Child Health in Complex Emergencies

OVERVIEW

Addressing the health needs of children in complex emergencies is critical to the success of relief efforts and requires coordinated and effective interventions. However, little systematic work has been undertaken to evaluate such care. To address this need, this monograph presents a review of the published literature in this area, providing background on the burden of disease, the major causes of morbidity and mortality, and the evidence base for effective interventions. It also describes surveys of nongovernmental organizations (NGOs) and international agencies providing care to children in complex emergencies, which were conducted to identify guidelines commonly used to provide such care and assesses the content and limitations of these guidelines. A more in-depth survey of several organizations was also conducted to assess obstacles to this kind of care.

On the basis of the survey findings and the review of the published literature, the working group recommended that evidence-based, locally adapted guidelines to address the curative and preventive care of children in complex emergencies and health systems planning should be adopted by ministries of health and supported by the World Health Organization (WHO) and UNICEF. The guidelines should target, as much as possible, the different levels of health care workers providing care to children to ensure appropriate, effective, and uniform care in a variety of situations. Specific examples of areas for further research and guideline development are presented.



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Child Health in Complex Emergencies Child Health in Complex Emergencies OVERVIEW Addressing the health needs of children in complex emergencies is critical to the success of relief efforts and requires coordinated and effective interventions. However, little systematic work has been undertaken to evaluate such care. To address this need, this monograph presents a review of the published literature in this area, providing background on the burden of disease, the major causes of morbidity and mortality, and the evidence base for effective interventions. It also describes surveys of nongovernmental organizations (NGOs) and international agencies providing care to children in complex emergencies, which were conducted to identify guidelines commonly used to provide such care and assesses the content and limitations of these guidelines. A more in-depth survey of several organizations was also conducted to assess obstacles to this kind of care. On the basis of the survey findings and the review of the published literature, the working group recommended that evidence-based, locally adapted guidelines to address the curative and preventive care of children in complex emergencies and health systems planning should be adopted by ministries of health and supported by the World Health Organization (WHO) and UNICEF. The guidelines should target, as much as possible, the different levels of health care workers providing care to children to ensure appropriate, effective, and uniform care in a variety of situations. Specific examples of areas for further research and guideline development are presented.

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Child Health in Complex Emergencies This monograph is not intended to be an exhaustive and definitive assessment of child health in complex emergencies. The topic is much too vast and complex, and different individuals and institutions will have incompatible perspectives. Rather, we aim to provide a starting point for discussion and debate on how to improve the care of children in these settings. CARE OF CHILDREN IN COMPLEX EMERGENCIES Addressing the health needs of children in complex emergencies is critical to the success of relief efforts and requires coordinated and effective interventions. The major causes of childhood morbidity and mortality in complex emergencies are similar to nonemergency settings: diarrheal diseases, acute respiratory tract infection, measles, malaria, and malnutrition. However, the severity and magnitude of these diseases are often exacerbated by conflict or disaster, necessitating rapid assessment and treatment of large numbers of severely ill children. Disease surveillance systems must be rapidly established, particularly for diseases known to cause outbreaks with high case fatality, such as measles, cholera, shigellosis, and meningococcal disease. Guidelines are necessary but not sufficient to ensure optimal care. Guidelines define the standard and scope of curative and preventive care, often guide training and needs assessment efforts, and are an important component of preparedness planning. In scope, guidelines can address curative aspects of disease diagnosis and treatment in ill children, preventive health interventions for the individual and community, and development and oversight of health systems. Each of these levels of care, from the individual child to the national level of health system planning, is important to the care of children in complex emergencies. However, many conditions must be in place for guidelines to be used effectively, including properly trained and supervised health care workers, adequate and appropriate drug supplies, knowledge of local epidemiology and appropriate health-seeking behavior, accessible health care facilities, functioning referral systems, and sufficient funding. Consideration of the broader context in which guidelines are used in complex emergencies is necessary to ensure their effectiveness. The type of emergency, whether an armed conflict, famine, or natural disaster, and the phase of the emergency determine specific health risks and demand responses sufficiently flexible to adapt to these risks. The health needs of

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Child Health in Complex Emergencies refugee children may not be the same as those of internally displaced and internally stranded children. Children differ in their baseline health, nutritional status, and risk of exposure to communicable diseases prior to the onset of an emergency, and these local differences persist for the duration of the emergency and into the postemergency phase. Human rights and gender issues also must be considered in developing and implementing guidelines for the care of children in complex emergencies, as discrimination by gender and ethnicity may adversely affect the care of some children. Finally, the general nature of complex emergencies is evolving from short-term emergencies in refugee camps to prolonged emergencies in large geographic areas, and thus the approach to the care and needs of children also must change (Salama, Spiegel, Talley, and Waldman, 2004). Guidelines for the care of children in complex emergencies should be revised and updated on the basis of field experience and the increasing body of evidence for the care of children in resource-constrained settings. METHODOLOGY Although its importance is recognized, little systematic work has been undertaken to evaluate the care of children in complex emergencies. Such a process must begin with an understanding of what is known about these problems and how well existing guidelines address them. Only then can recommendations be made to improve the care of children in these settings. To address these goals, we first conducted a review of the published literature to establish the burden of disease and the major causes of morbidity and mortality, as well as to review the effectiveness of interventions. We then surveyed nongovernmental organizations (NGOs) providing care to children in complex emergencies to identify the guidelines commonly used for the care of children and their limitations. More in-depth surveys of organizations working in Angola, Afghanistan, and the Democratic Republic of the Congo were conducted to assess obstacles to the care of children in specific emergency settings. On the basis of these findings, we identify the limitations of existing guidelines, make recommendations to improve these guidelines, and identify research needs for the further development of evidence-based guidelines for the care of children in complex emergencies. Complex emergency is defined broadly for the purpose of this review and refers to a situation of armed conflict, population displacement, or food insecurity—or a combination—with an associated increase in mortal-

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Child Health in Complex Emergencies ity and malnutrition. Child health during the acute phase of an emergency is emphasized, while recognizing important needs in the postemergency setting. The health of children younger than age 10 is addressed and encompasses primary health care, preventive care, and mental health as well as case management. Maternal health and the health of older children and adolescents are not a focus of this review. Recommendations addressing various levels of health intervention are considered: curative care at the level of the individual child, preventive care at the individual and community levels, and health systems planning at the community and national levels. Our review of the published literature on the causes of morbidity and mortality in children in complex emergencies is based on a search of the English language literature using the PubMed database and multiple combinations of search terms related to child health and complex emergencies, including “complex emergency,” “disaster,” “refugee,” and “war” with “child health” in combination with terms for specific diseases (e.g., “measles,” “malaria,” “micronutrient”). Our summary is not intended to be an exhaustive review of this very large body of literature and focuses on articles published in the past 20 years. Furthermore, review of the published literature is necessarily limited, because only a small proportion of the collective experience in caring for children in complex emergencies is published. For some childhood diseases, such as pneumonia, knowledge of etiology, diagnosis, treatment, and prevention are extrapolated from stable situations and have not been explicitly studied in complex emergencies. In addition, many organizations and health care workers do not have the time, resources, or incentives to publish their experiences. Nevertheless, this review highlights the broad range of conditions to be addressed by comprehensive guidelines for the care of children in complex emergencies. To further assess care and better understand how well existing guidelines address child health issues, we conducted surveys in 2003 of a convenience sample of international relief agencies involved in child health in complex emergencies, focusing on guidelines used for the care of children in complex emergencies (Appendix A). The first survey instrument was designed to elicit an overview of the child health activities in which different organizations are engaged, the guidelines used by these organizations to provide care to children in complex emergencies, and some of the limitations of these guidelines. Surveys were usually conducted by telephone or

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Child Health in Complex Emergencies email with a single individual at the organization’s central office. This approach had the advantage of providing an overview of the NGO’s activities, but it was limited, in some cases, by lack of detailed knowledge in all areas of the survey. Some organizations distributed the questionnaire so that individuals with specific expertise could respond. These survey results also are limited by the fact that many organizations function differently in different settings and the broad results gleaned from these surveys do not capture these differences. Because of the vastly different nature of complex emergencies in different settings, we conducted a second survey in 2003 to explore in-depth case studies of organizations working in three key countries: Afghanistan, Angola, and the Democratic Republic of the Congo (Appendix A). These countries represent different stages in the progression of humanitarian crises and have different political and social contexts that shape the challenges to providing care to children in complex emergencies. We generated a list of NGOs working in these countries. As many of these NGOs had been contacted for the first survey, the initial survey respondent was consulted to identify a country-specific contact person. All the surveys were sent by email to the country contacts in the field. Four NGOs responded from the Democratic Republic of the Congo, five from Afghanistan, and three from Angola (Appendix A). Information was collected on important practical issues, such as obstacles to providing care, personnel and resource needs, performance monitoring, and the roles of the ministry of health and WHO. In addition, WHO circulated the second survey instrument to field offices in nine countries. UNICEF representatives responded from Burundi, the Democratic Republic of the Congo, Malawi, Sri Lanka, and the West and Central African Regional Office. In Iraq, a representative of the ministry of health responded. In Kosovo, India, and Zimbabwe, WHO representatives responded (Appendix A). On the basis of the survey responses, we evaluated several comprehensive guidelines for the care of children in complex emergencies as well as specific guidelines focusing on a single disease or aspect of child health. This review enabled us to identify gaps and limitations of the currently used guidelines. The monograph concludes with our recommendations to improve the care of children in complex emergencies and suggests areas that require further research.

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Child Health in Complex Emergencies REVIEW OF THE PUBLISHED LITERATURE Burden of Childhood Disease The highest mortality rates in refugee populations often are in children younger than age 5 (Morbidity and Mortality Weekly Report, 1992; Toole and Waldman, 1997). Although mortality rates are highest in infants less than one year of age, the relative increase in mortality is probably highest in older children (Morbidity and Mortality Weekly Report, 1992; Toole and Waldman, 1990). Child mortality rates often are highest during the acute or early phase of a complex emergency (Toole and Waldman, 1988). One frequently cited example of the high mortality rate among children was among Kurdish refugees at the Turkey-Iraq border during 1991:63 percent of all deaths were children younger than age 5, although this age group constituted only 18 percent of the population (Morbidity and Mortality Weekly Report, 1992; Toole and Waldman, 1997). Numerous other examples support the conclusion that a high proportion of deaths in complex emergencies are children. A review of child mortality in refugee camps in Thailand, Somalia, and Sudan in the early 1980s reported a mortality rate more than twice as high in children younger than age 5 (32.6 per 10,000 children per day) than the overall crude mortality rate (Toole and Waldman, 1990). In the early 1980s in a Burmese refugee camp in Bangladesh, most deaths occurred among infants (640 per 1,000 per year) and children (357 per 1,000 per year) (Khan and Munshi, 1983). The overall mortality among Ethiopian refugees in Sudan in February 1985 was 8.9 per 10,000 persons per day, but it was 22 per 10,000 per day for children younger than age 5 (Shears, Berry, Murphy, and Nabil, 1987). Among refugees in Honduras between 1984 and 1987, deaths in infants accounted for 42 percent of all deaths, and deaths of children younger than age 5 accounted for 54 percent of all deaths (Desenclos et al., 1990). A survey conducted during the 1991 Kurdish refugee crisis found that two-thirds of all deaths were children younger than age 5, and half were infants younger than 1 year (Yip and Sharp, 1993). The Gulf war and trade sanctions were estimated to have caused a three-fold increase in mortality among Iraqi children younger than age 5, resulting in an excess mortality of 46,900 children between January and August 1991 (Ascherio et al., 1992). During the 1992 famine in Somalia, 74 percent of children younger than age 5 living in displaced person camps were estimated to have died over several months (Moore et al., 1993). Among Rwandan and

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Child Health in Complex Emergencies Burundian refugees in eastern Zaire in 1996, 54 percent of all deaths were among children younger than age 5; the daily mortality rate was as high as 12.5 per 10,000 children younger than age 5 per day (Nabeth, Vasset, Guerin, Doppler, and Tectonidis, 1997). However, in some settings, older children and adults suffer mortality rates comparable to or exceeding those of young children. Such excess mortality in older children and adults is most likely following outbreaks of cholera or dysentery or when armed conflict results in many civilian casualties (Paquet and van Soest, 1994; Spiegel and Salama, 2000). Among Rwandan refugees in Zaire, the crude mortality rate for children younger than age 5 was lower than the overall crude mortality rate (Paquet and van Soest, 1994). Ninety percent of all deaths were due to cholera, dysentery, or other diarrheal diseases, and the proportion of diarrhea-related deaths was lower in children younger than age 5 than in the rest of the population. In developed countries, where infectious diseases and malnutrition are less likely to be significant contributors to mortality, war-related trauma and chronic diseases cause a significant proportion of deaths. In a study of displaced and resident populations in Kabul, Afghanistan, in 1993, the most common causes of death in children younger than age 5 were measles, diarrhea, and acute respiratory tract infections (Gessner, 1994). However, the most common causes of death in all age groups were gunshot wounds and other war-related trauma. A survey of Kosovar Albanians in 1999 found higher mortality rates in men over age 15 than in children younger than age 15 (Spiegel and Salama, 2000). Major Causes of Morbidity and Mortality In stable situations, resource-poor countries have fairly consistent proportions of under-5 mortality attributable to pneumonia and diarrhea (about 20 percent each), but the proportions of deaths due to malaria, AIDS, and neonatal causes vary greatly from region to region and country to country (Black, Morris, and Bryce, 2003). Knowledge of the baseline burden of morbidity and mortality for children at a country level is important for comparison during a complex emergency and for predicting specific diseases to be targeted as the emergency evolves. During the early phase of an emergency, the most common causes of death are diarrheal diseases, acute respiratory infections, measles, malaria, and severe malnutrition (Toole and Waldman, 1997), the same major causes of death in countries with the highest child mortality rates. There is no

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Child Health in Complex Emergencies evidence that the major causes of childhood morbidity and mortality in complex emergencies have changed significantly in the past decade. For example, in 1999, 80 percent of the deaths of Congolese children younger than age 5 in Lugufu camp in Tanzania were due to malaria, diarrhea, and pneumonia (Talley, Spiegel, and Girgis, 2001. However, in addition to diarrhea, pneumonia, measles, and malaria, outbreaks of other infectious diseases can contribute substantially to childhood morbidity and mortality in complex emergencies. Examples include outbreaks of poliomyelitis in Angola in 1999 (Valente et al., 2002), pertussis (World Health Organization, 2003) and leishmaniasis in Afghanistan (Ahmad, 2002; Rowland, Munir, Durrani, Noyes, and Reyburn, 1999b); meningococcal meningitis in Sudanese refugee camps in 1994 (Santaniello-Newton and Hunter, 2000), and typhoid fever in Bosnia and Herzegovina during 1992-1993 (Bradaric et al., 1996). In some settings, injuries may contribute to excess mortality in children. For example, the age-adjusted mortality rates for both diarrhea and injuries increased in Iraqi children after the onset of the first Gulf war (Ascherio et al., 1992). Malnutrition and micronutrient deficiencies contribute substantially to child morbidity and mortality in complex emergencies (Morbidity and Mortality Weekly Report, 1992; Toole and Waldman, 1993, 1997). A nutritional assessment survey of children in the Democratic People’s Republic of North Korea, conducted by the World Food Programme in August 1997, found a prevalence of acute malnutrition as high as 33 percent in some regions of the country (Katona-Apte and Mokdad, 1998). Wasting was estimated to have contributed to 72 percent of all deaths among children younger than age 5 during a famine in Ethiopia in 2000 (Salama et al., 2001). However, not all complex emergencies are associated with high prevalence rates of malnutrition. For example, a survey of Bosnian children in 1993 found no evidence of malnutrition after the first year of war (Robertson et al., 1995). A nutritional survey of Liberian refugee children in 1990 found the prevalence of acute malnutrition to be similar to rates reported for African populations in noncrisis situations (Morbidity and Mortality Weekly Report, 1991). Special Considerations in Complex Emergencies Some complex emergencies are associated with large numbers of unaccompanied children (Sapir, 1993), and the special needs of these children have been addressed in several publications (Ressler, Boothby, and

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Child Health in Complex Emergencies Steinbock, 1988; Williamson and Moser, 1988; UNICEF/United Nations High Commissioner for Refugees, 1994). Although unaccompanied minors often are older children, in some situations, such as the Korean war and the Nigerian civil war, many were abandoned infants (Sapir, 1993). Extremely high mortality rates were documented in 1994 among unaccompanied Rwandan refugee children after their arrival in Goma, Zaire (Dowell et al., 1995). Most deaths (85 percent) occurred more than two days after arrival at the centers, suggesting that early and appropriate care could have significantly reduced mortality. There is some evidence that foster care is an effective strategy to protect unaccompanied children during the acute phase of an emergency. In one study based on the 1994 Rwandan refugee crisis, weight gain and rates of illness were similar between foster children and children of the same age accompanied by their parents (Duerr, Posner, and Gilbert, 2003). Demobilized child soldiers are another special population in some complex emergencies. The use of child soldiers arises from the “triad of anarchic civil war, light-weight weaponry, and drug or alcohol addiction” (Pearn, 2003, p. 169). The 1998 Statute of the International Criminal Court defined as a war crime the use of children younger than age 15 as soldiers. An estimated 120,000 to 200,000 child soldiers are engaged in conflicts in Africa (Albertyn, Bickler, van As, Millar, and Rode, 2003). Child soldiers are prone to several long-term consequences. As a result of their lost childhood, child soldiers are hard to rehabilitate and reengage in school. Early victimization and exposure to violence lead to “desocialization and dehumanization” and contribute to posttraumatic stress disorder (Pearn, 2003, p. 170). In complex emergencies, as in nonemergency situations, people may seek care outside the formal health sector. Traditional healers may be important providers of care, especially when the health care system has collapsed or is nonexistent. However, few published studies have addressed the role of traditional healers in providing care during complex emergencies. In one study, understanding traditional Khmer health beliefs was found to be important in providing care to Cambodian refugee children (Rosenberg and Givens, 1986). Acute Phase of Complex Emergencies The acute phase of an emergency is defined by the crude mortality rate and persists as long as that rate is at least double the baseline mortality rate.

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Child Health in Complex Emergencies In sub-Saharan Africa, this threshold is set at one death per 10,000 persons per day (Toole and Waldman, 1990). For emergencies in other parts of the world, where data are available on preemergency mortality rates, these local baseline figures should be used to define the acute phase of a complex emergency (Salama et al., 2004). In the acute phase, coordination among international, United Nations, and local agencies is critical to successful relief efforts. An external study commissioned by the Office for the Coordination of Humanitarian Affairs in the UN Secretariat found that a lack of clear terms of reference, guidance on responsibilities, reporting requirements, and consultation lines led to recurring problems in the provision of care during complex emergencies (Reindorp and Wiles, 2003). Binding principles of engagement, standardized indicators as part of a minimum, essential data set, and health-sector area-activity summaries are strategies to strengthen coordination and standardization of practice among different agencies in a complex emergency (Bradt and Drummond, 2003). Postemergency Phase Many of the major causes of child morbidity and mortality in the acute phase of an emergency persist into the postemergency phase. Nevertheless, when children have remained in refugee camps for prolonged periods, child mortality may be lower in the refugee population than among neighboring, resident children. In a retrospective study of 51 postemergency camps in seven countries from 1998 to 2000, the average under-5 mortality rate was 0.9 deaths per month per 1,000 children. Lower under-5 mortality rates were associated with camps that were older, were furthest from the area of conflict, had higher per capita ratios of local health care workers, had a greater per capita water supply, and had lower incidence of diarrheal disease (Spiegel, Sheik, Gotway-Crawford, and Salama, 2002). In another retrospective study conducted between 1998 and 2000 of refugees and internally displaced persons living in 52 camps in 7 countries, neonatal mortality rates and the proportion of low-birthweight infants were lower in the camps than in the host countries (Hynes, Sheik, Wilson, and Spiegel, 2002). The neonatal mortality rate among Afghan refugees in Pakistan between 1998 and 2000 (25 per 1,000 live births) was significantly lower than the neonatal mortality rate in Afghanistan (121 per 1,000 live births) (Bartlett et al., 2002). Infant mortality and under-5 mortality rates tended to be lower among Palestinian refugees between 1998 and 2000 compared with

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Child Health in Complex Emergencies their nonrefugee counterparts, and rates were also comparable or lower among refugees living in camps compared with those not in camps (Khawaja, 2004). The mortality rate for resident children in Prabis, Guinea-Bissau, in 1998 was 4.5 times higher than for refugee children (Aaby et al., 1999). The prevalence of acute malnutrition was higher among children in rural nonrefugee populations in the eastern Democratic Republic of the Congo in 1995 than among refugee children (Porignon et al., 2000). The annual risk of tuberculosis among 8-year-old boys living in refugee camps in Afghanistan in 1985 was lower than the annual risk reported in a national survey (Spinaci et al., 1989). Diarrheal Disease, Cholera, and Shigella Dysentery Diarrheal disease is a common cause of child morbidity and mortality in complex emergencies and in some settings results in extremely high mortality rates. A cross-sectional survey of children in mountain camps along the Turkey-Iraq border during the 1991 Kurdish refugee crisis documented high rates of acute malnutrition and diarrhea (Yip and Sharp, 1993). The mortality rate for children under age 5 was 15.3 per 1,000 children per month over an 8-week period, and diarrheal disease and associated malnutrition were estimated to have caused 75 percent of all deaths of children younger than age 5. Outbreaks of cholera have been reported frequently in complex emergencies (Hatch, Waldman, Lungu, and Piri, 1994; Morbidity and Mortality Weekly Report, 1998; Moren et al., 1991; Siddique et al., 1995; Swerdlow et al., 1997). A study of risk factors for cholera during an epidemic in a Mozambican refugee population in Malawi in 1988 found an increased risk associated with an increasing number of children younger than age 5 in the household, suggesting that young children may have played a role in cholera transmission (Hatch et al., 1994). Another study of Mozambican refugees in Malawi described the epidemiology of cholera over a three-month period in 1990 (Swerdlow et al., 1997). Mortality was highest for children younger than age 4 (relative risk of 4.5, CI = 2.6-7.9), and most deaths occurred within 24 hours of hospital admission. The authors suggest that improved access to care for children and increased use of oral rehydration therapy could have decreased child mortality. However, rapid provision of intravenous fluid therapy is necessary to significantly reduce the mortality rate in severely dehydrated children with cholera. Few published studies have evaluated preventive or treatment mea-

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Child Health in Complex Emergencies (malaria and pneumonia) is specifically addressed, and hospital referral is recommended in some cases. Nutritional supplementation is included as part of case management for children with dysentery and pneumonia, but not watery diarrhea. MSF has specific Nutrition Guidelines for the assessment of nutritional problems and the implementation of nutritional programs in complex emergencies. In addition, the MSF guidelines address the diagnosis and management of many other diseases of children in complex emergencies, specifically meningitis, mild and severe anemia, micronutrient deficiencies (vitamin A deficiency, pellagra, and scurvy), skin diseases (e.g., scabies), eye diseases (e.g., vitamin A deficiency, conjunctivitis, trachoma), and burns. The diagnosis of HIV-1 infection and the prevention of opportunistic infections are addressed and have been expanded in the fifth edition. The diagnosis and management of tuberculosis in children are addressed only under specific circumstances, with guidelines specific to the national tuberculosis control program of the ministry of health. There is an additional MSF handbook on tuberculosis. Not addressed in the MSF Clinical Guidelines are the diagnosis and management of persistent diarrhea, diseases of the neonate, and trauma apart from burns. Sexual abuse is discussed in general without specific reference to children. While the fifth edition of the Clinical Guidelines includes more discussion of mental health, the focus is on adults. Routine childhood immunizations are not specifically addressed in either edition of the Clinical Guidelines, and promotion of breastfeeding is briefly mentioned. The MSF Clinical Guidelines discuss active case finding and home visits but do not have a community-based component for health education, disease surveillance, or case management. These guidelines address surveillance for crude mortality and measles and provide some sample reports and simple case definitions for epidemiological purposes. Several disease-specific guidelines require the use of laboratory tests, including blood smears for malaria, microscopic examination of cerebral spinal fluid, detection of pathogenic bacteria (Shigella dysenteriae) in stool specimens, and blood typing for transfusions. Helping the Children: A Practical Handbook for Complex Humanitarian Emergencies is written for medical volunteers who are not child health specialists and is endorsed by the American Academy of Pediatrics (Mandalakas, Torjesen, and Olness, 1999). The strength of these guidelines is in briefly addressing preventive and public health measures, although they are not comprehensive clinical guidelines. For example, the manage-

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Child Health in Complex Emergencies ment of children with malaria or pneumonia is not addressed, and the handbook discusses the management of diarrhea, cholera, dysentery, and meningitis only briefly. The handbook emphasizes many less common diseases that are unlikely to be major causes of morbidity or mortality in complex emergencies. For example, when presented with a child with cough and tachypnea, the reader is reminded to think of meliodosis, hydatid cyst, or the pulmonary phase of nematode migration. The handbook is more appropriate in addressing mental health problems, the promotion of breastfeeding, and routine childhood immunizations. Comprehensive guidelines exist that focus on preventive health care at the individual and community level and thus have a public health emphasis. MSF’s Refugee Health: An Approach to Emergency Situations (Médecins sans Frontières, 1997) is targeted to public health officials and planners with a high level of expertise. However, integration of case management and preventive measures at the individual patient level is best done in IMCI guidelines. These guidelines address the care of children from 1 week to age 5 and are targeted to nurses and clinical officers at first-level health facilities. From a preventive standpoint, IMCI includes promotion of breastfeeding, routine childhood immunizations, and routine vitamin A supplementation. More recently, clinical guidelines in IMCI have been expanded to include the care of HIV-infected children and newborns. IMCI guidelines do not include nutritional supplementation as part of case management for pneumonia and diarrhea, and they do not specifically address tuberculosis, skin diseases, eye diseases, trauma, burns, child and sexual abuse, emergency resuscitation, or mental health problems. Disease surveillance is not part of IMCI. However, IMCI guidelines do include a less well-developed community and family component that emphasizes health education. Save the Children has instituted a Children and War Field Guide Series to provide practical guidance for program planners in each of six content areas: education in emergencies, youth, separated children, child soldiers, sexual and gender-based violence, and psychosocial care and support. This series addresses a broad array of issues and perspectives, including social, cultural, and educational factors that contribute to children’s health and development. A comprehensive approach to addressing the issue of separated and unaccompanied children is presented in the Inter-Agency Guiding Principles on Unaccompanied and Separated Children (International Committee of the Red Cross, United Nations High Commissioner for Refugees, UNICEF, World Vision International, and Save the Children, 2004). These

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Child Health in Complex Emergencies guidelines set up a framework to protect rights and identify the special needs of this vulnerable population of children. The most comprehensive guideline for health systems planning in complex emergencies is the Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response (Sphere Project, 2004). The Sphere Project was not designed to provide clinical care guidelines but to serve as a set of minimum standards for delivering health care during complex emergencies. The focus is on initial assessment standards, coordination among different levels of the health care infrastructure, management of human resources, health information systems, and disease control for all ages. Importantly, the Sphere Project supports capacity building at the local level and participation of the community in the design, implementation, and monitoring of health care programs. The Sphere Project details several interventions to minimize disease due to several of the major causes of child mortality in complex emergencies, including measles and malaria. There is also a section on programmatic considerations in the management and prevention of HIV/AIDS. Standard case management protocols and essential drug lists are mentioned as important for the clinical coordination of care; however, protocols for specific diseases are not detailed. The ministry of health is designated the lead in the health sector response whenever possible. IMCI is referred to as a guideline to use “where possible” in countries for which it has been adapted. The need for surveillance systems is emphasized, and a key indictor is an under-5 mortality rate of less than twice the baseline rate or less than 2 per 10,000 persons per day. Sample surveillance forms are provided. Disease-Specific Guidelines In addition to these comprehensive guidelines, disease-specific guidelines developed by WHO, UNICEF, and various NGOs are applicable to children in complex emergencies. One example is Infant Feeding in Emergencies (World Health Organization, UNICEF, LINKAGES, IBFAN, and ENN, 2001). These guidelines on infant feeding target all levels of emergency relief staff caring for women and children at health and nutrition centers. The guidelines are intended for use in natural disasters as well as complex humanitarian emergencies in developed and developing countries. For decision makers, the guidelines include practical steps in developing policies, training staff, and assessing and monitoring interventions. Promotion of breastfeeding is emphasized, and surveillance for breastfeeding

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Child Health in Complex Emergencies prevalence using qualitative and quantitative measures is discussed. Appropriate policies on and steps for use of breast milk substitutes are provided. Although not specific to children, several guidelines address reproductive health care in complex emergencies. Reproductive Health in Refugee Settings: An Inter-Agency Field Manual (United Nations High Commissioner for Refugees/United Nations Population Fund, 1995) addresses the reproductive health issues of women and adolescents. A minimal initial service package is presented that includes management and prevention of sexual abuse. Reproductive Health During Conflict and Displacement: A Guide for Programme Managers (World Health Organization, 2000b) focuses on women of reproductive age, briefly mentioning children, men, and boys as targets of sexual abuse. The Inter-Agency Standing Committee reference group for HIV/AIDS in emergency settings presents a hierarchical approach to standards of HIV/ AIDS care and prevention (Inter-Agency Standing Committee, 2003). These guidelines are designed as a resource for multisectoral planning for HIV/AIDS care and prevention and target program planners in all emergency settings, regardless of the underlying HIV prevalence. Initial minimum services must be in place before more resource-intensive, comprehensive services, such as prevention of mother-to-child transmission or long-term antiretroviral therapy, should be provided. When antiretroviral therapy is provided, treatment should be provided in conjunction with National AIDS Control Programs and follow host country protocols. Tuberculosis Control in Refugee Situations: An Inter-Agency Field Manual is designed for field managers and provides guidelines for the implementation, monitoring, and evaluation of tuberculosis control programs in refugee situations (World Health Organization and United Nations High Commissioner for Refugees, 1997). The manual states that tuberculosis control is not a priority in the immediate, acute phase of the emergency and should not commence until death rates are below 1 per 10,000 persons per day, basic needs are being met, and essential clinical services are in place. Additional criteria for the development of a tuberculosis control program are that the security situation is stable and the camp population is likely to be present for at least six months. The section on management briefly identifies diagnostic considerations specific to children. Guidelines developed for nonemergency settings could be modified for use in complex emergencies. Initiatives to improve neonatal survival have been undertaken by Save the Children and CARE. Care of the Newborn Reference Manual was developed to train health workers in the best

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Child Health in Complex Emergencies practices to care for newborns in developing countries (Beck, Ganges, Goldman, and Long, 2004). This manual covers practical skills, such as newborn examination and resuscitation, as well as health promotion and education issues, including counseling families on birth spacing, newborn care, and breastfeeding. The manual includes drug dosages and equipment checklists for newborn care. CARE, in conjunction with the Centers for Disease Control and Prevention, produced The Healthy Newborn: A Reference Manual for Program Managers, which targets health systems issues and program managers to facilitate the systematic implementation of evidence-based standards in newborn care (Lawn, McCarthy, and Ross, 2001). This manual describes the development of a newborn health management information system to provide the data to direct program and health planning decisions. It applies a continuous quality improvement methodology to analyze data, identify problems, select interventions, and evaluate outcomes for the design and monitoring of programs. Limitations of Existing Guidelines Despite the strengths of existing manuals, all of the guidelines needed for the care of children in complex emergencies are not located in a single source, and the majority target higher level health care workers and program planners. Many of the guidelines reviewed are designed for audiences with more medical and public health expertise than is commonly found in complex emergencies. Many guidelines need to be simplified and stream-lined. On the basis of the initial survey, organizations providing clinical care to children in complex emergencies were least likely to have formal guidelines on the prevention and management of neonatal illness, the diagnosis and management of children with HIV-1 infection, active case finding and treatment of tuberculosis in children, pediatric trauma (e.g., burns, sexual abuse), emergency resuscitation, and the diagnosis and management of mental health problems in children. Services for the diagnosis and management of mental health problems in caretakers were more commonly reported than those for children. However, Action Contra la Faim has piloted programs to address the mental health of infants and mothers in nutrition centers in Afghanistan and Sudan. Two organizations stated that tuberculosis control efforts in emergency situations were not part of their activities because the duration of therapy exceeded the expected duration of relief activities. Few organizations reported having guidelines that distin-

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Child Health in Complex Emergencies guish the management of severe disease (e.g., cerebral malaria, severe pneumonia, severe anemia) from the general management of childhood illness, and few reported the inclusion of nutritional support as part of case management (e.g., for diarrhea, pneumonia, and HIV). No organization reported distinct guidelines for the management of persistent diarrhea. Several organizations reported they were involved in developing guidelines for specific child health activities, including the diagnosis and management of pediatric HIV infection, physical and sexual abuse in children, and mental health problems in caretakers. From a preventive standpoint, few guidelines incorporate nutritional support as part of case management, and promotion of breastfeeding had limited programmatic emphasis. Guidelines on community-based surveillance for measles and cholera and community-based health interventions could be strengthened. Potential Use of Modified IMCI Guidelines IMCI guidelines were not developed for complex emergencies and their use in complex emergencies has not been evaluated. Adapting IMCI guidelines to the acute phase of a complex emergency has several limitations, including (1) the 11-day training course is too long to be implemented during the acute phase of a complex emergency, (2) the supporting infrastructure and referral facilities are frequently not in place to manage severe disease, (3) the time required to complete a single patient encounter is too long for the high caseload seen during the acute phase of a complex emergency, (4) disease surveillance is not addressed, and (5) and laboratory support for the diagnosis of malaria, cholera, and shigellosis is not included. Modifications to the IMCI guidelines would need to be made to make them more suited to the acute phase of complex emergencies. An attempt to simplify these guidelines was made for use in refugee camps in Tanzania (Robinson, 1998). Although the introduction of IMCI in this setting was deemed feasible, several limitations were noted. Because of high mortality within the first 24 hours of presentation, a triage system was recommended to ensure the prompt treatment of severely ill children. Reflecting the limitation of IMCI guidelines in dealing with such children, the evaluation concluded that emergency rooms should be established to manage their care. IMCI guidelines may be enhanced when used in combination with Emergency Triage Assessment and Treatment (ETAT) guidelines. ETAT

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Child Health in Complex Emergencies guidelines are designed to train health care workers to rapidly assess signs and symptoms of severe disease, including problems of airway and breathing, shock, convulsions, severe malnutrition, and severe dehydration. For each classification of severe disease, rapid resuscitation techniques are recommended. The potential usefulness of ETAT guidelines in complex emergencies is that many children present with severe disease, and rapid triage and treatment are critical for their successful management. The disadvantages of ETAT guidelines are that they require resources (e.g., oxygen) and skills (e.g., the ability to insert femoral or interosseous lines) not available in many complex emergency settings. Nevertheless, guidelines for triaging critically ill children are needed, and, as with other recommendations, the ETAT guidelines could be simplified for use by a variety of health care workers. IMCI guidelines also have been adapted to provide care to children in complex emergencies when trained health care workers are unavailable. In southern Sudan, village volunteers and community health workers were trained to use a much simplified version of IMCI guidelines (Beltramello, Zagaria, Masiello, and Robinson, 2002). The guidelines for village volunteers, called Essential Community-based Child Health Care (ECCHC), contain algorithms for the identification and management of general danger signs, pneumonia, dehydration, and malaria by literate persons without any health training. Training requires seven days. The ECCHC package was effectively introduced into regions of southern Sudan with very limited access to health care (more than 10 hours from a health facility). Guidelines for community health care workers were developed to include algorithms for anemia, malnutrition, intestinal parasites, and dysentery. The development and validation of simplified IMCI guidelines provide an important tool for the care of children in complex emergencies in which access to trained health care workers is limited. RECOMMENDATIONS TO IMPROVE GUIDELINES Despite the complexities of addressing the health needs of children in emergencies, much of the burden of disease is caused by malnutrition and several infectious diseases, diseases that are common to children in many nonemergency settings and for which there exist evidence-based guidelines for prevention and treatment. This body of information and clinical experience serves as the foundation for addressing the health needs of chil-

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Child Health in Complex Emergencies dren in complex emergencies. The effective management of the personnel, supplies, training, and logistics required for the optimal care of children is critical and should be part of the overall emergency management plan. Providers of care and protection to children in complex emergencies, although often overwhelmed by immediate concerns, should maintain a vision of fostering sustainable health care during the transition to the postemergency situation. Findings Our recommendations are based on the following findings: (1) Most organizations caring for children in complex emergencies use existing clinical guidelines rather than develop their own. (2) Health care in complex emergencies is delivered by different levels of health care workers from multiple organizations. (3) Guidelines for the prevention and management of child health problems in complex emergencies exist but need to be brought together into an accessible, comprehensive package. (4) Coordination across the many international relief organizations has been problematic, hindering the delivery of care. Furthermore, laying the foundation and planning for the transition out of the emergency phase toward a stable health system is an important component of emergency care. Our hope is that these recommendations and suggested areas of research will spur others to work toward improvements in the care of children in complex emergencies (Box 1). Recommendations Evidence-based, locally adapted guidelines to address treatment and preventive care of children in complex emergencies should be adopted by ministries of health, supported by WHO and UNICEF, and disseminated to international relief organizations as the best means to ensure appropriate, effective, and uniform care in most complex emergencies. The guidelines should take into consideration the unique priorities in different phases of the emergency. The clinical and preventive guidelines should be adapted from existing clinical guidelines used for the care of children in complex emergencies and stable situations (e.g., IMCI) and should focus on the rapid reduction of mortality due to measles, malaria, diarrhea (including cholera and shigellosis), acute respiratory tract infection, and acute malnutrition. The evidence

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Child Health in Complex Emergencies Box 1 Research Needs Development and evaluation of interventions to reduce neonatal mortality in complex emergencies. Development and evaluation of better tools to assess mental health problems in children that can be applied across cultures. Development and field testing of rapid diagnostic and antibiotic-susceptibility tests for Vibrio cholera and Shigella dysenteriae. Evaluation of the cost-effectiveness of short-course therapy for use in situations in which compliance and follow-up are poor. Examples include: short-course therapy with ciprofloxacin for Shigella dysenteriae short-course therapy with macrolides for Vibrio cholera short-course therapy for pneumonia single-dose therapy for malaria Evaluation of intermittent presumptive treatment of malaria for children in complex emergencies. base for preventive and curative interventions in stable settings was recently reviewed, and interventions with sufficient evidence should be prioritized and adapted for use in complex emergencies (Jones et al., 2003). In the acute phase of an emergency, it may be necessary to consider simplified triage protocols for children and simplified algorithms for less severely ill children who could be managed by the level of health worker most commonly providing care to children. The clinical guidelines also should address the management of severe disease in complex emergencies, in particular, how severely ill children should be managed in the absence of referral facilities or with referral that may require distant transport to more secure areas. In the postemergency or nonacute phase, strategies for expanding community capacity and the role of community health workers and volunteers should be recognized as they relate to such activities as community-based therapeutic care, disease monitoring, health-seeking behaviors, and environmental health. In the postacute phase, the curative guidelines should include nutritional assessment and intervention in order to address a child’s overall health. The applicability of simplified, revised

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Child Health in Complex Emergencies IMCI guidelines should be considered to better incorporate such preventive efforts in each visit. There should be provisions for addressing the health needs of special populations of children not addressed in normal situations, including provisions for unaccompanied children and for the mental health needs of children. International relief organizations should be a partner in the development and pretesting of the guidelines to ensure they are appropriate to the types of workers engaged in providing care to children. CONCLUSION Unique and varied challenges to the provision of health care to children are found in complex emergencies. Health care is often delivered by multiple organizations with different types of health workers using diverse guidelines and training materials, and it is therefore less uniform than in stable situations. Ensuring comprehensive, coordinated, and appropriate care is difficult when multiple organizations and different levels of health workers are operative. In the absence of a functioning health care system, referral services and supply delivery systems are unavailable, and health workers with minimal training are often the primary providers. In such situations, training of lower level health care workers must be rapid, simple, and targeted to the diseases causing the greatest morbidity and mortality. The logistics of drug delivery and distribution are made complex by the multiple organizations involved, inadequate communication and transportation systems, and threats to security. Social and political instability may impede access to vulnerable populations of refugees or internally displaced people by health care providers or relief workers. In an affected area, the population may be in flux. Large-scale migration requires mobile resources and services that can be redirected to target populations. Social and political instabilities also pose special challenges in caring for children who are unaccompanied, forced to fight as child soldiers, or who are sexually abused. In the face of significant and ever-changing challenges, improving and preserving the health of children in complex emergencies is the goal of many dedicated organizations and individuals. This report is a testimony to their efforts to care for children by furthering the development of comprehensive child health guidelines. Much collective experience has accumulated on which to base the development of guidelines for the care of children in complex emergencies, but much remains to be learned. Identifying specific gaps in current knowledge is intended to focus research efforts and generate discussion. While some of the research needs are dis-

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Child Health in Complex Emergencies ease-specific, questions remain on the operational and organizational structure of health delivery in complex emergencies. The Sphere Project is an important step in addressing some of these operational issues by setting minimum standards. The application of IMCI guidelines or other comprehensive guidelines will involve addressing resource constraints and operational issues in various situations. Sharing lessons learned in the field on the application of clinical, preventive, and health systems guidelines will remain central to the goal of reducing morbidity and mortality among children in complex emergencies. ACKNOWLEDGMENTS For helpful discussions and assistance we thank Richard Allen, Myron Belfer, Claudio Beltramello, Paul Bolton, Rayana Bu-Hakah, Gilbert Burnham, Manuel Carballo, Marie Connolly, Michelle Gayer, Elizabeth Hunt, Walt Jones, Sultana Khanum, Lianne Kuppens, Thomas Nierle, Agostino Paganini, Pierre Perrin, Anastasia Pharris-Ciurej, Elizabeth Rowley, R. Bradley Sack, Hakan Sandbladh, Paul Spiegel, Ronald Waldman, and the participants of the WHO-UNICEF Workshop on Child Health in Complex Emergencies held in Geneva 21-22 October 2003. We are especially grateful to the organizations that kindly responded to our surveys (Appendix A). This work was supported by a grant from the Department of Child and Adolescent Health and Development of WHO to the Center for International Emergency, Disaster and Refugee Studies (CIEDRS; now the Center for Refugee and Disaster Response) at the Johns Hopkins Bloomberg School of Public Health.