Quadrats method method Quadrats Material and human resources • 2 strings or plastic tape of 25 meters • 4 wood piles • 3 people 25m • 1 compass 25m 25m 25m E P I D E M I C A L E R T A N D R E S P O N S E
Outside Outside Inside Quadrats method method E P I D E M I C A L E R T A N D R E S P O N S E Inclusion criteria Inclusion criteria Quadrats Inside
T- - Squared Squared T Material and human resources • 1 Deca-meter • 3 people • 1 tele meter E P I D E M I C A L E R T A N D R E S P O N S E
T- -squared squared T Is based on the estimation of household density which is than extrapolate to the total surface E P I D E M I C A L E R T A N D R E S P O N S E
Extrapolation to the the total area total area Extrapolation to Quadrats method � X refugees (x) people/square (mean) X (n) squares in 1 area (y) Family shelter /square (mean) X (n) squares in 1 area � Y families after add the estimation of each area T-square method ^ π γ m ^ 1 ∑ ^ = S γ = + γ = 2 2 N T ( ) x z SE ( ) γ T T i i 2 m 2 m 2 T = i 1 E P I D E M I C A L E R T A N D R E S P O N S E
Some results appliying appliying Quadrat Quadrat and T square and T square Some results Golden standard: 9479 � Homogeneity of population (Mozambique) � Quadrat : 15-17 points Quadrat: 7681 � T square :45-50 points (CI 95%: 6160-9203) � Quadrat: design the quadrat T square: 9523 (100.4%) � T square : intrusive, structure Houses Grais F. et Al. Disasters 2005 E P I D E M I C A L E R T A N D R E S P O N S E
Interpolation Interpolation Closer values have a higher probability to be more similar than more distant measurements. Interpolation methods have been employed mostly for continuous data, as in the spatial distribution of temperature, rainfall, soil and groundwater chemistry pollution concentrations , lead poisoning, etc. E P I D E M I C A L E R T A N D R E S P O N S E
Interpolation Interpolation Material and human resources • 1 strings or plastic tape of 25 meters • 1 wood pile 25m • 2 people 25m E P I D E M I C A L E R T A N D R E S P O N S E
Outside Count Households Households E P I D E M I C A L E R T A N D R E S P O N S E 25m Inside Count Inside Outside 25m Inside
three methods methods the three E P I D E M I C A L E R T A N D R E S P O N S E of the results of Comparing results Comparing
Interpolation: Strenghts Strenghts/limits /limits Interpolation: � Easy to implement � Not intrusive � Few points 10-15 � Quick � Accept zero values � Still linked to expensive GIS � Computation still laborious E P I D E M I C A L E R T A N D R E S P O N S E
Running Ordinary Kriging Kriging to interpolated surface to interpolated surface Running Ordinary Running Kriging on the shapefile by using the value of population density Generate the interpolated surface on the study area The interpolated surface represent the population density in the study area E P I D E M I C A L E R T A N D R E S P O N S E
Using the grid points to extract the population value from the interpolated surface nterpolated surface Using the grid points to extract the population value from the i Create a point layer of 30 * 30 sq. meters over the study area X Y Predicted StdError Error Stdd_Error 530211.87 1477944.04 0.00000000000 0.00250103099 0.00000000000 0.00000000000 530241.87 1477944.04 0.00000000000 0.00219448208 0.00000000000 0.00000000000 530211.87 1477974.04 0.00000000000 0.00222658854 0.00000000000 0.00000000000 530241.87 1477974.04 0.00006889087 0.00175459122 0.00006889087 0.03926320054 530271.87 1477974.04 0.00000000000 0.00127230458 0.00000000000 0.00000000000 530301.87 1477974.04 0.00008977212 0.00167010604 0.00008977212 0.05375234601 Predicted population density Each record represents a point that hold data on the predicted population density. Calculate the population based the grid size (e.g. for 30m grid: Estimated population = sum of Predicted pop value * 30* 30) Using GIS to extract value from the interpolated surface E P I D E M I C A L E R T A N D R E S P O N S E
Denominators: dynamic process Recording flow • Arrival (reception centre) and living (back home) • Estimate the flow of population in and out Monitoring the demography of the camp • Number of daily deaths • Number of births E P I D E M I C A L E R T A N D R E S P O N S E
Recording the flow of refugees living Recording the flow of refugees living Rwanda (Tanzanian border 1994) Rwanda (Tanzanian border 1994) E P I D E M I C A L E R T A N D R E S P O N S E
E P I D E M I C A L E R T A N D R E S P O N S E Pause Pause
Contents A- The problem B- Initial assessment C- Surveillance/response in emergency phase D- Consolidation phase E - Conclusion E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR What is surveillance? What is an Early WArning Response System? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Definition of of Epidemilogical Epidemilogical surveillance surveillance Definition Continue collection and systematic analysis and interpretation of health data for planning, implementation and evaluation of public health actions timely diffusion of this data to decision makers final step � prevention and control of diseases and accidents Thacker SB. Surveillance. In : Gregg MB, editor. Field Epidemiology. New York : Oxford University Press, 1996:16-32. E P I D E M I C A L E R T A N D R E S P O N S E
Definition of EWAR Definition of EWAR An EWAR can be defined as the functions of an integrated surveillance system aiming to detect any abnormal health event and to provide an adequate and timely response E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHEN implement Focus on WHAT? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Surveillance in humanitarian humanitarian crisis crisis situation situation Surveillance in As soon as possible In emergency phase: to focus essentially on • Major health problems • Health events to whom we can implement a response System flexible: to adapt to new needs E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHY? (Objectives) 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Objectives of of EWAR EWAR Objectives General Control morbidity and mortality due to epidemic prone diseases Specifics • Detect unusual conditions(epidemics) in need of intervention/response of public health • Provide reliable data (indicators) to WHO/MOH/Humanitarian partners to adjust public health intervention • Evaluate the workload of health structures to optimize the resource allocation E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHAT? ( prioritize, tsunami) 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Pre- -existing communicable disease risks in Sumatra existing communicable disease risks in Sumatra Pre 2005 2005 Cholera Syphilis Diarrhoea Gonorrhoea Typhoid fever Pneumonia Leprosy Neonatal tetanus Tetanus Tuberculosis Dengue fever Aids Diphtheria Viral hepatitis Measles Influenza AFP Meningitis Filariasis Malaria E P I D E M I C A L E R T A N D R E S P O N S E
CD risk prioritization CD risk prioritization Cholera Syphilis Diarrhoea Gonorrhoea Typhoid fever Pneumonia Leprosy Neonatal tetanus Tetanus Tuberculosis Dengue fever Aids Diphtheria Viral hepatitis Measles Influenza AFP Meningitis Filariasis Malaria E P I D E M I C A L E R T A N D R E S P O N S E
Risk assessment assessment Risk Pre-existing situation (country of origins/hosting) • Normal morbidity • Immunization status • Recent or current epidemics (before living) Risk linked to the specific situation • War situation or natural disaster • Precarious condition (water, food, care) • Concentration of population • Epidemic in the hosting region or country E P I D E M I C A L E R T A N D R E S P O N S E
Darfur, Sudan Sudan May 2004 May 2004 Darfur, Epidemic prone diseases • Polio,measles, cholera • Malaria, yellow fever • Meningitis Diseases linked to precaroiuseness • diarrhea, shigellosis (disentery) • hepatitis • Respiratory infections • Malnutrition Vector born diseases • Malaria • Visceral Leishmaniosis E P I D E M I C A L E R T A N D R E S P O N S E
Hurricane Mitch, Central America, 1998 Epidemic prone diseases • Cholera Diseases linked to the precariouseness •Diarrhoea •Respiratory infection Diseases linked to the kind of disaster •Tetanus, skin diseases •Leptospirosis (rats) •Dengue, malaria (mosquitos) Other risks out of CD? Toxic/chemical risk (factory destruction) E P I D E M I C A L E R T A N D R E S P O N S E
Kosovar refugees in Albania, 1999 Epidemic prone diseases • polio, anthrax… • measles, cholera Diseases linked to the precariouseness • diarrhea, shigellosis (disentery) • hepatites • Respiratory infections Chronic diseaes • hypertension • Hearth insufficience • diabetes E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR How standardize the case detection? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Health event Definition Acute Watery Diarrhoea Acute watery diarrhoea with severe dehydration in a patients older than five years of age . Diarrhoea with blood (Dysentery) More than 3 loose stools per day (24 hours) with visible blood Acute respiratory infection Fever and at least one of the following : rhinitis, cough, redness or soreness of throat OR Fever and fast breath (> 50 breaths/min) and at least one of the following : cough, difficulty in breathing Suspected Measles Rash with fever and cough, runny nose or conjunctivitis Acute Jaundice syndrome Acute onset of yellows eyes or skin Suspected meningitis 12 months and over: sudden onset of fever (> 38° C) with stiff neck Under 12 months: fever with bulging fontanel Acute flaccid paralysis in a child aged < 15 years, including Guillain Barré syndrome or any acute AFP paralytic illness in a person of any age. Malaria Person with fever or history of fever >38°C within the last 48 hours with one or more of the following symptoms: such as nausea, vomiting and diarrhoea, headache, back joint pain, chills, myalgia) with positive laboratory test for malaria parasites blood film (thick or thin smear) or rapid diagnostic test . Neonatal tetanus Suspected case: Any neonatal death between 3 and 28 days of age in which the cause of death is unknown or any neonate reported as having suffered from neonatal tetanus between 3 and 28 days of age and not investigated Confirmed case: Any neonate with a normal ability to suck and cry during the first two days of life, and who between 3 and 28 days of age cannot suck normally, and becomes stiff or has convulsions or both Injuries Any person with traumas or wounds from any cause that require surgical treatment and hospitalisation Severe malnutrition Malnutrition: In children 6 to 59 months (65cm to 110cm in height): <70%Weight for height (W/H) index OR < –3z scores (on table of NCHS/WHO normalized reference values of weight-for-height by sex). OR MUAC < 11 cm Bilateral pitting oedema irrespective of W/H, in absence of other causes. Unexplained fever Fever (> 38°C) for more than 48 hours and not meeting the above case definitions Others All others medical conditions not meeting the above case definitions This category is used to compute Total Attendance E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR HOW? Design framework 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Detecting threatening health events Detecting threatening health events Surveillance components Surveillance components Surveillance: Event-based Indicator-based Report Data Capture Collect Filter Analyse Verify Interpret Strengthen Signal Response Assess Public health alert Investigate Control Post-outbreak strengthening Evaluate E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHAT should be the main attribute of the EWAR system? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Main attributes of EWAR in CE Main attributes of EWAR in CE � Simplicity � Sensitivity � Flexibility � Acceptability � Timeliness � Feasibility E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHAT VARIABLES COLLECT? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Surveillance/EWAR record Sensible: Syndroms Rumors detection Simple: • Standard forms • 12 syndroms • 2 age groups • Cases and deaths • Data entry/analysis Epidata/EpiInfo E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHERE to collect these VARIABLES? WHO should collect ? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
E P I D E M I C A L E R T A N D R E S P O N S E Data flow flow Data decentralization Define data and specimen flow,
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHICH frequency for data/information transmission? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Weekly epidemiological bulletin Weekly epidemiological bulletin E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR How to facilitate data transmission and standard data analysis? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
E P I D E M I C A L E R T A N D R E S P O N S E
E P I D E M I C A L E R T A N D R E S P O N S E
PC application for data management PC application for data management •Simple •Immediate understanding •Ensure quality of data •Facilitate the response for outbreak control E P I D E M I C A L E R T A N D R E S P O N S E
Phases in the the process process Phases in PHASE 6 : Ensure prompt analysis and standard report production at state and federal level – Simple computer application) at local and central level – Database files sent by e-mail from state to federal level every Saturday – Production of MMWR every Sunday for weekly health meeting with all partners at central level E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR WHAT indicators to produce? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
•Number of new cases and deaths for each health event by week •Total attendance per week •Case Fatality Ratio for each health event •Proportional morbidity by age groups (0-4 and 5+) •Distribution of new cases by geographical level •Distribution of new cases by age groups and geographical level •Number of deaths by age and geographical level, •Number of health facilities reporting/number of health facilities expected to report •Incidence of health events by week and geographical level •Under Five years Mortality rate per 10,000 Weekly population per week •Crude Mortality rate per 10,000 population per •State week •Administrative Unit •Timeliness from camps to the state •Camp •Timeliness from the state to the federal level •Completeness of the reporting units E P I D E M I C A L E R T A N D R E S P O N S E
Phase 8: produce outputs Health structures structures reporting reporting Darfur, Darfur, weeks weeks 21 to 30, 2004 21 to 30, 2004 Health Number IDPs camps (129) Number of reporting units Fig. 3: Weekly number of reporting units in Greater Darfur, from week 21 to 30, 2004 45 40 35 30 25 20 15 10 5 0 21 22 23 24 25 26 27 28 29 30 weeks reporting units weeks E P I D E M I C A L E R T A N D R E S P O N S E
Outbreak detection detection/ / lab lab Outbreak F ig . 4 : N u m b e r o f c a s e s o f B lo o d y d ia rrh o e a in A b u S h o a k c a m p , N o rth D a rfu r, fro m w e e k 2 1 s t to 3 0 th , 2 0 0 4 Fig 5: Number of cases of Acute Jaundice in Morni, West Darfur, from week 21 to week 30, 2004 2 5 0 .0 100.0 90.0 2 0 0 .0 80.0 70.0 60.0 1 5 0 .0 50.0 40.0 1 0 0 .0 30.0 20.0 5 0 .0 10.0 0.0 0 .0 21 22 23 24 25 26 27 28 29 30 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 weeks w e e k s E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR HOW to trigger a signal? 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Case definiton definiton Case thresholds definition definition thresholds Agreement on thresholds to trigger actions: – 1 case of measles, – 1 case of AFP, – 1 case of severe malnutrition, – 1 case of NNT, – Doubling cases of meningitis in two weeks (minimum 2 cases) – Unusual deaths in patients older > 5 presenting watery diarrhoea – Any unexpected health event (e.g. cluster of severe diseases, cluster of deaths) E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR How to support laboratory diagnosis 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Laboratory support support Laboratory Selection and agreement with National PHL in Khartoum as reference laboratory (enrolled in Lyon programme) Strenghtening diagnosis capacities Positioning media transportation Selection of private carrier (Polio) Information to all partners Allocation of budget E P I D E M I C A L E R T A N D R E S P O N S E
E P I D E M I C A L E R T A N D R E S P O N S E
Public Health Health Surveillance Communicable Surveillance Communicable Diseases Diseases Public EWAR system system EWAR INTERPRETdata analysis 5 minutes E P I D E M I C A L E R T A N D R E S P O N S E
Bloody diarrhoea by age group, Weeks 15-19, 1999, Albania Number of reported cases Proportional morbidity 1400 30 < 5 ans 5 ans et + < 5 ans 1200 5 ans et + 20 1000 10 800 0 15 16 17 18 19 600 Diarrheas / cardiovascular 2 400 200 1 0 0 15 16 17 18 19 15 16 17 18 19 E P I D E M I C A L E R T A N D R E S P O N S E
Health structures notifying and consultations notified Albania, weeks 15 to 19, 1999 Numbers of health structures Numbers of consultations 30000 ONG Min. de la santé 140 25000 120 20000 100 15000 80 60 10000 40 5000 20 0 0 15 16 17 18 19 15 16 17 18 19 Weeks Weeks E P I D E M I C A L E R T A N D R E S P O N S E
Number of cases and deaths in Abushok weeks 21-27, North Darfur 240 220 200 180 Increase population 160 26800 -> 35040 140 BLDIAR Laboratory 120 DEATHS Confirmed 100 3 cases Sh. Dys. 1 80 5 deaths 30 june Under five 60 40 20 0 21 22 23 24 25 26 27 weeks E P I D E M I C A L E R T A N D R E S P O N S E
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