HIV/AIDS in Complex Emergencies – A Call for Action



HIV/AIDS in Complex Emergencies – A Call for Action

Dr Peter Piot, Executive Director, UNAIDS

HIV/AIDS was first discussed in the Security Council in early January 2000 - the first time for a health issue to be debated in this forum - and the discussion redefined the AIDS epidemic as a threat to human security. History was then made in July this year, when the Security Council adopted a resolution drawing attention to the relationship between the spread of HIV/AIDS and the maintenance of global peace and security. The resolution also underlines the importance of a co-ordinated international response, given the growing impact of the epidemic on social stability and emergency situations.

It has long been evident that HIV/AIDS is more than a health hazard; it is also a paramount factor of individual and collective vulnerability. More than 33 million people world-wide live today with HIV/AIDS. It is well known how HIV infection and the burden of AIDS-associated diseases increase individual vulnerability. In collective terms, the same burden of diseases, suffering, early mortality, loss of manpower and income, overload on services and solidarity networks also have undeniable and increasingly manifest effects on the vulnerability of households and whole communities. Furthermore, the economic impact of HIV/AIDS and the stigma attached to the disease can contribute to marginalisation, inequities and, ultimately, to social instability and associated human-induced hazards.

The vast humanitarian implications of the pandemic become even more dramatic in conflict and emergency situations. HIV spreads fastest wherever poverty, social disenfranchisement and instability prevail. And nowhere all these conditions more extreme than in complex emergencies. Physical, financial and social insecurity erode the caring and coping strategies of individuals and households. This often results in forced high-risk sex behaviour and sexual abuse. Women and girls find themselves coerced into sex to gain access to basic needs such as food, shelter, and security. In addition, women and children are at heightened risk of violence, including rape.

War and civil strife also exclude any effective form of community support to AIDS sufferers and their families. HIV/AIDS control activities, whether undertaken by national or international entities, tend to be disrupted or broken down altogether. Thus, while the plight of those already affected worsens, all population groups in the country become more vulnerable to the infection. The range of issues that must be taken into account when looking at HIV transmission is always daunting: effectiveness and costs of drugs, health delivery systems, economics, demography, societal attitudes, human rights and legal issues, poverty, forced migration and violence against women are only some of them. The interactions between HIV/AIDS and armed conflicts, though, are so many, so obvious and of such gravity that, alone, they could be sufficient for health practitioners to take a stance for peace as one key precondition for controlling the epidemic at global level.

The challenge of how to tackle HIV/AIDS in complex emergencies is a pressing one. The United Nations Inter-Agency Standing Committee for humanitarian affairs (IASC) has established a task force to outline strategies and programme options in this area. Paradoxically, an entry point for interventions in complex emergencies can be found in the fact that even national and international relief efforts may contribute to the risk of HIV/AIDS.

Nobody will never know for sure how much the increased long-distance road traffic generated by the food relief operations during the drought of 1992 in Southern Africa may have contributed to accelerate the spread of HIV in the sub-region. However, it is a fact that commercial sex is one feature of the fringe economy generated by humanitarian operations and that, in complex emergencies, peacekeepers are at special risk for HIV. Armed forces make up large, young population blocks, already at risk in many countries. Once they are deployed abroad, in conflict situations, their sexual interaction with the host population can fuel rapid HIV transmission in both directions, ready to be replicated once the servicemen return home to their families.

But peacekeepers and more in general UN “uniformed services” of all nationalities are also a good target audience for education about HIV/AIDS and its prevention. We already know enough of HIV transmission to ensure minimum standards of precaution, prevention and care before, during and after conflicts or disasters occur. Through education of UN uniformed services we can ensure that the struggle against HIV/AIDS is reflected in all humanitarian interventions and in the behaviour of all humanitarian actors.

To this end, the UNAIDS Secretariat is spearheading urgent action in collaboration with United Nations Resident Co-ordinators and theme groups on HIV/AIDS at country level. UNAIDS will take a ‘bottom up’ approach to activities such as the training of trainers and information dissemination as part of a comprehensive plan to reduce the risk for HIV/AIDS in complex emergencies.

We hope to make uniformed services, peacekeeping forces and humanitarian aid workers in general agents of prevention and models for behavioural change. Training is already planned through collaboration with the United Nations Department for Peacekeeping Operations, UNFPA and WHO. Counselling is also foreseen. Voluntary HIV testing within national armies, especially of troops to be deployed in international peacekeeping missions, is another element of these scaled up HIV prevention efforts. It will be conducted in the full respect of human rights, confidentiality and dignity, and with the explicit goal to protect the peacekeepers as well as the communities where they are deployed.

Essential minimum packages

for protection

A UN expert group is to develop and field test two packages for the prevention and control of HIV/AIDS among affected populations in complex emergencies.

Developed from new recommendations drawn up by the Inter-Agency Standing Committee’s Sub-Working Group on HIV/AIDS in Complex Emergencies, the two programmes offer an essential minimum set of interventions for the acute phase of a disaster and the post conflict stage.

The objective of the first package, designed for use during the acute phase of an emergency, is to control HIV/AIDS in the affected population and prevent further spread of the disease. Consequently the main components of the essential minimum package are:

• Prevention of HIV transmission through blood transfusion;

• Adherence to universal precautions for all health staff;

• Provision of free condoms;

• Provision of information.

Other recommended interventions during the acute phase include those aimed at preventing and/or managing the consequences of gender-based violence and providing essentials for clean delivery.

The post conflict package broadens the scope of interventions to include activities aimed at:

• Preventing of transmission through the care of sexually transmitted diseases;

• Social marketing of condoms;

• Providing comprehensive care for people with HIV-related opportunistic illnesses.

The packages will be field tested in Africa; specific countries to take part in the testing have not yet been chosen. However, monitoring the proposed activities to determine effectiveness will be essential to improving approaches to the treatment and control of HIV/AIDS in emergency settings. For further information, please contact: Dr L Kuppens, email: kuppensl@who.int

Consolidated Appeal Process (CAP) Revision

The CAP is one tool to address HIV/AIDS in complex emergencies by both increasing awareness of the issue and obtaining funds for programmes. In fact, countries which need the assistance sought through the CAP are often those most severely affected by HIV/AIDS. Specific guidelines to assist the UN address HIV/AIDS strategies in the CAP 2001, due to be launched in November 2000, have been elaborated.

HIV/AIDS and emergencies – PAHO Experience

Caring for members of the community living with HIV/AIDS and controlling the spread of HIV/AIDS and other STIs in the event of a disaster requires special approaches. Although the HIV/AIDS epidemic is still concentrated among groups with specific risk conditions and practices in most countries in the Americas, evidence from the Atlantic coast of the Central American isthmus and places in the Caribbean indicates the generalization of the epidemic. Therefore, HIV/AIDS is a growing concern in emergency health management in the Americas.

For members of the community with pre-existing health conditions requiring special care, such as HIV/AIDS, an emergency situation often makes access to necessary care and treatment more difficult since community efforts are usually directed to the alleviation of the disaster’s effects. With the pressing conditions created by a disaster, some health issues of compelling urgency tend to take priority, pushing other health problems into a lower position. Some members of the community may even perceive individuals affected by chronic conditions as an extra burden.

An emergency situation can affect the health of a person who is already living with HIV/AIDS in several ways including:

1. Deterioration of sanitation and hygiene conditions, which facilitate the onset of opportunistic infections,

2. Development of infections as a result of pathogens in food (eg. salmonella in poultry, eggs), related to the lack of food safety procedures,

3. Shortage of medications necessary for the management of opportunistic infections,

4. Interruption of antiretroviral treatment which frequently aggravates clinical conditions,

5. Exposure to potentially fatal pathogens (eg. tuberculosis) as a result of crowding in shelters.

In terms of transmission of HIV and other sexually transmitted infections (STIs), emergencies create situations which need special consideration. For example, sexual intercourse can provide temporary relief of emotional distress. It should be remembered that during emergency situations people may use sex as a means of emotional closeness and relief from their tensions, and interventions (e.g. condom provision) targeted appropriately to reduce the probability of transmission of sexually transmitted diseases, including HIV.

Another factor which could facilitate the spread of HIV is an increase in the number of blood transfusions. Therefore, it is absolutely crucial to ensure the safety of the blood and blood products in emergency settings.

Taking good care of HIV-infected individuals during emergency situations ensures that productive adults are able to continue actively participating in the community responses so necessary to face the emergency situation. In reducing the risk of death from complications of HIV/AIDS, it also lessens the chance of children being left without parental protection during the emergency.

Rafael Mazin, M.D. Regional Advisor on HIV/AIDS, Pan American Health Organization

UNHCR : HIV/AIDS field guidance

“Experience shows that HIV spreads fastest in conditions of poverty and social instability - conditions which typify refugee emergencies. The priority should be on preventing HIV transmission: ensure there is respect for universal precautions and work closely with the community to promote HIV prevention strategies including condom education and distribution. Where blood transfusions are provided, ensure they are safe. Treatment of sexually transmitted diseases should be a routine part of the health services and should include appropriate follow up of partners.

Mandatory HIV testing in refugee circumstances, with the single exception of testing blood for transfusion, is not justified, and WHO has determined that, as a matter of policy, such testing should not be pursued.”

Taken from: UNHCR: Handbook for Emergencies (page166, para 50)

SPHERE : HIV Prevention

“Action must be taken in the acute stage following the disaster to minimise risk of infection. The nature of the disaster and the epidemiological situation of the people affected will dictate what HIV/AIDS interventions are called for and what is feasible. A basic response to any emergency must aim to maintain respect for the individual rights of people with HIV infection or AIDS, and to prevent nosocomial transmission of HIV (transmission that takes place in the health facility). The intervention must ensure: safe blood transfusion; access to condoms; availability of materials and equipment needed for universal precautions; and relevant information, education and communications.”

Taken from: Humanitarian Charter and Minimum Standards in Disaster Response (page 246, para 7)

Impact of HIV/AIDS on food security in the Horn of Africa

Food security is frequently threatened by natural disaster in the Horn of Africa, but now HIV/AIDS is also taking its toll. Around 6 million of the 24.5 million people living with AIDS in sub-Saharan Africa are found in the countries of the Horn.

Like any other disease, HIV/AIDS has direct costs in terms of medical and funeral expenses, and indirect costs associated with its impact on labour and the subsequent loss of income. But the impact of HIV/AIDS on population structure also damages agricultural production, with the people who would normally be the most productive in the agricultural sector being also the most affected.

The impact is pronounced in farming systems that are labour-intensive since fewer workers are available to prepare the land and to tend the growing crops. As a result there is a tendency to reduce the area of crops that require high labour inputs and to increase the area of fallow crops and those that do not require weeding or irrigating. Fewer workers also mean more pests and diseases and reduced soil fertility as conservation techniques that require labour cannot be undertaken.

Surviving women are put under even greater pressure than normal. Not only do they face problems of extra expenses and the care of children on their own, but often also suffer reduced access to land. Funeral expenses alone can wipe out a family’s entire savings, while time lost attending funerals also has a serious impact on labour availability. The survival strategies that result from this loss of labour tend to involve concentrating efforts on subsistence crops and progressively neglecting cash crops. Where livestock are part of the system, cattle often have to be sold to meet medical expenses. General standards of husbandry decline as less labour is available, and, where oxen are important for cultivation, HIV tends to increase the differentiation between those who own work animals and those who are reliant on human labour.

The overall effect is ultimately to reduce the cropped area and yields, and narrow the range of crops grown. This not only affects incomes but household food intake and, consequently energy balance and nutritional status. Poor food intake among those with HIV/AIDS in turn increases susceptibility to conditions such as venereal diseases, tuberculosis and pneumonia and malaria which hasten illness and death.

Country % total pop Prevalence(%)

living with 15-24 group

HIV/AIDS

Djibouti 6.2 11.4

Eritrea 1.2

Ethiopia 4.9 9.7

Kenya 7.2 9.7

Sudan 0.5

Uganda 3.8 5.7

Based on: ACC Inter-Agency Task Force on the UN Response to Long Term Food Security, Agricultural Development and Related Aspects in the Horn of Africa - FINAL REPORT, FAO, Rome 15 September, 2000

Guidelines: HIV Interventions in Emergency Settings

A recent IASC review of the Guidelines for HIV Interventions in Emergency Settings, prepared jointly by UNAIDS, UNHCR, and WHO in 1995, led to a number of suggested additions. These include a more multi-disciplinary approach, guidance for peacekeepers, along with consideration of young people’s behaviour and its positive effect for role modelling. Furthermore, guidance on the implementation of the essential minimum package (see article, page 2), once it is tested, will need to be included. Finally, a methodology for implementing the methodologies the principles outlined in the Guidelines needs to be included.

However, the IASC also concluded that the existing guidelines should be actively disseminated and implemented in the field while the current guidelines are updated.

For further information, please contact Dr L Kuppens, email: kuppensl@who.int

Survey to pin down HIV impact

The US Centers for Disease Control and Prevention are to carry out a customised seroprevalence survey to try and pin down the real impact of HIV/AIDS in Sierra Leone.

The survey – funded by the World Bank – will extend beyond normal target groups to include groups such as child combatants and displaced people.

“Past figures suggest that Sierra Leone is at 8-10% seroprevalence which is about the level at which cases start to grow exponentially,” says WHO representative, Dr William Aldis. ”But figures are unreliable and we really need solid information if we are to target activities effectively.”

Sierra Leone’s emergency situation is a “lethal mix for HIV transmission” according to the Ministry of Health national programme manager. “Population displacement, rape, occupying troops, women in desperate circumstances, insecure blood supplies, drug abuse, unsafe sex practices and insufficient control activities all add up to a disaster,” says Dr Patrick Moses, who spends most of his time on the road evangelising about prevention.

From: Health Update Sierra Leone 8 September 2000

For further information contact Dr K Shibib email: shibibk@who.int

Selected References:

AIDS and the Military (May 1998)



Epidemiological Fact Sheets by Country



Guidelines For HIV Interventions In Emergency Settings (04 September 1996)



Migrant Populations and HIV/AIDS The Development and Implementation of Programmes: Theory, Methodology and Practice (August 2000)



Mother-to-child transmission of HIV (3) - Technical Update (September 2000)



Reproductive Health In Refugee Situations: An Inter-Agency Field Manual (1999)



Risk and Prevention in Emergency-affected Populations: A Review (Disasters, Vol 24 Number 3 September 2000 pp181-197HIV)

The basic strategies to prevent the spread of HIV/AIDS and STIs during an emergency situation are the following:

• Reduce the probability of transmission of STIs, including HIV. For this purpose, remedial education interventions and condom distribution, particularly in shelters, may be the most urgent responses. Treatment of symptomatic STIs is absolutely essential. A syndromic approach for diagnosis and treatment is recommended if resources to make etiologic diagnosis and clinical management are not available.

• Ensure that there is a stock of safe blood and blood products. Moreover, use sterile injection and other skin-piercing equipment, always adhering to universal norms of biosafety. These norms are essential when treating injuries, especially if they bleed, or if tissues and fluids are exposed.

• Provide access to clean water for all members of the community, and in particular to those with impaired immune systems. If this is not feasible, instruct them on how to purify water for drinking and cooking (boiling, treatment with chloramine or bleach).

• Observe food safety norms when handling food and cooking meals. This is particularly important in shelters.

• Identify individuals who are receiving antiretroviral medications. Prepare a list of drugs that needs to be available to prevent interruption of schemes of treatment.

• Stock drugs for the management of common opportunistic infections (pneumonia, gastrointestinal infections, tuberculosis, and fungal infections)

• Avoid crowding, whenever possible.

Rafael Mazin, M.D., Regional Advisor on HIV/AIDS, Pan American Health Organization

WORLD HEALTH NEWS

Advocates move on Massive Effort

Two months after Dr Gro Harlem Bruntland, Director General of WHO, offered G8 members the vision of a ‘massive effort’ against diseases that keep the poor in penury, representatives of UN agencies, humanitarian NGOs, advocacy organisations, information specialists, philanthropic bodies and private

companies from across the developed and developing world have met to start thrashing out just what is needed to put this vision on the agenda - globally, regionally and locally.

The Massive Effort came into being after Dr Bruntland drove home the stark links between poverty and infectious disease at the July meetings of the G8 and G7 in Okinawa, Japan.

“We have known for years that poor people tend to die young. The poorest billion in our world are particularly vulnerable as a result of infectious diseases - notably HIV, TB and malaria. (Yet) each death can be avoided with low cost technologies that are available today,” she told world leaders.

“We know what needs to be done to tackle infectious diseases, and how to intensify action against HIV, malaria and TB… Quite simply, if we can take these interventions to scale – and by that I mean a global scale – we have in our hands a concrete results-oriented and measurable way of reducing death and suffering, and in doing so also poverty itself.”

Last week’s working meeting in Winterthür, Switzerland (Oct 3-6) focused on the advocacy and information needed to fire the partnerships and the activities that will allow this to move forward.

Target 2010: G8 goals

• Reduce HIV infection rates in 15-24 year olds by 25%

• Reduce deaths from TB by 50%

• Reduce the burden of disease associated with malaria by 50%

For further information, please contact: Mr G. Hartl, WHO spokesperson, hartlg@who.int

CAP 2001 to focus on ‘Women and War’

The theme of the 2001 UN Inter-Agency Consolidated Appeal (CAP) is ”Women and War” and a number of decentralized events in major donor capitals will mark the launch at the end of November.

For further information, please contact Dr Y Tegegn email tegegny@who.int or Ms S Ferazzi, email ferazzis@who.int

Good donation practices require education

Concerted inter-agency action and a high profile publicity campaign are needed to tackle the continuing problem of inappropriate ‘in-kind’ donations, according to WHO.

WHO’s Ms Zaccarelli brought the issue of inappropriate in-kind donations back to September’s meeting of the Inter-Agency Standing Committee Working Group (IASC-WG) in New York after recent disasters such as the earthquake in Turkey and the floods in Venezuela and Mozambique once again brought the problem to light.

Reminding working group members that in Bosnia alone US$20 million was needed to dispose of inappropriate donated medicines, Ms Zaccarelli argued that what is needed is an education campaign for the general public, and the development of an inter-agency information system to manage pledges and in-kind gifts.

“We need to come up with positive messages that encourage appropriate donations,” she said.

WHO has agreed to lead consultations with agencies on the adverse consequences of inappropriate donations, and report back to the next IASC-WG meeting in December on possible steps to be taken with government, the public and private sector.

Give your view – virtually

As part of WHO’s effort to engage partners in the effort to tackle inappropriate in kind donations, the strategy of a public education campaign was discussed in the Emergency Information Infrastructure Partnership (EIIP) Virtual Forum on 4 October.

The Forum works like a chat room where anyone with internet service can have access. It is a web page dedicated to information to support emergency management and disaster response. There is a new topic every week. The sessions are every Wednesday 16:00 (Greenwich time) and they last one hour. The address is

For further information please contact: Ms M Zaccarelli email: zacarelm@

The following websites provide information on appropriate drug donations:





Vaccinators beat yellow fever outbreak in Liberia

Liberian vaccination teams braved torrential rains, flooding rivers, mud holes and days of arduous walking to carry out an emergency campaign which has averted the threat of a yellow fever epidemic in the north-western coastal county of Grand Cape Mount.

Almost 86,000 men, women and children – some 70% of the 128,000 population – were reached in the one week active phase of the campaign carried out in early September. Mop up activities continued through the month, along with active surveillance for new cases. Before the action, fewer than 5% of the population was protected by yellow fever vaccination.

“The vaccinators haven’t let the rain stop them” says Dr Tanu Duworko, Grand Cape Mount County health officer, who has been in charge of the campaign, “Some people have had to walk up to seven hours in the rain to get to the hard-to-reach villages, or wait for rivers to go down so they can cross – but they are doing it.”

The campaign, funded by UK, Irish, Japanese and European Union foreign aid departments, was planned by WHO in collaboration with the ministry of health and the non-governmental organisations Oxfam, World Vision, Médicins sans Frontières and the Initiative pour Solidarité Africane, and has involved over 280 people.

For further information, please contact: Dr K Shibib, email shibibk@who.int

Kick-start for Roll Back Malaria in Sierra Leone

After two years of piecemeal activities disrupted by conflict and erratic funding, health players in Sierra Leone are determined to get the Roll Back Malaria (RBM) Initiative, agreed upon in 1998, back on track this year.

According to the new plan of action, drawn up jointly by Ministry of Health and WHO malaria focal point, September and October 2000 should see intensive activity to get national and international health and community partners on board, produce information kits and develop district action plans.

Four districts have been selected to pilot the programme scheduled to start in early 2001. WHO consultants were in Sierra Leone recently to train ministry programme leaders and will return in November to train the RBM taskforce in driving the programme forward.

Sensitisation workshops - funded by WHO – are being run to update district health team staff, community health officers and laboratory technicians on current prevention, diagnosis, management and investigation techniques.

The RBM Initiative, created by WHO, focuses on the fact that most victims of malaria die simply because they do not have access to health care close to their home, or their cases are not recognised as malaria by health care workers.

Taken from: Sierra Leone Health Update, 8 September 2000

For further information, please contact: Dr K Shibib, email: shibibk@who.int

Coordination to combat drought

The drought in Central and South Asia is adversely affecting health with increased incidences of diarrhoeal disease and malaria. In addition, rodents are migrating into more densely populated areas, increasing the risk of exposure to diseases such as tularaemia and other rat-borne communicable diseases.

Central and South Asia, particularly Afghanistan, India, Iran, Pakistan and Tajikistan, are now suffering the worst drought in 25 years, and the disaster has now spread to Mongolia, northern and western China, Iraq, Uzbekistan, Syria and Jordan. All areas have suffered significant losses of livestock and crops, rapid deterioration of health and sanitary conditions and population displacement.

WHO is co-ordinating the efforts for health assessment and response in the countries most affected including Tajikistan where current activities are focused on:

• strengthening the capacity of health care system to prevent and control outbreaks of water borne and other communicable diseases.

• reinforcing the emergency malaria control programme through providing necessary drugs and vector control measures

• expanding the disease surveillance system, and improving the diagnostic capacity of laboratory services.

For further information please contact: Dr E Kossenko, email: kossenkoe@who.int

Conflict no bar in war against polio

Stamping out polio in the last 20 countries to harbour the virus will require access to war zones and an extra US$450 million, according to WHO Director General Dr Gro Harlem Bruntland, who launched the final five year drive to wipe out the last recalcitrant traces of the polio at a summit of public and private sector partners in New York in September.

Backing her call for continued efforts, UN Secretary General Kofi Annan said all parties should throw their weight behind “negotiating access to all children for national immunization days, particularly in the priority countries affected by conflict.”

Just such efforts are taking place right now in West Africa, where partners in the polio campaign for Sierra Leone are working feverishly to try and build the kind of accord that allowed them last year to achieve what many in the outside world believed impossible – a vaccination coverage rate of 84% – and join what is planned to be a 17-country synchronised national immunization day campaign in late October.

“Despite the absence of a comprehensive agreement with opposing factions, NIDs organizers have managed to negotiate access to 38 of the 68 chiefdoms in the eight rebel-controlled districts. This means we will be able to reach around 291,000 of the estimated 576,000 children in RUF areas. Only the district of Bombali, a strategically important RUF area, remains completely inaccessible.”

Two cases of wild polio virus have been identified so far this year in Sierra Leone which, with Afghanistan, Angola, the Democratic Republic of the Congo, Somalia and Sudan, is considered one of the most challenging places in the eradication of polio.

Taken from: Sierra Leone Health Update, 8 September 2000

For further information, please contact: Dr K Shibib, email: shibibk@who.int

Action on first Rift Valley Fever outside Africa

The World Health Organization (WHO) and its partners are responding to an outbreak of Rift Valley Fever (RVF) in Saudi Arabia and an outbreak of acute haemorrhagic fever syndrome in Yemen, which is suspected to be RVF. These are the first cases of Rift Valley Fever reported outside traditionally affected areas in Africa.

It is important to establish whether this is a new introduction of the virus or whether, in fact, the pathogen has been present for some time and only now has come to the attention of public health authorities. Ecological studies are being carried out to determine the factors that may have triggered the outbreak.

WHO, in conjunction with its international partners in the field, is:

• providing expert advice to the governments concerned in disease confirmation, field investigation and implementation of control measures to contain the spread of the disease,

• advising on how cases can be treated with the antiviral drug, ribavarin,

• disseminating health education messages, and

• putting in place measures to protect high risk groups, such as laboratory technicians and veterinarians.

High-level agreement between Saudi Arabia and Yemen to conduct a joint investigation has ensured effective coordination of the international response to control the disease on both sides of the border.

For further information, please contact: Mr G. Hartl, WHO spokesperson, hartlg@who.int

Shigella outbreak in Eritrean displaced camp

The Ministry of Health of the State of Eritrea has notified an outbreak of shigella in the Harena IDP camp, 30 kms south of Asmara. The bacteria, identified with the support of WHO and Médecins sans Frontières France, were found to be resistant to the commonly used first line drugs. However, the outbreak has not reached epidemic dimensions thanks to a series of control measures, which have included provision of (more expensive) drugs, to which the bacteria are sensitive, sanitation measures and community education in the camp.

For further information please contact: Dr L Kuppens, email: kuppensl@who.int

SUMA looks to the future

The effectiveness and future of SUMA - the Supply Management System (SUMA) – developed by the WHO and its sister Pan American Health Organisation will come under the spotlight in a workshop in San Jose, Costa Rica this month (18-20 October).

Funded by the Government of the Netherlands SUMA has been available to countries as technical information management tool for small and large-scale disasters for almost a decade now.

During this time, SUMA has proved its value particularly in Latin America and the Caribbean, but also on a smaller scale in other regions of the world. More recently, it is being used as a management tool in non-emergency operations to guide the routine operation of warehouses and health units.

The workshop, attended by SUMA users and developers, will review the experiences, and the expectations of SUMA accumulated in many circumstances and look to map out its future development, particularly in the light of rapidly evolving technology provides.

The issue of co-ordinating database software development will also be in the agenda for the next meeting of the Inter-Agency Standing Committee Working Group.

For further information please contact: Ms M Zaccarelli email: zacarelm@

SUMA in Cuba

One immediate result of recent training in the use of SUMA in the town of Bayamo, Cuba is that three important new locations are now using the system:

1. The local Red Cross, which has a large warehouse for managing donations, and formally used the ‘Warehouse Module’.

2. The “Poder Popular de Bayamo” (town hall) which is using SUMA a tool for the donations and material that they manage.

3. The Maternity Children’s Hospital which is being built through donations from other countries, such as Germany, where SUMA is being used as a management tool.

For more information about the SUMA program please visit .

For further information please contact: Ms A Thomas email: thomasan@

If you would like to receive regular electronic updates and news on SUMA, subscribe to the e -mailing list. Go to: for information and instructions.

Mihrabs and T-shirts publicise polio

Posters, leaflets, newspapers, radio, TV and a few less conservative approaches were the order of the day for the launch of the first round of the polio immunisation campaign in Kosovo.

In Gnjilane/Gjilan and Pristina, religious leaders allowed people to announce the campaign from the loud speakers on the mosques. WHO staff wearing special vaccination logo T-shirts (courtesy of International Medical Corps) approached parents in the street to encourage them to make sure their children were vaccinated. Vehicles with loud speakers slowly patrolled the streets informing the public about the dangers of polio and the importance of vaccination.

This method of social mobilisation was not only effective but fun, as children appeared in the streets and people stopped their work to listen to the message. Several local radio stations provided free air time to publicise the campaign, and KFOR and UNMIK radios also broadcast public service announcements.

The campaign was not Kosovo-wide but targeted six municipalities found to have particularly low polio immunization coverage. The campaign was a co-ordinated effort of numerous organisations, led by the Institute of Public Health in co-operation with WHO and UNICEF, who also provided the necessary funds.

Taken from: Health Talks 33

For further information please contact: Dr E Kossenko, email:kossenkoe@who.int

The World Health Report 2000

Health Systems: Improving Performance

The World Health Report 2000 is an expert analysis of the increasingly important influence of health systems in the daily lives of people worldwide. To an unprecedented degree it takes account of the role of people as providers and consumers of health services, as financial contributors to health systems, as workers within them, and as citizens engaged in their responsible management, or stewardship.

Drawing upon a range of experiences and analytical tools, the report traces the evolution of health systems, explores their diverse characteristics, and uncovers a unifying framework of shared goals and functions.

Using this as a basis for analysis, the report breaks new ground in presenting an index of health system performance based on three fundamental goals: improving the level and distribution of health, enhancing the responsiveness of the system to the legitimate expectations of the population, and assuring fair financial contributions.

The report goes on to show how the achievement of these goals depends on the ability of each system to carry out four main functions: service provision, resource generation, financing, and stewardship. Chapters devoted to each function offer new conceptual insights and practical advice on how to assess performance and achieve improvements with available resources.

In doing so, The World Health Report 2000 aims to stimulate a vigorous debate about better ways of measuring health system performance and thus finding a successful new direction for health systems to follow. By shedding new light on what makes health systems behave in certain ways, WHO also hopes to help policy-makers understand the many complex issues involved, weigh their options, and make wise choices.

Available in English and French; Arabic, Chinese, Russian, and Spanish in preparation

ISBN 92 4 156198 X

To place an order, please email: bookorders@who.int

For further information, please email: publications@who.int

Management of the Child with a Serious Infection or Severe Malnutrition

Guidelines for Care at the First-referral Level in Developing Countries

This manual gives small hospitals in developing countries expert advice on the management of young children suffering from serious infections or severe malnutrition. Addressed to doctors and senior nurses, the manual aims to provide all the practical and technical guidance needed to facilitate quick decisions and life-saving interventions. Although advice on outpatient care is included, the manual concentrates on the inpatient management of diseases known to be the major killers of children in the developing world. Conditions covered range from pneumonia, diarrhoea, and severe malnutrition to malaria, meningitis, and measles.

The manual opens with a chapter on triage, which explains a rapid process for detecting emergency cases and starting treatment immediately. Chapter two, on assessment and diagnosis, presents the key symptoms and signs to look for in children with specific problems, giving particular attention to the importance of differential diagnosis.

Against this background, the core of the manual provides detailed treatment instructions for individual clinical conditions, specifying the standard course and duration of treatment. Separate chapters cover the management of over twenty diseases in children presenting with cough or difficult breathing, diarrhoea, and fever. Additional chapters cover the management of common problems in young infants, of children suffering from severe malnutrition, and of children with HIV/AIDS. The remaining chapters provide detailed guidelines for supportive care, propose a system for the regular monitoring of patients, and offer advice on when and how to discharge the child from hospital.

ISBN 92 4 154531 3

To place an order, please email: bookorders@who.int

For further information, please email: publications@who.int

EHA Highlights

This monthly publication, produced by the Department of Emergency and Humanitarian Action (EHA) at headquarters, focuses on issues of interest to our donor community. Each month, EHA Highlights provides updates on the financial status of new and on-going programmes. EHA Highlights is distributed free of charge by email and available on EHA’s website ( then click on ‘Newsletter’).

For further information, please contact Dr Y Tegegn email tegegny@who.int or Ms S Ferazzi, email ferazzis@who.int

Health in Emergencies is also available on EHA’s website. Go to:



then click on the

‘Newsletter’ icon at the bottom of the page.

EHA has revamped its website. The redesigned site focuses on providing information on what is happening in emergency situations (health situation reports, epidemiological surveillance, needs assessments, etc.) and what to do about it (technical guidance).

Visit the site at:



Management of Severe Malaria

A Practical Handbook, Second edition

This is the second revised edition of a pocket-sized guide to the rapid diagnosis and management of severe P. falciparum malaria. In view of the complexities of management, the need for speed, and the severe consequences of errors, the book adopts a highly didactic approach, offering an at-a-glance reference to the signs to look for, the tests to perform, the actions to take immediately and later, and the nursing care required. Special problems addressed throughout the book include the tendency of malaria to mimic many other diseases, the difficulty of diagnosis in cases of self-medication, the spread of parasite resistance to chloroquine and other drugs, and the need for special precautions in areas where blood may be contaminated with the human immunodeficiency virus (HIV).

Addressed to doctors and other medical staff, the book is designed to facilitate rapid decisions and immediate action.

ISBN 92 4 154523 2

To place an order, please email: bookorders@who.int

For further information, please email: publications@who.int

Overcoming Antimicrobial Resistance

World Health Organization Report on Infectious Diseases 2000

‘This year’s report focuses on the issue of drug resistance and how this disturbing development is closing the windows of opportunity to treat infectious diseases. By developing a global strategy to contain resistance and building alliances involving all healthcare providers – countries, governments, international organizations, non-governmental organizations and both the private and public health care sectors – we have an opportunity to launch a massive effort against infectious diseases that perpetuate poverty. Used wisely and widely, the drugs we have today can be made available to the world’s poorest to prevent the health care catastrophes of tomorrow.’ Dr Gro Harlem Bruntland, in the Introduction to the Report.

12 June 2000, 67 pages

WHO/CDS/2000.2

Distributed on request to: cdsdoc@who.int

The full text of the report is accessible from the WHO web site at:

Adolescents: Assessment of nutrition status in emergency-affected populations

(ACC/Sub-Committee on Nutrition, July 2000)

This article discusses the assessment of undernutrition in adolescents in emergency situations. The World Health Organization (WHO) defines adolescents as persons aged 10-19 years. The discussion emphasises practical issues of anthropometric assessment of nutritional status rather than general knowledge of adolescent growth and development. The article points out some of the deficiencies in the current recommendations regarding the nutritional assessment of adolescents, including those published by WHO.

The publication is available on-line at:



or by request to accscn@who.int

Adults: Assessment of nutrition status in emergency-affected populations

(ACC/Sub-Committee on Nutrition, July 2000)

This article describes simple techniques suitable for the assessment of the nutritional status of adults aged 20-60 years in emergency-affected populations. The BMI (body mass index) MUAC (mid-upper arm circumference) and clinical models are assessed for their usefulness in determining the prevalence of chronic undernutrition in adults at the population level and for screening severely undernourished adults for entrance to feeding clinics.

No consensus on a definitive method to assess adult undernutrition has been reached; more research is required to do this. This article makes only preliminary recommendations.

The publication is available on-line at:



or by request to accscn@who.int

CONTACTS

Department of Emergency and Humanitarian Action

World Health Organization

20 avenue Appia

1211 Geneva 27, Switzerland

Phone: (41 22) 791 2752/2727/2987

Fax: (41 22) 791 48 44

email: eha@who.int

Regional Office for Africa (AFRO)

Emergency and Humanitarian Action (EHA)

temporary location

Medical School, C Ward

Parirenyatwa Hospital, Mazoe Street

PO Box BE 773, Belvedere,

Harare, Zimbabwe

Phone: (263) 470 69 51 or 470 74 93

Fax: (263) 470 56 19 or 470 20 44

email: chellouchey@

Regional Office for the Eastern Mediterranean (EMRO)

Coordination, Resource Mobilization and Emergency Relief (CMR)

WHO Post Office

Abdul Razzak Al Sanhouri Street,

(opposite Children's Library)

Nasr City

Cairo 11371

Egypt

Phone: (202) 670 25 35

Fax: (202) 670 24 92

email: saleha@who.sci.eg

Regional Office for Europe (EURO)

Partners in Health and Humanitarian Assistance (PAR)

8, Scherfigsvej

2100 Copenhagen O, Denmark

Phone: (45) 39 17 17 17

Fax: (45) 39 17 18 18

email: jth@who.dk

Regional Office for the Americas (AMRO)/

Pan American Health Organization (PAHO)

Emergency Preparedness and Disaster Relief Coordination Programme (PED)

525, 23rd Street, NW

Washington, DC 20037, USA

Phone: (202) 974 3520

or (202) 974 3399

Fax: (202) 775 4578

email: disaster@

Regional Office for the Western Pacific (WPRO)

Division of Health Infrastructure (DHI)

PO Box 2932

1099 Manila, Philippines

Phone: (632) 528 80 01

Fax: (632) 521 10 36 or 536 02 79

email: takashimay@wpro.who.int

Regional Office for South-East Asia

(SEARO)

Health Services Development (HSD)

World Health House

Indraprastha Estate

Mahatma Gandhi Road

New Delhi 110002, India

Phone: (91 11) 331 7804/7823

Fax: (91 11) 331 8607 or 332 7972

email: sorensene@

Health in Emergencies is a newsletter of the Department of Emergency and Humanitarian Action of the World Health Organization (WHO). This newsletter is not a formal publication of WHO. All rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated in part or whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in this newsletter do not necessarily reflect those of WHO.

Production of this newsletter has been made possible by the support of the Italian Government.

Correspondence and inquiries for subscription should be addressed to:

The Editor

The Department of Emergency and Humanitarian Action, World Health Organization, 1211 Geneva, Switzerland

Phone: (41 22 ) 791 4676

Fax: (41 22) 791 4844

email: lorettia@who.int

Chief Editor: Dr Alessandro Loretti

Editors: Dr Alessandro Loretti, Ms Jane Wallace, Ms Hillary Bower,

Design: Mr Jean-Claude Fattier

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