3.4 Addressing communicable diseases

In emergencies, diarrhoeal diseases are a major cause of morbidity and mortality.  Inadequate water supplies, substandard and insufficient sanitation facilities, overcrowding, poor hygiene, scarcity of soap and malnutrition are the main factors contributing to the occurrence. Malnutrition and diarrhoeal diseases are closely linked: malnutrition contributes to the severity of diarrhoea, and diarrhoea can cause malnutrition. The most common diarrhoeal diseases are shigellosis (the most frequent cause of dysentery), cholera, rotavirus, and e-coli bacillus.

Routine surveillance systems should include indicators to track cases of bloody and non-bloody diarrhoea for all children. Adult mortality, increases in numbers of adult cases, significant increases in bloody diarrhoea, and a rise in the case fatality rate should be an indication to alert medical staff immediately.

Use of oral rehydration therapy (ORT) in accordance with early rehydration is the most critical element to treat and prevent severe morbidity or mortality. In the early phase of the emergency, at least one ORT corner should be set up immediately in the most central health facility with a plan for rapid scale-up to better accommodate the population.

Much morbidity and mortality can also be attributed to acute respiratory infections (ARIs).  Conditions that foster the spread of infections include overcrowding, indoor fires, and inadequate shelter and blankets, especially in cold climates. Interventions that are effective in helping to reduce the incidence of ARIs include: vaccinations for measles, diphtheria and pertussis; supplements of vitamin A; and breastfeeding children under two years of age.

Throughout the world, measles is still one of the leading causes of childhood mortality. It is a highly contagious disease and can be associated with high mortality, severe complications and an increased vulnerability to other infections, which can subsequently lead to malnutrition. When vaccinations are not promptly distributed, populations are vulnerable to outbreaks.

Prevention of measles is thus a high priority, particularly when the population is living in refugee camps or displaced person situations. Measles immunisation campaigns should be prioritised, along with immunisation for pertussis and diphtheria when determined through surveillance. Surveillance should be used to determine when it is appropriate for other vaccine programmes to be integrated into health services.

During a humanitarian response CARE will focus on strengthening or introducing SRHR services, either through collaboration with local ministries of health, or in partnership with other non-governmental organization implementing partners. However, CARE has an important role to play, where feasible, in assisting the local and national governments in contributing to reducing maternal, newborn, infant and under-five mortality and morbidity through programs introduced by the public sector of the concerned government. In the absence of a functioning government health system, CARE will assist, where feasible, with multilateral organizations to support life-saving interventions to reduce excessive maternal and newborn, including infant and under-five morbidity and mortality.

To ensure prevention and detection of measles in an emergency, the following points should be adhered to:

• At the outset of an emergency, an estimation of measles vaccination of all individuals aged nine months to 15 years of age should be made.
• If coverage is estimated to be less than 90%, then a mass vaccination campaign should be initiated in coordination with local and national health authorities, as well as partner organisations.
• Upon completion of the measles campaign, at least 95% of the population aged six months to 15 years of age must have received the measles vaccine.
• During this time, at least 95% of children six to 59 months of age should also receive an appropriate dose of vitamin A.
• Routine follow-up with another measles vaccination dose nine months later should be in place with children six to nine months of age.
• Fixed vaccination points should be immediately integrated into the health system with the collaboration of local and national health authorities.
• At least 95% of all newcomers into the host area should be vaccinated.
• All suspect cases for measles should be assessed immediately.

In addition to mass measles vaccinations, standardised case management protocols, such as the IMCI for diagnosis and treatment, should be used. Outreach activities and community education messages should be widely disseminated to ensure that individuals affected by the emergency are aware of when they should seek treatment or care.

In the early phase of an emergency, rapid assessment should determine the risk for malaria infection in the disaster location. In the case of displaced or refugee populations, determine where the population is settling and compare it to the area the population is relocating from. Some level of treatment and/or prevention should be considered, including distribution of treated bed nets and health promotion of malaria prevention.

Malaria infection during pregnancy is a significant public health problem with substantial risks for the pregnant woman, her fetus, and the newborn child. In parts of the world where malaria is endemic, it may directly contribute to almost 25% of all maternal deaths. In high-transmission settings, where levels of acquired immunity tend to be high, infection may be asymptomatic in pregnancy. However it still contributes to maternal anemia. Both maternal and placental parasitaemia can lead to low birth weight, which is an important contributor to infant mortality. In low-transmission setting, malaria in pregnancy is associated with anemia, an increased risk of severe malaria and may also lead to spontaneous abortion, stillbirth, prematurity and low birth weight.

In settings where malaria is a problem, programs should use long-lasting insecticidal nets (LLINs), and prompt diagnosis and effective treatment of malaria infections.

Displaced populations may find themselves at a greater risk for malaria infection. If the population settles in a malaria endemic region, laboratories, means for vector control and the most appropriate drug treatment for the region will need to be considered in the relief effort.  For populations travelling into a non-endemic region from an endemic region, drug treatments should be available to treat cases that might develop. In addition, surveillance should monitor malaria incidence, as the mosquito may also travel with the population and result in spread in the current location.

As social networks and livelihoods collapse due to emergencies and conflicts, people are subjected to situations that are known to increase their vulnerability and risk to HIV. An individual’s access to information and services-including prevention information, condoms or health care-is either limited or completely cut off.

Loss of livelihoods and income may force women and adolescent girls into transactional or commercial sex; many women have to trade sex for food or security, making contraception a necessity. Increased interaction between military, peacekeepers and local populations also put women and men at risk of contracting HIV and other sexually transmitted infections (STIs), especially when they practise unsafe sex (without condoms). Women and girls seldom have control over sexual negotiation or the relationship. Men who have sex with men (MSM) as well as LGBT populations may be disproportionately affected and marginalized, so may need particular attention in service delivery for HIV prevention/treatment as well as other STIs.

A minimum package of services should be in place to prevent transmission of HIV/AIDS among the population affected by the emergency. This includes free condoms, safe blood supply, universal precautions for infection prevention, relevant information and education, case management of STIs, and basic health care for people living with HIV/AIDS. HIV control activities should be continually informed by assessing local needs and circumstances. See also Chapter 41 HIV/AIDS. Refer to Annex 26.5.6 for a list of the minimum requirements for infection control.

Vertical transmission of HIV from mother to child must also be considered in the prevention response.  Current guidelines recommend that all pregnant women of unknown status be offered HIV testing and counseling, and that all women testing HIV+ should receive an appropriate prophylactic regimen to reduce the chance of HIV transmission during delivery and post-partum.  HIV+ mothers should also receive counselling on exclusive breastfeeding of infants for the first 6 months to further reduce the chances of transmission of the virus.

HIV control activities should be continually informed by assessing local needs and circumstances. See also Chapter 9.3 HIV/AIDS. Refer to Annex 26.5.7 for a list of the minimum requirements for infection control and for UNAIDS best practices on HIV and emergencies.