A major typhoon has caused severe flooding in Bangladesh resulting in significant population displacement. Anecdotal information indicates that cases of a diarrheal disease consistent with cholera have been reported. You are given responsibility for responding to this unfolding disaster.
1.Discuss the multiple areas of response specific for cholera that must be implemented. Which agencies would you request assistance from?
2.Describe other potential infectious disease problems that should be anticipated in these circumstances. What special pre-deployment preparations may be necessary for the responders to this emergency?
1.Discuss the multiple areas of response specific for cholera that must be implemented. Which agencies would you request assistance from?n
A major typhoon has caused severe flooding in Bangladesh resulting in significant population displacement. Early unconfirmed reports
indicate that cases of a diarrheal disease consistent with cholera have been reported. Vibrio cholera is responsible for approximately three to five million cases and anestimated 120,000 deaths per year worldwide. Despite the recent typhoon which resulted in mass population displacement, Cholera remains a major public health problem in many low income countries with poor access to safe water and proper sanitation, including Bangladesh(Haque, et al., 2013).However, with prompt and appropriate treatment,mortality can be kept low. Furthermore, cholera outbreaks can be prevented orcontrolled through a combination of public health interventions, predominatelythrough a comprehensive disease surveillance and early warning system, provision of safe water,adequate sanitation, health and hygiene promotion and early detection,prevention interventions, including oral cholera vaccine, and treatment. It is noted by Haque, et al., (2013)that the risk of transmission, illness and death from cholera is proportional to theinteraction of cholera with the host and the environment.Thus, it should be stressedthat the only way to become infected with cholera is to ingest thebacteria orally. However,in low income countries such as Bangladesh, flooding after heavy rains form the typhoon can result in sewage overflow and widespread water contamination, resulting in disease outbreak. Furthermore,Cholerais most commonlythe result of disaster survivors living in crowded temporary accommodation withoutadequate ventilation and/or adequate sanitary facilities for personal hygiene, food storage and preparation, and safe drinking water. The prolonged mass settlement of refugeesin temporary shelters with only minimal provision for essential personal hygiene is typicalof a situation that may cause epidemic outbreaks of many infectious diseases(Haque, et al., 2013).
Within the global health sector, the successful response, containment and controlof cholera outbreaks is dependent on an integrated local and international approach, including promptoutbreak investigation, adequate laboratory facilities for isolation, and availability of rehydration solutions, antibiotics, and adequately trained professionals at all levels ofhealthcare(Haque, et al., 2013). Given the large population of approximately 160 millionexposed to an increasing risk of cholera due to the population displacement caused by the typhoon and the already poor sanitation environment,water hygiene infrastructure, and limited access to healthcare;a massvaccination should be immediately explored to prevent cases of cholera and deathsin Bangladesh. Case studies a have shown that the modified killed-whole-cell oral vaccine is compliant with WHO standards and can provide protection against clinically significant cholera in endemic settings(Haque, et al., 2013).
Specific localhealth authorities from Bangladesh must be immediately contacted such as the Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh and the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) to provide rapid response and specialized experts todetermine the causes to better respond to these outbreaks(Haque, et al., 2013). Within 24hours, the collaborative team from IEDCR andicddr,bwillbe deployed to the outbreak site and collect epidemiological,environmental, and anthropological information.At the beginning of a cholera outbreak, large numbers of people can becomeinfected from a single contaminated water or food source. Most tend to become infected from surface water, well or damaged sewage penetrated piped water sources, rather than from food. Although, it is noted by Haque, et al., (2013) thatcontaminated foods at the temporary refugee campscan pose a major risk of infectinglarge numbers of displaced people. When a number of people are infected, dependingon their degree of over-crowding, fresh water, sanitation and hygiene practices,the multiple overlapping faecal-oral transmission routes can advance thespread of the disease(UNICEF, 2013). Therefore, while priority should be given to identifyingand blocking the main source of contamination, it is also extremely important towork on blocking all other possible transmission routes at the same time.Preventing cholera transmission after a major disaster of this magnitude can become challenging. The long term disaster response and recovery will ultimately require providing safedrinking water to inhabitantsthrough a well maintained water andsanitary infrastructure. However, safe water delivery and repair is often difficult incities such as this after a major disaster where water supply is intermittent and pipelines are commonly ruptured.Thus, Cholera prevention needs to reach beyond the health sector inorder to improve water and sanitary infrastructure(UNICEF, 2013). This will requirecollaborative actions by many national and international critical infrastructure resourcesas well as fresh water supply companies within and outside of thehealth sector, which may be difficult to achieve in this resource-poorsetting after the typhoon destruction. In the meantime, emphasis will be to obtain and secure a local protected water sources. In addition, to seeking innovative solutions, water purification strategies such as chlorination needs to be initiated. Effective water treatment shall be immediately disbursed and practiced within the community, displaced refugee camps,as well as all health care treatment facilities.Additional measures will be implemented to include; boiling water; use of proven water pumps through a microscopic filter that is rated with 0.2–1.0 micronsfilters; and/or appropriate chlorine dosing kits. The boiled, filtered and/or treated water is used for drinking, making juices, other drinks and ice (UNICEF, 2013). Additionally, the media needs to be immediately alerted to disseminate vital information to the public sector regarding safe hygiene practices and information on where to require proper resources. With that in mind, local responders within the emergency and public health sectors will be dispatched to facilitateand establish community-based Points of Dispensing (PODs) within 48 hours(Center for Disease Control and Prevention [CDC], 2008). After the initial response and all health facilities are properly staffed and supplied, PODs will be established in various strategic locations accordance with the Center for Disease and Control (CDC) and used during the disaster response and recovery phase to distribute fresh drinking water supplied from local companies, as well as mass quantities ofanti-infective therapy/prophylaxis and/or vaccination forthe entire community until adequate replenishment by international assets and NGOs can be obtained to control future communicable disease outbreaks (Center for Disease Control and Prevention [CDC], 2008).
Along with coordinatingthe initial response for this major disaster, international support must be contacted and utilized such as; the Global Disease Detection and Emergency Response, Centers for Disease Control and Prevention (CDCCentre for Communicable Diseases (CCD); the World Health Organization (WHO)Country Office for India; along with the Global Outbreak Alert and Response Network (GOARN) to assist and monitor the disease response and to establish a comprehensive early warning and surveillance system(Haque, et al., 2013). Surveillance is the ongoing systematic collection, analysis, and interpretation of outcomespecificdata for use in planning, implementing and evaluating public health policies andpractices. A communicable disease surveillance system serves two major functions; early warningof potential threats to public health and programme monitoring functions which may be diseasespecificor multi-disease(World Health Organization [WHO], 2015). GOARN is a collaboration of existing institutions and networks, constantly alert and ready to respond. WHO coordinates international outbreak response using resources from GOARN (WHO, 2015).Additionally, further support regarding supplies of fresh water, Cholera kits, medical supplies and equipment will also be solicited and coordinated through the use of various international Memorandums of Understanding (MOUs) through the government of Bangladesh andother affiliated international government assets as well as nongovernment (NGOs) such as the International Red Cross, Refugees International, The Office of U.S. Foreign Disaster Assistance (OFDA) and the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), just to name a few.After all supply assets have been established, proper facilities and sanitation requirements are in place, and an aggressive vaccination campaign underway; the entire team of experts must then focus on the early warning surveillance system to support furtherspread and control of communicable disease.
2.Describe other potential infectious disease problems that should be anticipated in these circumstances. What special pre-deployment preparations may be necessary for the responders to this emergency?
To understand the different challenges to be faced regarding communicable disease during the emergency and health response to Bangladesh after a typhoon, one must research the history of similar events. A major flood occurred in Bangladesh in 1988, where diarrhea was found to be most common illness and a major cause of death amongst the population(Center for Disease Control and Prevention [CDC], 2005). The effect of the flood also helped spread the disease. In addition to diarrheal, prevalent respiratory infection generatedby overcrowding conditions was also blamed for the high confirmed illnessof 46,740 and 154 deaths(CDC, 2005). In developing regions of the world such as Bangladesh, sanitation problems and various water-borne diseasessuch as diarrhea, dysentery, cholera, malaria, and typhoidare a common occurrence and should be expected after a typhoon, which will produce mass flooding. This is especially true for the poor and vulnerable, due to lack of access to safe drinking water, proper medicine and hygienic food(CDC, 2005).During choleraand associated communicable disease outbreaks it is very important to identify organizations that have significant proven experience in responding to cholera and can help lead and guide other stakeholders in the response. A number of internationalorganizationsand agencies are able to provide technical support. It is noted by UNICEF, (2013) that uqualified individuals or organizations should not be allowed to manage cholera control activities, especially those relating to health care, until they have received adequate training. In epidemic situations where cholera outbreaks have not occurred before, training of national personnel will be a critical priority prior to their response.
Emergency Workers Health and Training
When a major typhoon disaster strikes, the global community depends onemergency response workers who are preparedand trained to respond effectively. Within the established framework of anEmergencyResponse Health Monitoring and Surveillance (ERHMS) program, all pre-deployment health screening must be establishing as well as a baseline physical andemotional health exam prior to responding to health related emergencies(National Response Team [NRT], 2011).The purpose of the medicalmonitoring and surveillance is to identify any risk of exposuresand/or signs and symptoms early in the event of anactual emergency response in order to prevent or mitigateharmfulphysical and psychological aftereffectsandto ensure workers are able to maintain their ability to effectively respond(NRT, 2011). Monitoring is very common in such events and is an ongoing effort which can help determine whether protective measuresare adequately provided to the workforce andare sufficient to prevent or reduce harmful exposuresto emergency workers. Data collection is critical in the pre-response, during,and post-deployment phases, and will also help to identifywhich responders would benefit from medical treatment and possible enrollment in a long-termhealth surveillance programs(NRT, 2011).The responder’s safety and health is carefully assessed in order to ensurethat only medicallycleared, trained, and properly equipped personnelare selected for deployment. Additionally, NTR (2001) documented that their work environmentand health will be monitored and surveyedcontinually throughout the event; and provisions will made forpost-event health medical monitoring and surveillance as required.
Pre-response Training
To assist in strengthening the global response to all public health disaster, the WHO along with other global affiliates has obligated themselves in creating comprehensive training requirements. The training is committed to strengthening the national response capability by preparing and mobilizing the international humanitarian community’s capacity to address public health priorities in emergencies, and thereby reducing loss of lives and the afflictionof disease and disability(WHO, 2015). Through the developed Public Health Pre-Deployment (PHPD) Course, WHO and associate organizers collectively contributed in preparing public health and other professionals, who are already experts in their specific fields or in emergency settings, to work effectively and safely in emergency disaster situation (WHO, 2015). These professionals are expected to effectively and efficiently work with all national emergency health teams, and with the health groups at all levels. The course prepares the students on crises situations that could affect countries around the world and how effective emergency response proceduresat various levels is critical to address priority public health needs on effected populations(WHO, 2015). The course is primarily held in the United States but has expanded its capability to hold the course in many global areas that is supported by WHO organizations.
Pre-response Planning
In addition to training, effective prevention, preparedness and response for cholera requires complexcoordination and communication across multiple sectors and at differentlevels. The promptnessof response has significant influenceon the managementand impact of an outbreak.Therefore, special pre-planning preparations prior to the response is critical to effectively establish policy, procedures, and protocols that will be required for a multi coordinated response(UNICEF, 2013). Such preparations include consistencyof prevention across all sectors, preparedness or responseactivities through the development of collaborative plans andMOUagreements on technical standards within the entre local and international response teams. This will avoid both gaps and duplication, and promote strong relationships required for complex responses by making the most effective use of all actors, including governmentpartners, resources, funding, and supplies. This includes; undertake collaborative assessments, leading to aligned planningand response assumptions for effectively share information, while building capacities, and mobilizing resources. Further pre-planning includes; initiatea timely monitoring plan, prioritize reporting and decision making;increase the efficiency and timeliness of an early warning system; and establish common thresholds for activatinginterventions among all stakeholders (UNICEF, 2013).
References
Center for Disease Control and Prevention [CDC]. (2005). After a flood. Atlanta: CDC.
Center for Disease Control and Prevention [CDC]. (2008). Point of dispensing (POD) standards. Department of Health and Humans Services. Retrieved from http://health.mo.gov/emergencies/sns/pdf/12-PODStandards.pdf
Haque, F., Hossain, J., Kundu, S. K., Mohd, A., Nase, R., & Luby, S. P. (2013). Cholera outbreaks in urban Bangladesh in 2011. Epidemiology Open Access. doi:10.4172/2161-1165.1000126
National Response Team [NRT]. (2011). Emergency responder health monitoring and Surveillance Program (ERHMS). NRT. Retrieved from http://www.cdc.gov/niosh/topics/erhms/predeploy.html
UNICEF. (2013). Cholera toolkit. New York: UNICEF – Programme Division. Retrieved from http://www.unicef.org/cholera/Cholera-Toolkit-2013.pdf
WHO. (2015, May 18). Humanitarian Health Action; Public Health Pre-Deployment Course (PHPD) . Retrieved from World Health Organization: http://www.who.int/hac/techguidance/training/predeployment/phpd5/en/
World Health Organization [WHO]. (2015, May 15). Global Outbreak Alert and Response Network (GOARN). Retrieved from Global Alert and Response (GAR): http://www.who.int/csr/outbreaknetwork/en/
