Scripps Clinic/Scripps Green Hospital Grand Rounds Wednesday, Sept. 9, 2009 Kristian R Olson MD, MPH, DTM&H September 9, 2009 [email protected]Clinician Educator Unit, MGH Dept of Medicine CIMIT, Global Health Initiative Program Leader Harvard Humanitarian Initiative When Zebras Really Are Zebras: Global Health in Crises • The presenter has no potential conflicts of interest to disclose. When Zebras are Zebras: Global Health in Crises CONFLICT OF INTEREST STATEMENT Objectives: 1) To understand the definition and mortality cycle of Complex Humanitarian Emergencies (CHE’s) 2) To describe the four leading causes of death worldwide of children under five 3) To describe priorities and resources useful in these setting Meanwhile, during this hour… 4) More than 1200 children under the age of 5 will die. 5) More than 60 women will die in and around childbirth • 6.8 billion People* • More than one half live on <$2 per day** •Life expectancy in the 38 poorest countries is 48 yrs*** *US Census Bureau, World Population Clock, 9/2/09 **Population Reference Bureau, prb.org *** Skolnik 2007 www.worldmapper.org Map 228 Tuberculosis Territory size is proportional to worldwide cases of… Scripps Conference Services & CME www.scripps.org/conferenceservices 1
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Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009
Kristian R Olson MD, MPH, DTM&HSeptember 9, 2009
[email protected] Educator Unit, MGH Dept of MedicineCIMIT, Global Health Initiative Program Leader
Harvard Humanitarian Initiative
When Zebras Really Are Zebras:Global Health in Crises
• The presenter has no potential conflicts of interest to disclose.
When Zebras are Zebras:Global Health in Crises
CONFLICT OF INTEREST STATEMENT
Objectives:
1) To understand the definition and mortality cycle of Complex Humanitarian Emergencies (CHE’s)
2) To describe the four leading causes of death worldwide of children under five
3) To describe priorities and resources useful in these setting
Meanwhile, during this hour…
4) More than 1200 children under the age of 5 will die.
5) More than 60 women will die in and around childbirth
• 6.8 billion People*
• More than one half live on <$2 per day**
•Life expectancy in the 38 poorest countries is 48 yrs****US Census Bureau, World Population Clock, 9/2/09**Population Reference Bureau, prb.org*** Skolnik 2007 www.worldmapper.org Map 228
Tuberculosis
Territory size is proportional to worldwide cases of…
Situations in which mortality among the civilian population Situations in which mortality among the civilian population substantially increases above baseline, either as a result of thsubstantially increases above baseline, either as a result of the e direct effects of war or indirectly through increased prevalencedirect effects of war or indirectly through increased prevalenceof malnutrition and/or transmission of communicable diseases, of malnutrition and/or transmission of communicable diseases, particularly if the latter result from deliberate political and particularly if the latter result from deliberate political and military policies and strategies*military policies and strategies*
OrOr(Quantitative Definition) Crude Mortality Rate > 1 death per (Quantitative Definition) Crude Mortality Rate > 1 death per 10,000 per day**10,000 per day**……later qualified as a doubling of the baseline later qualified as a doubling of the baseline CMR where known.**CMR where known.**
2)2) Disaster:Disaster: ““an occurrence, either natural or man made, that an occurrence, either natural or man made, that causes human suffering and creates human needs that victims causes human suffering and creates human needs that victims cannot alleviate without assistance.cannot alleviate without assistance.””******
*Salama et al. 2004
** Toole and Waldman. 1990
***Skolnik. 2008
The Disease of DisplacementThe Disease of Displacement
1)1) 42 million Refugees and 42 million Refugees and IDPsIDPsworldwide.*worldwide.*
2)2) Once Once ““afflictedafflicted””, mortality , mortality increases 2 to 60 times above increases 2 to 60 times above baseline.baseline.
*www.unhcr.org Global Trends, 2008
What kills crowded, displaced people?What kills crowded, displaced people?
•• What kills vulnerable (U5M) in lowWhat kills vulnerable (U5M) in low--income countries in general?income countries in general?
•• Under 5 Mortality Rate (U5MR) Under 5 Mortality Rate (U5MR) -- Deaths per 10000 Children<5 per dayDeaths per 10000 Children<5 per day
(1.14 in Africa, 0.04 Industrialized Nations)(1.14 in Africa, 0.04 Industrialized Nations)
•• Neonatal Mortality Rate (NMR)Neonatal Mortality Rate (NMR)--Deaths per 1000 live births in the 1Deaths per 1000 live births in the 1stst 28 28 days of lifedays of life
•• Case Fatality Rate (CFR)Case Fatality Rate (CFR)-- % of people dying of all people with a % of people dying of all people with a diseasedisease
Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009
Vitamin A Campaign-Deficiency affects 40% of the world’s children and leads to approximately one million deaths per year*
* Skolnik, 2008
MeaslesMeasles
Can account for 10% of child deathsCan account for 10% of child deaths
Exacerbated by Vitamin A DeficiencyExacerbated by Vitamin A Deficiency
Case fatality rates: 2 to 33%Case fatality rates: 2 to 33%
Vaccination Priority 6moVaccination Priority 6mo--59mo (up to 15 years when 59mo (up to 15 years when resources)resources)
Repeat as soon after child reaches 9 mo as possible (after Repeat as soon after child reaches 9 mo as possible (after interval of 30 days)interval of 30 days)
Case Case DefDef’’nn: Generalized rash>3 days AND Fever AND : Generalized rash>3 days AND Fever AND cough, runny nose, or Red Eyescough, runny nose, or Red Eyes
Diarrheal Disease:
•Oral Rehydrations Solution (ORS)
•Integrated Management of Childhood Illness (IMCI)
Oral Rehydrations Solution (ORS)
-Integrated Management of Childhood Illness (IMCI)
Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009
Integrated Management of Integrated Management of Childhood Illness (IMCI)Childhood Illness (IMCI)
Includes three main Includes three main components:components:
1)1) Improving case management Improving case management skills of healthskills of health--care staff care staff
2)2) Improving overall health Improving overall health systemssystems
3)3) Improving family and Improving family and community health practicescommunity health practices
DiarrheaDiarrhea
ShigellaShigella = principal causes of epidemics= principal causes of epidemics•• Low infective dose (10Low infective dose (10--100 Organisms while cholera is counted in 100 Organisms while cholera is counted in
the millions the millions •• Sphere Standard: CFR<1%Sphere Standard: CFR<1%•• Case Definition: Any case of diarrhea with visible blood in stooCase Definition: Any case of diarrhea with visible blood in stoolsls•• Soap: great evidenceSoap: great evidence
Cholera = Acute Water DiarrheaCholera = Acute Water Diarrhea•• VibrioVibrio choleraecholerae O1 (classical and El Tor) and 1:139O1 (classical and El Tor) and 1:139•• Suspect an outbreak when: pts >5 develop severe dehydration or Suspect an outbreak when: pts >5 develop severe dehydration or
dies from acute watery diarrheadies from acute watery diarrhea•• Any adult death due to dehydration is highly suspectAny adult death due to dehydration is highly suspect•• Attack Rate Typically 1Attack Rate Typically 1--2% in 2% in ““open settingsopen settings”” but can be 5% in but can be 5% in
campscamps
•• MSF Case Definition: any patient developing acute water diarrheaMSF Case Definition: any patient developing acute water diarrhea(usually with vomiting), resulting in severe dehydration(usually with vomiting), resulting in severe dehydration
•• 8080--90% of cases can be treated effectively with ORS90% of cases can be treated effectively with ORS
•• EgEg. Preparation: 50,000 people might expect 2500 (5%) cases and . Preparation: 50,000 people might expect 2500 (5%) cases and up to 1875 (75%) requiring up to 1875 (75%) requiring IVfIVf
15 L per person per day and no fecal coliforms VIP Latrine being made: Ventilation Improved Pits
Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009
3 year old Burmese Refugee dying of Cerebral Malaria
MalariaMalariaPREVENTION:PREVENTION:
Individual Prevention (Individual Prevention (bednetsbednets)) Community Prevention (spraying, water Community Prevention (spraying, water
drainage)drainage) Consider prophylaxis for pregnant womenConsider prophylaxis for pregnant women Surveillance (No clear threshold for an epidemic)Surveillance (No clear threshold for an epidemic)
TREATMENT:TREATMENT: Strive for laboratory Strive for laboratory dxdx over case over case defdef’’nn ASAP.ASAP.
•• egeg Case Case DefDef’’nn: T>38.5 and absence of another infection: T>38.5 and absence of another infection
Learn local resistanceLearn local resistance Base treatments on WHO/MOH standards where Base treatments on WHO/MOH standards where
Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009
MeningitisMeningitis
Large Outbreaks exclusively due to Large Outbreaks exclusively due to NeisseriaNeisseriameningitidismeningitidis
Traditional Periodic outbreaks in subTraditional Periodic outbreaks in sub--Saharan Saharan ““Meningitis BeltMeningitis Belt”” is changingis changing•• (Q 8(Q 8--10 years and stop at the onset of the rainy season)10 years and stop at the onset of the rainy season)
A and C A and C SerogroupsSerogroups = principal causes of outbreaks = principal causes of outbreaks •• (W(W--135 more recently)135 more recently)
Routine vaccination during nonRoutine vaccination during non--epidemic periods not epidemic periods not (yet) cost(yet) cost--effective. (Perhaps change with effective. (Perhaps change with MenactraMenactra?)?)
Attack rate varies widely (10Attack rate varies widely (10--1000 per 100,000)1000 per 100,000) Case Fatality Rates: 70% without Rx, 5Case Fatality Rates: 70% without Rx, 5--15% with Rx15% with Rx WHO no longer recommends chemoprophylaxis for WHO no longer recommends chemoprophylaxis for
contactscontacts
Case Definition for Bacterial MeningitisCase Definition for Bacterial MeningitisSuspected CaseSuspected Case <12 mo:<12 mo:
>12mo to adults: >12mo to adults: --Sudden Onset Sudden Onset FeverFeverANDAND--Stiff NeckStiff NeckAND/ORAND/OR--PetechiaePetechiae or or purpurapurpura
Probable CaseProbable Case --Suspected CaseSuspected CaseANDAND--Turbid CSFTurbid CSFOROR--Ongoing OutbreakOngoing Outbreak
Confirmed CaseConfirmed Case --Suspected or Probable CaseSuspected or Probable CaseANDAND--Either positive CSF AgEither positive CSF AgOROR--Positive CulturePositive Culture
*Source: Refugee Health MSF 1997
Meningitis OutbreakMeningitis Outbreak
No universal epidemic threshold:No universal epidemic threshold:
•• PopPop’’nn <30,000:<30,000: 2 consecutive doubling of cases over three weeks2 consecutive doubling of cases over three weeks
•• Next to declared epidemic or urban area:Next to declared epidemic or urban area: 5/100,000/week5/100,000/week
Once Outbreak Declared:Once Outbreak Declared:
•• Mass Immunization CampaignMass Immunization Campaign
•• Mass Campaign is not recommended if already Mass Campaign is not recommended if already ““too latetoo late”” and and decreasing (consider when rains come)decreasing (consider when rains come)
•• Consider Immunizing only 6mo to 30 yrs if limited suppliesConsider Immunizing only 6mo to 30 yrs if limited supplies
•• Prompt ID and Treatment (Single IM Oily Prompt ID and Treatment (Single IM Oily ChloramphenicolChloramphenicol (3g (3g single dose or 100mg/kg); IV single dose or 100mg/kg); IV CeftriaxoneCeftriaxone))
Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 9, 2009
EvaluationEvaluation
Intervention
Control
1) Focus Group (adapted from World Health Organization (WHO) Verbal Autopsy for Infant Death)
• 5-7 people in each group; 6 groups in intervention and 2 groups in control
2) Survey with 44 questions
• 350 Total (244 in intervention; 106 in control)
3) Ventilation Device Assessment
• 211 device evaluations
Preliminary Findings Continued
Device EvaluationsIntervention Control Total Total
244 106 350 211
Intervention Control119 (out of 1840 births) 42 (out of 1268 births)
6.5% resuscitated 3.3% resuscitated
Capture:
Midwives Confident in Treating AsphyxiaIntervention Control
Outcomes:
Births3126
Of Babies Given Breathe Alive After 1 Day
Midwives Surveyed Total Births Assisted:
201 out of 244 35 out of 10682% confidant 33% confidant
* Olson, KR: Data not yet published.
Healthy 57 Day Old Infant Post‐Resuscitation
Top 10 Health PrioritiesTop 10 Health Priorities
AssessmentAssessment Measles immunizationMeasles immunization Water and SanitationWater and Sanitation Food and NutritionFood and Nutrition Shelter and site planningShelter and site planning Health CareHealth Care Control of EpidemicsControl of Epidemics Public Health SurveillancePublic Health Surveillance Human Resources and TrainingHuman Resources and Training CoordinationCoordination
Field References• MSF Clinical Guidelines; 7th Revised Ed. 2007
• Oxford Handbook of Tropical Medicine; M Eddleston and S Pierini; Oxford University Press, 2nd Ed. 2004
• Refugee Health: An approach to emergency situations; MSF; MacMillan Education; 1997.
• The Sphere Project Handbook: 2004 Ed
• Topics In International Health; CD ROM Series (www.talcuk.org)
• WHO: Communicable disease control in emergencies(www.who.int)
References:References:1)1) CoglanCoglan, B et al. Mortality in the Democratic Republic of Congo: a nati, B et al. Mortality in the Democratic Republic of Congo: a nationwide onwide
2)2) SalamaSalama P et al. Lessons learned from complex emergencies over past decP et al. Lessons learned from complex emergencies over past decade. ade. Lancet 2004; 364: 1801Lancet 2004; 364: 1801--13.13.
3)3) SkolnikSkolnik R. R. Essentials of Global Health.Essentials of Global Health. Boston: Jones and Bartlett; 2008.Boston: Jones and Bartlett; 2008.
4)4) Toole MJ, Waldman R. Prevention of excess mortality in refugee aToole MJ, Waldman R. Prevention of excess mortality in refugee and nd displaced populations in developing countries. JAMA 1990; 263: 3displaced populations in developing countries. JAMA 1990; 263: 3296296--302.302.
5) 5) Spiegel P et al. Health Spiegel P et al. Health programmesprogrammes and and policeispoliceis associated with decreased associated with decreased mortality in displaced persons in postmortality in displaced persons in post--emergency phase camps: a emergency phase camps: a retrospective study. Lancet 2002; 360: 1927retrospective study. Lancet 2002; 360: 1927--3434
6)6) 1951 Convention Relating to the Status of Refugees. Available at1951 Convention Relating to the Status of Refugees. Available athttp://http://www.ohchr.org/english/law/refugees.htmwww.ohchr.org/english/law/refugees.htm. Accessed October 21, . Accessed October 21, 2007.2007.