Measles transmission following the tsunami in a population with a high one-dose vaccination coverage, Tamil Nadu, India 2004–2005

BACKGROUND: On 26 December 2004, a tsunami struck the coast of the state of Tamil Nadu, India, where one-dose measles coverage exceeded 95%. On 29 December, supplemental measles immunization activities targeted children 6 to 60 months of age in affected villages. On 30 December, Cuddalore, a tsunami-affected district in Tamil Nadu reported a cluster of measles cases. We investigated this cluster to estimate the magnitude of the problem and to propose recommendations for control. METHODS: We received notification of WHO-defined measles cases through stimulated passive surveillance. We collected information regarding date of onset, age, sex, vaccination status and residence. We collected samples for IgM antibodies and genotype studies. We modeled the accumulation of susceptible individuals over the time on the basis of vaccination coverage, vaccine efficacy and birth rate. RESULTS: We identified 101 measles cases and detected IgM antibodies against measles virus in eight of 11 sera. Cases were reported from tsunami-affected (n = 71) and unaffected villages (n = 30) with attack rates of 1.3 and 1.7 per 1000, respectively. 42% of cases in tsunami-affected villages had an onset date within 14 days of the tsunami. The median ages of case-patients in tsunami-affected and un-affected areas were 54 months and 60 months respectively (p = 0.471). 36% of cases from tsunami-affected areas were above 60 months of age. Phylogenetic analyses indicated that the sequences of virus belonged to genotype D8 that circulated in Tamil Nadu. CONCLUSION: Measles virus circulated in Cuddalore district following the tsunami, although there was no association between the two events. Transmission despite high one-dose vaccination coverage pointed to the limitations of this vaccination strategy. A second opportunity for measles immunization may help reducing measles mortality and morbidity in such areas. Children from 6 month to 14 years of age must be targeted for supplemental immunization during complex emergencies

Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995–2004)

BACKGROUND: The fields of expertise of natural disasters and complex emergencies (CEs) are quite distinct, with different tools for mitigation and response as well as different types of competent organizations and qualified professionals who respond. However, natural disasters and CEs can occur concurrently in the same geographic location, and epidemics can occur during or following either event. The occurrence and overlap of these three types of events have not been well studied. METHODS: All natural disasters, CEs and epidemics occurring within the past decade (1995–2004) that met the inclusion criteria were included. The largest 30 events in each category were based on the total number of deaths recorded. The main databases used were the Emergency Events Database for natural disasters, the Uppsala Conflict Database Program for CEs and the World Health Organization outbreaks archive for epidemics. ANALYSIS: During the past decade, 63% of the largest CEs had ≥1 epidemic compared with 23% of the largest natural disasters. Twenty-seven percent of the largest natural disasters occurred in areas with ≥1 ongoing CE while 87% of the largest CEs had ≥1 natural disaster. CONCLUSION: Epidemics commonly occur during CEs. The data presented in this article do not support the often-repeated assertion that epidemics, especially large-scale epidemics, commonly occur following large-scale natural disasters. This observation has important policy and programmatic implications when preparing and responding to epidemics. There is an important and previously unrecognized overlap between natural disasters and CEs. Training and tools are needed to help bridge the gap between the different type of organizations and professionals who respond to natural disasters and CEs to ensure an integrated and coordinated response

Measles outbreaks in displaced populations: a review of transmission, morbidity and mortality associated factors

<p>Abstract</p> <p>Background</p> <p>Measles is a highly contagious infectious disease with a significant public health impact especially among displaced populations due to their characteristic mass population displacement, high population density in camps and low measles vaccination coverage among children. While the fatality rate in stable populations is generally around 2%, evidence shows that it is usually high among populations displaced by disasters. In recent years, refugees and internally displaced persons have been increasing. Our study aims to define the epidemiological characteristics and risk factors associated with measles outbreaks in displaced populations.</p> <p>Methods</p> <p>We reviewed literature in the PubMed database, and selected articles for our analysis that quantitatively described measles outbreaks.</p> <p>Results</p> <p>A total of nine articles describing 11 measles outbreak studies were selected. The outbreaks occurred between 1979 and 2005 in Asia and Africa, mostly during post-conflict situations. Seven of eight outbreaks were associated with poor vaccination status (vaccination coverage; 17-57%), while one was predominantly due to one-dose vaccine coverage. The age of cases ranged from 1 month to 39 years. Children aged 6 months to 5 years were the most common target group for vaccination; however, 1622 cases (51.0% of the total cases) were older than 5 years of age. Higher case-fatality rates (>5%) were reported for five outbreaks. Consistent factors associated with measles transmission, morbidity and mortality were vaccination status, living conditions, movements of refugees, nutritional status and effectiveness of control measures including vaccination campaigns, surveillance and security situations in affected zones. No fatalities were reported in two outbreaks during which a combination of active and passive surveillance was employed.</p> <p>Conclusion</p> <p>Measles patterns have varied over time among populations displaced by natural and man-made disasters. Appropriate risk assessment and surveillance strategies are essential approaches for reducing morbidity and mortality due to measles. Learning from past experiences of measles outbreaks in displaced populations is important for designing future strategies for measles control in such situations.</p

Improved Response to Disasters and Outbreaks by Tracking Population Movements with Mobile Phone Network Data: A Post-Earthquake Geospatial Study in Haiti

Linus Bengtsson and colleagues examine the use of mobile phone positioning data to monitor population movements during disasters and outbreaks, finding that reports on population movements can be generated within twelve hours of receiving data

Users' guides to the medical literature: how to use an article about mortality in a humanitarian emergency

The accurate interpretation of mortality surveys in humanitarian crises is useful for both public health responses and security responses. Recent examples suggest that few medical personnel and researchers can accurately interpret the validity of a mortality survey in these settings. Using an example of a mortality survey from the Democratic Republic of Congo (DRC), we demonstrate important methodological considerations that readers should keep in mind when reading a mortality survey to determine the validity of the study and the applicability of the findings to their settings

Characteristics and risk factors for typhoid fever after the tsunami, earthquake and under normal conditions in Indonesia

<p>Abstract</p> <p>Background</p> <p>Although typhoid transmitted by food and water is a common problem in daily life, its characteristics and risk factors may differ in disaster-affected areas, which reinforces the need for rapid public health intervention. Surveys were carried out post-tsunami in Banda Aceh, post-earthquake in Yogyakarta, and under normal conditions in Bandung, Indonesia. Logistic regression analysis was used to assess the risk factors with the dependent variable of typhoid fever, with or without complications.</p> <p>Findings</p> <p>Characteristic typhoid fever with complications was found in 5 patients (11.9%) affected by the tsunami in Aceh, 8 (20.5%) after the earthquake in Yogyakarta, and 13 (18.6%) in Bandung. After the tsunami in Aceh, clean water (OR = 0.05; 95%CI: 0.01-0.47) and drug availability (OR = 0.23; 95%CI: 0.02-2.43) are significant independent risk factors, while for the earthquake in Yogyakarta, contact with other typhoid patients (OR = 20.30; 95%CI: 1.93-213.02) and education (OR = 0.08; 95%CI: 0.01-0.98) were significant risk factors. Under normal conditions in Bandung, hand washing (OR = 0.07; 95%CI: 0.01-0.50) and education (OR = 0.08; 95%CI: 0.01-0.64) emerged as significant risk factors.</p> <p>Conclusion</p> <p>The change in risk factors for typhoid complication after the tsunami in Aceh and the earthquake in Yogyakarta emphasizes the need for rapid public health intervention in natural disasters in Indonesia.</p

Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya

<p>Abstract</p> <p>Background</p> <p>Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya.</p> <p>Methods</p> <p>We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation.</p> <p>Results</p> <p>Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness.</p> <p>Conclusion</p> <p>During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.</p

Malaria control in Timor-Leste during a period of political instability: what lessons can be learned?

<p>Abstract</p> <p>Background</p> <p>Malaria is a major global health problem, often exacerbated by political instability, conflict, and forced migration.</p> <p>Objectives</p> <p>To examine the impact of political upheaval and population displacement in Timor-Leste (2006) on malaria in the country.</p> <p>Method</p> <p>Case study approach drawing on both qualitative and quantitative methods including document reviews, in-depth interviews, focus group discussions, site visits and analysis of routinely collected data.</p> <p>Findings</p> <p>The conflict had its most profound impact on Dili, the capital city, in which tens of thousands of people were displaced from their homes. The conflict interrupted routine malaria service programs and training, but did not lead to an increase in malaria incidence. Interventions covering treatment, insecticide treated nets (ITN) distribution, vector control, surveillance and health promotion were promptly organized for internally displaced people (IDPs) and routine health services were maintained. Vector control interventions were focused on IDP camps in the city rather than on the whole community. The crisis contributed to policy change with the introduction of Rapid Diagnostic Tests and artemether-lumefantrine for treatment.</p> <p>Conclusions</p> <p>Although the political crisis affected malaria programs there were no outbreaks of malaria. Emergency responses were quickly organized and beneficial long term changes in treatment and diagnosis were facilitated.</p

Healthcare Barriers of Refugees Post-resettlement

The majority of refugees spend the greater part of their lives in refugee camps before repatriation or resettlement to a host country. Limited resources and stress during residence in refugee camps can lead to a variety of acute and chronic diseases which often persist upon resettlement. However, for most resettled refugees little is known about their health needs beyond a health assessment completed upon entry. We conducted a qualitative pilot-study in San Diego County, the third largest area in California, USA for resettling refugees, to explore health care access issues of refugees after governmental assistance has ended. A total of 40 guided in-depth interviews were conducted with a targeted sample of informants (health care practitioners, employees of refugee serving organizations, and recent refugee arrivals) familiar with the health needs of refugees. Interviews revealed that the majority of refugees do not regularly access health services. Beyond individual issues, emerging themes indicated that language and communication affect all stages of health care access—from making an appointment to filling out a prescription. Acculturation presented increased stress, isolation, and new responsibilities. Additionally, cultural beliefs about health care directly affected refugees’ expectation of care. These barriers contribute to delayed care and may directly influence refugee short- and long-term health. Our findings suggest the need for additional research into contextual factors surrounding health care access barriers, and the best avenues to reduce such barriers and facilitate access to existing services