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PubMed1995

Why treatment centres failed to prevent cholera deaths among Rwandan refugees in Goma, Zaire.

In July, 1994, in one of the worst cholera outbreaks in recent times, an estimated 12,000 Rwandan refugees died in Goma in eastern Zaire. The Vibrio cholerae strains were resistant to tetracycline and doxycycline, the commonly used drugs for cholera treatment. Despite the efforts of international organisations, which provided medical relief by establishing treatment centres in Goma, mortality from the disease was much higher than expected. In the area of Muganga camp, which had the largest concentration of refugees and where most of the medical aid organisations were active, the highest reported case-fatality ratio for a single day was 48%. The slow rate of rehydration, inadequate use of oral rehydration therapy, use of inappropriate intravenous fluids, and inadequate experience of health workers in management of severe cholera are thought to be some of the factors associated with the failure to prevent so many deaths during the epidemic. In one of the temporary treatment centres with the worst case-fatality record, our team showed that improvement of these factors could increase the odds of survival of cholera patients even in a disaster setting.

Ambulatory Care Facilities↗
PubMed1996

Targeting the vulnerable in emergency situations: who is vulnerable?

BACKGROUND: Emergencies such as wars and natural disasters increase the vulnerability of affected populations and expose these populations to risks such as disease, violence, and hunger. Emergency public health interventions aim to mitigate these effects by providing basic minimum requirements, reducing vulnerability, and reducing exposure to risk. Targeted services are generally aimed at children under 5. Mortality rates among young children are higher than the crude mortality rate (CMR) among the whole population in emergency settings, so attention is focused on this age group. However, even under normal conditions mortality is higher in young children. This analysis compared the relative risk of death for young children with that for older children and adults under normal conditions and in emergency settings. METHODS: Mortality data from refugee camps set up in response to three different emergencies were examined. Baseline mortality rates in the refugees' countries of origin were calculated from published data. Relative risks between normal and emergency conditions were calculated and compared. FINDINGS: Mortality rates were higher among children under 5 than among older children and adults both under normal circumstances and in the emergency setting in camps in Tanzania, Uganda, and Zaire. However, the relative risk for under-5 versus over-5 mortality was smaller under emergency conditions than under normal circumstances. Thus, children over 5 and adults are disproportionately more affected by exposure to emergency risks than are younger children. INTERPRETATION: If the objective of intervention, to reduce mortality, is to be achieved, the population over the age of 5 cannot be ignored. Emergency public health needs to develop specific tools to investigate risk in other age groups (as well as children under 5), to identify causes, and to design programmes to address such needs.

Adolescent↗
PubMed1997

Global assessment of El Niño's disaster burden.

BACKGROUND: Natural disasters have profound effects on health and require medical intervention as part of relief operations. The world's populations are becoming increasingly vulnerable to extreme weather events, which are responsible for most natural disasters. The El Niño Southern Oscillation (ENSO) is the most prominent global climate system associated with year-to-year weather variability and extreme events. We have estimated the burden on human health of natural disasters associated with ENSO. METHODS: We used time-series regression analysis of the relation between El Niño years and the annual rates of persons affected by natural disasters per 1000 population during 1964-93, globally and also by region and disaster type. Correlations between sea-surface temperature (SST) anomalies (index of ENSO) and the rates of persons affected by natural disasters per 1000 population were determined globally, by region and by disaster type. FINDINGS: The rate of persons affected by natural disasters worldwide is strongly associated with ENSO; rates are greater during the first El Niño year (p = 0.05) and the following year (p = 0.01) than in the pre-Niño year. The correlation between rates of persons affected by natural disasters and SST anomalies in the Eastern Pacific (a key ENSO indicator) is highest in the last quarter of the previous year (r = 0.53, p < 0.01). These associations are strongest in South Asia, the region where more than 50% of all disaster victims live. Worldwide, rates of persons affected by drought/famine (half of all disaster victims) and by volcanic eruptions show significant associations with the ENSO cycle, being highest in the post-Niño year and El Niño year, respectively, and being significantly associated with SST anomalies. INTERPRETATION: The strong relation between ENSO and populations affected by natural disasters can be described as a "natural disaster cycle". Determining the phase in this cycle, using SST from the Eastern Equatorial Pacific, could benefit disaster preparedness on a global scale, for South Asia in particular, and for all populations affected by drought/famine and volcanic disasters.

Disaster Planning↗
PubMed1998

Sales of food aid as sign of distress, not excess.

In 1996 the sale and export of food aid from refugee camps near Uvira, Zaire, prompted a reduction in donated rations. However, research has revealed that the sales did not reflect an excess of food in the camps. They were provoked by the absence of important components of the food basket, by cultural aversion to the staple (maize) and oil provided, by difficulties in food preparation, and by the refugees' limited ability to diversify their diet and cover pressing non-food needs. Food sales improved the micronutrient content of diets but at the expense of energy lost from an already energy-deficient diet. At most 23% of the refugee households were eating sufficient and adequate diets; the poorest one-fifth of households were twice as likely to sell or exchange food as were other households and their diets were the worst. These findings demonstrate the perils of the gap between policy and practice in food-aid distribution.

Burundi↗
PubMed1998

Effects of a refugee-assistance programme on host population in Guinea as measured by obstetric interventions.

BACKGROUND: Since 1990, 500000 people have fled from Liberia and Sierra Leone to Guinea, west Africa, where the government allowed them to settle freely, and provided medical assistance. We assessed whether the host population gained better access to hospital care during 1988-96. METHODS: In Guéckédou prefecture, we used data on major obstetric interventions performed in the district hospital between January, 1988, and August, 1996, and estimated the expected number of births to calculate the rate of major obstetric interventions for the host population. We calculated rates for 1988-90, 1991-93, and 1994-96 for three rural areas with different numbers of refugees. FINDINGS: Rates of major obstetric interventions for the host population increased from 0.03% (95% CI 0-0.09) to 1.06% (0.74-1.38) in the area with high numbers of refugees, from 0.34% (0.22-0.45) to 0.92% (0.74-1.11) in the area with medium numbers, and from 0.07% (0-0.17) to 0.27% (0.08-0.46) in the area with low numbers. The rate ratio over time was 4.35 (2.64-7.15), 1.70 (1.40-2.07), and 1.94 (0.97-3.87) for these areas, respectively. The rates of major obstetric interventions increased significantly more in the area with high numbers of refugees than in the other two areas. INTERPRETATION: In areas with high numbers of refugees, the refugee-assistance programme improved the health system and transport infrastructure. The presence of refugees also led to economic changes and a "refugee-induced demand". The non-directive refugee policy in Guinea made such changes possible and may be a cost-effective alternative to camps.

Adult↗
PubMed2001

Selection of clinical, patient-reported, and economic end points in acute exacerbation of chronic bronchitis.

BACKGROUND: Acute exacerbation of chronic bronchitis (AECB) places tremendous burden on patients, providers, employers, and health care systems. OBJECTIVE: The purpose of this paper is to (1) review the clinical, patient-reported, and economic measures used to evaluate disease burden and treatment effectiveness in AECB in clinical trials and (2) propose a guide for selecting study end points in AECB that will help capture all the relevant disease outcomes. METHODS: Two literature searches of the PubMed database were conducted to identify studies of clinical trials in bronchitis and evaluate the clinical, patient-reported, and economic end points used in these studies. RESULTS: Previous studies have focused primarily on clinician-assessed outcomes, which do not capture the full impact of AECB on patients' lives. Reporting mechanisms for most end points have been inconsistent, limiting the ability to compare information or interpret differences. Previous studies have given limited attention to patient-reported outcomes and the economic implications of AECB. Patient-reported outcomes such as speed of symptom relief and work productivity are important parameters for assessing treatment effectiveness and provide practical information for treatment evaluation. CONCLUSIONS: Additional research is needed to develop, examine, and validate patient-reported outcomes and the indirect costs of AECB. Measuring the relevant clinical, economic, and patient-reported outcomes in AECB patients using standardized methods may lead to a clearer understanding of the disease burden and the role, effectiveness, and cost-effectiveness of antibiotic treatment.

Acute Disease↗