Public HealtH Risk assessment and inteRventions

Public HealtH

Risk assessment and inteRventions

Tropical cyclone pam:

Vanuatu

Public HealtH

Risk assessment and inteRventions

Tropical cyclone pam:

Vanuatu

1. Cyclonic storms. 2. Disaster planning. 3. Risk management. 4. Vanuatu.

I. World Health Regional Office for the Western Pacific.

ISBN 978 92 9061 749 5 (NLM Classification: WA 295)

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conTenTs

Abbreviations . . . .iv

Preface . . . .1

Executive summary . . . .2

1. Background and risk factors

. . . .5

1.1 Tropical Cyclone Pam . . . .5

1.2 Priority areas for Public Health . . . .6

2. Priority areas

. . . .7

2.1 Trauma and Injuries . . . .7

2.2 Interruption of critical infrastructure: water, sanitation and hygiene . . . .8

2.3 Diseases associated with overcrowding . . . .9

2.4 Vector-borne diseases . . . .13

2.5 Loss of health infrastructure . . . .15

2.6 Food security and malnutrition . . . .16

2.7 Existing medical conditions and other health threats . . . .17

3. sPecific Priority interventions for immediate imPlementation

. . . .23

3.1 Water and sanitation . . . .24

3.2 Shelter and site planning . . . .25

3.3 Prevention and management of malnutrition. . . .25

3.4 Essential health services . . . .27

3.5 Early warning and response network . . . .30

3.6 Immunization . . . .30

3.7 Vector control and personal protection . . . .31

4. staff health

. . . .32

4.1 Vaccination recommendations . . . .33

4.2 Malaria prophylaxis and treatment . . . .34

4.3 Other precautions . . . .34

5. risk communications

. . . .35

annexes

. . . .36

Annex 1: Health Services in Vanuatu . . . .36

Annex 2: Communications messages (specific health issues) . . . .39

Annex 3: EWARN case definitions – Cyclone Pam, Vanuatu . . . .41

abbreviaTions

afr acute fever and rash aPi annual parasite incidence

alri acute lower respiratory tract infection ari acute respiratory infection

art antiretroviral therapy Bms breast-milk substitute dhP dengue haemorrhagic fever

ePi Expanded Programme on Immunization evm Effective Vaccine Management

eWarn Early Warning and Response Network

glean Global Leptospirosis Environmental Action Network hBv hepatitis B Virus

hev hepatitis E

iehk Interagency Emergency Health Kits ili influenza-like illness

imci Integrated Management of Childhood Illness irn indoor residual spraying

JmP Joint Monitoring Programme llin long-lasting insecticidal net mch maternal and child health misP Minimum Initial Service Package mou Memorandum of Understanding ncd noncommunicable diseases

ndmo National Disaster Management Office PeP post exposure prophylaxis

Plhiv people living with HIV

Pmtct prevention of mother to child transmission soP standard operating procedures

stis sexually transmitted infections

tB tuberculosis

tig tetanus immune globulin

unhcr Office of the United Nations High Commissioner for Refugees unicef United Nations Children’s Fund

vBd vector-borne disease vhW village health worker vhW village health workers vPd vaccine-preventable disease Who World Health Organization

This public health risk assessment provides health professionals in United Nations agencies, nongovernmental organizations, donor agencies and local authorities working with populations affected by the Cyclone Pam emergency in Vanuatu, with baseline health information and up-to-date technical guidance on the major public health threats. A related document, Public Health Risk Assessment and Interventions – Typhoon Haiyan, Philippines 16 November 2013 was used as a template for this document [1].

The health issues and risk factors addressed have been selected on the basis of the known burden of disease in Vanuatu, and their potential impact on morbidity, mortality, response and recovery.

Public health threats represent a significant challenge to those providing health- care services in this evolving situation. It is hoped that this risk assessment will facilitate the coordination of activities between all agencies working among the populations affected by the crisis.

preface

The Republic of Vanuatu was hit by a Category 5 cyclone on 13 March 2015, causing widespread destruction and damage to buildings, infrastructure and loss of communication [2]. Early reports indicate several fatalities and more than 3000 people were evacuated to emergency shelters [2].

Baseline health profile: Prior to the emergency, Vanuatu’s under-resourced health services had critical health worker shortages [3]. Vaccination rates for measles and other vaccine-preventable diseases (VPDs) have been suboptimal, and much of the population has very limited access to health services [4]. Children under-5 require special attention as natural disasters put children at increased risk of infections such as gastroenteritis and acute respiratory infections.

Priority areas for public health:

• Trauma and Injury

• Interruption of critical infrastructure

• Disease associated with overcrowding

• Increased communicable disease transmission and potential for outbreaks of diseases

• Increased exposure to vector-borne disease

• Loss of health infrastructure

• Nutrition and food security concerns

• Existing medical conditions and other disease threats.

execuTive summary

Immediate priorities:

• Provision of food, safe drinking-water, appropriate sanitation, shelter, and other essential non-food items including fuel for cooking

• Trauma care for the wounded with tetanus prevention

• Provision of medicines and medical supplies

• Establishment of emergency primary and secondary care for medical, surgical and obstetric emergencies

• Risk communication to the public

• Measles vaccination in high-risk areas

• Establishment of an early warning system for early detection and response to outbreaks

• Infection control in health-care settings including safe blood transfusion, medical waste management and adequate water supply and sanitation

• Management of acute malnutrition including medical complications

• Continuity of treatment for chronic diseases and chronic infections such as tuberculosis (TB).

Short-term priorities:

• Re-establishment of essential health-care services (primary, referral and hospital care)

• Emergency mental health care and psychosocial support

• Waste management

• Vector control and provision of personal protection against vector-borne diseases.

Medium-term priorities:

• Post-surgical care and management of disabilities

• Routine immunization

• Health of victims who have migrated and potential returnees.

A national list of case definitions for likely conditions has been defined for clinical and epidemiological purposes. Laboratory diagnostic support is limited and clinical definitions are therefore essential for disease management.

Background and risk factors

The Republic of Vanuatu (Vanuatu) is an archipelago in the South Pacific Ocean, comprising 83 islands, of which approximately 65 are inhabited, with a total land area of 12 189 square kilometres, spanning a distance 900 km in length [5].

Vanuatu has an estimated population of 271 000, of which approximately 37% are under the age of 15 years. Locals are predominantly of Melanesian origin, known as

ni-Vanuatu (98.5% population). The national language is Bislama (pidgin). English and French are widely spoken and are also official languages. There are more than 105 local Melanesian languages and dialects.

The country has six provinces:

Torba, Sanma, Penama, Malam- pa, Shefa and Tafea. There are two urban centres: in the cap- ital, Port Vila, on the island of Efate (population of 44 039);

and Luganville, on the island of Espiritu Santo, (population of 13 156 people) [3]. The majority of the population (74%) lives in rural areas [6], although rural to urban movement is increasing, leading to overcrowding in ur- ban centres.

The annual per capita income is US$ 3130 with 6.5% living in extreme poverty and 35%

vulnerable to poverty. The Human Development Index ranking for Vanuatu is 125 out of 187 [4]. Life expectancy is 70 years for males and 74 years for females [7]. Under-5 mortality has improved over the past 13 years from 33 deaths per 1000 live births in 1990 to 17 deaths per 1000 live births in 2013 [7]. Infant mortality (death before 1 year of age) in 2010 was estimated to be 28 deaths per 1000 live births – comprising a relatively lower neonatal mortality rate (12 deaths per 1000 deaths within the first month) compared to higher post-neonatal mortality (16 deaths per 1000 deaths in months 2–12) [6].

An estimated 20% of the population have no access to health services [3].

The Vanuatu economy is driven by exports of copra, timber, beef and cocoa (20% of gross domestic product (GDP)), tourism (20% GDP) and foreign aid contributions [3].

1. bacKGrounD anD risK facTors

1.1 Tropical cyclone Pam

OIn the evening of 13 March 2015, at approximately 23:00 local time, Tropical cyclone Pam struck Vanuatu, hitting Port Vila as an extremely destructive Category 5 cyclone [2]. The cyclone tracked along the length of eastern side of the Vanuatu archipelago, with the cyclone’s eye passing close to Efate Island, before heading south directly over the southern islands. Winds were estimated to have reached more than 250kmph. This caused serious damage to

infrastructure, left debris strewn across the capital and damaged an estimated 90% of structures. The southern-most islands of Tafea Province (population 32 540), were directly struck by the eye wall [2].

While the extent of the damage continues to be assessed, there are reports of several deaths and serious injuries, many homes have been damaged or destroyed, and access to health services, food and clean water is limited or unavailable in many places. On 23 March 2015, the National Disaster Manage- ment Office (NDMO) had confirmed 11 fatalities. An estimated 3300 people have been displaced in 37 evacuation centres. The provinces of Shefa, Tafea, Malampa and Penama are emerging as the worst impacted areas [8].

The cyclone has blocked roads with debris, knocked down bridges and caused flooding. Electricity was out in many places and communication systems were down or were unreliable, but are slowly being restored. Radio and telephone communication with the outer islands has been cut off. In Port Vila, commercial flights that were initially grounded, resumed on 15 March 2015 and access to water and electricity started to be restored, although an estimated 80% of power lines were damaged or down [8]. The main hospital in Port Vila was badly damaged, including the Children’s ward, kitchen and Central Medical Store.

The morgue is unserviceable [8].

In the face of this disaster, the Government of Vanuatu has declared a state of emergency and requested help from the international community. The Vanuatu National Disaster Management Office provided the following situation update on 27 March 2015:

• 166 000 people affected on 22 islands

• 15 000 homes destroyed or damaged

• 75 000 people in need of emergency shelter

• 110 000 people in need of clean drinking-water

• 8700 children vaccinated against measles.

1.2 Priority areas for public health

• Trauma and Injury

• Interruption of critical infrastructure

• Disease associated with overcrowding

• Increased communicable disease transmission and potential for disease outbreaks

• Increased exposure to vector-borne disease

• Loss of health infrastructure

• Nutrition and food security concerns

• Existing medical conditions and other disease threats.

2.prioriTy areas

2.1 Trauma and injuries

Wounds and injuries are frequently associated with the immediate post-cyclone g period due to strong winds, collapsed structures and debris or from near- drowning. The management of all injuries may be complicated by delays in presenting for care and limited access of skilled personnel to the affected areas.

Complications of untreated injuries are death, infections, tetanus and long-term disability.

2.1.1 Tetanus

Tetanus (“lock-jaw”) is a disease caused by a toxin produced by the bacterium, Clostridium tetani, affecting the nervous system. Clostridium tetani bacteria are found in dust and animal faeces. Infection may occur after minor injury (sometimes unnoticed punctures to the skin that are contaminated with soil, dust or manure) or after major injuries causing tetanus prone wounds such as open fractures, dirty or deep penetrating wounds, and burns. Neonatal tetanus can occur in babies born to inadequately immunized mothers, especially after unsterile treatment of the umbilical cord stump. Neonatal tetanus has

a case fatality rate of 70–100% without medical treatment and is globally underreported. The incubation period is usually 3 to 21 days.

The tetanus vaccination coverage in Vanuatu was reported in 2013 as 75%

(DTP3), and the Vanuatu Demographic Health Survey conducted in 2013 which collected information from all children under-5 years, reported coverage in under-5 year olds of only 55% [6]. The vaccination coverage for all Expanded Programme on Immunization (EPI) vaccines has varied greatly in past years, meaning some age groups will be inadequately vaccinated. Maternal and neonatal tetanus is assumed to have been eliminated from Vanuatu.

The management of wounds needs to consider the probability of tetanus.

Health-care workers operating in disaster settings should be alerted by the occurrence of cases of dysphagia (difficulty swallowing) and trismus (facial muscle spasm), often the first symptoms of the disease. A boosting dose of tetanus vaccine and tetanus immune globulin should be given to patients with tetanus prone wounds. Patients should also systematically receive prophylactic antibiotics.

2.2 Interruption of critical infrastructure:

water, sanitation and hygiene

Estimates from the Joint Monitoring Programme (JMP) for Water Supply and Sanitation are that in 2014, 91% of Vanuatu’s population uses an improved drinking-water source, and 25% of the population will have piped water to their home [9]. The JMP reports that 58% of the population have improved sanitation facilities, 20% have shared facilities, 20% unimproved facilities and 2% practise open defecation [9]. Prior to the cyclone, rural and remote communities were less likely than urban residents to have an improved drinking-water source and improved sanitation.

With severe windstorms, water sources can become unsafe for drinking due to the incursion of floodwaters, faecal contamination caused by overflow of latrines, inadequate sanitation and upstream contamination of interconnected water sources. Population displacement, crowding, poor access to safe drinking- water, inadequate hygiene and toilet facilities, and unsafe practices in handling and preparing food may cause outbreaks of diseases such as acute watery diarrhoea, typhoid fever, shigellosis, viral enteritis and hepatitis A and E.

2.3 Diseases associated with overcrowding

Population displacement caused by flooding can result in overcrowding in reset- tlement areas, increasing the risk of transmission of many communicable diseas- es. Acute respiratory infection, measles, diphtheria, and pertussis are transmitted from person to person through respiratory droplets during coughing and sneez- ing. The risks are increased when shelters are overcrowded and inadequately ventilated. The transmission of meningitis, water-related and vector-borne dis- eases also increases in such conditions.

Overcrowding leads to an increase in the potential for communicable disease transmission and outbreaks of diseases such as:

• acute respiratory infections

• measles and other vaccine-preventable disease (VPD)

• diarrhoeal disease (bacterial and viral)

• hepatitis A and E

• leptospirosis

• meningococcal disease.

2.3.1 Acute respiratory infection (ARI)

In 2014 there were 6219 cases of influenza-like-illness (ILI) reported. From Jan- uary 2015 to 8 March 2015, there were 1142 cases of ILI reported [7]. A major concern is acute lower respiratory tract infection (ALRI), such as pneumonia, bronchiolitis and bronchitis, particularly in children under-5. WHO estimates that 11% of deaths in children under-5 years in Vanuatu are caused by pneumonia.

ALRI kills more children globally than any other disease. Low birth weight, mal- nourished and non-breastfed children, and those living in overcrowded condi- tions are at higher risk of acquiring pneumonia as well as of experiencing more severe disease and death from pneumonia. Exclusive breastfeeding, adequate nutrition, and immunization can help reduce infection rates.

Early detection and case management of pneumonia and other common illness- es, guided by Integrated Management of Childhood Illness (IMCI), will prevent morbidity and mortality in children under-5. Trained health workers should refer to the national IMCI guidelines during and after the emergency [10].

2.3.2 Diarrhoeal disease

The risk of diarrhoeal disease in Vanuatu has increased due to overcrowding, inadequate sanitation and limited access to safe drinking-water. Acute gas- troenteritis (bacterial or viral) is often highly contagious. Transmission occurs through contaminated food and water and directly from person to person.

Bacillary dysentery is the most important cause of acute bloody diarrhoea in the post-disaster setting. It is caused by bacteria of the genus Shigella – of which S. dysenteriae type 1 causes the most severe disease and the largest outbreaks.

Bacillary dysentery is endemic in most low- and middle-income countries. Without prompt, effective treatment the case fatality rate can be as high as 10%.

Rotavirus outbreaks are well documented in the Pacific, and small children in particular are at high risk of developing severe dehydration, which can lead to death if not treated promptly with oral or intravenous fluids. Vanuatu does not vaccinate against rotavirus. During the 2013 Demographic and Health Survey, around 12% of children under age 5 years were reported to have had diarrhoea in the previous two weeks; and 1% reported bloody diarrhoea [6].

Large post-disaster outbreaks of diarrhoea have been documented in the Pacific in the context of floods. In 2014, Solomon Islands experienced a very large post- flood diarrhoea epidemic that resulted in more deaths than the initial flash-flood emergency. In that emergency, as is consistently reported, children under 5-years bore the greatest burden both in terms of morbidity and mortality: children under-5 years were almost 20 times (versus eight times at baseline) more likely to suffer from diarrhoea than those five-years of age and older (personal communication, Dr E Nilles, WHO).

2.3.3 Hepatitis

Hepatitis B is endemic in the adult population in Vanuatu, with limited data suggesting a prevalence of about 12%. Hepatitis B virus (HBV) immunization success has been modest with childhood prevalence of around 3% and HBV- vaccine birth dose coverage of about 80%. Hepatitis B birth dose is a priority for all newborns within the first 24 hours of life, especially those born of HBV- infected mothers, to prevent mother-to-child chronic hepatitis B transmission.

Hepatitis A can cause outbreaks but is considered less likely than other public health risks in this context. In most low- and middle-income countries, hepatitis exposure, infection and life-time immunity, occurs at a young age, when disease severity is low. Although small clusters of hepatitis A disease may occur in the disaster setting, large outbreaks are unlikely given high likelihood that most of the population are immune due to prior infection. Vigilance in appropriate water and food preparation techniques prior to consumption is, however, strongly recommended.

Hepatitis E (HEV) is usually a self-limiting disease but can progress to severe disease and death. Pregnant women in particular are at high risk of severe disease and death. Outbreaks can occur in settings with poor hygiene and sanitation typically via contamination of food or water sources. Little robust data on HEV in Vanuatu or the Pacific is available, but a sero-prevalance study in Papua New Guinea, Kiribati and Fiji reported HEV sero-positivity rates of 15%, 9%, and 2% respectively [11], demonstrating that this virus circulates in other Pacific island countries and areas, and thus probably in Vanuatu also. Prior exposure and immunity levels are not sufficient to prevent HEV outbreaks. There is no globally available vaccine.

2.3.4 Leptospirosis

Leptospirosis is a bacterial zoonosis present worldwide. Outbreaks of leptospi- rosis commonly occur following flooding, due to the crowding of rodents, wild and domestic animals and humans on shared dry ground. In this situation, the disease is likely to be spread through indirect contact with water contaminated with the urine of rodents, pigs, or other infected animals. Leptospirosis out- breaks have occurred in the Pacific, sporadic cases are known to occur in Vanuatu [13].

The Global Leptospirosis Environmental Action Network (GLEAN) has developed preliminary set of recommendations for the control of disaster-related

leptospirosis outbreaks; these recommendations include: laboratory screening of suspected cases, empiric treatment of probable cases, and prevention with the use of barrier protection if there is a potential to come into contact with contaminated water [14]. If individual exposure occurs when cleaning up after disasters, the affected body areas should be immediately cleaned with soap and clean bottled water. Use of mass chemoprophylaxis is not recommended, nor is mass decontamination of water, however, there is evidence that pre-exposure chemoprophylaxis decreases morbidity in controlled target populations including individuals of high risk such as military workers, disaster relief workers, sewage and sanitation workers [14].

2.3.5 Measles and other vaccine-preventable diseases

Vanuatu provides immunization for children against vaccine-preventable diseases (VPDs) including: tuberculosis, diphtheria, pertussis (whooping cough), tetanus, hepatitis B, haemophilus influenza, polio and measles [6].

In 2013, the Vanuatu Demographic and Health Survey, which conducted house- hold surveys, found that only one in three (33%) children, aged 12–23 months received all of the basic vaccinations (BCG, DPT, polio and measles) at some time prior to the survey, and 7% were fully vaccinated [6]. The Vanuatu Joint Reporting Form figures for vaccination coverage have greatly improved in the last few years and show good coverage. However, wide variability in coverage rates in the last 15 years, indicates that a large proportion of children may not be adequately covered for VPDs [12].

Measles vaccination coverage rates in children under-5 years was found to be 53%, and coverage rates for the third doses of DPT and polio vaccines in children under-5 years were found to be 55% and 52% respectively [6].

During 2014, a measles outbreak affected the Blacksand area of Port Vila, the first measles outbreak since 1997. In 2015, a second measles outbreak occurred.

In response, a catch-up campaign is being conducted on Efate. There are around 10 500 doses of monovalent measles vaccine in Port Vila and additional MR vaccines are available in Suva, Fiji through the United Nations Population Fund (UNICEF). Effective Vaccine Management (EVM) Assessment took place and training of assessors started in the week of 8 March 2015.

On 17 March 2015, six teams were deployed to Port Vila for measles vaccination;

another six teams are to be trained for integrated measles response (with Vitamin A and bed nets). Initial plans are to target Efate, Tanna and Sanma. Efate and Tanna were both severely affected by the cyclone and although Santo was not badly affected by the cyclone, they recently reported a large number of cases of acute fever and rash (AFR) through syndromic surveillance.

There is a requirement to strengthen the early warning alert and response net- work for AFR through the health centres in Port Vila and in the other affected areas. Reports are starting to be received from sentinel sites outside Port Vila.

The Western Pacific Region was declared polio free in October 2000 and all Pacific island countries have remained polio-free. The last reported polio case (clinical) in the Pacific was in 1979. The case was not laboratory confirmed.

2.3.6 Meningococcal disease

Neisseria meningitidis, the bacterium causing meningococcal disease, is spread from person to person through respiratory droplets from infected people. There are two classical clinical presentation of meningococcal disease: meningitis and severe sepsis, although cases may present with overlapping features. Transmission is facilitated by close contact and crowded living conditions. Health care workers need to be vigilant for cases of meningococcal disease, and urgently report any cases. The Case Fatality Rate of meningococcal disease is 5-10%, even with appropriate and rapid antibiotic treatment.

2.3.7 Tuberculosis

Vanuatu, with an estimated tuberculosis (TB) incidence of 65 cases per 100 000 population in 2013 has a moderate TB burden. The notification rate for 2013 was 44 cases per 100 000 population, with corresponding 126 TB cases notified. The TB burden is higher among women compared to men, unlike in the majority of countries. All age groups are affected, with a peak among the 14-24 age group among women, and in the over 65 years age group, for both women and men. Provinces with higher notification rates are Taefa and Shefa, although the lack of a patient-based national register does not allow a thorough geographical analysis.

In the acute phase of this emergency, follow-up and continuity of treatment of patients already on care should be maintained when feasible and for that purpose stocks of anti-TB medicines shall be ensured. Due to the demonstrated link between emergencies and TB, once response to trauma-related emergency has been provided, service provision in terms of TB detection by smear

microscopy should be conducted to displaced communities to identify cases and avoid TB transmission.

2.4 Vector-borne diseases

There is an increased risk of vector-borne diseases (VBD) such as dengue, chikungunya, Zika and malaria. Flooding may initially flush out mosquito breeding, which can restart when the waters recede. The lag time is usually 6-8 weeks before the onset of increased VBD transmission.

2.4.1 Chikungunya

Chikungunya fever is of moderate risk and presents very similarly to dengue usually with swelling and pain in large joints, although haemorrhagic complications are rare. A significant proportion of patients develop a long- term debilitating arthritis that lasts for months to years. Both infections are transmitted by Aedes mosquitoes that breed in close proximity to human settlements. Collections of water in debris and damaged houses can contribute to increased mosquito breeding sites.

2.4.2 Dengue

Dengue is a viral disease transmitted by the Aedes mosquito, which is endemic in the Pacific. In late 2013, a large outbreak of dengue fever occurred in Vanuatu, with 1561 cases reported in December 2013. The outbreak continued into 2014, however data was not available on the final numbers (Roth et. al 2014).

Dengue epidemiology is rapidly evolving, with outbreaks occurring more frequently and expanding to areas that were previously unaffected. The risk of transmission may increase among people living in inadequate shelters or overcrowded conditions, particularly where fresh water is stored in unprotected water containers and rainfall collects in other artificial containers, allowing mosquitoes to proliferate.

Dengue causes a severe influenza-like illness. Occasionally a severe form of the disease with potentially lethal complications including dengue haemorrhagic fever (DHF) can occur. Severe dengue can affect all age groups. Mortality is highest during the initial period of the outbreak or epidemic. Children are at particularly high risk of mortality as a result of complications, especially if treatment is delayed. Early detection and treatment of DHF can reduce the case-fatality ratio from 20% to less than 1%. Supportive treatment supplies should be stockpiled.

2.4.3 Malaria

Malaria is endemic in most islands of Vanuatu, which has an overall Annual Parasite Incidence (API) of 13.2 cases per 1000 population (2012). Transmission is generally higher in the northern provinces than the southern provinces, with an API of 38.2 reported on Torba, and 20–21 per 1000 reported in Malampa, Penama and Sanma in 2012. Shefa reported an API of 4.7 per 1000 and Tafea reported an API of 0.4 per 1000 in 2012. The national API decreased from 74 per 1000 in 2003 to 13 per 1000 in 2012, and the virtual disappearance of confirmed malaria-related deaths. Tafea achieved close to zero local malaria transmission in 2013 and is on track to achieve sub-national elimination by 2016.

The malaria programme is the most operationalized public health programme in Vanuatu. Preventive intervention is based on using the insecticide treated nets (long-lasting insecticide nets (LLIN)) and selective indoor residual spray in elimination provinces (Tafea and Torba). The Demographic Health Survey in 2013 indicated that 83% of households (91% in rural areas) owned at least one LLIN.

The last mass distribution campaign of LLIN was in 2013 when over 90 000 long- lasting insecticidal nets (LLINs) were distributed. Most health facilities including aid posts provide malaria diagnosis using rapid diagnostic tests or microscopy and recommended first-line regimen (Artemether-Lumefanthrin).

To prevent and mitigate the risk of a malaria outbreak:

• ensure full replacement of lost, damaged or destroyed LLINs;

• malaria case management services should be restored and strengthened as soon as possible to ensure adequate services are available and accessible;

• restore and maintain routine surveillance and surveillance of selective areas (e.g. evacuation centres); and

• develop a recovery plan for preventive intervention through distribution of LLINs to the affected areas.

2.4.4 Zika

Zika virus is a newly emerging cause of outbreaks and usually results in a mild disease characterized by low grade fever and rash. Recent outbreaks have been reported in French Polynesia, the Federated States of Micronesia, New Caledonia and Solomon Islands. As of 20 March 2015, six confirmed cases diagnosed in New Caledonia have been said to have originated from Vanuatu. However, there is no outbreak reported in Vanuatu.

2.5 Loss of health infrastructure

Government health services in Vanuatu comprise a four-tier system: referral hospitals, health centres, dispensaries and community supported aid posts.

Vanuatu is divided into the northern and southern health-care directorates.

The Northern Health Care Directorate, based in Luganville, delivers curative and preventive health services in Torba, Sanma, Penama and Malampa provinces.

The Southern Health Care Directorate coordinates health services for Shefa and Tafea provinces [12].

Each province is made up of several islands which are then divided into zones.

Health facilities are distributed among these zones. There is a referral hospital in each of the two Health Care Directorates. Community and preventive services include: malaria control, environmental health, immunizations, reproductive health, MCH/Reproductive Health/Family Planning, STIs and HIV/AIDS, TB/leprosy, IMCI, nutrition and health promotion programmes. Appendix 2 describes the type of services provided at each level [4].

A review of Human Resources for Health in Vanuatu in 2012 showed critical health worker shortages [3]; Vanuatu has the third lowest health workforce density in the Pacific region. The greatest shortages are in rural areas. It has been estimated that 1261 health workers were employed in the public sector in 2012, including 397 nurses and midwives, and 46 doctors [3]. This is equivalent to 1.77 health workers per 1000 population. This is considerably lower than the WHO minimum recommended 2.3 health workers per 1000 population.

2.6 Food security and malnutrition

Food security can be adversely affected by disruptions in the food system, including spoilage, crop loss, the inability to replenish stock due to transport constraints, and the inability to store and process foods. This may lead to limited availability of safe and nutritious food and consumption of potentially unsafe food and/or inadequate food consumption, with low dietary diversity and poor nutrient quality. Vulnerable groups include children, particularly children under- 5 years, pregnant and lactating women and older people.

In 2007, the Vanuatu Multiple Indicator Cluster Survey showed that the

underweight prevalence for the under-5 age group was 15.9% and the stunting prevalence (the percentage of children under-5 who have low height for their age) was 20.1% [13]. During emergency situations such as Tropical Cyclone Pam, disease and death rates among children under-5 are usually higher than for any other age group; the younger the infant the higher the risk. Mortality risk is particularly high because of the combined impact of a greatly increased incidence of infectious diseases, diarrhoea and malnutrition.

Breastfeeding provides critical protection from infection in environments without safe drinking-water supply and sanitation. In 2007, the initiation of breastfeeding (within 1 hour of giving birth) was reported to be 71.9%, with the exclusive breastfeeding rate among infants 0-5 months of 39.7% [13]. During emergencies, it is even more critical to encourage and support mothers to initiate breastfeeding within one hour after the delivery, to exclusively breastfeed up to six months and for those with infants under 6 months who “mix feed”, to revert back to exclusive breastfeeding if possible [14].

In accordance with internationally accepted guidelines, donations of infant formula, bottles and teats, and other powdered or liquid milk and milk products should not be made. Experience with past emergencies in other countries have shown an excessive quantity of products, which are poorly targeted, endangering infants’ lives. Any procurement of breast-milk substitutes (BMS) should be based on careful needs assessment and in coordination with UNICEF.

Any distribution and use of BMS should be carefully monitored to ensure that only the designated infants receive the product.

Basic interventions to facilitate breastfeeding include prioritizing mothers with young children for shelter, food, security, and water and sanitation. This will enable mother-to-mother support, specific space for skilled breastfeeding counselling and support to maintain or re-establish lactation.

The risk of foodborne disease outbreaks also increases during disaster situations.

Food contamination may occur at any point of the food chain. Inadequate washing and cooking of food before consumption is often a prime cause of inadvertent contamination. Similarly, power outage, limited access to safe drinking-water and inappropriate cooking facilities increase the risk of food contamination. There may also be improvised large-scale preparation of cooked food and/or distribution of imported and locally produced food items. In this context it is important that appropriate food safety measures are implemented to ensure food safety during mass feeding operations as well as inspection of pre-packaged food distributed to affected populations.

2.7 Existing medical conditions and other health threats

2.7.1 Noncommunicable diseases

During emergencies and disasters access to adequate nutrition and medicine is an issue, making people with noncommunicable diseases (NCDs) more vulnerable and at risk in developing acute complications. NCDs account for an increasing proportion of the disease burden in Vanuatu, with the prevalence of diabetes mellitus and hypertension in the adult population at approximately 20% and 28%, respectively [15]. Older people, who already comprise 6%

of the population, may be particularly at risk of and vulnerable to treatment interruption, due to age-related barriers to access such as reduced mobility as well as co-morbidities [16]. This group of diseases places a substantial burden on health services and an impoverishing drain on families and communities. The priorities during the acute phase of this emergency are to minimize treatment interruptions. Identification of NCD patients on treatment; supply of essential medicines, equipment and follow up are essential.

2.7.2 Skin infections

Infestations, such as scabies and lice may occur and require treatment once they occur. These infections occur due to overcrowding and as a result of a lack of water and reduced hygiene.

2.7.3 Sexually transmitted infections including HIV

Similar to most Pacific island countries, Vanuatu’s HIV prevalence among 15-19 years old is still below 0.1%; with a cumulative total of 9 reported cases from 2002 to December 2012. Four patients are currently on antiretroviral therapy (ART) [17].

With regards to other sexually transmitted infections (STIs), from 2011 to 2014 21% of 14 037 men and women tested were infected with Chlamydia; 5.6%

of 13 655 people tested had gonorrhoea; and 4.3% of 9831 people tested had syphilis. During the same period, STI testing among pregnant women showed infection rates of 23.5% (n = 336/1431) with Chlamydia; no cases of gonorrhoea (while 2008 Second Generation Surveillance data revealed 3%); and 4.3%

(n = 19/1097) had syphilis [17].

During emergency situations, essential STI and HIV prevention, treatment, care and support services are usually disrupted. Further, existing gender inequalities make women and children, specifically girls, disproportionately more vulnerable to STI and HIV infection. This increased vulnerability is a consequence of mass displacement, separation from family members and/or loss of livelihood or lack of employment opportunities that may force women and girls to resort to sex work or be subjected to sexual exploitation.

People living with HIV (PLHIV) and other key populations at higher risk to HIV (sex workers and men having sex with men) may require specific measures to protect themselves from physical and sexual violence and discrimination.

The initial and essential response to the prevention and control of STI/HIV transmission includes: provision of prevention information on STI and HIV, including prevention of mother-to-child transmission (PMTCT); condom supplies and information on correct condom use; availability of STI and antiretroviral drugs to those who are already on treatment, for PMTCT and for post exposure prophylaxis (PEP); and ensuring treatment adherence among those receiving ART and STI treatment.

An expanded response can occur once the situation is better understood and additional human and financial resources have been identified to support implementation. Palliative and home-based care should also be quickly re- established.

2.7.4 Gender and violence against women

Violence against women is a major health issue; it is reported that women have a 60% lifetime risk of experiencing physical and/or sexual violence by an intimate partner. Of those women, 90% report severe violence, only 10% report moderate violence.

The same factors affecting vulnerability to STI and HIV, such as existing gender inequalities, place women and girls at higher risk of experiencing physical and sexual violence post-disaster. The initial and essential response includes ensuring safety and security in evacuation centres (e.g. good lighting and ensuring the privacy of women and girls) and putting in place mechanisms to collect evidence

and file criminal complaints, monitor and respond to physical and sexual violence. Clear steps on the health sector’s response to intimate partner physical and sexual violence should be known to all health-service providers [18].

2.7.5 Mental health and psychosocial support

Any major loss (e.g. death of family, property) and stressful situation (e.g. short- age of food, living in emergency shelter) will contribute to the increase of mental health conditions. Incidence of any mental disorders such as depression, anxiety, acute and post-traumatic stress, and psychosis is likely to increase, particularly in vulnerable populations such as women, children, older people, poor people, those from low-income households, displaced people.

2.7.6 Neonatal and reproductive health

The fertility rate in Vanuatu is 4.2 children born per woman [6]; this has not changed since the last population census in 2009, which was 4.1. The Demographic and Health Survey in 2013 found that the crude birth rate (number of births per 1000 population) was 32.5 per year (equating to approximately 8000 births in Vanuatu per year). In general, the birth rate is higher in rural areas than in urban areas. At the time of the survey, nearly 17% of teenage women, aged 15-19 years had started childbearing [6]. Although family planning methods were recorded as high as 47%, only 34% used modern methods.

The maternal mortality rate is reported to be 110 deaths per 100 000 live births [4], or approximately 6-7 deaths per year in Vanuatu.

The Vanuatu Demographic and Health Survey reported that in 2013, more than 76% of women received antenatal care from a skilled provider, although only approximately 50% of women received the WHO recommended four or more antenatal visits during an uncomplicated pregnancy [6]. Approximately 89% of births were delivered in a health facility and were attended by a skilled provider.

Emergency reproductive services are available at two referral hospitals, Northern District Hospital (Santo) and Vila Central Hospital (Efate) and at the Lenakel Provincial Hospital (Tanna). The Demographic and Health Survey reported that 12% of births in the previous five years were delivered by caesarean section.

The Vila Central Hospital reports a lower rate for 2014 of approximately 8%.

2.7.7 Environmental risks

Safe drinking-water supply for communities

• Information on interruptions/insufficient water supply in communities

• Water is unchlorinated or insufficiently chlorinated (no chlorine smell or taste in water at the tap) or is turbid (cloudy)

• Broken water pipes or uncovered or unsanitary water reservoirs.

Essential environmental health services at health-care facilities and hospitals

• Water supply

- Information on Interruptions/insufficient water supply at the facilities - Water is unchlorinated or insufficiently chlorinated (no chlorine smell

or taste in water at the tap) or is turbid (cloudy)

- Broken water pipes or uncovered or unsanitary water reservoirs

• Waste management

- Insufficient or inadequate waste disposal containers

- No separation of wastes (e.g. sharps – organics – paper and plastics) - Lack of fenced medical waste disposal area or medical wastes (needles,

dressings, drugs) observed in the facility and public spaces

• Infection control

- Lack of personal protective equipment (gloves, overalls, masks) for staff - Lack of soap or handwashing posters at handwashing points

• Vector control

- Breeding sites (stagnant pools, food waste) in and/or around the facility - Prepared food is unprotected from flies, other insects or rats

- Latest information on this is expected to be shared in the health cluster bulletins issued by the Ministry of Health and WHO Country Office.

2.7.8 Dead body management

Large numbers of dead bodies can be traumatic for viewers and require urgent identification and proper burial. It is important to convey to all parties that corpses do not represent a public health threat. For those involved in the collection and burial of bodies, standard precautions for infection prevention and control should be followed. In Vanuatu, following Cyclone Pam, early reports regarding the damage at the hospital indicate that the morgue is non-functional, meaning an alternative storage facility will need to be found.

2.7.9 Drugs procurement and supply chain management

In emergency situations, negotiated procurement may be used to purchase es- sential medicines to expedite the process by foregoing formal advertising and price competition. The selection of a contractor will be made to the best ad- vantage of the Government, price and other factors considered. The aim of the negotiated procurement during emergency situation is to ensure that shortages of essential drugs over the next few months are minimized. The country has to ensure that an effective supply chain management system is in place that will ensure that the amount of inventory to be held at various locations or health facilities is adequate.

2.7.10 Drug donations

Drug donations should be of maximum benefit and they must be based on the needs of the recipient country. During an emergency, the Ministry of Health informs donors of their needs, approves donations and coordinates receipt and distribution.

Guidelines for medicine donation should be adhered to, conforming to the following principles:

• Maximum benefit to recipient or country – donated drugs are very often not relevant to the emergency situation or are donated in wrong quantities.

Donations should benefit the recipient to the maximum possible extent and only essential medications that are part of the national essential drug list should be sent.

• Respect for wishes and authority of the recipient – donor agencies often ignore the existence of the local pharmaceutical industry and administrative procedures for receiving and distributing pharmaceuticals and medical equip- ment. Donations should comply with government and organizational policies.

• No double standards quality – many donated drugs arrive expired, unsorted or labelled in languages unknown by local professionals. If the quality of drug is not acceptable in the donor country and does not comply with its standards, it is also not acceptable for the recipient. The date of expiration of the drugs must be no less than one year from arrival in the recipient country.

• Effective communication between donor and recipient – donations are very often sent without prior consultation or consent of the recipient. Donations should be based on an expressed need.

In emergency situations, it is appropriate for a country to receive standardized Interagency Emergency Health Kits (IEHK). The IEHK provide a complete spectrum of essential drugs and medical supplies specifically adapted to emergency situations.

2.7.11 Storage and distribution

Even essential drugs can be troublesome for a recipient country when sent in excessive quantities. Local medical storage capacity is often insufficient to house an enormous influx of drugs. Very often additional storage space has to be rented at extra cost, or space in health-care facilities has to be re-purposed to accommodate donations.

A well-designed and well-managed distribution system should:

• Keep medicines in good condition throughout the distribution process;

• Ensure medical supplies are distributed directly to health institutions in affected areas;

• Minimize medicine losses caused by spoilage and expiry;

• Maintain accurate inventory records;

• Rationalize medicine storage points;

• Use available transportation resources as efficiently as effectively as possible;

• Reduce theft and fraud; and

• Incorporate a quality assurance programme.

2.7.12 Disposal of pharmaceuticals

As the potential consequences of the influx of non-essential, expired or poorly labelled drugs pose serious threat, most need to be disposed of. This adds further costs for local governments. Constraints in funding for disposal of waste pharmaceuticals necessitate cost-effective management. This can be achieved by sorting the material to minimize the need for expensive or complicated disposal methods.

It is not advisable to use damaged or expired products and should only be collected ready for disposal. All medicines, which need to be disposed, should be disposed of in line with the approved procedures and WHO Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and After Emergencies [19].

Disposal of drugs should be by high-temperature incineration (i.e. >1200ºC) if facilities are available in which the cost of disposing of hazardous waste in this way ranges from US$ 2000 to US$ 4000 per tonne.

In emergency situations, temporary burial of pharmaceutical and other wasted medical supplies is an appropriate option until properly functioning incinerators are in working order. Poorly-destroyed supplies in medium-temperature

incinerators are as great a hazard as landfills. If facing a huge amount of damaged, expired or damaged labelled medicines, both liquid and solids, do not dispose of them but keep them in a safe place until a reliable disposal system is in place. Ensure these are not disposed of into rivers or seas.

3. specific prioriTy inTervenTions for immeDiaTe implemenTaTion

Immediate priorities:

1.

Provision of safe and nutritious food, safe drinking-water, appropriate sanita- tion, shelter and other essential non-food items including fuel for cooking

2.

Trauma care for the wounded with tetanus prevention

3.

Provision of medicines and medical supplies

4.

Establishment of emergency primary- and secondary-care services for medical, surgical and obstetric emergencies

5.

Risk communication to the public

6.

Measles vaccination in high-risk areas

7.

Establishment of an early warning system for early detection and response to outbreaks

8.

Infection control in health-care units including safe blood transfusion, medical waste management and adequate water supply and sanitation

9.

Management of acute malnutrition including medical complications

10.

Continuity of treatment for chronic diseases, such as diabetes, hypertension and chronic infections such as TB and HIV.

Short-term priorities:

1.

Re-establishment of essential health care services (primary, referral and hospital care)

2.

Emergency mental health care and psychosocial support

3.

Waste management

4.

Vector control and provision of personal protection against vector-borne diseases.

Medium-term priorities:

1.

Post-surgical care and management of disabilities

2.

Routine immunization

3.

Health of victims who have migrated and potential returnees.

3.1 Water and sanitation

Provision of essential environmental health services to affected populations includes ensuring a minimal amount of clean water per day and safe disposal of excreta and wastes. Ensuring uninterrupted provision of safe drinking-water is the most important preventive measure in reducing the risk of outbreaks of water-related diseases.

• The Office of the United Nations High Commissioner for Refugees (UNHCR), WHO and the Sphere project recommend that each person be supplied with at least 15–20 litres of clean water per day.

• Chlorine is the most widely available, easily used and affordable drinking- water disinfectant. It is also highly effective against nearly all waterborne pathogens.

- For point-of-use or household water treatment, the most practical forms of free chlorine are liquid sodium hypochlorite, sodium calcium

hypochlorite and bleaching powder.

- The amount of chlorine needed depends mainly on the concentration of organic matter in the water and must be determined for each situation.

After 30 minutes, the residual concentration of active free chlorine in the water should be 0.5 mg/litre, which can be determined by using a simple field test kit.

• The provision of appropriate and sufficient water containers, cooking pots and fuel can reduce the risk of cholera and other diarrhoeal diseases by ensuring that water storage is protected and that food is properly cooked.

• The need for good hygiene should be emphasized to the public.

• Adequate sanitation facilities must be provided in the form of latrines or designated defecation areas.

3.2 Shelter and site planning

• Shelters for displaced or homeless people should be positioned with sufficient space between them and, in accordance with UNHCR and Sphere standards aimed at preventing diseases related to overcrowding.

• In shelter sites and during food distribution, attention and protection should be given to women, older people, unaccompanied minors and people with disabilities. Women should be included in planning and implementing shelter and food-distribution activities.

• Waste should be disposed in a pit, away from shelters and protected from rodents to reduce the exposure of the population to rodents, flies and other vectors of disease.

• Shelters should be equipped with long-lasting insecticidal nets (LLIN) for each sleeping space to prevent malaria transmission. Where housing conditions allow, indoor residual spraying (IRS) can be carried out if less than 85% IRS coverage of dwellings in the locality can be assured.

• Distribution of non-food items will be required, including blankets, water containers, cooking materials.

3.3 Prevention and management of malnutrition

• Infants should have skin-to-skin contact with their mothers within 30 seconds of birth, and breastfeeding should start when the baby shows feeding cues (usually within 90 minutes).

• Exclusive breastfeeding (with no food or liquid (including water) other than breast milk) should continue until 6 months of age. The aim should be to create and sustain an environment that encourages frequent breastfeeding for children up to 2 years of age.

• Donations of milk-powder supplies usually increase in emergency situations and contribute to a higher number of infants with diarrhoea and pneumonia.

These donations also exacerbate the low percentage of exclusively breastfed infants. For those unable to be breastfed, the following hierarchy of feeding should be followed: 1) expressed breast milk by mother; 2) breastfeeding from surrogate donors and donor expressed breast milk. The few infants who have no access to breast milk require an adequate supply of infant formula, safe drinking-water and clean utensils. For those few cases, health-care providers, including mothers, should be provided with guidance on the safe preparation of infant formula products.

• Many adults will have been or will now also be of borderline nutritional status, and given that diarrhoeal disease may further compromise this, attention must be paid to adequate and equitable distribution of food, and maintaining nutrition of breastfeeding mothers.

• Bacterial infections are very common in severely malnourished children on initial admission to hospital. Clinical management of severely malnourished patients, including fluid management, must be thorough, carefully monitored and supervised. Common problems encountered in severe malnutrition include hypothermia, hypoglycaemia, dehydration and electrolyte

disturbances. Phases and principles of management of severely malnourished children should be followed as outlined in WHO Guidelines on the

Management of Severe Acute Malnutrition in Infants and Children [20] [21].

• Populations dependent on food aid need to be given a food ration of safe and adequate quantity and quality (ensuring dietary diversity, cultural acceptability and covering all macro- and micronutrient needs). Infants from six months of age onwards need hygienically prepared, and easy-to-eat, digestible complementary foods that nutritionally complement breast milk.

Regular assessments of household access to adequate safe and nutritious food (including market prices) needs to be undertaken and emergency food aid needs to be adapted accordingly. Household access to facilities for the safe preparation of food should also be assessed on a regular basis and emergency supplies of necessary utensils and appropriate energy sources for cooking should be adapted accordingly.

• After the acute phase of the emergency, efforts will be needed to improve sustainable household access to food (e.g. seed distribution, land/crop management, income generating activities) and to institute appropriate child-feeding and caring practices, including diversifying diets and improved hygiene.

• Poor hand hygiene exacerbates the spread of diarrhoeal diseases, even in the presence of adequate nutrition.

3.4 Essential health services

Access to health services is critical for affected populations, including case-man- agement protocols, and medications and materials to treat likely high-burden conditions (trauma/wounds, communicable and noncommunicable diseases and emergency reproductive health services).

Standardized simple therapeutic procedures

Therapeutic procedures should be economical in terms of human and material resources. Health personnel and supplies should support these procedures.

First line medical treatment should be simplified and aim to save lives and pre- vent major secondary complications or problems. Use of standardized proce- dures, such as extensive debridement, delayed primary wound closure or use of splints instead of circular casts, can produce a marked decrease in mortality and long-term impairment.

Redistribution of patients between hospitals

While health-care facilities within a disaster area may be damaged and under pressure from mass casualties, those outside the area may be able to cope with a much larger workload or provide specialized medical services such as neurosurgery.

The effective and equitable delivery of emergency medical treatment requires a high level of coordination among national health services and partner agencies that allows functioning hospitals to operate as part of a referral network. A net- work of prehospital relief teams can coordinate referrals from the disaster area.

Essential medical and surgical care

Priority must be given to providing emergency medical and surgical care to people with traumatic injuries, which account for many of the health-care needs among those requiring medical attention in the immediate aftermath of the disaster. Falling structures cause crush injuries, fractures, and a variety of wounds. Appropriate medical and surgical treatment of these injuries is vital to improving survival, minimizing future functional impairment and disability and ensuring as full a return as possible to community life. To prevent avoidable death and disability, field health personnel dealing with injured survivors should observe basic principles of trauma care:

• Patients should be categorized by the severity of their injuries and treatment prioritized in terms of available resources and chances for survival. The under- lying principle of triage is allocation of resources to ensure the greatest health benefit for the greatest number.

• Open wounds must be considered as contaminated and should not be closed.

Debridement of dead tissue is essential which, depending on the size of the wound, may necessitate a surgical procedure undertaken in appropriate (e.g. sterile) conditions. Any associated involvement of organs, neurovascular structures or open fractures will also necessitate appropriate surgical care.

• After debridement and removal of dead tissue and debris, wounds should be dressed with sterile dressings and the patient scheduled for delayed primary closure.

• Patients with open wounds should receive tetanus prophylaxis (vaccine and/

or immune globulin depending on vaccination history). If the vaccination history is unknown, both should be given. Antibiotic prophylaxis or treatment will likely be indicated.

• Wherever possible, search and rescue workers should be equipped with basic protective gear such as footwear and leather gloves to avoid puncture wounds and exposure to diseases such as leptospirosis.

• HIV post-exposure prophylaxis kits should be available to health-care workers, rescue and safety workers in case of accidental exposure to contaminated blood and body fluids.

Reproductive health services

Access to comprehensive emergency reproductive health services and implemen- tation of the Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations:

• A lead agency for reproductive health should be identified along with a repro- ductive-health officer to ensure coordination, communication, and collabora- tion in MISP implementation.

• Measures should be put in place to prevent sexual violence and to respond to the needs of victims of sexual violence.

• HIV transmission should be prevented.

• Excess maternal and newborn morbidity and mortality should be prevented.

• Plans should be put in place for the transition to comprehensive reproductive health services.

Communicable diseases

• Heightened community awareness of the need for early treatment and rein- forcement of proper case management are important in reducing the impact of communicable diseases. The use of standard treatment protocols in health- care facilities with agreed-upon first-line drugs is crucial to ensure effective diagnosis and treatment for ARI, the main epidemic-prone diseases (including

dysentery, typhoid, dengue and DHF, leptospirosis, measles, malaria, and meningitis) and STIs.

• Standard infection control practices should be in place in accordance with national protocols.

• Malaria treatment:

- Uncomplicated-unconfirmed: Artemether-Lumefantrine - Uncomplicated laboratory-confirmed P. falciparum infection:

Artemeter-lumefantrine + Primaquine (single dose) - Severe malaria: Quinine + Tetracycline

- Uncomplicated P. vivax infection: Chloroquine + Primaquine (14 days).

• Tetanus: Appropriate management of injured survivors should be implemented as soon as possible to minimize future disability and to prevent avoidable death following disasters.

• Tuberculosis: maintenance of routine supply of TB drugs is essential.

Noncommunicable diseases

• Continuation of treatment for people on medications for hypertension, diabetes, cancer, chronic respiratory disease and kidney disease. Where feasible, decentralization of care will increase treatment coverage given the restrictions on movement.

• People who are in shelters can be checked for a history of diabetes and high blood pressure. Management should include measuring blood pressure and blood glucose and continuing provision of drugs. Shelters and centres accommodating people should be made smoke free. Penicillin prophylaxis for rheumatic heart disease should be maintained where feasible.

• Mental health and psychosocial support should be considered in the provision of general health care. Psychological first aid should be given to distressed people who have been exposed to a crisis event. Psychological first aid involves:

- providing practical care and support, which does not intrude;

- assessing needs and concerns;

- helping people to address basic needs;

- listening to people, but not pressuring them to talk;

- comforting people and helping them to feel calm;

- helping people to connect to information, services and social supports; and - protecting people from further harm.

• Continued access to care should be assured for people with severe mental disorders. The mental health and wellbeing of the health-care workers also needs attention [22].

3.5 Early warning and response network

The Early Warning and Response Network (EWARN) aims to detect disease out- breaks. Rapid detection of cases of epidemic-prone diseases is essential to ensure rapid control. The EWARN is used to inform risk assessments of any disease incident, allowing resources to be allocated proportionally and appropriately.

To be effective, EWARN needs to:

• focus on the communicable diseases most likely to occur in the disaster- affected population;

• be simple to use, uniform in style and include standard case definitions and reporting forms (see Annex 3 for EWARN diseases/syndromes under surveil- lance with case definitions;

• ensure detailed outbreak response plans/standard operating procedures, including for identification and training of rapid response teams and ade- quate stockpiles of supplies (such as oral rehydration solutions, Zinc tablets, ciprofloxacin for Shigella, amoxicillin and vitamin A for measles, Artemether- Lumefanthrin for malaria, and intravenous (IV) solutions); and

• reinforce laboratory capacity: (i) to promptly test for the main communicable disease threats; and (ii) to assure shipping supplies and protocols are in place to facilitate international shipment for pathogen confirmation.

3.6 Immunization

• In evacuation centres or other crowded settings, vaccination using a measles containing vaccine, together with vitamin A, should be an immediate

priority health intervention (at least 20% of children are vitamin A deficient).

Children aged 6-59 months (susceptibility profile based on prior coverage through routine and supplementary immunization activities and immunity gaps identified through prior measles surveillance) should receive the measles vaccine, regardless of previous vaccination or disease history. Infants 6-11 months should receive 100 000 international unit (IU) of vitamin A and children 12-59 months should receive 200 000 IU of vitamin A.

Re-vaccination of infants who received their first dose of measles vaccine at 6-8 months of age is recommended once they reach 9 months; the minimum interval between doses is one month.

• A single suspect measles case is sufficient to prompt the immediate imple- mentation of activities to control measles.

• Mass tetanus vaccination programmes to prevent disease are not indicated.

• Wounds or lacerations may occur from objects submerged in floodwaters.

Tetanus vaccine (TT or Td) and tetanus immune globulin (TIG) is indicated for

those with open wounds who have never been vaccinated. TIG is indicated for previously vaccinated people who sustain wounds (e.g. clean-up workers), depending on their tetanus immunization history.

• Mass vaccination against influenza is not indicated.

• When the situation stabilizes, vaccinations routinely offered by the national immunization programme should be made available.

• Hepatitis A vaccine is not recommended to prevent outbreaks in the affected population.

• Typhoid vaccination, in conjunction with other preventive measures, may be useful to control typhoid outbreaks, depending on local circumstances.

• Vaccination efforts should always be supplemented by health education and improved sanitation. Special attention should be paid to the safe manage- ment and disposal of waste from immunization activities to prevent the trans- mission of bloodborne pathogens.

3.7 Vector control and personal protection

• Long-lasting insecticidal nets should be made universally available, with priority given to pregnant women and children under-5 years.

• Refuse must be collected and appropriately disposed of to discourage rodent and vector breeding.

• Water-storage containers should be closed or covered with mosquito- proof lids.

• Space spraying and larviciding will control fly and mosquito populations, and may be desirable around displacement centres.