KOSI FLOOD 2008

A NATIONAL DISASTER

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 Objectives of the session

1. Apply principles of epidemiology in Disaster

Management
2. Apply surveillance tools as an early warning system to
detect major outbreaks and epidemics
3. Know Measurements/Indicators/Triggers in
Emergencies
4. Preparedness for Medical Relief (mobile medical teams and
fixed site teams) and services render
• Immunization
• Newborn minimal package of care
• Maternal Health services (ANC/PNC)
• Referral Services (Sick Newborn- NSU & SAM-MTC)
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SHELTER…..
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Rescue……
THE SUFFERING

FOOD……. 5
DISPLACED POPULATION IN MEGA
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CAMPS
CAMPS OTHER THAN MEGA CAMPS

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TAKING SHELTER IN GOVERNMENT
Epidemiology
and
Surveillance

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 Driving
without looking at the traffic?

Is like making public health

decisions in the absence of data
 Surveillance:
A role of the public health system

The systematic process of collection,

transmission, analysis and
feedback of public health data for
decision making

Surveillance
 Information collected by the
surveillance system
• How many get them?
• Who get the disease?
• Where they get them?
• When they get them?
• Why they get them?
• What needs to be done as response?

Surveillance
 A dynamic vision of
surveillance
Collect and
Make
transmit
decisions
data
All levels use
information
to make
decisions
Feedback Analyze
information data

The private sector can treat patients but

only the public sector can coordinate surveillance
Surveillance
Syndromes under surveillance

• Fever
• Cough
• Diarrhea
• Acute flaccid paralysis
• Jaundice
• Unusual syndrome causing
death/ hospitalization
 Fever
1. Fever less than 7 days with:
– Rash and cough or coryza or conjunctivitis (suspected measles)
– Altered sensorium (suspected Japanese encephalitis or malaria)
– Convulsions (suspected Japanese encephalitis )
– Bleeding from skin, mucus membrane, vomiting blood or passing
fresh blood or black motion (suspected Dengue)
– With none of the above (suspected malaria)
1. Fever > 7 days
– Suspected typhoid
• Triggers
– More than 2 similar case in the village (1000 Population)/ Camp
site
 Cough
• Short duration (Cough < 2 weeks)
– Suspected acute respiratory tract infection
• Longer duration (Cough of > 2 weeks)
– Suspected tuberculosis
 Diarrhea
• Any new case of watery diarrhea
– Passage of 3 or more loose / watery stools in
24 hours
– With or without dehydration
– Total duration of illness < 14 days
• Dysentery : Presence of visible blood in stool
• Trigger
– More than 10 houses with diarrhea in a village
or urban ward or a single case of severe
dehydration or death in a patient > than 5
years with diarrhea
 Jaundice
• A new patient with an acute illness (<4
weeks) and following symptoms:
– Jaundice, dark urine
– Anorexia, malaise, fatigue
– Pain in abdomen (right upper quadrant)
• Trigger
– More than two cases of jaundice in different
houses irrespective of age in a village or 1000
population
 Acute flaccid paralysis
• A case of acute flaccid paralysis is defined
as any child:
– Aged <15 years
– Has acute onset of flaccid paralysis for which
no obvious cause is found
• Trigger
– Single case of AFP
 Anticipated health problems and
Phases Anticipatedinterventions
health Possible Interventions
problems
Days 1-3 Injury/drowning and deaths Safe disposal of dead bodies
Injury management
Needs assessment for health

Days 3-5 Diarrhoeal diseases Health promotion

Acute respiratory infections – Sanitation, environment
Psychosocial problems – Water purification
– Personal hygiene
– Immunization (measles)
–ORS & Zinc
Emerging disease surveillance (morbidity/
mortality)

5-10 days Above plus: Dehydration, Above plus;

Pneumonia, conjunctivitis, Antibiotics for pneumonia ; IV Fluids
and skin infections Drugs for skin infections and conjunctivitis

>10 days Above plus: Vector-borne Ongoing surveillance

diseases (malaria, DF), Health education, measures for vector
Typhoid fever, Measles, and control, antimalarial
Malnutrition Supplementary feeding program
Rebuilding health infrastructure 20
Mortality
• Measured as number of deaths per 10000 population per day
• Crude mortality rate (CMR) is for entire population and under 5 mortality
rate (U5MR) is for children under 5 years of age

CMR = No. of deaths X 10000

Population X Period
Benchmark Mortality Rates in
Emergencies
Crude Mortality Rate CMR
(deaths/10,000/day)
– Baseline 0.5
– Serious 1.0-2.0
– Crisis >2.0

U5MR
– Baseline 0.8-1.2
– Serious >2.0-4.0
Morbidity
Morbidity is the number of NEW cases of a GIVEN DISEASE among the population over a certain period of TIME
• Measured per 10000 population per day
•
AR and CFR
• Attack rate (outbreaks): The cumulative incidence of cases
(persons meeting case definition since onset of outbreak) in
a group observed over a period during an outbreak.
• Case-fatality ratio (CFR): the percentage of persons
diagnosed as having a specified disease who die as a result
of that disease within a given period, usually expressed as a
percentage (cases per 100).
Case study
• The first onset of Measles occurred in
Madhepura on the 2nd of September 2008.
• The total population affected is estimated
to be 10,000 .
• The Measles outbreak had a cumulative
admission total of 145 males child and
155 female child.
• The daily admission rate is approx 35
patients.
• This outbreak claimed 6 lives
Calculate AR and CFR. What do they tell
you?
Attack Rate = number of cases x 100
population at risk

Attack Rate = (145+155) = .030 ;

10,000

.03 x 100 = 3.0%

There was a 3.0% attack rate. Based on the

population, what does this attack rate indicate?
(The attack rate is very high.This is a crisis
situation. Response activities should be re-
evaluated.)
Case Fatality Ratio (CFR)= number of deaths x 100
number of cases
= 6 = .02
(145+155)

= .02 x 100 = 2.0%

There was a 2.0% CFR. Based on the standards for Measles

treatment, what does this CFR indicate? (This exceeds the
standard of 1%. Serious action needs to be taken to improve
health seeking behaviour and response activities).
 Mortality in Refugee and Displaced
Populations

• Major causes of death in the emergency

phase
– Measles
– Diarrheal disease
– Acute respiratory infections
• 50% - 90% of deaths in some refugee settings
due to these 3 diseases
 DISEASE DETERMINANTS IN CAMPS
PROLONGED STRESS- NOT/ ENOUGH FOOD- ZERO HYGIENE- OVERCROWDED
POPULATION
 Catch-up Health and Nutrition Round :
Intervention Age group
Routine immunization Pregnant women and children as per
EPI schedule

Catch-up immunization 6 months to 14 years

(Measles Vaccination)

Catch–up Vitamin A 9 months to 5 years

doses

IFA supplementation 6months to 5 years

De-worming tablets 2 years to 5 years

Low osmolarity ORS All children affected with diarrhea; 6

months to 5 years

Zinc Along with ORS

• Manpower support for Micro planning, Orientation and

Monitoring
• Supplies 30
• IEC (Session site banners, banners, posters, handouts etc)
Preventing Measles Illness and Death in Emergencies

Prevent or detect the outbreak

Vaccination
- Timely, high quality mass campaigns in emergencies
- Routine childhood vaccination
Appropriate treatment of illness
- Vitamin A
Infants <6m 50,000 IU – repeat next day
Infants 6-11m 100,000 IU – repeat next day
Children 1y+ 200,000 IU – repeat next day
- Antibiotics for bacterial secondary infections
- Treat dehydration
 Measles and Vitamin A Campaign

Objective
• To prevent outbreaks in flood affected areas
Target Populations
• Congregated populations displaced by flood, living in
relief camps.
Target Age Group
• Measles immunization: Children from 6 months through
14 years age.
• Vitamin A: Children from 9 months to 5 years age

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 Microplan: Essential Background Information:
Infrastructure and Manpower

• Existing cold chain equipment

– Cold boxes, vaccine carriers, ice packs
– Functioning freezers and ILR
• Electricity sources
• Functioning facilities
• # trained vaccinators, supervisors
• Available vehicles/motorcycles
• Vehicles/motorcycles for hire
 CALCULATING SUPPLY NEEDS:
VACCINE & INJECTION MATERIALS

• Doses of measles vaccine and diluent-

– # doses = target population + wastage + reserve
– Doses needed = target X 1.17 + 20% reserve

• Number of vials = doses needed / 5

• Diluent = number of vials
• Syringes and needles for dilution = # vials
• AD syringes = Doses needed
• Safety boxes = AD syringes + syringes for dilution
100
• Vit A- 10 % reserve
CALCULATING COLD CHAIN NEEDS:
• Vaccine carriers: at least 2 per team
– 1 for vaccine 1 for extra icepacks
• Cold boxes: 1 for each storage depot
• Icepacks: = vaccine carriers X 4 + large cold boxes X 50
• Fuel for generator (icepacks need to be frozen 3-5 days before
campaign)
• ILR, freezers?
Calculating Transport Needs
• Transport for supplies
• Transport for teams, supervisors, coordinators, monitors
• Fuel for vehicles & Hiring cost of vehicles
 ASHA for Floods
• ASHA workers need to be mobilized
• Minimal package for Newborn, child and maternal health care: Training of
ASHAs, PNC visit for maternal and newborn care, Breast feeding training for early initiation and
exclusive Breastfeeding, ORS and Zinc for the management of Diarrhoea
• ASHAs to be equipped with counseling materials, ASHA kits
• The ASHA worker will be responsible for
 Ensuring chlorination of hand pumps,
 Testing water quality,
 PNC visits for mother and newborns and
 Referral services.

HOME VISIT FOR PNC BY ASHA WORKER COUNSELLING FOR BREASTFEEDING

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 ENSURING POST NATAL CARE FOR MOTHER AND CHILD IN
EMERGENCY

ASHA THE REFERRAL LINK

FROM VILLAGES TO DISTRICT HOSPITAL NSU
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 REFERRAL LINKAGE:
ASHA WORKER PROVIDING POST NATAL CARE AND REFERRAL IN
VILLAGES
To reduce the threat of epidemics regarding acute watery
diarrhea & malaria/dengue following steps are to be taken

a. Sustained & continuous provision of safe drinking water through

i. Water purification plants.
ii. Provision of Aqua Pure tablets for household.
iii. Provision of chlorinated water through tankers.

b. Provision of L-ORS & Zinc.

c. Provision of soap for hand washing before meals and after defecation.
d. Health Education and awareness campaign through Banners, leaflets &
electronic media.
e. Fogging in all already covered as well as un-covered areas.
f. Continuous indoor residual spray
g. Continuous and sustained supply of Anti-diarrhoea & Anti malarial drugs.
h. Early diagnosis through rapid diagnostic kits.
i. Quick epidemic response through regional & district epidemic response
team.

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Government of Bihar
Flood Response 2007
Daily IDSP Morbidity Reporting for the Facility / PHC / Mobile Clinic/Camp

Name of PHC / GH / Municipal Health post:

Team leader of the Mobile team:

Date of reporting

Syndrome Cases Reported Total

(To put the total no. against each syndrome at the end of the day)
Under 5 years 5 years and over
No. of cases No. of deaths No. of cases No. of deaths
1. Fever

2. Fever with rash

3. Acute Diarrheal Diseases

(including cholera)
4. Acute Jaundice

5. Acute Respiratory Infections

6. Others

Total

Total patients seen at the facility / Mobile Clinic: :

Reporting Person (MO / I / C / Heath Officer) :

Instructions:
a) Each Mobile team to report consolidated figures for all sites visited at PHC level on a daily basis.
b) The PHC to send compiled report of PHC and all other activities to District Data Cell and State Data Cell daily.
Government of Bihar
Flood Response 2007

COMPILATION of Daily IDSP Morbidity Reporting for the PHC Area

Name of PHC (District)

Population under PHC
Date of reporting
PHC Mobile Clinics Other Fixed TOTAL
Sites under
PHC
Syndrome No. of clinics / sites
Fever Under 5 years
5 years and over
Fever with Rash Under 5 years
5 years and over
Acute Diarrheal Diseases Under 5 years
5 years and over
(Including Cholera)
Acute Jaundice Under 5 years
5 years and over
Acute Respiratory Infections Under 5 years
5 years and over
Others Under 5 years
5 years and over
Total CASES Under 5 years
5 years and over
TOTAL DEATHS Under 5 years
5 years and over

Other Remarks / Comments:

Reporting Person (MO / I / C / Health Officer) :

Instructions:
a) Each Mobile team to report consolidated figures for all sites visited at PHC level on a daily basis.
b) The PHC to send compiled report of PHC and all other activities to District Data Cell and State Data Cell daily.
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 DISTRICT HEALTH SOCIETY

Daily Immunization Report Date-

S No- Name of Block OPV Vit A Measles Pregent woman Any Adverse No of team
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 DISTRICT HEALTH SOCIETY
Mobile Team Activity Chart: -

Date:
Name of PHC Reg. No. of No. of No. of Medicines (Distributed by Mobile Others Name & No. of
Team)
Ambulance Health Patients Services Contact Person of
Camp (Treated by Name Quantity provided by concerned PHC
Visited by Mobile Mobile (Where Mobile
Mobile Team) Team (if team is deployed)
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GROUP Work

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 Contingency/Preparedness Planning

Following Components :–
1) Logistics – Inventory of resources (existing +
required), prepositioning
2) Human Resources
3) Transportation
4) Technical – Capacity building, Investigations,
treatment protocol, control…

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 Resources required
• Budgetary provision
• Personnel
• Medical care
• Laboratory support
• Field teams
• Immunization
• Vector control
• Environmental sanitation
• Supplies (Bleaching Powder; IFA; Vitamin A; ASHA kits;
Halogen tablets; ORS & Zn; Medicine Kits ; Midwifery Kits;
Baby Blankets; Cholera Kit etc)
• Transport
• Communication
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