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Communicable Disease Control During Major Emergencies.

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VOL: 101, ISSUE: 06, PAGE NO: 30

Sue Campbell, BSc, RGN, MPH, is a freelance health writer.

On 26 December 2004 a violent rupture of the sea floor along a fault close to the Indonesian island of Sumatra shunted the sea floor vertically by about 10 metres. This generated a massive sea surge or tsunami. It is estimated that 159,665 people were killed, 24,159 were missing and up to two million were displaced by the tsunami (USAID, 2005).

On 26 December 2004 a violent rupture of the sea floor along a fault close to the Indonesian island of Sumatra shunted the sea floor vertically by about 10 metres. This generated a massive sea surge or tsunami. It is estimated that 159,665 people were killed, 24,159 were missing and up to two million were displaced by the tsunami (USAID, 2005).

From the point of view of disease, the five most common causes of death in emergencies are diarrhoea, acute respiratory infection, measles, malnutrition and, in endemic zones, malaria. Although not a communicable disease directly related to environmental health conditions, malnutrition is greatly exacerbated by communicable disease (Wisner and Adams, 2002).

Public health prevention measures
Prevention includes: good shelter and site planning; provision of basic clinical services; clean water and proper sanitation; mass vaccination against specific diseases; a regular food supply; and control of disease vectors (Connolly 2005). All interventions must include the participation of the affected community. Table 1 lists the main disease groups targeted by such interventions.

Site selection must be well planned to avoid risk factors for disease transmission, such as overcrowding, poor hygiene, vector breeding sites and lack of shelter. Critical factors include water, transport, fertile soil, and - for security reasons - sufficient distance from national borders or frontlines (Connolly, 2005).

Affected populations need immediate access to water. The first objective is to provide sufficient water - quality can be addressed later (Connolly, 2005).

The aim of a sanitation programme is to prevent disease transmission. Development of latrines and methods of waste disposal are vital (Connolly, 2005).

A vector-borne disease is one in which the pathogenic micro-organism is transmitted from an infected individual to another individual, sometimes with animals serving as intermediary hosts. The main methods of vector control are: personal protection; environmental control; shelter and food store sanitation; and chemical control, such as residual or space spraying, insecticide-treated traps, selective larviciding and the use of rodenticides.

It is vital to ensure the nutritional needs of an emergency-affected population are met. Failure to do so may result in protein-energy malnutrition and micronutrient deficiencies such as iron-deficiency anaemia, pellagra, scurvy and vitamin A deficiency.

The major vaccines used in emergencies are measles, meningococcal meningitis and yellow fever (Connolly, 2005). Mass measles immunisation is a priority in emergencies, regardless of whether or not a single case of measles has been reported (Wisner and Adams, 2002).

Areas where health education and community participation can be beneficial include improving recognition of severe disease by the population, and promotion of hygiene, safe water use, sanitation and community mobilisation for vaccination campaigns (Connolly, 2005).

Identification and case management
Diarrhoeal diseases

The key diarrhoeal diseases in an emergency are bacillary dysentery (shigellosis) and cholera. Medical staff should be alerted when one of the following observations are made (MSF, 1997):

- Adult deaths due to diarrhoea;

- Increased adult cases of diarrhoea and dehydration;

- Significant increase of cases with bloody diarrhoea;

- A rise in the case fatality rate.

Bacillary dysentery is an acute bacterial disease involving the large and small intestine. Transmission is by faecal-oral route from person-to-person and through contaminated food and water. It is highly contagious (10-100 bacteria has caused disease in volunteers).

Clinical features of bacillary dysentry:

- Bloody diarrhoea often associated with fever, abdominal cramps and rectal pain;

- Incubation period usually 1-3 days;

- Complications include sepsis, rectal prolapse, haemolytic uraemic syndrome, seizures.

Case management includes rehydration of the patient. Seriously ill or severely malnourished patients should be referred to hospital immediately. Antibiotics are essential and should be decided on the basis of susceptibility testing of the organisms grown from affected patients. The drug must be effective against at least 80 per cent of local Sd1 strains. Clinical improvement should be noted within 48 hours if using an effective antimicrobial.

Cholera is usually characterised by acute, profuse watery diarrhoea of one or a few days duration. It can be a rapidly fatal infectious disease. Within 3-4 hours of onset of symptoms, a healthy person may become hypotensive and die within 6-8 hours. More commonly, fatal cases progress to shock within 6-12 hours with death following in 18 hours to several days.

Clinical features of cholera:

- Abrupt onset of copious watery diarrhoea (rice water stool) with or without vomiting;

- Severe dehydration.

Dehydration is treated with oral rehydration salts. In severe cases, intravenous rehydration treatment is required. Antibiotics are not recommended in the treatment of mild and moderate cholera or for mass prophylaxis. However, in severe cases, antibiotics may be considered for reducing the duration of symptoms. Vaccination should be undertaken only in concert with other World Health Organization prevention measures such as education, safe water and sanitation (WHO, 2005).

Acute respiratory infections (ARIs)

ARIs can be characterised as acute, moderate or severe. They can also be divided into upper (for example common cold, otitis media) or lower (for example pneumonia, bronchitis). Almost all ARI deaths are due to lower ARIs. Case management depends on the early detection and treatment of pneumonia. A careful assessment must be carried out of all children presenting with cough and/or difficulty breathing (MSF, 1997).

Measles

Measles is a highly communicable viral infection. It is transmitted through airborne spread of respiratory droplets from person to person, contact with nasal and throat secretions of infected persons, or via objects that have been in close contact with an infected person.

Clinical features of measles:

- Incubation period is usually 10 days;

- High fever, runny nose, coryza, cough, red eyes and Koplik spots (small white spots on the buccal mucosa);

- Characteristic erythematous (red) maculopapular (blotchy) rash appears on the third to seventh day;

- Temperature subsides after 3-4 days and the rash fades after 5-6 days;

- Case fatality rates estimated to be 3-5 per cent in developing countries, but may reach 10-30 per cent in displaced populations.

Assessment should include: ability to take feeds of fluids; any cough and difficulty breathing; nutritional status; breathing rate, chest indrawing, stridor; diarrhoea or blood in stools; sore mouth, eyes or ears; dehydration and fever. Isolation of patients with measles is not indicated in emergency situations. Antimicrobials should only be given if there is a specific indication such as pneumonia, otitis media or dysentery. Children at significant risk of secondary bacterial infection should have prophylactic antimicrobials such as those with severe malnutrition (Connolly, 2005).

Malaria

Malaria is a life-threatening parasitic disease transmitted by some mosquitoes. Typically it produces fever, headache, vomiting and other flu-like symptoms. Malaria can kill by destroying the red blood cells (anaemia) and by clogging the capillaries that carry blood to the brain (cerebral malaria) or other vital organs (WHO, 2004). Treatment of malaria has become more complicated with an increase in resistance to drugs available. Check what drugs are effective in the area where you are working.

This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net.

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