Child Health in Complex Emergencies (2006) / Chapter Skim
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Child Health in Complex Emergencies
Child Health in Complex Emergencies
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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.
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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.
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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)
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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")
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. 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.
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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)
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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.
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. 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)
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. Extremely high mortality rates were documented in 1994 among unaccompanied Rwandan refugee children after their arrival in Goma, Zaire (Dowell et al., 1995)
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. 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)
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. 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.
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. A multicenter study conducted in nonemergency settings between 1996 and 2000 showed that a 3-day course of ciprofloxacin was as effective as the standard 5-day course in children with dysentery due to Shigella dysenteriae type 1 (Dysentery Study Group, 2002)
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Measles Measles has been a major cause of child morbidity and mortality in refugee camps and internally displaced populations, and further contributes to childhood deaths by exacerbating malnutrition and vitamin A deficiency (Toole, Skeketee, Waldman, and Nieburg, 1989; Toole and Waldman, 1997)
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Indoor residual spraying with malathion in refugee camps in eastern Sudan in 1997 was associated with reduced mortality but not with a reduction in the incidence of clinical malaria (Charlwood et al., 2001)
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In nonemergency settings, insecticideimpregnated nets have been shown to have a 17 percent protective efficacy in preventing child mortality, and they are considered highly effective in reducing childhood morbidity and mortality from malaria (Lengeler, 2005)
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However, in part because of the difficulties in diagnosing tuberculosis in children, few published data exist on the prevalence or treatment of childhood tuberculosis in complex emergencies. Highlighting the potential burden of tuberculosis in children in complex emergencies, the average annual risk of infection among internally displaced persons in Tbilisi, Republic of Georgia, in 1999 was highest in children younger than age 10 (5 percent)
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. Other Communicable Diseases Examination of stool specimens for intestinal parasites in Barawan Somali refugees in Kenya in 1997 found a prevalence rate of 51 percent in children younger than age 15 (Morbidity and Mortality Weekly Report, 1998)
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. Malnutrition and micronutrient deficiencies contribute substantially to child morbidity and mortality in complex emergencies (Morbidity and Mortality Weekly Report, 1992; Toole, 1992; Toole and Waldman, 1997)
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Two-thirds of Palestinian children living in refugee camps were found to be anemic in a nutrition survey conducted in 1990 (Hassan, Sullivan, Yip, and Woodruff, 1997)
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A survey conducted in 1998 by the United Nations High Commissioner for Refugees (UNHCR) within eight refugee settings found that neonatal mortality rates and maternal deaths were lower than for the host population and home countries of the refugees (Bitar, 2000)
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. Other types of pediatric trauma reported during conflicts or in refugee camps include bomb-blast injuries among Kurdish refugee children (Haddock and Pollok, 1992)
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. Most studies concluded that children exposed to the violence of armed conflict or the harsh living conditions of refugee camps have high rates of serious psychiatric problems (Fazel and Stein, 2002; Hodes 1998, Lock et al., 1996, Montgomery 1998; Southall and Abassi, 1998)
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CARE International, for example, does not directly provide clinical care but assists other NGOs or ministries of health in providing such care. Catholic Relief Services also does not provide clinical care but focuses on community-oriented preventive and public health activities and supports local partners in these activities.
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As a result of the diversity of health care workers at or below the level of nurses, clinical guidelines for the care of children in complex emergencies need to target personnel with nursing backgrounds and lower level health workers. Most organizations mentioned the need to translate guidelines into local languages and to make them more concise and transportable.
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Health Education and Promotion Some organizations provide health education and health promotion as part of their child health activities in complex emergencies. Action Contra la Faim, Africare, and World Vision, for example, provide health education on disease prevention and personal hygiene.
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Performance Measures Organizations reported collecting data on basic indicators, such as morbidity, crude mortality rates, and case fatality rates that are compiled and reported, usually on a monthly basis. Process indicators used by different groups included the percentage of children younger than age 5 with access to services (Democratic Republic of the Congo)
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Other methods of technical assistance are to train ministry of health staff, for example, as in the establishment of a central epidemiological unit in Afghanistan. The need to provide technical expertise in the establishment or expansion of health information systems also was raised by two groups in the Democratic Republic of the Congo.
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guidelines also were reviewed using the same tool. Existing guidelines are used for the diagnosis and management of cholera, shigellosis, and meningococcal meningitis; management of severe dehydration, severe malnutrition, and micronutrient deficiencies; counseling on infant feeding; and case management and immunization against measles.
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The manual also specifically calls for communication and feedback to the referring community health worker to help strengthen the community and health center referral base. Detailed clinical management guidelines are provided for some of the major causes of child mortality, including measles, malaria, pneumonia, and diarrhea (with guidelines for cholera and dysentery)
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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)
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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.
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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.
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. 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.
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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.
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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.
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. The guidelines for village volunteers, called Essential Community-based Child Health Care (ECCHC)
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(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.
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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.
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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.
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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.
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