Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 153 CHAPTER 9 Epidemiological Studies Junaid A. Razzak and Uzma Rahim Khan EPIDEMIOLOGY Epidemiology is defined as the study of the distribution and determination of healthrelated states or events in specific populations. This field also includes the application of these investigations in an attempt to control health problems. It helps planners to focus on the main problems of a community rather than of individual patients, and to identify measures for improving the health of the community as a whole. EPIDEMIOLOGICAL STUDIES Epidemiology allows public health professionals to learn more about the effects that emergencies have on the health of affected populations. Case-series, cross-sectional, case-control, and cohort studies are commonly used in public health emergencies (see Table 9-1). In contrast, ecological and correlation studies have rarely been used to assess emergencies because the unit of analysis is an aggregate of individuals and information is collected on a population rather than on individual members.1 Case-series studies have been useful to identify the clinical features and specialized treatment of specific types of injuries. However, they usually include a single hospital sample whose members may not be representative of the full spectrum of injuries for the event, and they do not address the variety of outcomes experienced during the disaster, including less severe injuries treated outside the hospital setting. Cross-sectional surveys are an efficient way to collect information about behaviors during and after disasters, the precise location of individuals during the event, and the diversity of outcomes experienced during the event, including less-severe – 153 – EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 154 9/16/10 12:33 AM Page 154 CHAPTER 9 / Epidemiological Studies TABLE 9-1 Role of Epidemiological Studies in Public Health Emergencies Type of Epidemiological Study Data Collected Case series: sequence of case • Clinical features reports with common elements such as similar clinical features and • Specialized treatment of specific types of suspected common injuries exposures Limitations • Lack of generalizations • Nonreporting of less severe injuries treated outside the hospital setting Cross-sectional: study of several • Frequencies of mortality • Absence of population counts individuals at one point in time, and morbidity • Poor sampling methods focusing information on health leading to nonrepresentative • Behaviors during and status, health-related behaviors, samples after emergencies and other exposure factors • Diversity of outcomes experienced during the event Case control: study of individuals • Risk factors in whom a disease has already occurred to find out whether these individuals have been exposed to a particular risk factor Cohort study: study of a group exposed to a particular factor and another group not exposed to this factor, who are followed over time to determine the occurrence of disease • Bias from selective survival, population movement, and recall • Bias due to selection of cases and controls • Estimate incidence and • Identification of a defined magnitude of risk • Short- and long-term and direct and indirect health effects cohort • Logistics of long-term data collection • Loss to follow-up • Emergency-related outcomes injuries treated outside the hospital setting. Limitations of cross-sectional studies of disasters include poor sampling methods leading to nonrepresentative samples and bias from selective survival, population movement, and recall. Retrospective studies involving victims or healthcare workers involved in a disaster may include only a small percentage of the victims (35 to 40 percent), and they may not report the disaster events accurately. These shortcomings can reduce the internal and external validities of emergency public health epidemiological studies. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 155 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Epidemiological Studies However, if collection of data in real time occurs, patient reliability and response rates may be more accurate. Confounding factors that potentially could be introduced into such a study by use of proxy measurements also are reduced. If primary care workers or emergency personnel (prehospital care or emergency department professionals) are able to record the medical data in real time, there will be no need to use proxy measurements; by comparison, such proxies are often used in retrospective studies to collect research data. Case-control studies are an efficient design for estimating specific risks, and their use for examining disaster-related outcomes has increased during the last decade. Cases can be collected from multiple sources of data, including existing records or surveys. Controls should be sampled from the same population from which the cases arose (e.g., controls from the community). Finding a representative control group is the most complicated feature of the case-control design because of the difficulty in defining a base population for a disaster. Matching can be used to control for confounding factors that might be difficult to measure at the population level, such as location within a building. For example, Roces et al. matched injured cases to uninjured family members to estimate the risk of mortality associated with such factors as building type and being inside a building compared with being outside a building in an earthquake.2 In reality, family members are likely to be in the same structures and to be located together. The ideal epidemiological design is the cohort study. In emergency public health studies, follow-up can be substantially shortened if only direct consequences are examined; accounting for injuries after extrication or during post-disaster activities could lead to a lengthier study process. Some loss to follow-up of the cohort may occur because of death, relocation, and missing contact information. Cohort studies are rarely conducted in the setting of emergency-related injuries because of the difficulties in identifying a defined cohort. Part of the problem is that researchers cannot define when and where an emergency will occur and, therefore, must necessarily rely on retrospective cohorts. Epidemiological studies have also introduced public health emergency statistics and analysis into assessment of quality of life indicators. Some examples include restricted-activity days, number of days for which the ability to work was lost, number of days hospitalized with disabilities, and disability adjusted life-years (DALY ). Most of the DALYs attributable to emergencies occur immediately at the time of the incident, such as in cases involving burns, drowning, suffocation, or fractures. Numerous questions arise after a large-scale emergency has resolved—for example, the number of disabilities and deaths that might have been prevented through improved search EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 155 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 156 9/16/10 12:33 AM Page 156 CHAPTER 9 / Epidemiological Studies and rescue operations, the importance of time to interventions in reducing DALY losses, and the assessment of the effectiveness of external search and rescue assistance teams and temporary facilities. Refining the existing methodology and developing quantitative indicators to estimate both direct and indirect losses and costs due to public health emergencies should be a research priority.3 EPIDEMIOLOGY IN PUBLIC HEALTH EMERGENCIES The basic epidemiological approach in large-scale emergency settings is no different from that used in any standard epidemiological investigation. Specifically, researchers describe the adverse health effects of natural and human-caused public health emergencies and the factors that contribute to those effects (Table 9-2). However, the difference lies in the importance of gathering data and making decisions in a short period of time. The three fundamental phases of public health emergencies are preparedness, response, and rehabilitation. Each of these phases is characterized by predictable patterns of health indicators and expected public health responses.4 If these patterns are addressed with appropriate management responses, a decline in morbidity and mortality and a shortening of the duration of each epidemiological phase will result. TABLE 9-2 Application of Epidemiology in Public Health Emergencies Rapid needs assessment (vulnerability and hazard assessment) Demographic studies of population size and structure, death, disease, nutrition, and immunization (outbreak investigation) Public health monitoring and information systems management (surveillance and action-oriented information systems) Research methodologies Injury and disease profiles Disease-control strategies for well-defined problems Needs of special populations Assessment of the use and distribution of health services Etiologic research on morbidity and mortality Development of long-term epidemiological studies of the affected populations EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 157 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Epidemiology in Public Health Emergencies Epidemiology in the Preparedness Phase Epidemiological preparation and planning before an event includes collecting information on infrastructure, institutional knowledge and capabilities, training, and prediction models. In short, all these activities will lead to risk reduction. Having current and continuously updated epidemiological data on the capacities of the various components of public health systems in a community will allow public health professionals and policy makers to direct resources appropriately (Table 9-3). In addition, the data from the preparedness phase can ensure plans are developed that respond to actual threats and serve actual at-risk populations rather than to hypothetical situations. The goals of this phase are as follows: • Developing baseline data for assessing the needs of affected populations and matching available resources to needs • Preparing for training resources • Planning for contingencies • Evaluating program effectiveness Strong community linkages are essential to a public health organization’s overall preparedness for emergencies and are key to achieving these goals. TABLE 9-3 Epidemiological Studies During the Preparedness Phase of Public Health Emergencies Study Questions Study Design/Information Source • Size and distribution of the population area • Surveys (demographic health survey) • Major communication lines and topography • Observation • Distribution and services provided by health facilities • Mapping • Surveillance and prevention strategies • Interviews • Identification of groups at the highest risk • Focus groups (displaced groups, specific age groups, low-income groups) • Media reports • Estimation of the number of people needing assistance • Determination of baseline parameters to monitor the impact of planning and future response EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 157 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 158 9/16/10 12:33 AM Page 158 CHAPTER 9 / Epidemiological Studies Epidemiology in the Response Phase Carrying out epidemiological investigations in the middle of a public health emergency may be viewed as an unnecessary endeavor when many people require immediate and direct assistance. In reality, contingency response and relief programs can be implemented and managed more effectively if decisions are based on epidemiological findings. The goals of the response phase are outlined here: • • • • • • Rapid assessment of health and medical needs during the emergency situation Understanding of the effects of current and forecasted weather conditions Continuous monitoring of the health problems faced by the affected population Knowledge of available resources Implementation of disease control strategies Evaluation of the use and distribution of health services The epidemiological information gathered through study during this phase can be used to direct ongoing response activities and provide feedback for mitigation efforts. Collecting data in “real time” during an active public health emergency is challenging, but recent technological innovations can certainly assist these efforts (Table 9-4). Computer hardware and software databases are now able to collect data rapidly under highly adverse conditions, and this information can be analyzed rapidly to provide timely intelligence on morbidity and mortality to public health decision makers. In addition, this technology makes it possible to model or simulate complex public health emergencies for planning and drills. Moreover, information technology facilitates disease telemonitoring that will help in monitoring the spread of disease in the affected area and help in determining necessary interventions. Geographic information systems (GIS) also serve an important role in effective community hazard and vulnerability analysis.5 Surveillance systems are another important target of epidemiological studies of public health emergencies. These systems are intended to ensure that the number of casualties can be reduced and the cases that do occur can be treated promptly and effectively.6 Surveillance data on health events are analyzed, transformed, and disseminated to decision makers for policy development and action. The media, including the Internet, radio, and television, can be used for collecting and disseminating emergency surveillance data. Without question, media coverage plays an important role in the epidemiology of an emergency. It should also be considered a potential intervention strategy, an indirect exposure, or an effect modifier. The ability of a society to use the media to provide warnings and forecasts, motivate volunteers, and raise funds can play a crucial role in limiting the short-term effects of emergencies. However, just as the media can limit primary exposures, so they can be contributors to secondary, psychologically driven, health outcomes.6 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 159 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Epidemiology in Public Health Emergencies TABLE 9-4 Checklist for Planning and Implementing a Survey in a Public Health Emergency 1. Which population is to be assessed (e.g., country, region, ethnic group)? 2. What is the smallest unit to be assessed (e.g., camp, village, district)? 3. Is there a need to analyze subgroups (e.g., by gender, age, ethnicity)? 4. Which sampling methods will be used (e.g., systematic, cluster)? 5. Which personnel, equipment, transport, number of teams, and resources will be needed? 6. Workload: How many subjects (clusters) per day per team? 7. Has a training schedule for field workers been prepared? 8. Who will conduct the training? Where? 9. Who will supervise the teams during the survey? 10. Are computers and operators available? 11. Who is responsible for the logistics (e.g., transport, equipment, accommodation, information for target population)? 12. Who is responsible for report writing and interpretation of findings? 13. Who is the target audience? 14. What is the target date? 15. Who is responsible for taking action on the report’s findings? Local response capability and infrastructure management must be strengthened to reduce mortality and morbidity in the first hours and days following an emergency because external assistance teams are unlikely to arrive within the scope of one or two days. Table 9-5 outlines ways that epidemiological studies can facilitate achieving the goals of the response phase for a public health emergency. Epidemiology in the Rehabilitation Phase By collecting mortality and morbidity data in real time, critical information about the health needs of a vulnerable population can be applied to mitigation efforts and the rehabilitation phase. This phase is characterized by a prolonged period that may take months or years to complete. The primary endpoint is returning the affected community back to pre-emergency baseline levels of functioning for most parameters such as health, EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 159 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 160 9/16/10 12:33 AM Page 160 CHAPTER 9 / Epidemiological Studies TABLE 9-5 Epidemiological Studies During the Response Phase of Public Health Emergencies Study Questions Study Design/Information Source • Assessment of physical condition of health, • Aerial observation transport, and communications facilities by competent technicians and engineers • Status of relief activities: food, shelter, and protective clothing • Cross-sectional surveys • Observation • Mapping • Total number of casualties • Interviews • Number of people requiring immediate treatment • Focus groups • Number of people requiring continued care after • Review of census, situation reports emergency treatment • Prevalence or incidence of adverse health outcomes (injuries, death) • Development of a registry of adverse health outcomes • Disease outbreaks and the major disease risks in the affected area • Number of people requiring evacuation • Availability of essential health supplies and • Reports from the community/relief workers and media • Screening • Regular reporting from existing facilities • Case-control studies that can identify risk factors, eliminate confounding factors, and study the interactions of multiple factors personnel • Needed supplies and repairs to local medical facilities • Characterization of the population at risk and/or exposed to the emergency (e.g., size, location, susceptibility, and age distribution) • Estimation of the exposure to the emergency (e.g., being in an area affected by an earthquake, flood, heat wave, or war) • Exposure to physical or psychological stressors • Location and number of people who have moved away from their homes • Estimates of the number of unaccounted deaths and missing people EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 161 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Challenges of Epidemiological Studies in Public Health Emergencies TABLE 9-6 Epidemiological Studies During the Rehabilitation Phase of Public Health Emergencies Study Questions Study Design/Information Source • Short- and long-term, direct and indirect health • Longitudinal studies to measure effects, effect modifiers (e.g., building infrastructure, living conditions, communication systems including the media and the Internet) • Identification of a control (not exposed) population • Incidence and magnitude of risk • Identification of risk factors for death and injury changes over time • Population-based surveys • Ongoing health information system data collection • Cohort studies with sufficient followup for long-term consequences • Planning strategies to reduce impact-related morbidity and mortality • Evaluation of the effectiveness of various types of assistance and the long-term effects of the emergency housing, transportation, and communications. Epidemiological studies are easier to conduct during this phase because the pressures of an ongoing public health emergency are no longer constraining data collection. The goals of this phase are as follows: • To estimate incidence and magnitude of risk • To determine short- and long-term direct and indirect health effects and effect modifiers • To identify risk factors for death and injury • To plan strategies that reduce impact-related morbidity • To evaluate the effectiveness of various types of assistance and long-term effects after the response phase of an emergency Directing reconstruction efforts so as to restore the public health infrastructure to pre-emergency conditions is the key to achieving these goals. Table 9-6 outlines the types of epidemiological studies undertaken as part of this effort. CHALLENGES OF EPIDEMIOLOGICAL STUDIES IN PUBLIC HEALTH EMERGENCIES Data are often ephemeral in an emergency. As time passes on, populations change in terms of their exposure to and effects experienced from the public health emergency. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 161 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 162 9/16/10 12:33 AM Page 162 CHAPTER 9 / Epidemiological Studies In addition, individuals and officials are often more willing to share information in the immediate aftermath of an emergency than later, during the rehabilitation phase. In sudden-onset events, the researcher usually cannot select the location where the data collection will occur, and the number of variables that can be controlled is often limited. The unexpected nature of public health emergencies also leads to retrospective data collection. These retrospective data, in turn, create difficulties in making before-and-after comparisons of the community affected by the emergency situation. For example, many of the affected individuals may be displaced from their homes or may be in the area only temporarily as visitors, whereas others may have been in the area only to assist with the emergency response (assigned or volunteer responders). These individuals may prove difficult to identify and locate after the immediate crisis has passed. Over time, recall bias also becomes a problem. Some researchers have found that preliminary assessment of needs by drawing a representative sample of the affected population may be the preferable approach.7 However, obtaining a truly representative sample of adequate size may be difficult due to the vastness of the affected area, poor connectivity to the disrupted communities, and the limited time available with the team. Data gathering may also be hindered by poor communications, reliance on secondary sources for information, lack of expert personnel, loss of preexisting data during the emergency, and loss of street signs and landmarks due to destruction of the geographical area. Many local physicians, public health, and nearly all other professionals who remain in the local setting will confront personal problems with loss of family, friends, and property, and these personal challenges will affect their ability to respond effectively during the crisis situation. In addition, healthcare workers involved in a public health emergency may be assisting only a small percentage of the victims, and they may not report the emergency events accurately. These factors and the destruction of the healthcare facilities make the epidemiological assessment and the management of the public health emergency even more complex.8 Frequently, a lack of an organized effort for gathering data by governmental organizations and a lack of coordination with the separate efforts of nongovernmental organizations (NGOs) are observed during an emergency situation. The shortage of available information from NGOs and the reluctance of NGOs to share data on their activities has been reported following sudden-onset emergencies due to natural hazards.9 All of these shortcomings can reduce the internal and external validities of emergency epidemiological studies. Table 9-7 summarizes these challenges. In an emergency situation, rigorous epidemiological approaches may not produce data quickly enough to aid responders. Nevertheless, an immediate need for quantitative data with which to manage emergencies does exist. Record keeping sometimes EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 163 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Challenges of Epidemiological Studies in Public Health Emergencies TABLE 9-7 Epidemiological Challenges in Emergencies Unexpected nature of public health emergencies Retrospective data collection Recall bias Representative sample size Poor communication Secondary sources of information Lack of expert personnel/deaths of local physicians and professionals Loss of preexisting data Loss of street signs and landmarks Lack of coordination may be abandoned in favor of patient care under the pressure to provide life-saving assistance to a large number of victims. In these situations, because abstraction of historical data is highly time-consuming, decisions may be made based on data that are received from hasty assessments and quick estimates made at times of crisis, rather than being based on concrete data. In other words, health decisions made during emergencies are often based on insufficient, or even false, information. Clearly, there is a need for reliable and early data collection to assist in making correct decisions. Research on responses to public health emergencies has, for the most part, used qualitative methods. Generally, this material has come from interviews, sometimes supplemented by government documents, private organizations’ reports, emergency department logs, after-action critiques, media, and other sources of information. It may then be coded for quantification and analysis. Examples of information that may be coded include the existence of an emergency plan, number or proportion of casualties transported by ambulance, hospital notifications, number of casualties received or admitted, injury or illness severity, and damage to hospital systems. Some reports provide quantitative estimates, albeit often without documentation of methodology. The statistics identified in these reports include such variables as number of casualties, number of patients rescued by other survivors, and number of patients transported by ambulance. Furthermore, although mean values are reported, measures of variation (e.g., standard deviation or 95 percent confidence intervals) are often lacking in the analysis part of these studies. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 163 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 164 9/16/10 12:33 AM Page 164 CHAPTER 9 / Epidemiological Studies Behavioral health consequences are prominent after emergencies but are understudied in epidemiologic investigations.10 Notably lacking are studies that examine mitigation, preparedness, response, and recovery variables with respect to their outcomes in terms of morbidity and mortality. Another limitation of the existing literature is that many of the research reports are not published in peer-reviewed journals, but rather appear in reports published by government agencies or academic institutions. Finally, some of the more useful case studies are outdated, and significant changes in public health and emergency medical systems have occurred since their publication. Although these studies need to be validated with more recent data, some case studies and anecdotal reports suggest that problems identified by these earlier systematic studies may still be major obstacles to effective response. Because of these limitations, research on public health emergencies is not likely to meet with the expectations of those who think of research in terms of randomized, double-blind, clinical studies, or even the less rigorous observational case-control or cohort studies. ACTION VERSUS RESEARCH: ETHICS OF RESEARCH Progress in medical care and disease prevention depends on an understanding not only of physiological and pathological processes, but also of the social, cultural, economic, and other environmental determinants of health, including the effects of the healthcare system and other social institutions. Producing this broad understanding requires performing research involving human subjects. Such research should be carried out only by, or strictly supervised by, suitably qualified and experienced investigators under accepted ethical guidelines. All research involving human subjects should be conducted in accordance with three basic ethical principles: respect for persons, beneficence, and justice. Researchers and ethicists generally agree that these principles, which in the abstract have equal moral force, guide the conscientious preparation of proposals for scientific studies. The emerging best practice for research conducted during a public health emergency, such as population studies of outbreaks of disease or of disaster relief efforts, is to establish the basic research design for various categories of research before the public health emergency actually occurs. Among other benefits, this preparation permits prior ethical review of the major features of the research design. When prior review has not occurred, a review should be conducted as quickly as possible. A further question to be raised in this context focuses on how much knowledge is needed before action can be taken. Within NGOs, tension often exists between researchers and program managers: The former, who are typically more detached and analytical, want to understand the situation as fully as possible before intervening, and the latter, EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH09_Kapur.qxd:Achorn Int'l 9/16/10 12:33 AM Page 165 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Notes who are typically much closer to communities, are keen to get involved with a minimum of delay. Challenges associated with allocating facilities and resources to people with different kinds of disabilities and rehabilitation needs in the face of time, personnel, and equipment shortages present everyone with ethical dilemmas, including many persons who have not had the benefit of training and guidance in how to make decisions in emergency situations.8 One can see how this consideration might also apply to emergency mitigation and preparedness work, where the methodological difficulties in obtaining good data on costs and benefits of interventions add strength to the argument for rapid engagement without waiting for the data. Exploiting or abusing emergency survivors for inexpensive or easy research should never be tolerated. Perhaps not everything can be measured or calculated. INTERNET RESOURCES Centers for Disease Control and Prevention: Disaster Epidemiology www.cdc.gov/nceh/hsb/disaster/ Centers for Disease Control and Prevention: Principles of Epidemiology in Public Health Practice http://www.ihs.gov/medicalprograms/portlandinjury/pdfs/principlesofepidemiologyinpublichealth practice.pdf Centers for Public Health Preparedness: National network of academic institutions collaborating with state and local public health departments and community partners http://preparedness.asph.org/cphp/ National Institutes of Health: Division of International Epidemiology and Population Studies http://www.fic.nih.gov/about/dieps.htm World Health Organization: Technical guidelines for health action in crises http://www.who.int/hac/techguidance/en/ World Health Organization: Epidemiology http://www.who.int/topics/epidemiology/en/ NOTES 1. Ramirez M, Peek-Asa C. Epidemiology of traumatic injuries from earthquakes. Epidemiology Review. 2005;27:47–55. 2. Roces MC, White ME, Dayrit MM, Durkin ME. Risk factors for injuries due to the 1990 earthquake in Luzon, Philippines. Bulletin of the World Health Organization. 1992;70(4): 509–514. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 165 58707_CH09_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 166 9/16/10 12:33 AM Page 166 CHAPTER 9 / Epidemiological Studies 3. de Ville de Goyet C, Zapata Marti R, Osorio C. Natural disaster mitigation and relief. In: Disease control priorities in developing countries (2nd ed.). New York: Oxford University Press; 2006, pp. 1147–1162. 4. Burkholder BT, Toole MJ. Evolution of complex disasters. Lancet. 1995;346(8981):1012–1015. 5. Mathew D. Information technology and public health management of disasters: A model for South Asian countries. Prehospital Disaster Medicine. 2005;20(1):54–60. 6. Dominici F, Levy JI, Louis TA. Methodological challenges and contributions in disaster epidemiology. Epidemiology Review. 2005;27:9–12. 7. Chadda RK, Malhotra A, Kaw N, Singh J, Sethi H. Mental health problems following the 2005 earthquake in Kashmir: Findings of community-run clinics. Prehospital Disaster Medicine. 2007;22(6):541–545; discussion: 546. 8. Raissi GR. Earthquakes and rehabilitation needs: Experiences from Bam, Iran. Journal of Spinal Cord Medicine. 2007;30(4):369–372. 9. von Schreeb J, Riddez L, Samnegard H, Rosling H. Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan. Prehospital Disaster Medicine. 2008;23(2):144–151; discussion: 152–153. 10. Shultz JM, Russell J, Espinel Z. Epidemiology of tropical cyclones: The dynamics of disaster, disease, and development. Epidemiology Review. 2005;27:21–35. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:17 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 167 CHAPTER 10 Surveillance and Monitoring Gregg Greenough and Satchit Balsari INTRODUCTION Emergency managers and providers consider establishing surveillance to be one of the top 10 priorities in an emergency response.1 Surveillance is variously described as an iterative systematic collection of data, usually a set of specific public health outcome indicators of interest to public health planners, programmers, and policy makers, collected through a networked system and regularly analyzed and disseminated to these key stakeholders. Surveillance information provides a consistent means for not only recognizing and characterizing events of public health concern as they arise, but also for monitoring events as they evolve and are addressed. Therefore, the surveillance process incorporates both functions for prevention and control and links public health practice to public health action. Surveillance may be active or passive, household or facility based, depending on its intended purpose, the needs of the population under surveillance, and the degree to which the event constitutes a public health emergency and a need for immediate response. Surveillance and monitoring methods should be simple, easily understood by and acceptable to all stakeholders, flexible enough to take new public health concerns into account, and specific to the type of humanitarian crisis at hand. Surveillance systems established during emergencies should either draw on the framework of established surveillance systems (where they exist) or, if created de novo, provide a foundation for a more robust and sustainable surveillance mechanism in a rebuilt health information system once the public health crisis has passed. – 167 – EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 168 9/15/10 11:58 PM Page 168 CHAPTER 10 / Surveillance and Monitoring Case Study Surveillance is one of the critical actions that should occur early in any public health emergency response. In August 2005, Hurricane Katrina’s devastation of the Gulf Coast triggered the largest mass population displacement in U.S. history. Nearly 50,000 evacuees fled to Louisiana shelters, most operated and staffed by the American Red Cross (ARC). Shelter populations varied in size from a handful of families in rural church social halls to several dozens and hundreds in school buildings to several thousand individuals in civic auditoriums and sports arenas. Regardless of the shelter size, local, state, and federal public health officials were concerned about venues of high population density (numbers of individuals per square meter of space), given the likelihood for overcrowding and high shelter resident to sanitary facility ratio and the potential for airborne and waterborne disease outbreaks. Although initial rapid assessments indicated that communicable diseases among the evacuee population were less of an immediate concern than noncommunicable diseases, the potential of such an outbreak certainly existed.2 Other epidemiological and demographic data suggested that noncommunicable health indicators unique to this largely urban and socioeconomically disadvantaged population—notably, chronic disease (e.g., coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease), access to health care and medications, mental health, and injury—should be considered for surveillance given that acute exacerbations of chronic disease could also overwhelm sheltering operations.3 By mid-September 2005, the Centers for Disease Control and Prevention (CDC), in collaboration with the Louisiana Red Cross branch, the Louisiana Department of Health and Hospitals, Office of Public Health, and the U.S. Public Health Service had established a basic shelterbased surveillance system at 489 evacuation centers (ECs) that tracked symptoms of communicable and noncommunicable disease potential.4 Because ECs provided first-aid care only (and were not equipped with diagnostic laboratory capacity), shelter health managers defined potential cases based on syndromes. For instance, diarrheal illness was defined as three or more watery stools per day and differentiated as bloody or nonbloody. Flu-like illness was defined as fever with either sore throat or cough. Besides airborne and waterborne communicable disease, the surveillance instrument elucidated skin infections, conjunctivitis, and injury as well as preexisting or newly diagnosed chronic diseases, substance abuse, and mental health problems (Figure 10-1). Thus this particular surveillance instrument took into account the unique characteristics of the population of interest. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 169 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Introduction American Red Cross Hurricane Katrina Emergency Disease Surveillance Shelter Name: Phone: Current Shelter Census: FAX: Point of Contact: EMail: For the past 24 hour period from 12:00 am to 11:59 pm: Number of patients treated in past 24 hour period: date (mm/dd/yy) Count each person receiving medical attention only once, according to their most severe symptom (chief complaint): Total # patients evaluated or treated Symptom category # Patients referred to another facility for care Epidemic Disease Potential Fever ⬎100.4°F (38°C) ALONE without localizing symptoms/signs Bloody diarrhea Watery diarrhea (3 or more watery bowel movements per day) with or without vomitting Vomiting only (One episode or more) Flu-like or other severe respiratory infection (e.g., fever and either cough or sore throat) Rash (circle: measles, rubella, chickenpox/varicella, skin infections, other) Scabies, lice, or other infestation Wound infection Conjunctivitis (pink eye) Other (suspected tuberculosis or hemoptysis, whooping cough, meningitis/encephalitis, jaundice/hepatitis,etc) Please specify: Mental Health/Psychological Problems Any pre-existing psychiatric disorder (major depression, anxiety, depression, bipolar disorder, schizophrenia) New psychiatric disorder since hurricane (post traumatic stress disorder, disorientation, dementia, confusion, out of control behavior, threats to self or others, loss of touch with reality) Drug/alcohol substance abuse or withdrawal Injury/Chronic Disease/Other Self inflicted injury Injury – Intentional (circle: violence, sexual assault) Injury – Unintentional (accidents) Dehydration Heat related injury (not dehydration) Diabetes Mellitus Asthma/COPD High blood pressure and other cardiovascular diseases Sexually Transmitted Disease/HIV Number of deaths within the past 24 hours Do you need assistance with or additional resources for: Yes No Yes Physician staffing Nurse staffing Pharmacist staffing Mental Health staffing Sanitation/Environmental Health Medications/Drugs/Medical supplies No Additional Comments/Concerns: THE FORM SHOULD BE TRANSMITTED DAILY. (FAX 225-216-2337) If you do not have access to a fax, please call us at 225-216-2313 to provide the information by phone, or if you have any difficulties, questions or comments. Rev: 9/9/2005 - final FIGURE 10-1 Hurricane Katrina Louisiana Shelter Surveillance Form Source: U.S. Centers for Disease Control and Prevention. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 169 58707_CH10_Kapur.qxd:Achorn Int'l 11:58 PM Page 170 CHAPTER 10 / Surveillance and Monitoring 7.00 Rash Scabies Bloody Diarrhea 6.00 5.00 4.00 3.00 2.00 1.00 10/7/2005 10/6/2005 10/5/2005 10/4/2005 10/3/2005 10/2/2005 10/1/2005 9/30/2005 9/29/2005 9/28/2005 9/27/2005 9/26/2005 9/25/2005 9/24/2005 9/23/2005 9/22/2005 9/21/2005 9/20/2005 9/19/2005 9/18/2005 0.00 9/17/2005 Incidence per 1000 Population Health managers faxed, emailed, or phoned the data on the completed forms on a daily basis to a central reporting center at ARC Louisiana headquarters in Baton Rouge for analysis and rapid identification. Using CDC-developed software for surveillance indicators—the Early Aberration Reporting System (EARS)5—each indicator posted a cumulative sum score (CUSUM) that served Date FIGURE 10-2 Hurricane Katrina Louisiana Shelter Surveillance for Select Diseases, 2005 Source: U.S. Centers for Disease Control and Prevention. 50.00 45.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 Asthma Diabetes High Blood Pressure/CVD 9/6/2005 9/7/2005 9/8/2005 9/9/2005 9/10/2005 9/11/2005 9/12/2005 9/13/2005 9/14/2005 9/15/2005 9/16/2005 9/17/2005 9/18/2005 9/19/2005 9/20/2005 9/21/2005 9/22/2005 9/23/2005 9/24/2005 9/25/2005 9/26/2005 9/27/2005 9/28/2005 9/29/2005 9/30/2005 10/1/2005 10/2/2005 10/3/2005 10/4/2005 10/5/2005 10/6/2005 10/7/2005 Incidence of Chronic Disease per 1000 Population Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 170 9/15/10 Date FIGURE 10-3 Hurricane Katrina Louisiana Shelter Surveillance for Chronic Disease, 2005 Source: U.S. Centers for Disease Control and Prevention. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 171 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Introduction as the “threshold” for further investigation. The CUSUM technique, as a sequential statistical method for detecting a shift in baseline, is more sensitive for moderate changes in health event rates and can be adjusted when the structure or size of the population changes.6 Although no airborne or waterborne outbreaks occurred at the ECs, a scabies infestation cluster was identified during the week of September 20, 2005 (Figure 10-2), and subsequently investigated and managed by local public health providers. As might be expected, patients with chronic diseases visited EC health posts early in the displacement period (Figure 10-3), reflecting the fact that the act of rapid evacuation with no other sheltering alternative meant they American Red Cross 1-888-819-SWAB 24 hr CONTACT LINE FOR INFECTIOUS DISEASE RELATED TO HURRICANE KATRINA If a shelter occupant or evacuee develops any of the following signs or symptoms, call the contact number listed above: 1. Fever ⬎100.4⬚F in a person who is ill-appearing 2. Flu-like or other severe respiratory infection 3. Cough with blood 4. Bloody diarrhea 5. Watery diarrhea (ⱖ3 daily) with or without vomiting 6. Severe skin infection or rash *This hotline does not replace normal health services. If concerned about a patient’s well-being, please notify the local doctor or call 911 immediately. FIGURE 10-4 Hurricane Katrina Mississippi Case Definition Form for Shelter Health Managers Source: The Working Group on the American Red Cross Public Health Response to Hurricane Katrina. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 171 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 172 9/15/10 11:58 PM Page 172 CHAPTER 10 / Surveillance and Monitoring were likely to be without prescribed medications, without access to their regular health providers, and often without access to health insurance.3 ARC volunteers in Mississippi initiated an alternative surveillance mechanism in the aftermath of Hurricane Katrina, working with the Mississippi Department of Health (MDH), a cadre of public health academics, trained shelter health managers, and educated evacuees on communicable disease case definitions (Figure 10-4) at each of the 43 ARC-managed shelters in the state. They then instituted a toll-free telephone hotline through which cases could be identified, investigated by the team, and referred as needed. While 37 percent of 93 cases were referred for further evaluation, no outbreaks of communicable diseases occurred. This simple, flexible, inexpensive, proactive, and rapid response model not only provided much-needed surveillance for shelter venues likely to be out of the public health safety net, but also raised public health awareness in medical providers and evacuees and reassured providers that public health support was readily available to them.7 HISTORICAL PERSPECTIVES Traditionally surveillance mechanisms involved a network of health services delivery actors, trained to detect changes in defined health events (indicators), usually rises in death rates or communicable disease cases. If, during their analysis, a certain threshold for an event was crossed, the actors would “sound the alarm” to those who should respond—typically agents within ministries of health at the national or district level with appropriate technical support from the World Health Organization (WHO) or other international support agencies as needed.8 Surveillance evolved from the public health science of epidemiology: In this discipline’s parlance, an epidemic exists when the observed number of cases of a given disease exceeds what is expected and is associated with a common or propagated source of infection. Over time, surveillance has become the informative process by which public health officials can make this comparison between observed and expected cases in the population. With the recognition that complex emergencies generate an equally complex and multidisciplinary response, humanitarian stakeholders have moved surveillance beyond its communicable disease outbreak role. Today, surveillance is designed to monitor responses to particular interventions, inform public health programs, evaluate resource use, track noncommunicable diseases and injuries, recognize early signs of bioterrorism, and engage in program quality improvement, to name a few. In any application, surveillance defines itself as a trending mechanism of information. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 173 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Historical Perspectives The first globally focused communicable disease surveillance began in 1948 for influenza viruses. This system rapidly expanded to include a long list of reportable common communicable and rare noncommunicable diseases in developed countries where established health information systems could sustain them. By the latter quarter of the twentieth century, when large refugee and internally displaced population movements in developing countries necessitated a systematic vigilance for outbreaks of endemic diseases (particularly among persons who were not immune to those diseases), implementing surveillance became a humanitarian necessity. For instance, the active surveillance system for 73,000 Bhutanese refugees displaced to Nepal in 1991 identified that the leading causes of death were measles, diarrhea, and acute respiratory infections, and subsequently informed what we have come to learn as essential program interventions in the early phase of a humanitarian crisis: measles vaccination, vitamin A supplementation, and diarrhea and acute respiratory infection control using oral rehydration therapy and early antibiotic therapy, respectively. By identifying these target interventions, the surveillance system reduced high mortality rates over a period of several months.9 Surveillance also identified and tracked the most lethal infectious disease outbreak in a displaced population in recent history: The high crude mortality rates from the infections with Vibrio cholera 01 (and later Shigella dysenteriae) that swept through the massive Rwandan refugee population that crossed into Goma, Zaire, in July 1994 bordered on apocalyptic.10 A rigorous daily surveillance system initiated by humanitarian nongovernmental organizations (NGOs) followed crude death and death from diarrhea rates in nearly 800,000 refugees, along with the effects of a rapid NGO response consisting of treatment, water, and sanitation interventions. Crude mortality rate peaked at 25 to 30 deaths per 10,000 per day, then quickly declined to 5 to 8 deaths per 10,000 per day by the second month. Since this incident, the international community—especially donor governments, the United Nations (UN) operational agencies, NGOs, and affected ministries of health—have come to expect surveillance mechanisms during crises to routinely trend crude mortality rates, mortality rates in children (younger than 5 years), malnutrition, and cause-specific mortality rates in light of relief interventions. The lethality of the Goma outbreak provided the momentum to establish humanitarian practice standards among a major consensus of stakeholders. The resultant Sphere guidelines (a manual that establishes humanitarian response best practices) mandated surveillance as a standard for health and nutrition information systems in humanitarian crises.11 Humanitarian actors further realized the need to train and professionalize providers on evidence-based practice, skillfully designing and implementing such datagenerating activities as surveillance in a timely and informative fashion. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 173 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 174 9/15/10 11:58 PM Page 174 CHAPTER 10 / Surveillance and Monitoring For present-day suddenly displaced populations with marginal access to a full range of health services, the focus of surveillance activities remains communicable diseases, particularly high-impact morbidity and mortality events (i.e., diseases with high epidemic potential) such as diarrheal illness (often nonspeciated), acute respiratory infections (frequently differentiated between upper and lower respiratory infections), measles, malaria, and meningococcal meningitis. Other endemic communicable diseases such as typhoid, dengue, rabies, neonatal tetanus, HIV/AIDS, and tuberculosis are also considered as geographically dictated. Acute and chronic malnutrition—indicated by weight-for-height ratios and height-for-age ratios below two standard deviations of the mean—is often a contributing factor to mortality from these preventable infectious diseases and, therefore, is included in the form of “nutritional surveillance.” The rationale for selecting this initial group of indicators derives from the risk of mortality they pose to the most vulnerable of humanitarian populations, notably children younger than age 5 years, immunocompromised persons, malnourished persons, and larger populations lacking herd immunity for vaccine-preventable diseases. Maternal death, neonatal death (a live-born infant death younger than 28 days old), and trauma/injury (intentional and unintentional) are often included early in surveillance programs during emergencies. To conduct surveillance for communicable diseases through networks of healthcare facilities, providers identify cases using standardized case definitions, as facility diagnostic capacity (i.e., microscopy or rapid diagnostic testing for malaria) may be nonexistent during emergencies. If a case meets the clinical case definition, it is considered “suspect.” If, in addition, other clinical or epidemiologic evidence is identified, the case is termed “probable.” If it can be identified through laboratory tests regardless of clinical signs or symptoms, it is called “confirmed.” Some examples of case definitions follow: • Diarrhea: three or more loose or watery stools per 24-hour period, with or without dehydration • Measles: maculopapular rash and cough, coryza, or red eyes • Acute (lower) respiratory infection in children: cough or increased work of breathing and respiration rate of more than 50 breaths per minute (for infants aged 2 to 12 months) or more than 40 breaths per minute (for children aged 1 to 5 years) • Meningitis: sudden onset of fever (greater than 100.4°F/38°C) and either stiff neck, altered level of consciousness, or petechial/purpuric rash Cholera, as the etiology of a diarrheal case, would be suspected if severe dehydration or death from diarrhea resulted; would be considered probable if it occurred among other similar cases; and would be confirmed by isolation of V. cholerae from a stool EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 175 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Historical Perspectives sample. A list of commonly used case definitions and reporting forms can be found in the WHO’s Communicable Disease Control in Emergencies field manual, which was last updated in 2005.12 Public health emergencies that precipitate sudden or prolonged food insecurity (e.g., famines, collective losses of livelihood from conflicts or natural disasters) require surveillance for acute or chronic malnutrition. Nutritional surveillance is typically based at health facilities capable of monitoring growth and, therefore, following a cohort of children younger than age 5 years. In this type of surveillance, weight-forheight ratios (for acute malnutrition), height-for-age ratios (indicator of chronic malnutrition), and kilocalorie/day intake are linked to not only other health and demographic indicators, but also measures of household food distribution and access. By 2005, WHO had modified the conceptual framework suggested by McNabb et al.,13 establishing through consensus the six core activities of surveillance: detection, registration, confirmation, reporting, analysis, and feedback (Figure 10-5). Four functions—communications, training, supervision (for quality assurance), and resource acquisition—support these six core activities. Health providers at surveillance sites must be trained in case definition and recognition, and communication networks must exist for data streams (reporting) to reach trained and supervised data managers, who analyze the information and send it on to decision makers at the programmatic level. Critically, the activities that bring this analysis to light in real time—surveillance—are inextricably linked to public health action at the policy and decision levels of local and national governments and, in the case of emerging infectious diseases and terrorism events, regional and global actors. The emergence of severe acute respiratory distress syndrome (SARS) in March 2003 highlighted the fundamental need for shared information across global surveillance networks. This disease spread rapidly across borders (through personal travel), appeared to be readily transmissible, had nonspecific symptoms, and was associated with a high case-fatality rate. Given those characteristics, the need for rapid detection and containment and the identification of measures for prevention and control were immediate and international. The transborder, transcontinental spread of established infectious disease and the prospect of emerging infectious diseases remain the primary concerns of international surveillance efforts. To this end, WHO maintains the Global Alert and Response (GAR) program, which provides technical support to signatory countries for strengthening their respective surveillance mechanisms and public health preparedness efforts. In accordance with the 2005 International Health Regulations, state parties are obligated, under defined criteria, to notify WHO of “events that may constitute a public health emergency of international concern.”14 The document EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 175 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 176 9/15/10 11:58 PM Page 176 CHAPTER 10 / Surveillance and Monitoring Data Information Messages Detection Registration Planned (management-type) response Confirmation PUBLIC HEALTH Reporting SURVEILLANCE PUBLIC HEALTH ACTION Acute (epidemic-type) response Analysis Feedback Support Activity Communications FIGURE 10-5 Training Supervision Resource Provision WHO Framework for Surveillance Source: World Health Organization. further elaborates the conditions by which such public health information must be shared in a timely fashion. PREPAREDNESS AND RESPONSE The prospect of bioterrorism events, emerging infectious diseases such as SARS and influenza A subtype H1N1, mass chemical or radiation exposure, mass gatherings,15 and natural disasters or conflicts generating massive population movements or the cataclysmic devastation of a country’s socioeconomic and governing structures—all signal the need for preparedness through surveillance mechanisms. Ideally, a country will have a functioning surveillance and vital registration system in place prior to the occurrence of a disaster or conflict. A vital data registration system that systematically records births, deaths, and in- and out-migrations is critical to establishing a baseline estimation of the population chosen for surveillance. Unfortunately, resource-poor health ministries rarely have the capacity to sustain or EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 177 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Preparedness and Response manage these systems while at the same time often being located in countries prone to disaster- and conflict-generated public health emergencies. On occasions when public health emergencies have occurred in these countries, the international community, led by WHO (often with assistance from international governmental agencies) and working through the large international humanitarian relief agencies, will assist the specific ministry of health in constructing or fortifying its surveillance system. Regardless of whether a surveillance system is constructed (or rebuilt) in the preemergency, immediate aftermath, or post-emergency phase, all such efforts share similar qualities, common data sources, and comparable indicators. For instance, surveillance systems should be simple, flexible (adaptable to changes in focus as an emergency evolves and resolves), easily understood by all stakeholders (public health practitioners and policy makers, international and local communities), and readily accessible (preferably through the Internet, fax, email, or SMS [short message service] text). These qualities enhance the speed of data collection, analysis, and dissemination. Data sources are typically health facility or household based, depending on the indicators of interest. Facility-based surveillance sites are usually hospitals and/or clinics, but other facilities of interest may include factories, ports of entry such as airports or other customs stations, or places where large populations tend to gather. In general, the choice of surveillance sites is dictated by the place where an individual with a specific disease entity would likely present himself or herself. Household-based sites may be needed if the population of interest cannot access health facilities due to lack of transportation or finances. For example, in a rural district of Zimbabwe where access to healthcare facilities is limited, a water and sanitation NGO relied on a network of community volunteers in villages throughout the district to periodically report syndromically defined diarrheal incidence during the cholera outbreak of 2008–2009. Community-perceived “blips” above baseline were investigated and reported to the ministry of health and WHO officials in the country’s capital.16 Comparable emergency indicators typically include high mortality communicable disease incidence; crude, pediatric (younger than age 5 years), and cause-specific mortality rates; acute and chronic malnutrition and food security; and program specific impact markers (e.g., immunization coverage, health system function). As the emergency transitions to a post-emergency development phase, the surveillance system will expand to include demographic information; other group mortality (maternal, infant); morbidity from noncommunicable disease and injury (e.g., traffic accidents, sexual and nonsexual violence); morbidity from additional, less rapidly fatal communicable diseases (e.g., HIV, TB, sexually transmitted diseases); mental health; and livelihoods. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 177 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 178 9/15/10 11:58 PM Page 178 CHAPTER 10 / Surveillance and Monitoring In constructing a surveillance system, one must take into account the “disease profile” of a place—namely, the air-, water-, and vector-borne endemic diseases likely to emerge above baseline with environmental disruption and subsequent degree of exposure. For example, in the surveillance system established following the January 2010 Haiti earthquake, malaria and dengue—both endemic in Haiti—were included, especially given that the rainy season was fast approaching and would increase vector (mosquito) activity. Surveillance systems that are constructed and implemented during crises tend to be active systems—that is, they require trained providers to actively record (and possibly investigate) cases into the system. Ministry of health administrative personnel regularly solicit data logs from providers at regular intervals. In contrast, passive systems, which tend to be ongoing concerns in post- and pre-disaster phases, rely on the initiative of the provider to bring cases to the system. As a result, passive systems, while cheaper and less labor-intensive over the long run, are less detailed and complete than active systems. As a consequence, passive systems tend to be less sensitive to changes in indicators from baseline and, in general, less representative of the population under surveillance. Deaths from a specific cause may go unreported in a passive system due to a cultural need to dispose of a body quickly; unless a monitor observes a mass burial, talks to grave diggers, and interviews village leaders, causespecific mortality rates may be falsely low and an opportunity for life-saving intervention missed as a result. The choice of sites for a surveillance network depends on whether the population under surveillance is the whole population, a representative sample of that population, or a specific population that might frequent only a certain site. Universal surveillance systems favor entire populations or whole segments of populations and, like active systems, are demonstrably more representative for a given indicator. Sentinel surveillance implies the use of specialized sites that are linked to indicators of specific interest: A voluntary testing center for HIV or a prenatal clinic, for instance, would be most appropriate for capturing increases in the transmission of HIV; a clinic at a major airport with international routes would be a logical sentinel site for identifying passengers with flulike illnesses returning from abroad. GeoSentinel is an example of a network of global travel medicine clinics that opt-in as sentinel sites for patients presenting with travelrelated illnesses. While the data they collect are less representative of the entire population than the data collected at universal sites, sentinel sites provide higher-quality, more complete, and more timely data on high-risk populations. Multiple examples of surveillance networks exist, each with specific objective functions and health areas of concern. The rise in global networks reflects the EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 179 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Preparedness and Response boundary-ignorant quality of emerging infectious diseases and the irreversible trajectory of international travel. WHO’s Global Alert and Response Network (GAR) supports individual states’ surveillance efforts, links surveillance information across member states, and manages surveillance databases to ensure a timely coordinated and collaborative global response. Government surveillance information networks also play a critical role in sharing real time outbreak information: Public Health Agency of Canada’s Centre for Emergency Preparedness and Response, the United Kingdom’s Health Protection Agency, the U.S. Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC), to name a few, all contribute to this effort. The policy consequences of the terrorist attacks on September 11, 2001, in the United States included shifting public health resources to biological and chemical terror event surveillance at U.S. federal and state levels. That said, local surveillance systems—whether in the developing world or the developed world—continue to serve as the fundamental first line of defense for identifying changes in the baseline of a population’s health. The global networks depend on local systems’ ability to function iteratively and sustainably. The boom in rapid communications technology and information management has significantly enhanced surveillance networks’ ability to gather and disseminate information. ECDC’s Eurosurveillance, an open-source journal, CDC’s Morbidity and Mortality Weekly Report, and WHO’s Weekly Epidemiologic Record are salient examples of timely peer-reviewed, quality surveillance analysis for programmatic and public awareness purposes. Canada’s Global Public Health Intelligence Network (GPHIN) monitors global media sources, Web sites, and newsfeeds for infectious disease outbreaks, including foodborne and waterborne diseases; events with the potential for bioterrorism exposure; and health outcomes of natural disasters. CDC’s National Electronic Disease Surveillance System (NEDSS) maintains an Internetbased cyber-infrastructure for the exchange of surveillance data from state and local partners. Taken together, communications technology and the refining of digital information management have exponentially improved the speed and efficiency of the entire surveillance process. Data collected at sentinel sites can be immediately SMS-texted from mobile phones directly into easily managed, readily familiar database programs such as Microsoft Excel. Many cell phones come equipped with global positioning systems (GPS) capable of “tagging” specific surveillance data with a spatial characteristic (coordinates of latitude and longitude) at a moment in time. This additional geospatial information can be readily analyzed and presented in an animated format, graphically depicting an outbreak as it develops over time and place. Maps also provide EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 179 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 180 9/15/10 11:58 PM Page 180 CHAPTER 10 / Surveillance and Monitoring rapid, user-friendly “analysis” for policy makers and decision makers, answering questions about whether the new events arise in a geographically significant pattern (e.g., in a cluster perhaps) in addition to the more traditional temporal and orders of magnitude pattern changes. When these data are combined as a time–space scan statistic in the analysis, public health officials can craft a more targeted response—equipping specific health facilities with antibiotics or initiating local vector control measures, for example—with greater confidence and a clearer mandate. Beyond the established surveillance networks, public health experts are gleaning infectious disease information from such nontraditional sources as local observers and news informants through rapid mobile communications such as SMS, blogs, and Twitter feeds. Health Map, an independent organization supported by Google, uses automated text processing to gather outbreak information from unsolicited crowd sources as well as official sources. While reliability and information quality remain a challenge with this approach, the open, user-friendly manner of data collection has brought a new public awareness and engagement at the local level that can only benefit the surveillance process and improve response. ANALYSIS OF CASE STUDY Both CDC and WHO have published detailed guidelines for the evaluation of surveillance systems.17 These recommendations take into account the qualities, design, degree of stakeholder engagement, and costs of the system, in addition to the technical components. Multiple factors, individually or in combination, can disrupt the trending of even basic morbidity and mortality indicators. Perhaps the greatest challenge to any surveillance system, however, is sustaining it. Stakeholders—donor governments, operational UN agencies, field-level NGO personnel, ministry of health, and local data collectors—must all have a sufficient level of “buy-in” to consistently maintain a flow of communication to and from field sites. Lack of feedback to field personnel, loss of morale, arduous reporting demands, and lack of training can be significant factors leading to the failure of surveillance systems over time. Insecure environments may limit access to sites or the ability of surveillance sites to function. The rote, manual method of collecting data slows down the process; incomplete data can leave critical gaps in the analysis. Surveillance systems have limitations, of course. Because not all cases with a given indicator will necessarily have access to the surveillance network, surveillance systems will not be able to capture every morbidity event and, therefore, cannot provide incidence or prevalence rates of an event in a population. Depending on how the surveil- EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 181 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Conclusion lance system is designed, it may not be able to explain reasons for changes in indicators (i.e., why are children younger than age 5 years dying of diarrheal illness in this population?), without links to other data sources (e.g., the quality and quantity of water, access to sanitation, hygiene). Likewise, surveillance may not be able to explain the reasons for improvement or failure of a given program or initiative. The shelter-based Hurricane Katrina example discussed earlier in this chapter illustrates the typical challenges and limitations involved in establishing and maintaining surveillance systems in public health emergencies. Compliance from harried shelter health managers tasked with daily surveillance reporting over several weeks was nominal: On average, CDC received reports from 23 percent (range: 3 to 49 percent) of the surveillance sites daily. As a result, only an average of one third (range: 4 to 64 percent) of the shelter site population was under surveillance each day. Also, even though shelter health managers had been trained to gather surveillance data, the majority were unable to identify diseases with outbreak potential in another study,18 indicating a general lack of public health understanding in a displaced population. CONCLUSION Although today’s surveillance systems, with their integration of mobile technology, sophisticated analysis software, and Internet access, look very different from the traditional paper-based surveys of the last century, their objectives remain the same: early recognition of changes in baseline epidemiological characteristics of disease in a population to trigger and guide an appropriate emergency public health response. Intuitively, earlier recognition should translate into better mitigation and response strategies. This quest for speed has driven the explosive rise in the use of new technology to promote crowd sourcing, real-time data integration, and live feedback. As the ease of use, acceptance, and dependence on new data-gathering methods grow, a paradigm shift may occur in how passive data reporting is perceived. While technology may, indeed, make it easy for a larger number of agents to serve as event reporters (especially through open crowd-sourcing platforms), researchers may— probably for the first time—face the prospect of having too much data. Mining for statistical “gold” in this influx of live data streaming into surveillance platforms, ensuring strict adherence to epidemiological definitions, sustaining stakeholder engagement and a focus on local events in real time, and validating the authenticity of the users and data, while simultaneously maintaining the relevance of potentially large data sets to local programming and policy needs, may be the challenges for the surveillance efforts of the coming decade. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 181 58707_CH10_Kapur.qxd:Achorn Int'l Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 182 9/15/10 11:58 PM Page 182 CHAPTER 10 / Surveillance and Monitoring INTERNET RESOURCES Health Map: http://healthmap.org WHO Global Alert & Response network: http://www.who.int/csr/outbreaknetwork/en/ Global Public Health Intelligence Network (GPHIN): http://www.phac-aspc.gc.ca/media/nr-rp/ 2004/2004_gphin-rmispbk-eng.php Health Protection Agency (United Kingdom): http://www.hpa.org.uk/HPA/ GeoSentinel: http://www.istm.org/geosentinel/main.html NOTES 1. Medecins sans Frontiere. Refugee health in emergency situations. London: Macmillan; 1997. 2. Working Group on the American Red Cross Public Health Response to Hurricane Katrina. American Red Cross and public health: The response to Hurricane Katrina and beyond. Cambridge, MA: Harvard Humanitarian Initiative; March 2006. 3. Greenough PG, Lappi MD, Hsu EB, et al. Burden of disease and health status among Hurricane Katrina–displaced persons in shelters: A population-based cluster sample. Annals of Emergency Medicine. 2008;51(4):426–432. 4. Centers for Disease Control and Prevention. Surveillance in hurricane evacuation centers— Louisiana, September–October 2005. Morbidity and Mortality Weekly Report. 2006;55(2):32–35. 5. Centers for Disease Control and Prevention. Early Aberration Reporting System. Available at: http://www.bt.cdc.gov/surveillance/ears/. Accessed March 7, 2010. 6. Rossi G, Lampugnani L, Marchi M. An approximate CUSUM procedure for surveillance of health events. Statistics in Medicine. 1999;18:2111–2122. 7. Cavey AMJ, Spector JM, Ehrhardt DT, et al. Mississippi’s infectious disease hotline: A surveillance and education model for future disasters. Prehospital Disaster Medicine. 2009;24(1):11–17. 8. World Health Organization. Disease surveillance: WHO’s role. Weekly Epidemiologic Record. 1998;73(43):333–334. 9. Marfin AA, Moore J, Collins C, et al. Infectious disease surveillance during emergency relief to Bhutanese refugees in Nepal. Journal of the American Medical Association. 1994;272(5):377–381. 10. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: What happened in Goma, Zaire in July, 1994? Lancet. 1995;345(8946):339–344. 11. Sphere Project. Humanitarian charter and minimum standards in disaster response. Geneva: Sphere Project, 2004. 12. Connolly MA (ed.). Communicable disease control in emergencies: A field manual. Geneva: World Health Organization; 2005. 13. McNabb SJN, Chungong S, Ryan M, et al. Conceptual framework of public health surveillance and action and its application in health sector reform. BMC Public Health. 2002;2. doi: 10.1186/1471-2458-2-2. 14. World Health Organization. International health regulations (2005) (2nd ed.). Geneva: World EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 58707_CH10_Kapur.qxd:Achorn Int'l 9/15/10 11:58 PM Page 183 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Notes Health Organization; 2008. 15. Aung M. Syndromic surveillance in major sporting event: Jamaican experience. Advances in Disease Surveillance. 2007;4:144. 16. Harvard Humanitarian Initiative, Oxfam America. Diarrhea early warning system and cholera response assessment. Cambridge, MA: Harvard Humanitarian Initiative, 2009. Available at: www.hhi.harvard.edu. Accessed April 7, 2010. 17. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: Recommendations from the Guidelines Working Group. MMWR Recommendations and Reports. 2001;50:RR-13. 18. Brahmbhatt D, Chan JL, Hsu EB, et al. Public health preparedness of post-Katrina and Rita shelter health staff. Prehospital Disaster Medicine. 2009;24(6):500–505. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 183 9/15/10 11:58 PM Page 184 Copyright © 2011. Jones & Bartlett Learning. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 58707_CH10_Kapur.qxd:Achorn Int'l EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/9/2019 10:18 PM via THOMAS JEFFERSON UNIVERSITY - EAST FALLS AN: 347934 ; Smith, Jeffrey P., Kapur, G. Bobby.; Emergency Public Health: Preparedness and Response Account: s4084935 To start off, I’d like to divert and discuss the lack of adequate research surrounding international humanitarian crises. I have struggled during this class to find an array of articles on the topics that we have discussed that I have been able to find for other courses, such as the Clinical Disaster Medicine course. This research barrier alone indicates that it is difficult for even the academic community to identify and corroborate on best practices for public health in international crises. One comprehensive literature review stated that there were only 345 evidence-based studies that utilized modernly-acceptable research methods to analyze public health issues in international crises from 1980 to 2014 (Blanchet, 2017). While that may seem like a lot of studies, each article has a specific scope and focus that leads to only a thin covering of all of the topics involved in public health. Blanchet et al. stated that “The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6)” (2017). Blanchet et al. (2017) also cited that study designs led to an inability to accurately determine the causation of the examined issues. Further, I was unable to find another similar literature review to verify the statements made by Blanchet et al., indicating that the peer-review process is not well developed in the field. I digress. I'd like to delve a little deeper into women’s health in complex international humanitarian emergencies. The topic includes pregnancy-related mortality and morbidity, sexual violence, and access to contraceptives/infection risks. Approximately 32 million people in need of help in ongoing complex humanitarian crises are female of child-bearing age (Guttmacher Institute, 2019). Pregnancy and sexual violence don’t stop during a conflict or displacement, making the topic applicable to almost all incidents. Specifically, there has been progress made in reducing the maternal mortality rate in some parts of the world, secondary to education initiatives. In Pakistan, Afghan refugees were offered education on safe motherhood and providing emergency services, which dropped the maternal mortality rate from 0.291% to 0.102%, accompanied by a similar decrease in the neonatal mortality rate (Purdin, Khan & Saucier, 2009). Other areas have offered midwifery programs to refugees which has increased the accessibility of competent birthing attendants and theoretically improved mortality rates as well. Additionally, other health initiatives tackled the issue of STIs, like HIV in these populations. A couple of studies have cited the effectiveness of educational programs on the usage rate of barrier contraceptives and their effect on reducing STI transmission in vulnerable populations (Singh et al., 2018). The initiative to reduce the spread of HIV has been largely successful, with a 40% reduction in transmissions globally (UNAIDS, 2019). Unfortunately, there is still much work to be done, since the majority of new infections in Sub-Saharan Africa are girls between the ages of 15 and 19, with around 6,200 young women becoming infected every week on the global scale (UNAIDS, 2019). I think that education is the key to opening doors for people, and that family planning and sexual health is a critical component of female healthcare. Since the resources are not readily available to IDP/refugee women educating them and providing them with tools to protect themselves is the ‘satisficing' solution that utilizes resources most effectively until they can be bolstered. Blanchet, K., Ramesh, A., Frison, S., Warren, E., Hossain, M., Smith, J., … Roberts, B. (2017). Evidence on public health interventions in humanitarian crises. The Lancet, 390(10109), 2287–2296. https://doi.org/10.1016/S0140-6736(16)30768-1 Guttmacher Institute. (2019, August 15). Adding It Up: Investing in Contraception and Maternal and Newborn Health, 2017. Retrieved from https://www.guttmacher.org/factsheet/adding-it-up-contraception-mnh-2017. Singh, N., Smith, J., Aryasinghe, S., Khosla, R., Say, L., Blanchet, K., & Singh, N. (2018). Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: A systematic review. PloS One, 13(7), e0199300–e0199300. https://doi.org/10.1371/journal.pone.0199300 Purdin, S., Khan, T., & Saucier, R. (2009). Reducing maternal mortality among Afghan refugees in Pakistan. International Journal of Gynecology & Obstetrics, 105(1), 82–85. doi: 10.1016/j.ijgo.2008.12.021 UNAIDS. (2019). PDF. Retrieved from https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf
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