Tropical cyclone pam: Vanuatu - WPRO IRISiris.wpro.who.int/bitstream/handle/10665.1/13547/9789290617495-eng.pdf · soP standard operating procedures stis sexually transmitted infections

Public HealtH Risk assessment and inteRventionsTropical cyclone pam: Vanuatu

march 2015

Public HealtH Risk assessment and inteRventionsTropical cyclone pam: Vanuatu

march 2015

WHO Library Cataloguing-in-Publication Data

Public health risk assessment and interventions: tropical cyclone Pam, Vanuatu 1. Cyclonic storms. 2. Disaster planning. 3. Risk management. 4. Vanuatu. I. World Health Regional Office for the Western Pacific.

ISBN 978 92 9061 749 5 (NLM Classification: WA 295)

© World Health Organization 2016All rights reserved.

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be pur-chased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications–whether for sale or for non-commercial distribution–should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines (fax: +632 521 1036, email: [email protected]).The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

For further information, please contact: Emergency Support Team

World Health Organization – Regional Office for the Western PacificManila, Philippines Email: [email protected]

Division of Pacific Technical SupportWorld Health OrganizationSuva, FijiEmail: [email protected]; [email protected]

iii

Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015

iii

conTenTsAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1. Background and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.1 Tropical Cyclone Pam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.2 Priority areas for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2. Priority areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.1 Trauma and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.2 Interruption of critical infrastructure:

water, sanitation and hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.3 Diseases associated with overcrowding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.4 Vector-borne diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.5 Loss of health infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

2.6 Food security and malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

2.7 Existing medical conditions and other health threats . . . . . . . . . . . . . . . . . . . . . .17

3. sPecific Priority interventions for immediate imPlementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

3.1 Water and sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

3.2 Shelter and site planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

3.3 Prevention and management of malnutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

3.4 Essential health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

3.5 Early warning and response network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

3.6 Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

3.7 Vector control and personal protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

4. staff health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

4.1 Vaccination recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

4.2 Malaria prophylaxis and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

4.3 Other precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

5. risk communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Annex 1: Health Services in Vanuatu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Annex 2: Communications messages (specific health issues) . . . . . . . . . . . . . . . . . . . . . . . .39

Annex 3: EWARN case definitions – Cyclone Pam, Vanuatu . . . . . . . . . . . . . . . . . . . . . . . . . .41


iv

abbreviaTions

afr acute fever and rash

aPi annual parasite incidence

alri acute lower respiratory tract infection

ari acute respiratory infection

art antiretroviral therapy

Bms breast-milk substitute

dhP dengue haemorrhagic fever

ePi Expanded Programme on Immunization

evm Effective Vaccine Management

eWarn Early Warning and Response Network

glean Global Leptospirosis Environmental Action Network

hBv hepatitis B Virus

hev hepatitis E

iehk Interagency Emergency Health Kits

ili influenza-like illness

imci Integrated Management of Childhood Illness

irn indoor residual spraying

JmP Joint Monitoring Programme

llin long-lasting insecticidal net

mch maternal and child health

misP Minimum Initial Service Package

mou Memorandum of Understanding

ncd noncommunicable diseases

ndmo National Disaster Management Office

PeP post exposure prophylaxis

Plhiv people living with HIV

Pmtct prevention of mother to child transmission

soP standard operating procedures

stis sexually transmitted infections

tB tuberculosis

tig tetanus immune globulin

unhcr Office of the United Nations High Commissioner for Refugees

unicef United Nations Children’s Fund

vBd vector-borne disease

vhW village health worker

vhW village health workers

vPd vaccine-preventable disease

Who World Health Organization

1


This public health risk assessment provides health professionals in United Nations

agencies, nongovernmental organizations, donor agencies and local authorities

working with populations affected by the Cyclone Pam emergency in Vanuatu,

with baseline health information and up-to-date technical guidance on the major

public health threats. A related document, Public Health Risk Assessment and

Interventions – Typhoon Haiyan, Philippines 16 November 2013 was used as a

template for this document [1].

The health issues and risk factors addressed have been selected on the basis

of the known burden of disease in Vanuatu, and their potential impact on

morbidity, mortality, response and recovery.

Public health threats represent a significant challenge to those providing health-

care services in this evolving situation. It is hoped that this risk assessment will

facilitate the coordination of activities between all agencies working among the

populations affected by the crisis.

preface

2


The Republic of Vanuatu was hit by a Category 5 cyclone on 13 March 2015,

causing widespread destruction and damage to buildings, infrastructure and

loss of communication [2]. Early reports indicate several fatalities and more than

3000 people were evacuated to emergency shelters [2].

Baseline health profile: Prior to the emergency, Vanuatu’s under-resourced health

services had critical health worker shortages [3]. Vaccination rates for measles and

other vaccine-preventable diseases (VPDs) have been suboptimal, and much of the

population has very limited access to health services [4]. Children under-5 require

special attention as natural disasters put children at increased risk of infections such

as gastroenteritis and acute respiratory infections.

Priority areas for public health: • Trauma and Injury

• Interruption of critical infrastructure

• Disease associated with overcrowding

• Increased communicable disease transmission and potential for outbreaks of diseases

• Increased exposure to vector-borne disease

• Loss of health infrastructure

• Nutrition and food security concerns

• Existing medical conditions and other disease threats.

execuTive summary

3


Immediate priorities:• Provision of food, safe drinking-water, appropriate sanitation, shelter,

and other essential non-food items including fuel for cooking

• Trauma care for the wounded with tetanus prevention

• Provision of medicines and medical supplies

• Establishment of emergency primary and secondary care for medical,

surgical and obstetric emergencies

• Risk communication to the public

• Measles vaccination in high-risk areas

• Establishment of an early warning system for early detection and response

to outbreaks

• Infection control in health-care settings including safe blood transfusion,

medical waste management and adequate water supply and sanitation

• Management of acute malnutrition including medical complications

• Continuity of treatment for chronic diseases and chronic infections such

as tuberculosis (TB).

Short-term priorities:• Re-establishment of essential health-care services (primary, referral

and hospital care)

• Emergency mental health care and psychosocial support

• Waste management

• Vector control and provision of personal protection against vector-borne

diseases.

Medium-term priorities:• Post-surgical care and management of disabilities

• Routine immunization

• Health of victims who have migrated and potential returnees.

A national list of case definitions for likely conditions has been defined for

clinical and epidemiological purposes. Laboratory diagnostic support is limited

and clinical definitions are therefore essential for disease management.

Background and risk factorsThe Republic of Vanuatu (Vanuatu) is an archipelago in the South Pacific Ocean,

comprising 83 islands, of which approximately 65 are inhabited, with a total land

area of 12 189 square kilometres, spanning a distance 900 km in length [5].

Vanuatu has an estimated population of 271 000, of which approximately 37% are

under the age of 15 years. Locals are predominantly of Melanesian origin, known as

4


ni-Vanuatu (98.5% population). The national language is Bislama (pidgin). English

and French are widely spoken and are also official languages. There are more than

105 local Melanesian languages and dialects.

The country has six provinces:

Torba, Sanma, Penama, Malam-

pa, Shefa and Tafea. There are

two urban centres: in the cap-

ital, Port Vila, on the island of

Efate (population of 44 039);

and Luganville, on the island of

Espiritu Santo, (population of

13 156 people) [3]. The majority

of the population (74%) lives in

rural areas [6], although rural to

urban movement is increasing,

leading to overcrowding in ur-

ban centres.

The annual per capita income

is US$ 3130 with 6.5% living

in extreme poverty and 35%

vulnerable to poverty. The

Human Development Index

ranking for Vanuatu is 125 out

of 187 [4]. Life expectancy is

70 years for males and 74 years for females [7]. Under-5 mortality has improved

over the past 13 years from 33 deaths per 1000 live births in 1990 to 17 deaths per

1000 live births in 2013 [7]. Infant mortality (death before 1 year of age) in 2010

was estimated to be 28 deaths per 1000 live births – comprising a relatively lower

neonatal mortality rate (12 deaths per 1000 deaths within the first month) compared

to higher post-neonatal mortality (16 deaths per 1000 deaths in months 2–12) [6].

An estimated 20% of the population have no access to health services [3].

The Vanuatu economy is driven by exports of copra, timber, beef and cocoa (20% of

gross domestic product (GDP)), tourism (20% GDP) and foreign aid contributions [3].

5


1. bacKGrounD anD risK facTors

1.1 Tropical cyclone Pam

OIn the evening of 13 March 2015, at approximately 23:00 local time, Tropical

cyclone Pam struck Vanuatu, hitting Port Vila as an extremely destructive

Category 5 cyclone [2]. The cyclone tracked along the length of eastern side of

the Vanuatu archipelago, with the cyclone’s eye passing close to Efate Island,

before heading south directly over the southern islands. Winds were estimated

to have reached more than 250kmph. This caused serious damage to

infrastructure, left debris strewn across the capital and damaged an estimated

90% of structures. The southern-most islands of Tafea Province (population

32 540), were directly struck by the eye wall [2].

While the extent of the damage continues to be assessed, there are reports

of several deaths and serious injuries, many homes have been damaged or

destroyed, and access to health services, food and clean water is limited or

unavailable in many places. On 23 March 2015, the National Disaster Manage-

ment Office (NDMO) had confirmed 11 fatalities. An estimated 3300 people

have been displaced in 37 evacuation centres. The provinces of Shefa, Tafea,

Malampa and Penama are emerging as the worst impacted areas [8].

6


The cyclone has blocked roads with debris, knocked down bridges and caused

flooding. Electricity was out in many places and communication systems were

down or were unreliable, but are slowly being restored. Radio and telephone

communication with the outer islands has been cut off. In Port Vila, commercial

flights that were initially grounded, resumed on 15 March 2015 and access

to water and electricity started to be restored, although an estimated 80% of

power lines were damaged or down [8]. The main hospital in Port Vila was badly

damaged, including the Children’s ward, kitchen and Central Medical Store.

The morgue is unserviceable [8].

In the face of this disaster, the Government of Vanuatu has declared a state of

emergency and requested help from the international community. The Vanuatu

National Disaster Management Office provided the following situation update

on 27 March 2015:

• 166 000 people affected on 22 islands

• 15 000 homes destroyed or damaged

• 75 000 people in need of emergency shelter

• 110 000 people in need of clean drinking-water

• 8700 children vaccinated against measles.

1.2 Priority areas for public health

• Trauma and Injury

• Interruption of critical infrastructure

• Disease associated with overcrowding

• Increased communicable disease transmission and potential for disease

outbreaks

• Increased exposure to vector-borne disease

• Loss of health infrastructure

• Nutrition and food security concerns

• Existing medical conditions and other disease threats.

7


2.prioriTy areas

2.1 Trauma and injuries

Wounds and injuries are frequently associated with the immediate post-cyclone

g period due to strong winds, collapsed structures and debris or from near-

drowning. The management of all injuries may be complicated by delays in

presenting for care and limited access of skilled personnel to the affected areas.

Complications of untreated injuries are death, infections, tetanus and long-term

disability.

2.1.1 TetanusTetanus (“lock-jaw”) is a disease caused by a toxin produced by the bacterium,

Clostridium tetani, affecting the nervous system. Clostridium tetani bacteria

are found in dust and animal faeces. Infection may occur after minor injury

(sometimes unnoticed punctures to the skin that are contaminated with soil,

dust or manure) or after major injuries causing tetanus prone wounds such

as open fractures, dirty or deep penetrating wounds, and burns. Neonatal

tetanus can occur in babies born to inadequately immunized mothers, especially

after unsterile treatment of the umbilical cord stump. Neonatal tetanus has

8


a case fatality rate of 70–100% without medical treatment and is globally

underreported. The incubation period is usually 3 to 21 days.

The tetanus vaccination coverage in Vanuatu was reported in 2013 as 75%

(DTP3), and the Vanuatu Demographic Health Survey conducted in 2013 which

collected information from all children under-5 years, reported coverage in

under-5 year olds of only 55% [6]. The vaccination coverage for all Expanded

Programme on Immunization (EPI) vaccines has varied greatly in past years,

meaning some age groups will be inadequately vaccinated. Maternal and

neonatal tetanus is assumed to have been eliminated from Vanuatu.

The management of wounds needs to consider the probability of tetanus.

Health-care workers operating in disaster settings should be alerted by the

occurrence of cases of dysphagia (difficulty swallowing) and trismus (facial

muscle spasm), often the first symptoms of the disease. A boosting dose of

tetanus vaccine and tetanus immune globulin should be given to patients with

tetanus prone wounds. Patients should also systematically receive prophylactic

antibiotics.

2.2 Interruption of critical infrastructure: water, sanitation and hygiene

Estimates from the Joint Monitoring Programme (JMP) for Water Supply and

Sanitation are that in 2014, 91% of Vanuatu’s population uses an improved

drinking-water source, and 25% of the population will have piped water to their

home [9]. The JMP reports that 58% of the population have improved sanitation

facilities, 20% have shared facilities, 20% unimproved facilities and 2% practise

open defecation [9]. Prior to the cyclone, rural and remote communities were

less likely than urban residents to have an improved drinking-water source and

improved sanitation.

With severe windstorms, water sources can become unsafe for drinking due

to the incursion of floodwaters, faecal contamination caused by overflow of

latrines, inadequate sanitation and upstream contamination of interconnected

water sources. Population displacement, crowding, poor access to safe drinking-

water, inadequate hygiene and toilet facilities, and unsafe practices in handling

and preparing food may cause outbreaks of diseases such as acute watery

diarrhoea, typhoid fever, shigellosis, viral enteritis and hepatitis A and E.

9


2.3 Diseases associated with overcrowding

Population displacement caused by flooding can result in overcrowding in reset-

tlement areas, increasing the risk of transmission of many communicable diseas-

es. Acute respiratory infection, measles, diphtheria, and pertussis are transmitted

from person to person through respiratory droplets during coughing and sneez-

ing. The risks are increased when shelters are overcrowded and inadequately

ventilated. The transmission of meningitis, water-related and vector-borne dis-

eases also increases in such conditions.

Overcrowding leads to an increase in the potential for communicable disease

transmission and outbreaks of diseases such as:

• acute respiratory infections

• measles and other vaccine-preventable disease (VPD)

• diarrhoeal disease (bacterial and viral)

• hepatitis A and E

• leptospirosis

• meningococcal disease.

2.3.1 Acute respiratory infection (ARI)In 2014 there were 6219 cases of influenza-like-illness (ILI) reported. From Jan-

uary 2015 to 8 March 2015, there were 1142 cases of ILI reported [7]. A major

concern is acute lower respiratory tract infection (ALRI), such as pneumonia,

bronchiolitis and bronchitis, particularly in children under-5. WHO estimates that

11% of deaths in children under-5 years in Vanuatu are caused by pneumonia.

ALRI kills more children globally than any other disease. Low birth weight, mal-

nourished and non-breastfed children, and those living in overcrowded condi-

tions are at higher risk of acquiring pneumonia as well as of experiencing more

severe disease and death from pneumonia. Exclusive breastfeeding, adequate

nutrition, and immunization can help reduce infection rates.

Early detection and case management of pneumonia and other common illness-

es, guided by Integrated Management of Childhood Illness (IMCI), will prevent

morbidity and mortality in children under-5. Trained health workers should refer

to the national IMCI guidelines during and after the emergency [10].

10


2.3.2 Diarrhoeal diseaseThe risk of diarrhoeal disease in Vanuatu has increased due to overcrowding,

inadequate sanitation and limited access to safe drinking-water. Acute gas-

troenteritis (bacterial or viral) is often highly contagious. Transmission occurs

through contaminated food and water and directly from person to person.

Bacillary dysentery is the most important cause of acute bloody diarrhoea in

the post-disaster setting. It is caused by bacteria of the genus Shigella – of which

S. dysenteriae type 1 causes the most severe disease and the largest outbreaks.

Bacillary dysentery is endemic in most low- and middle-income countries. Without

prompt, effective treatment the case fatality rate can be as high as 10%.

Rotavirus outbreaks are well documented in the Pacific, and small children in

particular are at high risk of developing severe dehydration, which can lead to

death if not treated promptly with oral or intravenous fluids. Vanuatu does not

vaccinate against rotavirus. During the 2013 Demographic and Health Survey,

around 12% of children under age 5 years were reported to have had diarrhoea

in the previous two weeks; and 1% reported bloody diarrhoea [6].

Large post-disaster outbreaks of diarrhoea have been documented in the Pacific

in the context of floods. In 2014, Solomon Islands experienced a very large post-

flood diarrhoea epidemic that resulted in more deaths than the initial flash-flood

emergency. In that emergency, as is consistently reported, children under 5-years

bore the greatest burden both in terms of morbidity and mortality: children

under-5 years were almost 20 times (versus eight times at baseline) more likely

to suffer from diarrhoea than those five-years of age and older (personal

communication, Dr E Nilles, WHO).

2.3.3 Hepatitis Hepatitis B is endemic in the adult population in Vanuatu, with limited data

suggesting a prevalence of about 12%. Hepatitis B virus (HBV) immunization

success has been modest with childhood prevalence of around 3% and HBV-

vaccine birth dose coverage of about 80%. Hepatitis B birth dose is a priority

for all newborns within the first 24 hours of life, especially those born of HBV-

infected mothers, to prevent mother-to-child chronic hepatitis B transmission.

Hepatitis A can cause outbreaks but is considered less likely than other public

health risks in this context. In most low- and middle-income countries, hepatitis

exposure, infection and life-time immunity, occurs at a young age, when disease

severity is low. Although small clusters of hepatitis A disease may occur in the

disaster setting, large outbreaks are unlikely given high likelihood that most of

the population are immune due to prior infection. Vigilance in appropriate water

and food preparation techniques prior to consumption is, however, strongly

recommended.

11


Hepatitis E (HEV) is usually a self-limiting disease but can progress to severe

disease and death. Pregnant women in particular are at high risk of severe disease

and death. Outbreaks can occur in settings with poor hygiene and sanitation

typically via contamination of food or water sources. Little robust data on

HEV in Vanuatu or the Pacific is available, but a sero-prevalance study in Papua

New Guinea, Kiribati and Fiji reported HEV sero-positivity rates of 15%, 9%,

and 2% respectively [11], demonstrating that this virus circulates in other Pacific

island countries and areas, and thus probably in Vanuatu also. Prior exposure

and immunity levels are not sufficient to prevent HEV outbreaks. There is no

globally available vaccine.

2.3.4 LeptospirosisLeptospirosis is a bacterial zoonosis present worldwide. Outbreaks of leptospi-

rosis commonly occur following flooding, due to the crowding of rodents, wild

and domestic animals and humans on shared dry ground. In this situation, the

disease is likely to be spread through indirect contact with water contaminated

with the urine of rodents, pigs, or other infected animals. Leptospirosis out-

breaks have occurred in the Pacific, sporadic cases are known to occur in

Vanuatu [13].

The Global Leptospirosis Environmental Action Network (GLEAN) has developed

preliminary set of recommendations for the control of disaster-related

leptospirosis outbreaks; these recommendations include: laboratory screening

of suspected cases, empiric treatment of probable cases, and prevention with

the use of barrier protection if there is a potential to come into contact with

contaminated water [14]. If individual exposure occurs when cleaning up after

disasters, the affected body areas should be immediately cleaned with soap and

clean bottled water. Use of mass chemoprophylaxis is not recommended, nor is

mass decontamination of water, however, there is evidence that pre-exposure

chemoprophylaxis decreases morbidity in controlled target populations including

individuals of high risk such as military workers, disaster relief workers, sewage

and sanitation workers [14].

2.3.5 Measles and other vaccine-preventable diseasesVanuatu provides immunization for children against vaccine-preventable diseases

(VPDs) including: tuberculosis, diphtheria, pertussis (whooping cough), tetanus,

hepatitis B, haemophilus influenza, polio and measles [6].

12


In 2013, the Vanuatu Demographic and Health Survey, which conducted house-

hold surveys, found that only one in three (33%) children, aged 12–23 months

received all of the basic vaccinations (BCG, DPT, polio and measles) at some time

prior to the survey, and 7% were fully vaccinated [6]. The Vanuatu Joint Reporting

Form figures for vaccination coverage have greatly improved in the last few years

and show good coverage. However, wide variability in coverage rates in the last

15 years, indicates that a large proportion of children may not be adequately

covered for VPDs [12].

Measles vaccination coverage rates in children under-5 years was found to be

53%, and coverage rates for the third doses of DPT and polio vaccines in children

under-5 years were found to be 55% and 52% respectively [6].

During 2014, a measles outbreak affected the Blacksand area of Port Vila, the

first measles outbreak since 1997. In 2015, a second measles outbreak occurred.

In response, a catch-up campaign is being conducted on Efate. There are around

10 500 doses of monovalent measles vaccine in Port Vila and additional MR

vaccines are available in Suva, Fiji through the United Nations Population Fund

(UNICEF). Effective Vaccine Management (EVM) Assessment took place and

training of assessors started in the week of 8 March 2015.

On 17 March 2015, six teams were deployed to Port Vila for measles vaccination;

another six teams are to be trained for integrated measles response (with Vitamin

A and bed nets). Initial plans are to target Efate, Tanna and Sanma. Efate and

Tanna were both severely affected by the cyclone and although Santo was not

badly affected by the cyclone, they recently reported a large number of cases of

acute fever and rash (AFR) through syndromic surveillance.

There is a requirement to strengthen the early warning alert and response net-

work for AFR through the health centres in Port Vila and in the other affected

areas. Reports are starting to be received from sentinel sites outside Port Vila.

The Western Pacific Region was declared polio free in October 2000 and all

Pacific island countries have remained polio-free. The last reported polio case

(clinical) in the Pacific was in 1979. The case was not laboratory confirmed.

2.3.6 Meningococcal diseaseNeisseria meningitidis, the bacterium causing meningococcal disease, is spread

from person to person through respiratory droplets from infected people. There

are two classical clinical presentation of meningococcal disease: meningitis and

severe sepsis, although cases may present with overlapping features. Transmission

is facilitated by close contact and crowded living conditions. Health care workers

need to be vigilant for cases of meningococcal disease, and urgently report any

cases. The Case Fatality Rate of meningococcal disease is 5-10%, even with

appropriate and rapid antibiotic treatment.

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2.3.7 TuberculosisVanuatu, with an estimated tuberculosis (TB) incidence of 65 cases per

100 000 population in 2013 has a moderate TB burden. The notification rate

for 2013 was 44 cases per 100 000 population, with corresponding 126 TB cases

notified. The TB burden is higher among women compared to men, unlike in

the majority of countries. All age groups are affected, with a peak among the

14-24 age group among women, and in the over 65 years age group, for both

women and men. Provinces with higher notification rates are Taefa and Shefa,

although the lack of a patient-based national register does not allow a thorough

geographical analysis.

In the acute phase of this emergency, follow-up and continuity of treatment

of patients already on care should be maintained when feasible and for that

purpose stocks of anti-TB medicines shall be ensured. Due to the demonstrated

link between emergencies and TB, once response to trauma-related emergency

has been provided, service provision in terms of TB detection by smear

microscopy should be conducted to displaced communities to identify cases and

avoid TB transmission.

2.4 Vector-borne diseases

There is an increased risk of vector-borne diseases (VBD) such as dengue,

chikungunya, Zika and malaria. Flooding may initially flush out mosquito

breeding, which can restart when the waters recede. The lag time is usually

6-8 weeks before the onset of increased VBD transmission.

2.4.1 ChikungunyaChikungunya fever is of moderate risk and presents very similarly to dengue

usually with swelling and pain in large joints, although haemorrhagic

complications are rare. A significant proportion of patients develop a long-

term debilitating arthritis that lasts for months to years. Both infections are

transmitted by Aedes mosquitoes that breed in close proximity to human

settlements. Collections of water in debris and damaged houses can contribute

to increased mosquito breeding sites.

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2.4.2 DengueDengue is a viral disease transmitted by the Aedes mosquito, which is endemic

in the Pacific. In late 2013, a large outbreak of dengue fever occurred in Vanuatu,

with 1561 cases reported in December 2013. The outbreak continued into 2014,

however data was not available on the final numbers (Roth et. al 2014).

Dengue epidemiology is rapidly evolving, with outbreaks occurring more

frequently and expanding to areas that were previously unaffected. The risk

of transmission may increase among people living in inadequate shelters or

overcrowded conditions, particularly where fresh water is stored in unprotected

water containers and rainfall collects in other artificial containers, allowing

mosquitoes to proliferate.

Dengue causes a severe influenza-like illness. Occasionally a severe form of the

disease with potentially lethal complications including dengue haemorrhagic

fever (DHF) can occur. Severe dengue can affect all age groups. Mortality is highest

during the initial period of the outbreak or epidemic. Children are at particularly

high risk of mortality as a result of complications, especially if treatment is

delayed. Early detection and treatment of DHF can reduce the case-fatality ratio

from 20% to less than 1%. Supportive treatment supplies should be stockpiled.

2.4.3 MalariaMalaria is endemic in most islands of Vanuatu, which has an overall Annual

Parasite Incidence (API) of 13.2 cases per 1000 population (2012). Transmission

is generally higher in the northern provinces than the southern provinces, with

an API of 38.2 reported on Torba, and 20–21 per 1000 reported in Malampa,

Penama and Sanma in 2012. Shefa reported an API of 4.7 per 1000 and Tafea

reported an API of 0.4 per 1000 in 2012. The national API decreased from 74 per

1000 in 2003 to 13 per 1000 in 2012, and the virtual disappearance of confirmed

malaria-related deaths. Tafea achieved close to zero local malaria transmission in

2013 and is on track to achieve sub-national elimination by 2016.

The malaria programme is the most operationalized public health programme

in Vanuatu. Preventive intervention is based on using the insecticide treated

nets (long-lasting insecticide nets (LLIN)) and selective indoor residual spray in

elimination provinces (Tafea and Torba). The Demographic Health Survey in 2013

indicated that 83% of households (91% in rural areas) owned at least one LLIN.

The last mass distribution campaign of LLIN was in 2013 when over 90 000 long-

lasting insecticidal nets (LLINs) were distributed. Most health facilities including

aid posts provide malaria diagnosis using rapid diagnostic tests or microscopy

and recommended first-line regimen (Artemether-Lumefanthrin).

15


To prevent and mitigate the risk of a malaria outbreak:

• ensure full replacement of lost, damaged or destroyed LLINs;

• malaria case management services should be restored and strengthened

as soon as possible to ensure adequate services are available and accessible;

• restore and maintain routine surveillance and surveillance of selective areas

(e.g. evacuation centres); and

• develop a recovery plan for preventive intervention through distribution

of LLINs to the affected areas.

2.4.4 ZikaZika virus is a newly emerging cause of outbreaks and usually results in a mild

disease characterized by low grade fever and rash. Recent outbreaks have been

reported in French Polynesia, the Federated States of Micronesia, New Caledonia

and Solomon Islands. As of 20 March 2015, six confirmed cases diagnosed in

New Caledonia have been said to have originated from Vanuatu. However,

there is no outbreak reported in Vanuatu.

2.5 Loss of health infrastructure

Government health services in Vanuatu comprise a four-tier system: referral

hospitals, health centres, dispensaries and community supported aid posts.

Vanuatu is divided into the northern and southern health-care directorates.

The Northern Health Care Directorate, based in Luganville, delivers curative and

preventive health services in Torba, Sanma, Penama and Malampa provinces.

The Southern Health Care Directorate coordinates health services for Shefa and

Tafea provinces [12].

Each province is made up of several islands which are then divided into zones.

Health facilities are distributed among these zones. There is a referral hospital in

each of the two Health Care Directorates. Community and preventive services

include: malaria control, environmental health, immunizations, reproductive

health, MCH/Reproductive Health/Family Planning, STIs and HIV/AIDS, TB/leprosy,

IMCI, nutrition and health promotion programmes. Appendix 2 describes the

type of services provided at each level [4].

A review of Human Resources for Health in Vanuatu in 2012 showed critical

health worker shortages [3]; Vanuatu has the third lowest health workforce

density in the Pacific region. The greatest shortages are in rural areas. It has been

estimated that 1261 health workers were employed in the public sector in 2012,

including 397 nurses and midwives, and 46 doctors [3]. This is equivalent to

1.77 health workers per 1000 population. This is considerably lower than the

WHO minimum recommended 2.3 health workers per 1000 population.

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2.6 Food security and malnutrition

Food security can be adversely affected by disruptions in the food system,

including spoilage, crop loss, the inability to replenish stock due to transport

constraints, and the inability to store and process foods. This may lead to limited

availability of safe and nutritious food and consumption of potentially unsafe

food and/or inadequate food consumption, with low dietary diversity and poor

nutrient quality. Vulnerable groups include children, particularly children under-

5 years, pregnant and lactating women and older people.

In 2007, the Vanuatu Multiple Indicator Cluster Survey showed that the

underweight prevalence for the under-5 age group was 15.9% and the stunting

prevalence (the percentage of children under-5 who have low height for their

age) was 20.1% [13]. During emergency situations such as Tropical Cyclone

Pam, disease and death rates among children under-5 are usually higher than

for any other age group; the younger the infant the higher the risk. Mortality

risk is particularly high because of the combined impact of a greatly increased

incidence of infectious diseases, diarrhoea and malnutrition.

Breastfeeding provides critical protection from infection in environments

without safe drinking-water supply and sanitation. In 2007, the initiation of

breastfeeding (within 1 hour of giving birth) was reported to be 71.9%, with the

exclusive breastfeeding rate among infants 0-5 months of 39.7% [13]. During

emergencies, it is even more critical to encourage and support mothers to

initiate breastfeeding within one hour after the delivery, to exclusively breastfeed

up to six months and for those with infants under 6 months who “mix feed”, to

revert back to exclusive breastfeeding if possible [14].

In accordance with internationally accepted guidelines, donations of infant

formula, bottles and teats, and other powdered or liquid milk and milk products

should not be made. Experience with past emergencies in other countries

have shown an excessive quantity of products, which are poorly targeted,

endangering infants’ lives. Any procurement of breast-milk substitutes (BMS)

should be based on careful needs assessment and in coordination with UNICEF.

Any distribution and use of BMS should be carefully monitored to ensure that

only the designated infants receive the product.

Basic interventions to facilitate breastfeeding include prioritizing mothers

with young children for shelter, food, security, and water and sanitation. This

will enable mother-to-mother support, specific space for skilled breastfeeding

counselling and support to maintain or re-establish lactation.

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The risk of foodborne disease outbreaks also increases during disaster situations.

Food contamination may occur at any point of the food chain. Inadequate

washing and cooking of food before consumption is often a prime cause of

inadvertent contamination. Similarly, power outage, limited access to safe

drinking-water and inappropriate cooking facilities increase the risk of food

contamination. There may also be improvised large-scale preparation of cooked

food and/or distribution of imported and locally produced food items. In this

context it is important that appropriate food safety measures are implemented

to ensure food safety during mass feeding operations as well as inspection of

pre-packaged food distributed to affected populations.

2.7 Existing medical conditions and other health threats

2.7.1 Noncommunicable diseasesDuring emergencies and disasters access to adequate nutrition and medicine

is an issue, making people with noncommunicable diseases (NCDs) more

vulnerable and at risk in developing acute complications. NCDs account for an

increasing proportion of the disease burden in Vanuatu, with the prevalence

of diabetes mellitus and hypertension in the adult population at approximately

20% and 28%, respectively [15]. Older people, who already comprise 6%

of the population, may be particularly at risk of and vulnerable to treatment

interruption, due to age-related barriers to access such as reduced mobility as

well as co-morbidities [16]. This group of diseases places a substantial burden

on health services and an impoverishing drain on families and communities. The

priorities during the acute phase of this emergency are to minimize treatment

interruptions. Identification of NCD patients on treatment; supply of essential

medicines, equipment and follow up are essential.

2.7.2 Skin infections Infestations, such as scabies and lice may occur and require treatment once they

occur. These infections occur due to overcrowding and as a result of a lack of

water and reduced hygiene.

2.7.3 Sexually transmitted infections including HIVSimilar to most Pacific island countries, Vanuatu’s HIV prevalence among

15-19 years old is still below 0.1%; with a cumulative total of 9 reported cases

from 2002 to December 2012. Four patients are currently on antiretroviral

therapy (ART) [17].

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With regards to other sexually transmitted infections (STIs), from 2011 to 2014

21% of 14 037 men and women tested were infected with Chlamydia; 5.6%

of 13 655 people tested had gonorrhoea; and 4.3% of 9831 people tested had

syphilis. During the same period, STI testing among pregnant women showed

infection rates of 23.5% (n = 336/1431) with Chlamydia; no cases of gonorrhoea

(while 2008 Second Generation Surveillance data revealed 3%); and 4.3%

(n = 19/1097) had syphilis [17].

During emergency situations, essential STI and HIV prevention, treatment, care

and support services are usually disrupted. Further, existing gender inequalities

make women and children, specifically girls, disproportionately more vulnerable

to STI and HIV infection. This increased vulnerability is a consequence of mass

displacement, separation from family members and/or loss of livelihood or lack

of employment opportunities that may force women and girls to resort to sex

work or be subjected to sexual exploitation.

People living with HIV (PLHIV) and other key populations at higher risk to HIV

(sex workers and men having sex with men) may require specific measures to

protect themselves from physical and sexual violence and discrimination.

The initial and essential response to the prevention and control of STI/HIV

transmission includes: provision of prevention information on STI and HIV,

including prevention of mother-to-child transmission (PMTCT); condom supplies

and information on correct condom use; availability of STI and antiretroviral

drugs to those who are already on treatment, for PMTCT and for post exposure

prophylaxis (PEP); and ensuring treatment adherence among those receiving

ART and STI treatment.

An expanded response can occur once the situation is better understood

and additional human and financial resources have been identified to support

implementation. Palliative and home-based care should also be quickly re-

established.

2.7.4 Gender and violence against women Violence against women is a major health issue; it is reported that women

have a 60% lifetime risk of experiencing physical and/or sexual violence by

an intimate partner. Of those women, 90% report severe violence, only

10% report moderate violence.

The same factors affecting vulnerability to STI and HIV, such as existing gender

inequalities, place women and girls at higher risk of experiencing physical and

sexual violence post-disaster. The initial and essential response includes ensuring

safety and security in evacuation centres (e.g. good lighting and ensuring the

privacy of women and girls) and putting in place mechanisms to collect evidence

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and file criminal complaints, monitor and respond to physical and sexual

violence. Clear steps on the health sector’s response to intimate partner physical

and sexual violence should be known to all health-service providers [18].

2.7.5 Mental health and psychosocial supportAny major loss (e.g. death of family, property) and stressful situation (e.g. short-

age of food, living in emergency shelter) will contribute to the increase of mental

health conditions. Incidence of any mental disorders such as depression, anxiety,

acute and post-traumatic stress, and psychosis is likely to increase, particularly

in vulnerable populations such as women, children, older people, poor people,

those from low-income households, displaced people.

2.7.6 Neonatal and reproductive healthThe fertility rate in Vanuatu is 4.2 children born per woman [6]; this has

not changed since the last population census in 2009, which was 4.1. The

Demographic and Health Survey in 2013 found that the crude birth rate (number

of births per 1000 population) was 32.5 per year (equating to approximately

8000 births in Vanuatu per year). In general, the birth rate is higher in rural

areas than in urban areas. At the time of the survey, nearly 17% of teenage

women, aged 15-19 years had started childbearing [6]. Although family planning

methods were recorded as high as 47%, only 34% used modern methods.

The maternal mortality rate is reported to be 110 deaths per 100 000 live births

[4], or approximately 6-7 deaths per year in Vanuatu.

The Vanuatu Demographic and Health Survey reported that in 2013, more than

76% of women received antenatal care from a skilled provider, although only

approximately 50% of women received the WHO recommended four or more

antenatal visits during an uncomplicated pregnancy [6]. Approximately 89% of

births were delivered in a health facility and were attended by a skilled provider.

Emergency reproductive services are available at two referral hospitals, Northern

District Hospital (Santo) and Vila Central Hospital (Efate) and at the Lenakel

Provincial Hospital (Tanna). The Demographic and Health Survey reported that

12% of births in the previous five years were delivered by caesarean section.

The Vila Central Hospital reports a lower rate for 2014 of approximately 8%.

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2.7.7 Environmental risks Safe drinking-water supply for communities

• Information on interruptions/insufficient water supply in communities

• Water is unchlorinated or insufficiently chlorinated (no chlorine smell or

taste in water at the tap) or is turbid (cloudy)

• Broken water pipes or uncovered or unsanitary water reservoirs.

Essential environmental health services at health-care facilities and hospitals

• Water supply

- Information on Interruptions/insufficient water supply at the facilities

- Water is unchlorinated or insufficiently chlorinated (no chlorine smell

or taste in water at the tap) or is turbid (cloudy)

- Broken water pipes or uncovered or unsanitary water reservoirs

• Waste management

- Insufficient or inadequate waste disposal containers

- No separation of wastes (e.g. sharps – organics – paper and plastics)

- Lack of fenced medical waste disposal area or medical wastes (needles,

dressings, drugs) observed in the facility and public spaces

• Infection control

- Lack of personal protective equipment (gloves, overalls, masks) for staff

- Lack of soap or handwashing posters at handwashing points

• Vector control

- Breeding sites (stagnant pools, food waste) in and/or around the facility

- Prepared food is unprotected from flies, other insects or rats

- Latest information on this is expected to be shared in the health cluster

bulletins issued by the Ministry of Health and WHO Country Office.

2.7.8 Dead body managementLarge numbers of dead bodies can be traumatic for viewers and require

urgent identification and proper burial. It is important to convey to all parties

that corpses do not represent a public health threat. For those involved in the

collection and burial of bodies, standard precautions for infection prevention and

control should be followed. In Vanuatu, following Cyclone Pam, early reports

regarding the damage at the hospital indicate that the morgue is non-functional,

meaning an alternative storage facility will need to be found.

21


2.7.9 Drugs procurement and supply chain management In emergency situations, negotiated procurement may be used to purchase es-

sential medicines to expedite the process by foregoing formal advertising and

price competition. The selection of a contractor will be made to the best ad-

vantage of the Government, price and other factors considered. The aim of the

negotiated procurement during emergency situation is to ensure that shortages

of essential drugs over the next few months are minimized. The country has to

ensure that an effective supply chain management system is in place that will

ensure that the amount of inventory to be held at various locations or health

facilities is adequate.

2.7.10 Drug donationsDrug donations should be of maximum benefit and they must be based on

the needs of the recipient country. During an emergency, the Ministry of Health

informs donors of their needs, approves donations and coordinates receipt

and distribution.

Guidelines for medicine donation should be adhered to, conforming to the

following principles:

• Maximum benefit to recipient or country – donated drugs are very often not

relevant to the emergency situation or are donated in wrong quantities.

Donations should benefit the recipient to the maximum possible extent and

only essential medications that are part of the national essential drug list

should be sent.

• Respect for wishes and authority of the recipient – donor agencies often

ignore the existence of the local pharmaceutical industry and administrative

procedures for receiving and distributing pharmaceuticals and medical equip-

ment. Donations should comply with government and organizational policies.

• No double standards quality – many donated drugs arrive expired, unsorted

or labelled in languages unknown by local professionals. If the quality of

drug is not acceptable in the donor country and does not comply with its

standards, it is also not acceptable for the recipient. The date of expiration of

the drugs must be no less than one year from arrival in the recipient country.

• Effective communication between donor and recipient – donations are very

often sent without prior consultation or consent of the recipient. Donations

should be based on an expressed need.

In emergency situations, it is appropriate for a country to receive standardized

Interagency Emergency Health Kits (IEHK). The IEHK provide a complete

spectrum of essential drugs and medical supplies specifically adapted to

emergency situations.

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2.7.11 Storage and distributionEven essential drugs can be troublesome for a recipient country when sent in

excessive quantities. Local medical storage capacity is often insufficient to house

an enormous influx of drugs. Very often additional storage space has to be

rented at extra cost, or space in health-care facilities has to be re-purposed to

accommodate donations.

A well-designed and well-managed distribution system should:

• Keep medicines in good condition throughout the distribution process;

• Ensure medical supplies are distributed directly to health institutions in

affected areas;

• Minimize medicine losses caused by spoilage and expiry;

• Maintain accurate inventory records;

• Rationalize medicine storage points;

• Use available transportation resources as efficiently as effectively as possible;

• Reduce theft and fraud; and

• Incorporate a quality assurance programme.

2.7.12 Disposal of pharmaceuticals As the potential consequences of the influx of non-essential, expired or poorly

labelled drugs pose serious threat, most need to be disposed of. This adds

further costs for local governments. Constraints in funding for disposal of waste

pharmaceuticals necessitate cost-effective management. This can be achieved by

sorting the material to minimize the need for expensive or complicated disposal

methods.

It is not advisable to use damaged or expired products and should only be

collected ready for disposal. All medicines, which need to be disposed, should

be disposed of in line with the approved procedures and WHO Guidelines for

Safe Disposal of Unwanted Pharmaceuticals in and After Emergencies [19].

Disposal of drugs should be by high-temperature incineration (i.e. >1200ºC)

if facilities are available in which the cost of disposing of hazardous waste in

this way ranges from US$ 2000 to US$ 4000 per tonne.

In emergency situations, temporary burial of pharmaceutical and other wasted

medical supplies is an appropriate option until properly functioning incinerators

are in working order. Poorly-destroyed supplies in medium-temperature

incinerators are as great a hazard as landfills. If facing a huge amount of

damaged, expired or damaged labelled medicines, both liquid and solids, do

not dispose of them but keep them in a safe place until a reliable disposal

system is in place. Ensure these are not disposed of into rivers or seas.

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3. specific prioriTy inTervenTions for immeDiaTe implemenTaTion

Immediate priorities:1. Provision of safe and nutritious food, safe drinking-water, appropriate sanita-

tion, shelter and other essential non-food items including fuel for cooking

2. Trauma care for the wounded with tetanus prevention

3. Provision of medicines and medical supplies

4. Establishment of emergency primary- and secondary-care services for

medical, surgical and obstetric emergencies

5. Risk communication to the public

6. Measles vaccination in high-risk areas

7. Establishment of an early warning system for early detection and response

to outbreaks

8. Infection control in health-care units including safe blood transfusion,

medical waste management and adequate water supply and sanitation

9. Management of acute malnutrition including medical complications

10. Continuity of treatment for chronic diseases, such as diabetes, hypertension

and chronic infections such as TB and HIV.

24


Short-term priorities:1. Re-establishment of essential health care services (primary, referral and

hospital care)

2. Emergency mental health care and psychosocial support

3. Waste management

4. Vector control and provision of personal protection against vector-borne

diseases.

Medium-term priorities:1. Post-surgical care and management of disabilities

2. Routine immunization

3. Health of victims who have migrated and potential returnees.

3.1 Water and sanitationProvision of essential environmental health services to affected populations

includes ensuring a minimal amount of clean water per day and safe disposal

of excreta and wastes. Ensuring uninterrupted provision of safe drinking-water

is the most important preventive measure in reducing the risk of outbreaks of

water-related diseases.

• The Office of the United Nations High Commissioner for Refugees (UNHCR),

WHO and the Sphere project recommend that each person be supplied with

at least 15–20 litres of clean water per day.

• Chlorine is the most widely available, easily used and affordable drinking-

water disinfectant. It is also highly effective against nearly all waterborne

pathogens.

- For point-of-use or household water treatment, the most practical forms

of free chlorine are liquid sodium hypochlorite, sodium calcium

hypochlorite and bleaching powder.

- The amount of chlorine needed depends mainly on the concentration

of organic matter in the water and must be determined for each situation.

After 30 minutes, the residual concentration of active free chlorine in

the water should be 0.5 mg/litre, which can be determined by using a

simple field test kit.

• The provision of appropriate and sufficient water containers, cooking pots

and fuel can reduce the risk of cholera and other diarrhoeal diseases by

ensuring that water storage is protected and that food is properly cooked.

• The need for good hygiene should be emphasized to the public.

• Adequate sanitation facilities must be provided in the form of latrines

or designated defecation areas.

25


3.2 Shelter and site planning• Shelters for displaced or homeless people should be positioned with sufficient

space between them and, in accordance with UNHCR and Sphere standards

aimed at preventing diseases related to overcrowding.

• In shelter sites and during food distribution, attention and protection should

be given to women, older people, unaccompanied minors and people with

disabilities. Women should be included in planning and implementing shelter

and food-distribution activities.

• Waste should be disposed in a pit, away from shelters and protected from

rodents to reduce the exposure of the population to rodents, flies and other

vectors of disease.

• Shelters should be equipped with long-lasting insecticidal nets (LLIN) for each

sleeping space to prevent malaria transmission. Where housing conditions

allow, indoor residual spraying (IRS) can be carried out if less than 85% IRS

coverage of dwellings in the locality can be assured.

• Distribution of non-food items will be required, including blankets, water

containers, cooking materials.

3.3 Prevention and management of malnutrition• Infants should have skin-to-skin contact with their mothers within 30 seconds

of birth, and breastfeeding should start when the baby shows feeding cues

(usually within 90 minutes).

• Exclusive breastfeeding (with no food or liquid (including water) other than

breast milk) should continue until 6 months of age. The aim should be to

create and sustain an environment that encourages frequent breastfeeding

for children up to 2 years of age.

• Donations of milk-powder supplies usually increase in emergency situations

and contribute to a higher number of infants with diarrhoea and pneumonia.

These donations also exacerbate the low percentage of exclusively breastfed

infants. For those unable to be breastfed, the following hierarchy of feeding

should be followed: 1) expressed breast milk by mother; 2) breastfeeding

from surrogate donors and donor expressed breast milk. The few infants who

have no access to breast milk require an adequate supply of infant formula,

safe drinking-water and clean utensils. For those few cases, health-care

providers, including mothers, should be provided with guidance on the safe

preparation of infant formula products.

26


• Many adults will have been or will now also be of borderline nutritional

status, and given that diarrhoeal disease may further compromise this,

attention must be paid to adequate and equitable distribution of food, and

maintaining nutrition of breastfeeding mothers.

• Bacterial infections are very common in severely malnourished children on

initial admission to hospital. Clinical management of severely malnourished

patients, including fluid management, must be thorough, carefully monitored

and supervised. Common problems encountered in severe malnutrition

include hypothermia, hypoglycaemia, dehydration and electrolyte

disturbances. Phases and principles of management of severely malnourished

children should be followed as outlined in WHO Guidelines on the

Management of Severe Acute Malnutrition in Infants and Children [20] [21].

• Populations dependent on food aid need to be given a food ration of

safe and adequate quantity and quality (ensuring dietary diversity, cultural

acceptability and covering all macro- and micronutrient needs). Infants from

six months of age onwards need hygienically prepared, and easy-to-eat,

digestible complementary foods that nutritionally complement breast milk.

Regular assessments of household access to adequate safe and nutritious

food (including market prices) needs to be undertaken and emergency food

aid needs to be adapted accordingly. Household access to facilities for the

safe preparation of food should also be assessed on a regular basis and

emergency supplies of necessary utensils and appropriate energy sources for

cooking should be adapted accordingly.

• After the acute phase of the emergency, efforts will be needed to improve

sustainable household access to food (e.g. seed distribution, land/crop

management, income generating activities) and to institute appropriate

child-feeding and caring practices, including diversifying diets and improved

hygiene.

• Poor hand hygiene exacerbates the spread of diarrhoeal diseases, even in the

presence of adequate nutrition.

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3.4 Essential health services

Access to health services is critical for affected populations, including case-man-

agement protocols, and medications and materials to treat likely high-burden

conditions (trauma/wounds, communicable and noncommunicable diseases and

emergency reproductive health services).

Standardized simple therapeutic proceduresTherapeutic procedures should be economical in terms of human and material

resources. Health personnel and supplies should support these procedures.

First line medical treatment should be simplified and aim to save lives and pre-

vent major secondary complications or problems. Use of standardized proce-

dures, such as extensive debridement, delayed primary wound closure or use of

splints instead of circular casts, can produce a marked decrease in mortality and

long-term impairment.

Redistribution of patients between hospitalsWhile health-care facilities within a disaster area may be damaged and under

pressure from mass casualties, those outside the area may be able to cope with a

much larger workload or provide specialized medical services such as neurosurgery.

The effective and equitable delivery of emergency medical treatment requires a

high level of coordination among national health services and partner agencies

that allows functioning hospitals to operate as part of a referral network. A net-

work of prehospital relief teams can coordinate referrals from the disaster area.

Essential medical and surgical carePriority must be given to providing emergency medical and surgical care to

people with traumatic injuries, which account for many of the health-care

needs among those requiring medical attention in the immediate aftermath of

the disaster. Falling structures cause crush injuries, fractures, and a variety of

wounds. Appropriate medical and surgical treatment of these injuries is vital to

improving survival, minimizing future functional impairment and disability and

ensuring as full a return as possible to community life. To prevent avoidable

death and disability, field health personnel dealing with injured survivors should

observe basic principles of trauma care:

• Patients should be categorized by the severity of their injuries and treatment

prioritized in terms of available resources and chances for survival. The under-

lying principle of triage is allocation of resources to ensure the greatest health

benefit for the greatest number.

28


• Open wounds must be considered as contaminated and should not be closed.

Debridement of dead tissue is essential which, depending on the size of

the wound, may necessitate a surgical procedure undertaken in appropriate

(e.g. sterile) conditions. Any associated involvement of organs, neurovascular

structures or open fractures will also necessitate appropriate surgical care.

• After debridement and removal of dead tissue and debris, wounds should be

dressed with sterile dressings and the patient scheduled for delayed primary

closure.

• Patients with open wounds should receive tetanus prophylaxis (vaccine and/

or immune globulin depending on vaccination history). If the vaccination

history is unknown, both should be given. Antibiotic prophylaxis or treatment

will likely be indicated.

• Wherever possible, search and rescue workers should be equipped with

basic protective gear such as footwear and leather gloves to avoid puncture

wounds and exposure to diseases such as leptospirosis.

• HIV post-exposure prophylaxis kits should be available to health-care workers,

rescue and safety workers in case of accidental exposure to contaminated

blood and body fluids.

Reproductive health servicesAccess to comprehensive emergency reproductive health services and implemen-

tation of the Minimum Initial Service Package (MISP) for Reproductive Health in

Crisis Situations:

• A lead agency for reproductive health should be identified along with a repro-

ductive-health officer to ensure coordination, communication, and collabora-

tion in MISP implementation.

• Measures should be put in place to prevent sexual violence and to respond to

the needs of victims of sexual violence.

• HIV transmission should be prevented.

• Excess maternal and newborn morbidity and mortality should be prevented.

• Plans should be put in place for the transition to comprehensive reproductive

health services.

Communicable diseases• Heightened community awareness of the need for early treatment and rein-

forcement of proper case management are important in reducing the impact

of communicable diseases. The use of standard treatment protocols in health-

care facilities with agreed-upon first-line drugs is crucial to ensure effective

diagnosis and treatment for ARI, the main epidemic-prone diseases (including

29


dysentery, typhoid, dengue and DHF, leptospirosis, measles, malaria,

and meningitis) and STIs.

• Standard infection control practices should be in place in accordance

with national protocols.

• Malaria treatment:

- Uncomplicated-unconfirmed: Artemether-Lumefantrine

- Uncomplicated laboratory-confirmed P. falciparum infection:

Artemeter-lumefantrine + Primaquine (single dose)

- Severe malaria: Quinine + Tetracycline

- Uncomplicated P. vivax infection: Chloroquine + Primaquine (14 days).

• Tetanus: Appropriate management of injured survivors should be implemented

as soon as possible to minimize future disability and to prevent avoidable

death following disasters.

• Tuberculosis: maintenance of routine supply of TB drugs is essential.

Noncommunicable diseases• Continuation of treatment for people on medications for hypertension,

diabetes, cancer, chronic respiratory disease and kidney disease. Where

feasible, decentralization of care will increase treatment coverage given the

restrictions on movement.

• People who are in shelters can be checked for a history of diabetes and

high blood pressure. Management should include measuring blood pressure

and blood glucose and continuing provision of drugs. Shelters and centres

accommodating people should be made smoke free. Penicillin prophylaxis for

rheumatic heart disease should be maintained where feasible.

• Mental health and psychosocial support should be considered in the provision

of general health care. Psychological first aid should be given to distressed

people who have been exposed to a crisis event. Psychological first aid

involves:

- providing practical care and support, which does not intrude;

- assessing needs and concerns;

- helping people to address basic needs;

- listening to people, but not pressuring them to talk;

- comforting people and helping them to feel calm;

- helping people to connect to information, services and social supports; and

- protecting people from further harm.

• Continued access to care should be assured for people with severe mental

disorders. The mental health and wellbeing of the health-care workers also

needs attention [22].

30


3.5 Early warning and response network

The Early Warning and Response Network (EWARN) aims to detect disease out-

breaks. Rapid detection of cases of epidemic-prone diseases is essential to ensure

rapid control. The EWARN is used to inform risk assessments of any disease

incident, allowing resources to be allocated proportionally and appropriately.

To be effective, EWARN needs to:

• focus on the communicable diseases most likely to occur in the disaster-

affected population;

• be simple to use, uniform in style and include standard case definitions and

reporting forms (see Annex 3 for EWARN diseases/syndromes under surveil-

lance with case definitions;

• ensure detailed outbreak response plans/standard operating procedures,

including for identification and training of rapid response teams and ade-

quate stockpiles of supplies (such as oral rehydration solutions, Zinc tablets,

ciprofloxacin for Shigella, amoxicillin and vitamin A for measles, Artemether-

Lumefanthrin for malaria, and intravenous (IV) solutions); and

• reinforce laboratory capacity: (i) to promptly test for the main communicable

disease threats; and (ii) to assure shipping supplies and protocols are in place

to facilitate international shipment for pathogen confirmation.

3.6 Immunization

• In evacuation centres or other crowded settings, vaccination using a measles

containing vaccine, together with vitamin A, should be an immediate

priority health intervention (at least 20% of children are vitamin A deficient).

Children aged 6-59 months (susceptibility profile based on prior coverage

through routine and supplementary immunization activities and immunity

gaps identified through prior measles surveillance) should receive the measles

vaccine, regardless of previous vaccination or disease history. Infants 6-11

months should receive 100 000 international unit (IU) of vitamin A and

children 12-59 months should receive 200 000 IU of vitamin A.

Re-vaccination of infants who received their first dose of measles vaccine

at 6-8 months of age is recommended once they reach 9 months; the

minimum interval between doses is one month.

• A single suspect measles case is sufficient to prompt the immediate imple-

mentation of activities to control measles.

• Mass tetanus vaccination programmes to prevent disease are not indicated.

• Wounds or lacerations may occur from objects submerged in floodwaters.

Tetanus vaccine (TT or Td) and tetanus immune globulin (TIG) is indicated for

31


those with open wounds who have never been vaccinated. TIG is indicated

for previously vaccinated people who sustain wounds (e.g. clean-up workers),

depending on their tetanus immunization history.

• Mass vaccination against influenza is not indicated.

• When the situation stabilizes, vaccinations routinely offered by the national

immunization programme should be made available.

• Hepatitis A vaccine is not recommended to prevent outbreaks in the affected

population.

• Typhoid vaccination, in conjunction with other preventive measures, may be

useful to control typhoid outbreaks, depending on local circumstances.

• Vaccination efforts should always be supplemented by health education and

improved sanitation. Special attention should be paid to the safe manage-

ment and disposal of waste from immunization activities to prevent the trans-

mission of bloodborne pathogens.

3.7 Vector control and personal protection

• Long-lasting insecticidal nets should be made universally available,

with priority given to pregnant women and children under-5 years.

• Refuse must be collected and appropriately disposed of to discourage

rodent and vector breeding.

• Water-storage containers should be closed or covered with mosquito-

proof lids.

• Space spraying and larviciding will control fly and mosquito populations,

and may be desirable around displacement centres.

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4. sTaff healThVaccinations and malaria prophylaxis are recommended for staff deployed to

Vanuatu.

Emergency settings differ vastly, including their epidemiological context. As such,

medical preparation must be as comprehensive as possible (within the limitations

imposed by departure at short notice) and tailored specifically for Vanuatu.

A minimum period of time is required following vaccination, to build up

protective levels of antibodies. A series of injections may be necessary. It is

advised that staff receive vaccinations two weeks in advance of departure if

possible (see Table 1 below). In the event of immediate departure, the duration

of the mission may influence the choice of vaccines.

Personal protection against mosquito bites, both during the day and at night is

important in preventing vector-borne diseases such as dengue, chikungunya,

Zika and malaria (long-sleeved clothes, repellents, mosquito nets, clean-up of

breeding sites).

Basic knowledge of first aid and stress management is important. Although not

always avoidable, good preparation can be useful in preventing and limiting

stress.

33


4.1 Vaccination recommendations

Adult vaccination booster recommendations vary between countries so staff

should check their vaccination requirements with their local health provider

before leaving for the disaster area.

table 1. Vaccinations recommended for travel to Vanuatu

necessity vaccine validity comments

essential

Diphtheria 10 years Can be combined with tetanus

Tetanus 10 years Booster does is recommended if not taken in the last 10 years

Polio 10 years

Typhoid 3 years

Hepatitis A Life If there is no proof of immunity by vaccine or illness; can be combined with Hepatitis B

Measles Potential risk in emergency situation. If not fully immunized in childhood, obtain vaccination

optional Hepatitis B 15 years

34


4.2 Malaria prophylaxis and treatment

Malaria prophylaxis is recommended for all staff deployed in Vanuatu. The risk is

predominantly due to P. falciparum. The recommended drugs for prophylaxis are:

• Atovaquone 250 mg & Proguanil 100 mg (malarone): one day before expo-

sure, one tablet daily until 7 days after last exposure

• doxycycline 100 mg: one day before, one tablet daily until 4 weeks expo-

sure after last exposure

• mefloquine 250 mg: one week before exposure; one tablet weekly until 4

weeks after last exposure.

It is recommended that individuals carry supplies of reserve treatment for all

missions lasting longer than 8 days, in view of the potential difficulty in accessing

health services. The recommended treatment for malaria is Artemether-

Lumefantrine combination tablet (Coartem™).

4.3 Other precautions

Teams may consider bringing:

• medical kits including chlorine tablets for water purification

• Post-Exposure Prophylaxis Kit

• surgical masks

• gloves

• food and water: given that there will be an extreme shortage of basic food

and drinking-water.

35


5. risK communicaTionsRisk communication is a critical tool for effective management of public health

emergencies. When the public is at risk of a real or potential health threat,

treatment options may be limited, direct interventions may take time to organize

and resources may be limited. Communicating advice and guidance, therefore,

is often the most important public health tool in managing a risk. Key risk

communications actions are:

• As soon as possible, assess public communication capacity and research

community understanding of the risks, population demographics, literacy

levels, languages spoken and socioeconomic and cultural backgrounds. This

will help inform an effective communications approach and messages that

resonate with target audiences.

• Review how the population consumes information and identify

communication partners, with appropriate language and media skills, to help

get the message out to those at risk. Ministry of Health counterparts are a

good place to start.

• Risks will also need to be communicated outside of the country, so identify

external channels of communication. Consider designating a spokesperson

– skilled at communicating using plain language – and seek opportunities

to communicate with the traditional media. Explore opportunities to

communicate messages regularly via social media.

• Coordinate closely with your communications partners to maintain consistent

and complementary messages and to build and maintain trust.

36


annexes

annex 1: Health services in Vanuatu

table 2. Primary health services in Vanuatu (level of care, facility and description of services)

health Promotion and disease Prevention

Village health workers are minimally trained to work with communities to promote hygiene, good sanitation and disease prevention. Each province has a health promotion officer. Health Promotion Unit in the Ministry of Health provides overall policy direction, coordination and support to provinces.

UN agencies and other development partners support health promotion and community programmes in water and sanitation, health literacy, HIV/AIDS, reproductive health, alcohol tobacco and other drugs.

Primary care and community health services

Aid posts* Staffed by village health worker providing basic primary health care and referral to the nearest Dispensary or Health Centre. Services include dressings, malaria testing and treatment, family planning and community education. Under an MOU, the village health workers programme is outsourced to an international organization, Save the Children.

Dispensaries Serving a population of up to 5000 and staffed by a registered nurse and Nurse Aid providing essential primary health care through general outpatient consultations for common illnesses, MCH/RH services and with 2 to 4 inpatient beds. The main purpose of beds is for stabilization of patients before transfer to Provincial Hospital but also deliveries. Open from 8:00 to 17:00 with staff living nearby and on-call 24 hours.

Health centres

Serving a population of 5 to 8000 and staffed by Nurse Practitioner, Midwife, Registered Nurse and Nurse Aid possibly with a driver and vehicle providing essential primary health care through outpatient consultations, MCH/RH services with 10-15 inpatient beds for paediatrics, medical and maternity patients. The most common reason for admission is delivery. Open from 8.00 am to 5.00 pm with staff living nearby and on-call 24 hours. No pharmacist or other support services so rely on provincial hospital.

Municipal clinics

Primary and preventive care; coordination of hospital management for pa-tients in urban catchment areas; family planning Run by the Urban Councils in Port Vila (5 Clinics) and Luganville (3 Clinics) on a semi-private basis. Staffed by Nurse Practitioner and a registered nurse.

Private clinics and services

Include 6 medical clinics, 4 private pharmacists, 1 physiotherapy clinic, 1 dental clinic, 1 laboratory and 4 counselling centres run by NGOs. In addition there are traditional medical practitioners.

37


table 3. Health services in Vanuatu (level of care, facility and description of services)

Private Pharmacies

Five located in urban centres provide over the counter and prescription medicines. Procure own medicines and stock a broader range of medical supplies than government-run pharmacies but are more expensive.

* Aid posts are community built and owned, with medicines and basic commodities supplied by government.

• Village health workers (VHWs) are volunteers who have received three months training in primary and preventive care, focusing on community education, treatment of minor ailments and prompt referrals.

• VHWs have limited training and may be presented with medical conditions beyond their level of expertise. VHWs need to work closely with dispensaries and health centres to refer such cases.

• The Ministry of Health has a Memorandum of Understanding with Save the Children to manage the VHW programme, but faces a challenge to effectively link the out-sourced VHW programme with the Ministry of Health primary-care facilities – especially dispensaries and health centres – and to maintain the focus of VHW activities on preventive health care and community education for healthy lifestyles rather than clinical services.

secondary care

referral hospitals Vila Central Hospital in Port Vila and Northern Provincial Hospital in Luganville are the two referral hospitals. Staffed by doctors, nurses and allied health professionals providing obstetric, medical, paediatric, surgical, inpatient and outpatient services and a range of specialist outpatient clinics. Open 24 hours. Inpatient services include: medical, surgical, maternity and neonatal, paediatric, infectious diseases, psychiatry, ear nose and throat, eye care. Allied health services include: laboratory, radiology, orthotics, nutrition, pharmacy, dental, physiotherapy. Patients referred overseas for services not available locally.

Provincial hospitals

Located in Torba (Torba mini-hospital), Penama (Lolowai Hospital), Malampa (Norsup Hospital) and Tafea (Lenakel Hospital) providing obstet-ric, medical, paediatric, surgical, an inpatient and outpatient services. The only doctor at Lenakel is an expatriate Canadian doctor on a six-monthly rotation basis. Norsup Hospital has one recently graduated junior doctor while Lolowai Hospital and Torba Mini Hospital are yet to be assigned doctors. In this case, the health service team comprises a nurse practi-tioner, a nurse and a midwife. The Pharmacist is responsible for medical supplies at each hospital.

Private hospital Vila Bay Health Centre is a private international health centre in Port Vila run by expatriates, offering primary and secondary care with capacity for medical evacuation and medical emergency.

38


table 4 Health Services in Vanuatu by location

Pro

vin

ce

ho

spit

als

hea

lth

cen

tres

dis

pen

sari

es

aid

po

sts

tota

l fac

iliti

es

Pop

ula

tio

n (

2013

est

.)

faci

litie

s p

er 1

,000

po

pu

lati

on

an

nu

al o

utp

atie

nt

con

sult

atio

ns

p

er c

apit

a, 2

012

nu

mb

er o

f vi

llag

es

vill

ages

per

pri

mar

y ca

re f

acili

ty

TORBA 1 2 6 23 32 9,903 3.23 1.53 34 1.1

SANMA 1 7 6 38 52 49,242 1.06 1.59 403 7.8

PENAMA 1 6 8 42 57 32,227 1.77 2.20 129 2.3

MALAMPA 1 7 14 45 67 38,060 1.76 1.17 N/A —

SHEFA 1 3 7 42 53 87,789 0.60 0.61 N/A —

TAFEA 1 5 6 41 53 33,626 1.58 1.21 245 4.6

TOTAL 6 30 47 231 314 250,847 1.25 1.20 — —

Source: Vanuatu Health Service Delivery Profile (2012); updated using data from VHW Evaluation 2013 and VHW training programme records held by Save the Children Australia. 2012 consultations were derived from the health information system.

39


annex 2: Communications messages (specific health issues)

Safe drinking-water• Even if it looks clear, water can contain germs. Under the present emergency

in Vanuatu, water in the affected areas should be assumed to be contaminated.

• Add drops of chlorine to the water, water purification tablets or boil, before

drinking or using for food preparation.

• Keep drinking-water in a clean, covered pot or bucket or other container with

a small opening and a cover. It should be used within 24 hours of collection.

• Pour the water from the container – do not dip a cup into the container.

• If dipping into the water container cannot be avoided, use a single cup or

other utensil with a handle and which is attached to the container.

Promote good hygienic practices• Wash hands with soap, ash or lime.

• Wash hands before cooking, before eating and before feeding children.

• Wash hands after using the latrine (toilet) or cleaning children after they have

used the latrine (toilet).

• Wash all parts of hands – front, back, between the fingers and under the

nails.

Avoid mosquito bites (once dwellings are re-established)• Sleep under an insecticide-treated bed net.

• Make sure your house or tent/shelter has been properly sprayed with

insecticide during the transmission season.

• Wear protective clothing at times when mosquitoes and other biting insects

are active.

• Stay indoors when outdoor biting mosquitoes are most active.

• Use insect repellents and mosquito coils if available.

• Remove, destroy or empty small rain-filled containers near the house or

tent/shelter.

Five keys to safer food • Keep clean (hand hygiene).

• Cook thoroughly, separate raw and cooked.

• Keep food at safe temperature (piping hot).

• Use safe drinking-water and raw materials.

40


• Seek treatment early (once health services are established).

- Diagnosis and treatment of fever, diarrhoea and other illnesses should

be within 24 hours from observation of first signs of symptoms.

- For diarrhoea, oral dehydration salts made with safe (boiled and

chlorinated) water should be consumed.

41


annex 3: EWARN case definitions – Cyclone Pam, Vanuatu

syndrome case definitions

acute fever and rash (afr)

Sudden onset of fever (>380C) with acute non- blistering rash

Prolonged fever Any fever (>380C) lasting 3 or more days

Watery diarrhoea 3 or more loose or watery stools in 24 hrs (non- bloody)

Bloody diarrhoea Any episode of acute bloody diarrhoea

influenza-like- illness (ili)

Sudden onset of fever (>380C) with cough and/or sore throat

acute jaundice syndrome

Jaundice (yellow eyes or dark urine) AND severe illness with or without fever

suspected dengue

Fever (>380C) PLUS two of the following:

1. Aches and pains (headache, eye pain, muscle/joint pain),

2. Anorexia, nausea or vomiting,

3. Rash,

4. Tourniquet test positive,

5. Mucosal bleeding,

6. Abdominal pain,

7. Lethargy or restlessness

malaria Clinically suspected malaria PLUS positive RDT or Malaria Parasite Smear (MPS)

42


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For further information, please contact: Emergency Support Team World Health Organization – Regional Office for the Western PacificManila, Philippines Email: [email protected]

Division of Pacific Technical SupportWorld Health OrganizationSuva, FijiEmail: [email protected]; [email protected]

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