccination status. This nonselective vaccination strategy has the following advantages:
- A second dose of the measles vaccine does not have adverse effects and can improve the immunological response.
- The vaccination campaign can cover the population rapidly, while checking individual vaccine cards is time consuming.
- There is less possibility of error, like cards read incorrectly or sibling cards being switched.
However, vaccine availability, funding, human resources and local measles epidemiology may influence the choice of the groups covered. If it is impossible to immunise the entire camp population, then the following groups should be vaccinated, in this order of priority:
- malnourished or sick children aged six months to 12 years who are enrolled in feeding centres or in-patient wards
- all other children aged six–23 months
- all other children aged 24–59 months
- all other children aged 60 months–14 years of age.
Vaccination of children under six months of age is not recommended as there is a risk of interfering with maternal antibodies. Measles vaccination programmes in stable situations vaccinate only to age five, but due to the high risk environment in camp situations the recommendation extends to children aged 14. Mass measles immunisation campaigns should be coupled but not delayed by Vitamin A distribution to children aged six months to 14 years. Vitamin A supplementation has been shown to markedly reduce measles-associated mortality.
Doses of Measles Vaccine
All children under nine months of age should receive a second dose of measles vaccine at nine months of age, with a minimum interval of one month between the two doses. Children may receive a second dose of Vitamin A if there has been an interval of four/six months since the previous dose.
Measles vaccination can occur on arrival in the camp. However, if this is not possible because the population is settled or is overwhelming reception centres, then a mass immunisation campaign is required. This campaign has the following elements:
- information and education campaigns: Camp populations should be informed in their local language(s) about location of vaccination posts, information about the vaccine, risks involved and the importance of receiving the vaccine.
- training of immunisation teams: Some team members do not have to be qualified health workers as comprehensive training can prepare them for the campaign.
- immunisation posts: There should be one or two vaccination posts per 10,000 people as distance to vaccination posts is a potential obstacle to immunisation and multiple posts dispersed within the camp are preferable to a centralised facility.
- outreach activities: Community health workers can move through the camp during the campaign and refer children to the immunisation posts.
- vaccination cards: These are issued to every child. If a child is between six and eight months old it should be clearly indicated on the card, and explained to the caregiver that a second vaccine should be given at the age of nine months.
- reporting: A daily record should be made of the numbers vaccinated per day (and per site) and the number of doses used.
Supplemental Immunisation Activities (SIAS) for Measles Control:
- Catch-up campaigns: a one-time effort to vaccinate all children under the age of 15.
- Follow-up campaigns: periodic mass immunisation campaigns every two to four years following catch-up campaigns.
Voice From the Field - Immunisation as a Cost-effective Tool to Protect Children’s Health
Vaccination campaigns inside Za’atari Refugee camp in Jordan in 2013 were stepped up following measles outbreaks in the region among displaced populations affected by the Syrian crisis. A massive information campaign using flyers, posters and mobilisation of volunteers going from tent to tent were critical factors in ensuring that children and young adults in the camp received measles vaccination and Vitamin A supplements.
Logistical Considerations for Measles Vaccines
- The quantity of measles vaccine ordered has to be based on the size of the target population. Vaccine lost during a mass campaign should not be higher than 15 per cent. Vaccine reserves should, ideally, be held an additional 25 per cent of the total quantity.
- The measles vaccine is heat-sensitive and must be transported and stored between 2-8°C. A cold chain system must be established that keeps vaccines safely in appropriate temperatures whatever the outside temperature and seasonal climatic variations.
- To support universal precautions – the set of procedures designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care – sufficient quantities of auto-destruct syringes, designed to make reuse impossible, and safety boxes for sharps disposal should be available.
Effective measles mass campaigns depend on dedicated teams composed of trained health personnel as vaccinators and volunteers with no specific health training assigned to do crowd control, screening children and recording/tallying. Under normal circumstances, a team of two vaccinators together with three to four volunteers can vaccinate 300 to 400 children per day.
Other Vaccines for Epidemic-prone Diseases
Unlike the measles vaccine, all other mass vaccination campaigns should be initiated only after confirmation of an epidemic- prone disease in the camp and an epidemic threshold, a point at which an outbreak is declared and mass vaccination can be considered, has been reached. The lead health agency should confer with national health authorities, officials and experts in communicable disease when considering whether to start a mass immunisation vaccination campaign for epidemic- prone diseases, as the methodology for vaccination differs according to context. Some important vaccine preventable epidemic-prone diseases include:
- Bacterial meningitis – caused by the pathogen Neisseria meningitidis and commonly referred to as meningococcal meningitis. Clinical features include a sudden onset with fever, intense headache, stiff neck and occasional vomiting and irritability. As the infection is usually transmitted person-to-person via aerosols in crowded situations, the epidemic threshold is lower in a camp situation. The priority group for vaccination is children aged between two and ten.
- Yellow fever causes very serious epidemics with high mortality rates. The virus is spread to humans via mosquito vectors. Clinical features include a sudden onset of fever, headache and backache, muscle pain, nausea and vomiting and red eyes. These clinical symptoms appear in the acute phase and can be confused with many other diseases. A period of remission follows and then a toxic phase where the patient presents with jaundice (yellowing of the skin) two weeks after onset of the first symptoms. There may also be bleeding from the gums, nose, in the stool and vomit. A vaccine can be given to everyone in the camp from the age of two months and gives immunity for at least ten years.
Epidemic Threshold and Outbreak
An epidemic threshold is how many cases of a disease must be confirmed in order to declare an outbreak. A low epidemic threshold indicates that the environment is more sensitive to the transmission of epidemic-prone diseases.
Routine Immunisation: Expanded Programme of Immunisation (EPI)
In the post-emergency phase, a complete EPI programme should be an integral part of the longer term health care programmes. The standard EPI programme consists of measles, diphtheria, pertussis (whooping cough) and tetanus toxoid (DPT), oral polio (OPV) and Bacille Calmette-Guerin (BCG) vaccines. All children under five should receive necessary immunisations for their relevant age groups. This programme should not be started unless:
- the population is expected to remain stable, tentatively after six months but still depending on the context
- the human and material resources, such as cold chains, are adequate for implementation
- a plan exists for integration into the national immunisation programme.
Routine immunisations should be offered via fixed immunisation points such as a hospital, health centre, health posts, feeding centres or screening/registration centres. Each of these points should check vaccination status via vaccination cards and vaccinate children on the spot if vaccine facilities are available, or otherwise refer them to an immunisation point. Outreach activities via community health workers should also check vaccination status and refer to immunisation points.
In a displaced population inadequate or threatened food security often leads to an increased risk of malnutrition, which is a factor for increased morbidity and mortality. Malnutrition can be caused by deficiencies in macronutrients (nutrients that provide energy such as carbohydrates, protein and fat) and deficiencies in micronutrients (such as vitamins and minerals). Often, camp populations are vulnerable to nutritional deficiencies due to livelihoods lost, food supplies interrupted, long journeys to the camp and disease outbreaks. Persons arriving at the camp may already have high levels of malnutrition. Causes of malnutrition are often complex and cross-sectoral.
Coordination With Other Sectors
The Camp Management Agency needs to monitor whether food and nutritional programmes are coordinated with health and other vital sectors such as Water, Sanitation and Hygiene (WASH), education and livelihoods. UNICEF is the global lead for nutrition and should be consulted by the Camp Management Agency or lead health agency for advice or additional expertise. World Food Programme (WFP) is the lead agency on food, responsible for both general and supplementary feeding rations.
When calculating energy requirements and designing food rations in a camp, 2,100 kcal/person/day is the initial planning figure in the emergency phase. An increase in the kilocalories/ person/day of general rations should be considered if:
- there is a disproportionate number of adult men, as adult men require more kilocalories per day to maintain optimal nutritional status
- there are widespread illness, epidemics, general malnutrition and/or a crude mortality rate (CMR) > 1. (CMR is defined as deaths per 10,000 per day)
- there are increased activity levels among the entire population, like when a food-for-work programme is implemented in the camp and labour-intensive work is undertaken
- the average temperature is below 20˚C.
Voice From the Field - Malnutrition in Drought Situations
In 2011, the drought in several areas of the Horn of Africa resulted in very high malnutrition rates. Aid agencies provided food supplements loaded with micro-nutrients such as fortified biscuits, powders and pastes high in nutrients and calories, for people moving or without the ability to cook.
Major Nutritional Deficiency Diseases
Nutritional deficiencies can occur or deteriorate during an emergency. Such deficiencies and disease are inter-related. Diarrhoea can result in malabsorption and nutrient loss and other diseases suppress appetite while increasing the need for macro- and micronutrients to help fight illness.
There are two categories of malnutrition, acute and chronic. Chronic malnutrition is associated with malnutrition over a long period of time and is not associated with high rates of mortality. Acute malnutrition is the category that contributes to high morbidity and mortality rates in a camp and is thus what should be assessed during the emergency phase. Severe acute malnutrition (SAM) can present itself in different forms:
- marasmus: Characterised by severe wasting of fat and muscle, which the body breaks down for energy. This is the most common form of protein energy malnutrition in an emergency.
- kwashiorkor: Characterised primarily by oedema (swelling due to an accumulation of fluid in intercellular spaces of the body usually beginning in the feet and legs) and sometimes accompanied by changes in hair colour to greyish or reddish. Clinical features also include apathetic and irritable demeanour and a lack of appetite.
- marasmic kwashiorkor: Characterised by a combination of severe wasting and oedema.
Vitamins and minerals are also needed for adequate functioning of the body and protection against disease. Vitamins B, C, A and D and minerals such as iron, sodium, iodine, zinc, magnesium and potassium are the major nutrients the body needs in order to function properly. Micronutrient deficiencies can lead to an increased risk of mortality, morbidity, blindness, adverse birth outcomes and susceptibility to infection. With food distributions in camps it is imperative to verify that people are provided with appropriate micronutrients. Special groups with specific micronutrient needs include pregnant women, lactating mothers and young children. The general food ration should provide required micronutrients, which is normally achieved by adding some fortified food commodities (for example, iodised salt, fortified grains or vegetable oil enriched with Vitamin A). However, it may still be necessary to provide micronutrient supplementation through the health system (for example, iron tablets for pregnant women and Vitamin A for children).
☞ For more information on food distribution, see Chapter 13, Food Security and Non-Food Items.
Assessment and Surveillance of Nutritional Status
A nutrition survey will quantify the acute malnutrition in the population and is used to establish the degree of emergency for the delivery of food aid and to plan complementary food interventions. It is also baseline data used for comparison with future surveys to monitor the situation over time. An initial assessment of the nutritional status of the camp population should be done as soon as possible in the emergency phase and should be supervised by a nutritionist. The survey should measure a representative sample of children aged from six to 59 months. When the age of a child is difficult to ascertain height in the range 65 cm-110 cm is the inclusion criteria. The measurements collection during the survey should include:
- weight and height: These two measurements used to calculate the weight for height (WFH) index of each child is an objective assessment of acute malnutrition. This index is expressed as a Z score. The Z score is a standard deviation from a reference population.
- age and gender of child: Z score formulas are different for males and females and recording age verifies the inclusion criteria.
- presence of oedema: Defined above, bilateral oedema indicates severe malnutrition even without a corresponding WFH Z score.
Additional measurements to be collected as deemed necessary are:
- mid upper arm circumference: MUAC is a rapid, simple measurement of the left arm circumference at the midpoint between the elbow and shoulder. It can be a predictor of the immediate risk of death from malnutrition. However, this measurement has a high risk of error and it should be part of a two-step screening process. If a child falls below a certain cut-off circumference, then s/ he is referred to a WFH measuring post where a second measurement is taken for inclusion in a selective feeding programme.
- body mass index: BMI measurements can be used in adolescents (persons> 137 cm) and non-pregnant adults to determine malnutrition. Adults and adolescents are usually at less risk than young children from malnutrition, but in specific contexts it may be necessary to include this age group. The formula is calculated as [weight in kg /(height x height in m)] = BMI.
There are no specific rules for repeated nutritional surveys, but it is recommended in the emergency phase that a nutritional survey be repeated as often as necessary and as resources allow. Where food supply systems are weak, there may be influxes of more people and thus a greater risk of epidemics and elevated mortality rates. Additional surveys can expand the indicators to include assessment such as of micronutrient deficiencies or measles vaccination status according to the priorities of the evolving situation.
Voice From the Field - Capturing Representative Samples
A displaced population fled an insecure area in East Africa. Those who arrived first established a self-settled camp and new arrivals settled in ever-widening circles around its periphery. There was no systematic population count or organisation of households and the camp population fluctuated on a daily basis. A cluster sampling technique was implemented for a nutrition survey, but only started measuring children from the centre of the camp. Those households on the periphery had spent longer on their journey to the camp, including longer periods without proper food or basic health services. The results of the nutritional survey were reviewed by the lead health agency and malnutrition levels were low. No complementary nutritional programmes were implemented. However, there were needs among the newly arrived population which were not measured. Were the most vulnerable and at highest risk for malnutrition properly represented in the survey? What questions could the Camp Management Agency have asked to the nutritional survey team before making programmatic decisions? Could corroborative data from health facilities have raised alarms?
Survey results are relevant and useful only if sampling procedures are standardised and properly applied to ensure that the individuals measured are representative of the whole population and that the results are comparative over time.
Selective Feeding Programmes
There are two types of feeding programmes:
- Blanket/General Supplementary Feeding: feeding of all affected population without targeting specific population groups
- Selective Feeding Programmes: supplementary (for moderately malnourished) and therapeutic (for severely malnourished) feeding programmes
- Supplementary Feeding: provision of an additional food ration for moderately malnourished children or adults 'targeted SF;' or to the most nutritionally vulnerable groups, labeled 'blanket SF'
- Therapeutic Feeding: provision of medical and dietary treatment to those with severe acute malnutrition.
The hierarchy of nutrition interventions prioritises the provision of basic food rations to the majority of the population over intensive, specialised nutritional support to malnourished individuals. Once the majority of the population has access to adequate quantities of food, the second priority is to provide high quality supplementary food to individuals with acute/moderate malnutrition. When adequate supplementary rations are available for the majority of people affected by moderate/acute malnutrition, therapeutic care for those with severe/acute malnutrition can then be effective. Persons with specific needs, such as pregnant women, infants, children, nursing mothers and older people, may be included in supplementary and therapeutic feeding programmes even if they do not qualify as acutely malnourished.
Selective feeding programmes can be implemented in two ways: feeding at health centres or take home rations for supplementary feeding. In the case of the latter, rations are increased to take into account sharing at household level.
Below is a decision chart for the implementation of selective feeding programmes. Please note that this should be used only as a guide and should be adapted to local camp situations.
|Food availability at household level below 2,100 kcal per person per day and/or inadequate micronutrient availability||
|Malnutrition prevalence 15% or more or 10–14% with aggravating factors||
|Malnutrition prevalence 10–14% or 5–9% with aggravating factors||
|Malnutrition prevalence under 10% with no aggravating factors||
Aggravating factors include a general food ration below the mean energy requirement, crude mortality rate greater than 1/10,000 population/day, epidemics (measles or other) and high incidence of respiratory or diarrhoeal diseases.
New Methodologies in Therapeutic Feeding Programmes
WHO, WFP, the United Nations Standing Committee on Nutrition (SCN) and UNICEF have highlighted new evidence that about three-quarters of children with severe acute malnutrition - those who have a good appetite and no medical complications, can be treated at home with fortified, Ready-to- Use Therapeutic Foods (RUTFs). These are soft nutrient and energy-rich foods that can be eaten by children over the age of six months without adding water, thereby reducing the risk of bacterial infection. RUTFs provide the nutrients required to treat a severely malnourished child at home, without refrigeration, and even where hygiene conditions are unsatisfactory. This community-based approach to severe malnutrition may be considered by the health service providers in camp environments with severe malnutrition.
Voice From the Field - Integration of Therapeutic Feeding Programmes With Existing Clinical Health Systems
A nutritional survey of a camp found Global Acute Malnutrition rates of 14 per cent with Severe Acute Malnutrition rates of 3.5 per cent. Consequently, plans were made to establish a therapeutic feeding programme in a referral hospital. However, the plan was revised during a coordination meeting with the Camp Management Agency, which revealed that a government health centre within the camp already had an in-patient therapeutic feeding programme for severely malnourished children with medical complications. Unfortunately, practices were out of date and default rates (number of children leaving the feeding programme before their discharge date) were 55 per cent. Support was provided to the government health centre and the health lead agency also worked with the clinical officer and supervisor to update protocols and teach staff appropriate methodologies for therapeutic feeding centres. The lesson learned here was that support to existing services, instead of setting up parallel systems, increases the long-term capacity of government health staff to treat severe malnutrition.
Feeding Practices for Infants and Young Children
Mortality among infants and children is highest in an emergency phase when conditions are the most threatening. Exclusive breastfeeding for infants up to six months of age is recommended. From six months to the age of two it is recommended that breastfeeding continues while adequate supplementary foods are added. Supporting caregivers and channeling scarce resources to meet the nutritional needs of infants and young children in the camp are priority. Guidance on breastfeeding and complementary feeding for mothers living with HIV/AIDS have different and specific recommendations.
The following activities can reduce malnutrition amongst infants and children:
- Community health workers (CHWs) should identify vulnerable households with infants, young children, pregnant women or nursing mothers.
- Priority registration for food distribution should be negotiated for persons with specific needs and members of groups at risk.
- Sheltered breastfeeding stations should be organised near registration and distribution points.
- Women can be recruited to provide encouragement and practical assistance on feeding practices to households with infants and small children.
- Those responsible for unaccompanied children need to be identified and should receive appropriate food supplementation, such as breastmilk substitutes for orphaned infants.
CHWs are trained in hygiene, first aid, immunisation, active case finding, health referrals and other essential primary health care services. They are a critical workforce in any emergency health response and have relevant cultural and language skills, and may be identified from the camp population.
Structure of Health Care Services
The structure of health care services in a camp should offer active case finding, early diagnosis and appropriate treatment of the priority diseases. It is essential to coordinate with and support established health structures. However, in most camp situations the high number of patients using the services, especially during the emergency phase, may overwhelm national state or private health services, even when supported. Therefore, it may be necessary to implement a new health structure. Regardless of the strategy, health services in a camp structured according to the following four-tier model have proven successful in various conditions.
- Outreach activities: community health workers and trained birth attendants provide outreach activities. Their duties include home visiting, identification and referral of sick persons and malnourished children, identification of pregnant women for referral to reproductive health services, basic health education and mortality data-gathering for the health information system.
|Health Structure Level||Position||Staffing Levels|
at community level
|Community Health Worker||One per 500-1000 population|
|Traditional Birth Attendant (TBA)||One per 2,000 population|
|Supervisor||One per 10 Community Health Workers/TBA|
- Peripheral facilities: Health posts should provide basic consultations, basic curative care (no injectable medications and a limited essential drug list), oral rehydration therapy (ORT), dressings for wounds, a locked pharmacy, simple sterilisation facilities and data collection.
|Health Structure Level||Position||Staffing Levels|
Peripheral health facility
|Total staff||Two to Five|
|Qualified health worker||At least one, based on a maximum of 50 consultations per worker per day|
|Non-qualified staff||At least one for ORT, dressings, registrations and administration|
- Central facility: This should provide a 24-hour service with in-patient and out-patient services. Basic laboratory services may be available, but this is not the priority in the emergency phase.
|Health Structure Level||Position||Staffing Levels|
Central Health Facility
|Qualified health workers||Minimum five, maximum 50 consultations per worker per day (out-patient care), 20–30 beds per worker per shift (in-patient care)|
|Midwife||At least one|
|Doctor||At least one|
|Laboratory Technician||At least one|
|Pharmacist||At least one|
|Non-qualified health worker||At least one for ORT; at least one for pharmacy; at least one for dressings, injections and sterilisations|
|Non- qualified staff||Registration and Security|
- Referral Hospital: The health system within the camp must be able to refer patients to hospitals for advanced services. A referral hospital should provide emergency surgical and obstetric care, laboratory and X-ray services and treatment of severe diseases. Only in very specific cases, when a referral hospital is not available or is overwhelmed, for example by many warwounded surgical cases, should a camp/field hospital be established. Normally only a small number of patients will require referral. Therefore a local referral hospital should be supported instead of setting up a parallel structure within the camp.
|Health Structure Level||Position||Staffing Levels|
|Doctor with surgical skills||At least one|
|Nurse||At least one: 20-30 beds per shift|
Coordination Meetings for Coordinated Actions
The Camp Management Agency should support the lead health agency or health service provider in establishing regular health coordination meetings so as to ensure a clear referral system within each tier of the health structure and standardised treatment protocols and data collection tools.
Voice From the Field - Facilitating Coordinated Referrals to and From Hospitals and Camp Services in Haiti
In sudden onset natural disasters or man-made emergencies, existing public services including temporary field hospitals soon become overstretched in their capacity to provide urgent medical and surgical treatment with demand far exceeding availability. This overload persists for a certain period of time where the remaining functional hospitals report congestion and significant backlog of patients ready for discharge but unable to leave hospital wards or makeshift parking lots because they are newly homeless, unable to return to their destroyed houses, lack means of transport to return to preferred communities or camp settlements and/or are unable to secure medical follow-up after discharge because of the distance between camp settlements and rehabilitation and wound care services. Following the Haiti 2010 earthquake, an agency responded to this service gap by working with the Camp Management Agency, health and shelter partner agencies to establish an assisted hospital discharge and referral mechanism to decongest hospitals, link patients’ needs with available services, navigate timely referrals and ensure transportation and adequate placement in camps that had access to medical and rehabilitative health services.
In the emergency phase, it is not a priority to establish a laboratory in the camp. The key priority is to identify an established referral laboratory where specimens collected for outbreak investigation (for example shigellosis and cholera) may be sent. Most patients presenting to camp health facilities in the emergency phase can be treated based on a clinical diagnosis derived from protocols. Before blood transfusion services commence within the camp a laboratory that tests all blood for HIV must be established.
Health Services Free of Charge
In emergencies, preventive and curative health services should be provided free of charge to refugees and displaced populations. Evidence has shown that systems of cost recovery in developing countries at best recover five per cent of costs, and act as barriers to those most in need of health services. Local populations living nearby may also be offered extended free-of-charge services, and this should be negotiated with the health authorities in line with national policy.
Staff salaries and incentives should be addressed from the outset of recruitment. In principle, all staff working on a daily basis with clearly identified responsibilities and defined working hours should receive salaries or incentives. The Camp Management Agency should support the lead health agency in coordinating all health actors in the camp, ensuring all are adhering to the same standards.
When recruiting staff for health services the order of preference for selection is: camp population, experienced nationals from the local host community and only then outsiders. Most camp situations will require a mixture of these sources, but it is important to remember that health services are being developed with, and not for, the camp population. Women are an important part of the health system within the camp. They should be encouraged to apply for health care jobs. Health services dominated by men may discourage use or acceptance by the primary users who are mostly women.
Qualified health workers are defined as formally trained clinical providers, such as physicians, nurses, clinical officers or medical assistants. However, in a camp setting it may be difficult to recruit formally-trained clinical staff. Staff without formal clinical training may be able to perform certain clinical duties with additional support and careful supervision. There also may be camp residents who have received formal training from their home countries but whose qualifications are not recognised by host country national health authorities. In these cases, it is important for the health agencies and the Camp Management Agency to discuss with national health authorities the possibility of employing such individuals in clinical jobs if necessary.
It is essential that if a mix of health staff recruited among the camp population and local government are working together in a health facility, initial training should be provided to clarify case definitions and appropriate protocols for case management.
Even if national health authorities’ case definitions and protocols are utilised, regular refresher training for local staff is highly recommended, offering an opportunity to harmonise and ensure that all staff are carrying out responsibilities in the same way.
Training all health workers and non-health workers assisting in health care in proper universal precautions is essential when managing health systems within a camp. Health agencies should ensure that all clinical staff have logistical supplies, like sharps disposal containers, appropriate quantities of disposable needles and syringes, so as to ensure universal precautions are carried out. The basic concepts of universal precautions are:
- All workers should wash hands thoroughly with soap and water, especially after contact with body fluids or wounds.
- Protective gloves and clothing should be used when there is a risk of contact with blood or other potentially infected body fluids.
- Safe handling and disposing of waste material, needles and other sharp instruments is essential together with properly cleaning and disinfecting medical instruments before their use with other patients.
Logistics and Supply
During the initial assessment of a camp, all available medical materials should be documented. If these resources are inadequate for the camp population’s health needs and additional resources cannot be sourced from national authorities or other health actors, this gap should be immediately flagged.
Following medium or large scale emergencies, medicines and replenishable medical supplies are usually made immediately available by national health authorities and agencies to allow for predictable and efficient response. The WHO 2011 Inter Agency Emergency Health Kit ensures that a standardised and quickly obtainable source of essential medicines and supplies adequately meets health care needs of 10,000 people for three months. These kits could be secured through WHO and other health partners. Similarly the United Nations Population Fund (UNFPA) Inter Agency Reproductive Health Kit for Use in Crisis Situations provides essential supplies to address different reproductive health needs. However, these kits should only be used in the short term and a regular supply of essential medicines and materials should be identified to stock all health facilities in the camp as soon as possible.
Health facility site planning, infection control, referral transport, cold chain maintenance and medical store/pharmacy issues also need to be considered when planning health care structures.
Health Information System (HIS)
Monitoring and Surveillance of Communicable Diseases and Health Care Services
Health information systems should be implemented as soon as health care services are initiated. There are three methods of data collection:
- routine reporting of consultations on a weekly or monthly basis, including an alert system to report epidemic-prone diseases
- outbreak investigations, collected on an ad hoc basis when an outbreak is suspected
- surveys, implemented when routine reporting is delayed or for specific data collection, for example, nutrition or vaccination household surveys.
As soon as health care systems are in place and consultations performed, routine reporting should be established. Case definitions should be developed for each health event or disease and all health workers should be trained in them, especially the epidemic-prone diseases. Case definitions and the HIS should follow the definitions and systems of the host country. If these are inadequate or not available, these systems need to be formulated in cooperation with the national health authorities.
In routine reporting from health centres health workers provide data on the number of consultations (morbidity) and deaths (mortality) from diseases disaggregated by age (under five and over five) and gender. Where possible, it is usually recommended to further break down the age categories, for example, zero to four years, five to 11 years, 12 to 17 years, 18 to 59 years, 60+ years of age. This will allow the identification of health needs related to age-groups, for example adolescents and older people, and assist the design of tailored health interventions.
All levels of a health system, including the central health facility, health post or field hospital should contribute data. Community health workers active in the camp should also submit mortality figures, but not morbidity figures because they refer these cases to the appropriate health facility. Mortality figures from the community health workers contribute to the health post statistics from their respective zones.
The morbidity and mortality surveillance forms should highlight epidemic-prone diseases such as bloody diarrhoea, acute watery diarrhoea, suspected cholera, lower respiratory tract infections, measles, meningitis and malaria. Alert thresholds for epidemic-prone diseases should be established and communicated to all health actors in the camp. One designated health worker should tally all consultations seen at the end of each day. When an alert threshold is reached, this person initiates an outbreak alert report to the lead health agency. Time is crucial when reporting on epidemic-prone diseases. Delays in outbreak response can increase mortality within the camp.
Collect Essential Data
It is important to note that HIS should be simple and easy to implement. Do not collect data that health actors will not use. Extremely complex and time-consuming health data forms discourage use by health providers.
At the end of each week or month, data collected from each health facility in the camp should be compiled by the lead health agency and disseminated to all relevant actors as well as the Camp Management Agency. This data will influence health strategies for the following week or month and should include the following key health indicators (those most commonly used):
- Crude Mortality Rate (CMR) = (total number during time period/total population) x (10,000/number of days in the time period) = deaths/10,000/day
- Under Five Mortality Rate (U5MR) = (total number of deaths of under-fives during time period/total number of children under five years of age) x (10,000/number of days in time period)
- Case Fatality Rate (CFR) = (total number of people dying from disease during a time period/people who have the disease during the same time period)
- Incidence Rate = (Number of new cases due to a specific disease in time period/population at risk of developing disease) x (1,000 persons/number of months in a time period)
- Health Facility Utilisation Rate = (total number of visits to health facilities in one week/total population) x 52 weeks
- Number of Consultations per Clinician per Day = total number of consultations (new and repeat)/number of full time equivalent clinicians in health facility)/number of days health facility is open per week.
Full-time equivalent clinicians refers to the number of clinicians working in a health facility adjusted for part-time work. For example, if the clinic has ten full-time staff and two half-time staff then the full-time equivalent would be ten (full-time staff) + 1 (this is both half-time staff calculated to one full-time staff) = 11.
Crude Mortality Rate Benchmarks
Under five crude mortality rates are usually twice the CMR:
Average rate in most developing countries: 0.5 deaths/10,000/day
Relief Programme under control: <1.0 deaths/10,000/day
Relief Programme very serious situation: >1.0 deaths/10,000/day
Emergency out of control: >2.0 deaths/10,000/day
Major catastrophe: >5.0 deaths/10,000/day
If a baseline CMR is known (normally not the case in camp situations) then the Sphere Standards advise that a doubling of the baseline CMR indicates a significant public health emergency which requires an immediate response.
When collecting health data, patient confidentiality and data protection must be ensured. All information regarding the patient, her/his history, condition, treatment and prognosis is discussed only between the patient, the health provider and the supervisors. No staff member should share patient information with others not directly involved in patient care without the patient’s permission. In the emergency phase, training health care workers in issues around patient and data confidentiality should be completed.
Practically, this is often not the case. It is the responsibility of the Camp Management Agency and/or the lead health agency to ensure that all staff undergo proper training in confidentiality and protection of data issues during the post-emergency phase if it has not already been done in the emergency phase. It is highly advisable that health agencies brief their staff on policies, guidelines and appropriate reporting mechanisms to ensure confidentiality if they come across sensitive health information. Health care workers should also be provided with appropriate logistical support to maintain confidentiality, such as cupboards with locks, registration books with appropriate covers and rooms available for private consultations.
Reports and alerts of outbreaks are usually frequent in camp environments. Each and every report should be followed up by the lead health agency or a designated outbreak response team. Diagnosis must be confirmed either by laboratory testing or by clinical presentation, depending on the disease and context.
Epidemics often follow a pattern. Cases are fewer at the beginning of an outbreak, crescendo to a peak and then fade. However this is not always the case. Once an outbreak is declared, the lead health agency should graph daily or weekly cases of the disease. This graph uses the ‘number of cases’ on the vertical axis and the time in ‘days’ or ‘weeks’ on the horizontal axis. Interpreting the curve should be done cautiously, but it can give an indication of the future of the epidemic and enable resources to be mobilised appropriately. The implications of the epidemiological curve should be explained to all health actors in the camp.
Control of Communicable Diseases and Epidemics
The lead health agency in coordination with the Camp Management Agency should initiate epidemic contingency plans when an outbreak is declared. Health and other implicated service providers must be ready to react to epidemics and the lead health agency should have contingency plans in place before an outbreak occurs in order to prevent high morbidity and mortality rates. A contingency plan should include:
- verifying stocks of vaccines and materials, for example intravenous fluids and specific antimicrobials (medication for treating bacterial infections)
- maintaining an updated map of all actors in the camp and their available supplies and human resources.
Training for active/passive case finding and appropriate reporting mechanisms should be continually reinforced. Standard protocols for prevention, diagnosis and treatment must be made available to all health staff regarding the priority communicable diseases in the camp and specifically the epidemic-prone diseases. These protocols should be harmonised with the local health authorities or adapted from WHO guidelines and agreed by all health actors.
Many communicable diseases surface in camp situations such as cholera, typhus, relapsing fever, tuberculosis, typhoid fever, yellow fever, meningococcal meningitis and hepatitis. As the cause-specific mortality rates of these diseases during the emergency phase are usually minimal, a response is indicated if an alert threshold has been reached. In the post-emergency phase, health services able to respond to the above communicable diseases may be implemented as appropriate. The following is a synopsis of the priority communicable diseases to be addressed during the emergency phase and their appropriate case management and outbreak responses.
Diarrhoeal diseases are a leading cause of morbidity and mortality in a camp environment. In camp situations, diarrhoeal diseases have accounted for more than 40 per cent of deaths in the acute phase of the emergency.
The Camp Management Agency, in coordination with the relevant service providers, should ensure rapid implementation of prevention methods such as clean water, adequate latrine coverage, distribution of soap and education on proper personal hygiene practices, promotion of food safety and breastfeeding. Uncomplicated, non-bloody diarrhoea can normally be managed with appropriate rehydration methods, but in a camp environment it is important to always train staff, including health volunteers, and monitor for the epidemic-prone diarrhoeal diseases like shigellosis and cholera.
Shigellosis, also known as bacillary dysentery, is an acute bacterial disease affecting the large and small intestines. The most severe form of the disease and the cause of outbreaks in camp settings is Shigella dysenteriae Type 1 (Sd1) presenting as acute bloody diarrhoea. Transmission occurs through contaminated food and water and from person-to-person contact and is highly contagious. Case fatality rates can be as high as ten per cent without prompt and effective treatment.
The Camp Management Agency should ensure that if Sd1 is suspected the health worker should first verify blood in a stool specimen and then report to the lead health agency or outbreak team using the outbreak reporting form. Proper laboratory confirmation and antimicrobial sensitivity tests should be completed. This may require a referral laboratory as the tests are complicated. However, this should not delay treatment or control activities. If the supply of effective antimicrobials is limited, then treatment of high-risk patients should be the priority. These are:
- children under five years of age, especially infants, a child younger than two, severely malnourished children and children who have had measles in the previous six weeks
- older children and adults who are obviously malnourished
- patients who are severely dehydrated, have had convulsions or are seriously ill when first seen
- all adults 50 years of age or older.
Vibrio cholerae is an acute bacterial disease causing profuse watery diarrhoea sometimes coupled with projectile vomiting. If these patients are not promptly treated, the life cycle of the disease results in loss of large amounts of fluid and salts leading to severe dehydration and death within hours. The transmission mode is faecal-oral and it is often transmitted by contaminated food or water.
Voice From the Field - Cholera Outbreak in Haiti
The Haiti cholera outbreak that began in October 2010 is one of the worst epidemics in recent years and is predicted to continue in the most vulnerable areas and populations. The relatively low reported cholera cases and deaths in IDP camps is attributed to Camp Management Agencies and partners’ collective efforts to ensure rapid scaled-up cholera prevention and containment efforts through hygiene promotion, water purification kit distribution, case surveillance, installation of oral rehydration posts and latrines and sensitisation campaigns among IDPs.
The Camp Management Agency should ensure that all health staff are trained to suspect cholera when:
- a patient over five years of age develops severe dehydration from acute watery diarrhoea, usually with vomiting
- any patient over two years of age has acute watery diarrhoea in an area where there is an outbreak of cholera.
Cholera is asymptomatic in 90 per cent of cases, but these asymptomatic carriers actively pass the bacteria in stools. About 20 per cent of those who are infected with Vibrio cholerae develop the acute, watery diarrhoea and of some 10 to 20 per cent develop severe watery diarrhoea with vomiting. The number of cases can rise rapidly because the incubation period is extremely short (two hours to five days). One confirmed case of cholera indicates an outbreak. Cholera treatment centres for case management should be established and a WASH prevention programme initiated.
Stop Cholera Spreading
Once cholera is suspected in a camp, the spread of the bacteria should be prevented through early detection, confirmation of cases, appropriate treatment, isolation of patients and dissemination of hygiene messages using local languages and culturally appropriate methods.
Case management for cholera includes treatment of dehydration via oral rehydration salts and/or intravenous fluids. The use of antimicrobials is not essential for the treatment of cholera and should only be used for severe cases or when bed occupancy or stocks of intravenous fluids are expected to reach critical levels.
☞ For more information on the prevention and control of diarrhoeal diseases, see Chapter 14, Water, Sanitation and Hygiene.
Acute Respiratory Infections (ARIs)
ARIs of the upper respiratory tract include the common cold and those of the lower respiratory tract include pneumonia. Lower respiratory tract infections (LRTIs) are a significant cause of morbidity and mortality in camp situations. The Camp Management Agency should therefore ensure that trained health workers are able to recognise the signs and symptoms of pneumonia and diagnose, treat or refer cases as quickly as possible. Community health workers should be trained to refer all children with a cough and/or breathing difficulties to the health post for further investigation. WHO recommends the following for appropriate case management of LRTIs:
- Signs of malnutrition should be assessed. Malnutrition increases the risk of death from pneumonia.
- Severely malnourished children must be referred to inpatient care at a referral hospital.
- Management of pneumonia consists of antimicrobial therapy, but choice of antimicrobial depends on national protocols and available drugs.
- If protocols or drugs are not available from the national health authorities, then oral cotrimoxazole can be used for most cases. For severe pneumonia, injectable antimicrobials can be used such as penicillin, ampicillin or chloramphenicol.
- Supportive measures, such as oral fluids to prevent dehydration, continued feeding to avoid malnutrition, measures to reduce fever and protection from cold are all essential.
Measles is a highly communicable viral infection spread person-to-person via respiratory droplets which damage the immune system. Deaths most frequently occur from complications of co-morbidities, accompanying but unrelated diseases, such as pneumonia, diarrhoea and malnutrition. The Camp Management Agency, in cooperation with relevant health agencies, should ensure that all staff working in close contact with the camp population are educated regarding the initial symptoms in order to facilitate early referral and case management. They should know that initial signs and symptoms are high fever, cough, red eyes, runny nose and Koplik spots (small white spots on the inner lining of the cheeks and lips). A red, blotchy rash may also appear behind the ears and on the hairline spreading to the entire body. All those found with these initial signs and symptoms should be referred to the closest health facility for symptomatic management and should have their nutritional status monitored for possible enrolment in selective feeding programmes. It is not necessary however to isolate cases in an emergency situation.
Four species of the parasitic disease termed malaria develop in humans, but Plasmodium falciparum is of prime public health importance, especially when managing a camp in sub-Saharan Africa.
The disease is transmitted by the bite of the female anopheles mosquito, which mainly attack during the night. Simplified case definitions to be used in an emergency are:
- Uncomplicated malaria is characterised by fever or history of fever in the previous 48 hours, with or without symptoms of headache, back pain, chills, nausea, vomiting, diarrhoea or muscle pain where other obvious causes of fever have been excluded. In a high malaria risk area or season, all children under five with fever or history of fever should be classified as having malaria. In a low malaria risk area or season, children with fever or history of fever are classified as having malaria and given an anti-malarial only if they have no runny nose (a sign of acute respiratory infection), no measles or other obvious sign of fever such as pneumonia or a sore throat. In the low-risk areas, parasitological confirmation is recommended.
- Severe malaria is characterised by the fever and symptoms of uncomplicated malaria but with associated neurological signs such as disorientation, convulsions, loss of consciousness and/or severe anaemia, jaundice, spontaneous bleeding, pulmonary oedema and/or shock.
The Camp Management Agency should recognise that in the emergency phase of a camp, laboratory diagnosis for malaria is usually not feasible. Thus diagnosis and treatment should be based on clinical symptoms coupled with knowledge of the risk of malaria in the camp area. As soon as laboratory services can be established, diagnosis should be confirmed, unless there is a malaria epidemic in which case clinical diagnosis is acceptable. Rapid diagnostic tests, although expensive, can be useful during the emergency phase to confirm malaria cases in a low malaria risk area or season before appropriate laboratory services can be established.
Effective treatment for malaria should be implemented with current knowledge of the drug resistance patterns in the camp area. In camp situations where mortality from malaria is high, drug combinations with artemesin (ACT) are recommended. These combination drugs are increasingly used as first-line treatments in many countries and are rapidly effective in most areas. If the national health authorities do not use ACT as a first-line treatment, and no recent efficacy studies on their recommended first-line drug have been conducted, then ACT is recommended. Coordination with the national health authorities is imperative and may require lengthy discussions in order to implement ACT in a camp situation. If there are high treatment failure rates and high case fatality rates for malaria, it is recommended that the lead health agency and/or Camp Management Agency, together with the Cluster/Sector Lead Agency, should advocate for change in the drug regime with the national health authorities.
The first health priority in an emergency is to implement early diagnosis and effective treatment for malaria. Additionally, barrier methods for mosquito bite prevention, for example insecticide-treated mosquito nets, are important to implement, but after the above priorities have been accomplished. Community distribution of treated nets in the emergency phase of a camp is only recommended when the camp residents are already in the habit of using nets because of the behavioural change needed to make the intervention a success. If treated nets are distributed, new and long-lasting ones should be chosen. Vector control activities and extended distributions of personal protection against mosquito bites is important. So is Intermittent Preventive Treatment (IPT), a dose of antimalarial medication given to pregnant women on a regular basis, to prevent malaria throughout the pregnancy.
- For more information on vector control activities, see Chapter 14, Water, Sanitation and Hygiene.
Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS)
Vulnerability to HIV/AIDS is intensified during an emergency. Social norms regulating behaviour can be weakened. Fragmentation of families threatens stable relationships. Displacements may bring populations with different HIV prevalence rates into contact. Displaced persons may have been forced to submit to unprotected survival sex. Health structures may be stressed and have inadequate supplies to prevent the transmission of HIV, such as universal precautions supplies or condoms. As well, in camps with large numbers of arriving war-wounded, HIV infection can be passed via blood transfusions. HIV can be transmitted via four main modes:
- sexual intercourse with an infected partner, especially in the presence of a sexually transmitted infection
- contaminated needles (needle stick injuries, injections)
- transfusion of infected blood or blood products
- mother-to-child transmission during pregnancy, labour and delivery or through breastfeeding.
The Camp Management Agency should ensure that the response to HIV/AIDS is multi-sectoral. The lead health agency in cooperation with the Camp Management Agency should supervise and ensure a minimum set of interventions are initiated by health service agencies in the camp to mitigate the transmission of HIV. Beyond the context of the immediate crisis HIV/AIDS influences the life and situations of persons and their social networks for years to come.
In accordance with guidelines prepared by the Joint United Nations Programme on HIV and AIDS (UNAIDS) for addressing HIV in humanitarian settings (2010), the inter-sectoral HIV response should include the following minimum interventions within preparedness, minimum initial and expanded responses:
- raising HIV awareness
- providing a safe blood supply, by having HIV testing of blood before transfusion, and avoiding all non-essential blood transfusions
- adhering to universal precautions
- providing basic HIV education materials
- providing good quality condoms, preferably free of charge, via appropriate channels as identified during the rapid initial assessment
- offering syndromic sexually-transmitted infection (STI) treatment, an approach which treats STIs according to signs and symptoms, requiring no laboratory confirmation
- managing the consequences of gender-based violence
- ensuring safe maternal deliveries.
No Mandatory HIV Testing
Mandatory testing for HIV represents a violation of human rights and has no public health justification. A HIV voluntary confidential counselling and testing (VCCT) programme can be established in the camp, but it is not a priority intervention during an emergency phase.
HIV services during the post-emergency phase should expand to more comprehensive interventions related to preventing HIV transmission, as well as providing support, care and treatment to those living with HIV/AIDS and their families. These should include:
- services or strategies to prevent sexual violence
- post-exposure prophylaxis
- information, education, communication materials for high-risk groups
- voluntary counseling and testing
- services for preventing mother-to-child transmission of HIV.
Palliative and home-based support and care should be provided for people living with AIDS. Other care and treatment interventions for people living with HIV include prophylaxis and treatment of opportunistic infections and antiretroviral therapy.
Disposal and Management of Dead Bodies
Natural disasters, sudden onset or prolonged conflict situations as well as diseases, epidemics and malnutrition often result in large numbers of deaths. The management of dead bodies in general, as well as in camps, is one of the difficult aspects of a crisis response. The collection and disposal of dead bodies is crucial and should be carried out quickly in appropriate ways to mitigate possible social and political implications as well as to avoid emotional or psychological distress among those who have lost family members, among camp communities and also among rescue and recovery workers.
Health related risks are normally negligible even in emergency situations and cultural obligations and traditions should not be foregone except in rare circumstances. The primary concern of the teams in charge of body disposal should be to carry out the cultural and religious obligations and traditions required, rather than potential disease transmission.
Contrary to popular belief, evidence suggests that dead bodies, particularly those who died as a result of physical trauma, for example natural disasters, accidents or armed conflict, are not likely to result in disease outbreaks such as typhoid fever or cholera or plague. However, if these bodies are not disposed of properly, gastroenteritis or food poisoning syndrome may occur if there is contamination of water sources such as wells, streams and aquifers.
In medical epidemics, special precautions should be taken to prevent disease transmission from dead bodies to other members of the community. Bodies should be handled whenever possible by medical staff. Vehicles used for transport of bodies should be disinfected after use. Limits should be placed on the size of gatherings and risks of practices, such as washing of the dead should be communicated to the community. WHO Technical Note for Emergencies No. 8 outlines specific practices in the event of cholera, Ebola, typhus and plague. Under all circumstances WHO Guidelines on Disposal of Dead Bodies in Emergency Conditions suggest adherence to the following principles:
- prioritise the living over the dead
- dispel myths about health risks posed by corpses
- identify and tag corpses
- provide appropriate mortuary services
- reject unceremonious and mass disposal of unidentified corpses
- respond to the wishes of the family
- respect cultural and religious observances
- protect communities from the transmission of medical epidemics.
Reproductive Health (RH)
Reproductivre health services should be provided in a camp environment as an integral part of primary health care services. Providing appropriate services can overcome the complications of pregnancy and delivery which are the leading causes of death and disease among refugee/IDP women of child-bearing age. A RH response in the emergency phase of a camp is necessary.
Quality RH services provided by trained staff should be available in the camp. Use of them should be left to the decision to each individual. As RH services affect very personal aspects of a persons’ life, they must be implemented in a culturally appropriate manner, considering the religious and ethical values of the camp population. Those providing the services should provide an enabling environment where those seeking services can feel comfortable and secure. The following minimum reproductive health interventions should be provided in the emergency phase:
- A reproductive focal person/agency should be identified to supervise all services within the camp and bring issues and information to health coordination meetings.
- All pregnant women, birth attendants and midwives should be identified within the camp and issued with clean delivery kits: a square metre of plastic sheet, a bar of soap, a razor blade, a length of string and a pictorial instruction sheet. Multiple kits should be provided to birth attendants and midwives and a system established to replenish them as needed. Health facilities and trained midwives should be issued with professional midwife delivery supplies using WHO’s New Emergency Health Kit.
- A referral facility and transport should be identified for obstetric emergency transfers.
- A medical response should be provided to survivors of sexual violence, including emergency contraception as appropriate via the health facilities (small quantities are available in the WHO New Emergency Kit).
- Community leaders, pregnant women, birth attendants and community health workers should start community education on indications for referral.
As soon as feasible, comprehensive services for antenatal, delivery and postpartum care must be organised. These must include family planning services, information on sexually transmitted infections (STIs), vaccinations (tetanus toxoid) and well-baby clinics. The objectives of comprehensive RH services include:
- ensuring all pregnant women attend antenatal clinics at least four times during pregnancy for antenatal care
- health education and early detection and management of complications of pregnancy
- ensuring all women have access to clean, safe delivery attended by a skilled health worker
- providing post-natal care to all newborn infants
- promoting, protecting and supporting early, exclusive (up to six months), and sustained (up to two years) breastfeeding
- ensuring all women receive basic post-natal care through home visits and referral for complications
- managing the complications of spontaneous or induced abortion and reducing the incidence of unsafe abortion
- providing family planning services as needed
- preventing HIV transmission through universal precautions
- providing prevention of mother-to-child transmission (PMTCT) of HIV
- preventing and reducing sexual transmission of STIs and HIV/AIDS.
Mental Health and Psychosocial Support
Emergencies create a wide range of problems experienced at the individual, family, community and societal levels. Every individual will experience the same event in a different manner and will have different resources and capacities to cope with that event. Psychosocial problems in emergencies are highly interconnected, yet they may be predominantly social or psychological in nature.
Significant problems of social and psychological nature - some examples:
|Pre-existing / pre-emergency||
Mental health and psychosocial needs in emergencies encompass far more than psychological conditions like PTSD or disaster-induced depression. A selective focus on these two problems is inappropriate because it overlooks many other mental health and psychosocial support needs in emergencies and may ignore individual, family and community resources and coping mechanisms.
Psychosocial support should be cross-cutting in all services provided in camps. Camp Management Agency and all health actors must have essential knowledge of protecting psychosocial well-being and be aware of Do No Harm principles and psychological first aid. They need to acknowledge that camps will have people with pre-existing mental disorders. In emergencies, the percentage of people with severe mental disorders seems to increase by one per cent over the baseline. About ten per cent of people have mild to moderate mental disorders. This may rise to 15 per cent in emergencies. In most situations, people recover naturally, healing without outside intervention. To assess and assist people with mental disorders, the Camp Management Agency should facilitate access to clinical mental health care, whether delivered within or outside camps. Preferably, such services are attached to general health or social services (for adults) or to schools (for children). An expected subset of the people with mental disorders need specialised care.
While it is understood that the provision of mental health services does not lie within the responsibility or capacity of the Camp Management Agency, some key actions are nevertheless identified:
- All actors should be trained to confidentially identify and refer people who seem very confused, unable to care for themselves or who have attempted suicide. The collection of information should be dignified and confidential and further assessed by trained mental health professionals. It is important to ensure that people with specific needs are protected by family members or neighbours and referred immediately to health providers. There must be special living arrangements for those formerly living in psychiatric institutions.
- Mental health providers in camps should be encouraged to learn about and, where appropriate, collaborate with local, indigenous and traditional healing systems.
- Support must be provided to holistic mental health-specialised care in camps when needed, avoiding single-service mental health centres. Clinical mental health care, when made available, should focus on emergency-induced mental health problems and also cover pre-existing mental health problems.
- Favor the engagement of mental health agencies, which could grant sustainable mid-term therapeutic pathways.
All persons in the camp should have access to health information that allows them to protect and promote their own health status and that of their children. Women, men, adolescents and children should understand how their bodies work and how they can maintain good health in an unfamiliar environment. Dissemination of health information is usually done via health education programmes and should be initiated with the first activities in a camp. Although health education is primarily disseminated via community-based outreach programmes, every contact the health system has with an individual should be an opportunity for health information dissemination. The following should be remembered:
- Health education in the camp should be context specific and take into account the health-seeking behaviours of the population as well as their personal health beliefs.
- The messages and materials should be formulated in local languages with options for non-literate populations.
- Information provided should concentrate on the priority diseases within the camp, major health risks for these diseases, the availability and location of health services and promotion of behaviours that protect and promote good health.
- Education on feeding- and care practices of infants and children should be implemented as this is critical in preventing malnutrition and diseases.
- The lead health agency and the Camp Management Agency should coordinate health education messages to ensure that all health service providers in the camp are providing consistent and accurate messages.
- Health service providers should conduct regular assessments of the effectiveness of the health messages to the target audience and those who implement them.
- Health messages can be expanded during the postemergency phase to include messages coinciding with comprehensive health services implemented in the camp.
Voice From the Field - Effective Health Agent in Haiti
In Haiti, oral-rehydration-post health workers, known as ‘brigadiers’, were selected from IDP camps and became effective health agents to sustain community based efforts in preparation for expected cholera outbreaks during the rainy season in 2012. They were trained in how to reactivate first line treatment, to sensitise camp residents about prevention of cholera, to decontaminate and to conduct monitoring and surveillance in the camps.
Health Priorities at Camp Closure
The closure of a camp is complex and requires coordination from all sectors. The lead health agency and Camp Management Agencies coordinating activities during this planning phase should remember:
- Epidemics of communicable diseases with high mortality should warrant the camp remaining open. Those affected should be treated in the area of transmission as camp closure and movement out to a larger population may spread the disease further.
- Health facility utilisation rates and total population remaining in the camp are indicators for planning to phase down health services, like decreasing the number of inpatient beds and outreach activities.
- Health services must be available until every camp resident has left. Usually those last to leave the camp, such as women delayed by childbirth, malnourished children and older people, have the greatest health needs.
The camp population should be aware of health services available to them on leaving the camp. The Camp Management Agency and the lead health agency should coordinate with the national health authorities in areas where the population will return to gather and share information. Information gathered should be disseminated to the population before leaving the camp. This is more difficult in cases where camp residents subsequently scatter to diverse areas and will require a more detailed plan of action.
Ideally, health examinations should take place before departure, particularly for the very young, older people, pregnant women and those with physical and mental disabilities. However, this may be difficult in camps where return is spontaneous. When health assessment prior to departure is possible, information campaigns should have clear objectives as this can be misinterpreted as a way to prevent persons from leaving the camp or to gather confidential health data for reporting to areas of return.
Objectives for pre-departure health examinations include:
- Providing information, facilitating referral and correct management for groups with specific needs such as the malnourished, pregnant women and people with disabilities while maintaining the confidentiality and securing, where possible, the written consent of the individual, parents or other legal guardian for minors with mental health conditions.
- Recognising the need to remain in treatment or continuity of care upon arrival at destination site. Travel assistance may be needed. The consequences of deciding to return must be considered. Special vehicles, wheelchairs, stretchers, feeding programmes and medical escorts may be needed to take them to their area of return.
- Identification of persons who should be referred to specific health services in their area of return. A referral letter should be issued to each person identified in the language of their area of return. Persons receiving treatment must receive extra supplies of medications.
- Identification of children who need referral for immunisations ensuring the confidentiality of medical records and destruction of any outdated or unwanted documentation.
Pre-departure Health Checks
Simple pre-departure health checks ensure that the person is fit to travel by road, sea, or air. The health checks minimise risks associated with the movement for the individual and the receiving host communities, and facilitate access to health care services at the destination site.
Voice From the Field - Continuity of Health Care and Referral Process Across International Borders
The sudden onset of crisis in Libya in 2011 resulted in a massive outflow of people across the borders of neighbouring countries. Hundreds of thousands of vulnerable displaced and conflict-affected persons including refugees were stranded in the Choucha border camp in Tunisia. They were provided rapidfitness- to-travel health checks before departure and some received treatment or were hospitalised until their medical conditions had stabilised. Medical escorts accompanied them to their countries of destination and handed over to receiving health authorities or family members.