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I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies

Epidemiology and surveillance

Treguine Refugee Camp, Chad, November 2006 684 children were vaccinated and 1302 women were vaccinated against tetanus.International Federation

Public health guide for emergencies I 221


This chapter provides an overview of the key epidemiological principles and the epidemiological tools needed in managing emergency public health programmes. The main goals are to reduce morbidity and mortality among disaster affected and displaced populations.

To provide a basic understanding of key epidemiological principles and terminology; To develop skills for defining and calculating indicators; To describe standard methods for conducting needs assessment; To define the steps for setting up a surveillance system for emergency situations; To describe the main principles and practical methods for conducting a population survey; To identify key steps in investigating disease epidemics; To develop skills in analysing and presenting epidemiological information.

Key competencies
To recognise the main constraints in applying epidemiological methods to emergency situations; To calculate key indicators of the health status of a population; To plan a rapid needs assessment; To set up a surveillance system for emergency situations; To conduct a population survey using the appropriate sampling and analysis methods; To investigate an epidemic and apply findings to an epidemic control programme; To analyse and present epidemiological data in a logical manner for use in programme management.

Basic principles of epidemiology in emergencies
Epidemiology is the study of the causes and distribution of disease in human populations. An epidemiological approach helps planners to focus on the main problems of a community rather than of individual patients and to identify measures for improving the health of the community as a whole. Commonly used terms in epidemiology are defined in the glossary at the end of this chapter. Epidemiology can increase the general understanding about a disease and particularly how it is transmitted even when the cause is unknown. In epidemiology, the assumption is that diseases do not occur randomly, but follow predictable patterns that can be studied and expressed in terms of

what, who, where, when, how, why, and what next.

Epidemiology and surveillance

Epidemiology and surveillance



I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies

Epidemiology and surveillance

The goal of epidemiology is to identify subgroups of the population who are at a higher risk of disease than usual and who will benefit the most from disease specific interventions. Epidemiological information can be used to develop prevention strategies according to: Time (peaks at a particular season); Place (limited to specific geographic areas); or Person (groups at risk). In emergencies, epidemiology has three elements: Descriptive Epidemiology determines the distribution of a disease among displaced populations. It describes the health problem, its frequency, those affected, where, and when. The events of interest are defined in terms of the time period, the place and the population at risk. Examples: Monitoring the health status of a population to detect cholera cases, such as, by age, sex, location, water source and duration of stay in a dispersed population or camps. Conducting a nutritional survey to determine the prevalence of acute malnutrition among children under five. Analytical epidemiology compares those who are ill with those who are not in order to identify the risk of disease or protective factors (determinant of a disease). It examines how the event (illness, death, malnutrition, injury) is caused (e.g. environmental and behavioural factors) and why it is continuing. Standard mathematical and statistical procedures are used. Example: Investigating an outbreak of an unknown disease in a displaced population settlement. Evaluation epidemiology examines the relevance, effectiveness and impact of different programme activities in relation to the health of the affected populations. Example: Evaluating a malaria control programme for displaced populations.

Role of epidemiology in emergencies
Epidemiology in emergencies goes beyond simply understanding how diseases are contracted and spread. Humanitarian relief programmes can be managed better if decision-making is based on epidemiological findings. Relief workers need training to help them collect more reliable information and use it to improve health care for the displaced population. During the emergency response, applied epidemiology can be used to define the long-term needs of communities. Community capacity to respond to emergencies can be strengthened if members are engaged to learn ‘shoe-leather’ epidemiology including how to map their villages, conduct reliable needs assessments and identify groups who are at a particularly high risk from disease. Developing such skills can also be highly valuable for communities long after emergencies have been resolved. Objectives of epidemiology in emergencies include: Identifying the priority health problems in the affected community; Determining the extent of disease existing within a community; Identifying the causes of disease and the risk factors; Determining the priority health interventions; Determining the extent of damage and the capacity of the local infrastructure; Monitoring health trends of the community; Evaluating the impact of health programmes.

g. Demographic studies determining the population size and structure of affected communities in camp settings or dispersed within a host population. Limited access to a significant fraction of the affected population due to chaos or insecurity. Survey samples might not represent all the affected population. nutrition and immunisation status) and assessing programme coverage. Rapid turnover of skilled staff. Note: governments might be part of a conflict and are thus less likely to care for the IDPs while the original mandate of UNHCR does not cover IDPs. Examples of quantitative indicators include: Incidence—the number of cases or events that occur within a defined population that is divided by the total population in which the cases or events occurred in a specific period e. Investigating a disease outbreak.g. They might also reflect the process and outcome of existing services. indicators are useful for measuring and describing the effects of a disaster on a population and for providing baseline measurements. the incidence of measles among children. Difficulty in estimating the population size.Public health guide for emergencies I 223 6 Constraints of epidemiology in emergencies Constraints in using epidemiology in emergencies include: Poor understanding of basic epidemiological principles and measurement techniques. Lack of support to undertake assessments and address needs of Internally Displaced Persons (IDPs). incidence/prevalence of disease. . Prevalence—the proportion of the population with a particular condition that is divided by the total number of persons at risk for the condition during that period e. Morbidity rate—all persons in the population under consideration e. Epidemiology and surveillance Epidemiology has many uses in emergency situations. Programme monitoring and evaluation. Public health surveillance and management information system. Key epidemiological indicators Indicators are measures that reflect the state of a population in terms of health..g. mortality rate of infants during their first year of life. They might be quantitative or qualitative in nature. Population surveys for determining health status (death rates. Indicators may be defined from surveys or an existing health information system. the prevalence of HIV/AIDS in a population. Difficulty in investigating long-term needs of an affected population. the number of people according to age and sex etc. including: Rapid needs assessment. belonging to a specific gender or age-group who become clinically ill during the specific period.g. Mortality rate—the number of deaths occurring in a population in a specific period (usually a year) divided by the number of persons at risk of dying during that period e. these measurements will help determine the outcome of the relief response. Quantitative indicators are easily calculated from numeric information such as the total number of people. socioeconomic status etc. In humanitarian emergencies. Limited resources for processing information. Later.

maternal) Incidence and prevalence of common disease Rate of under-five malnutrition Availability of the following resources: Facilities and equipment (health centre. expatriate) Basic supplies (food. A lack of understanding about the “Abstinence. Barriers to seeking treatment for malaria—barriers to seeking treatment such as unaffordable health services. The following qualitative indicators are commonly used for assessing programme outcomes: Access: the proportion of the target population that can use the service or facility. Adherence to preventive interventions against HIV/AIDS—poor compliance from youths in preventive interventions (e. Be Faithful.g. under fives. Table 6-1: Quantitative and qualitative indicators for emergency health programmes Indicator Examples Health policy (might be difficult to measure) Demographic profile Health status Programme inputs Degree of political commitment Adherence to agreed/national case definitions and treatment protocols Level of community participation Degree of inter-sector collaboration Equity in distribution of resources Inter-agency co-ordination Adherence to universal precautions against HIV/AIDS Adherence to minimum standards of the Sphere Project Estimated size and structure of displaced population: Age and sex composition Migration patterns (proportion moving in and out) Proportion of high-risk groups Ratio to local resident population Rate and causes of death (crude. local.. Examples of qualitative indicators include: Awareness of the value of immunisation—low awareness may explain the high incidence of measles in a population living within five kilometres from a health facility. These indicators might be critical in explaining unexpected values of quantitative indicators. Equity in distribution of resources—inequitable distribution of food might explain the increased mortality detected in a subgroup of a population. Availability: amount of services compared with total target population. infant. charcoal) Transport .6 224 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Qualitative indicators that measure people’s attitudes and knowledge are more difficult to measure. Social processes influencing health outcomes might also be elucidated by using qualitative indicators. might explain an increase in malaria-specific mortality. shelter material. Use a Condom” (ABC) programme)) might explain the increasing prevalence of HIV/AIDS in a population. beds) Staff (beneficiary population. This should be based on minimum standard requirements. Coverage: the proportion of the target population that has received service. domestic equipment) Energy sources (fuel. The following table summarises the quantitative and qualitative indicators that can be used to evaluate an emergency health programme’s process and outcome. Quality of services: the actual services received compared with the standards and guidelines.

For better estimation of the population size during the acute emergency phase. The ideal method for estimating the population size is by a census or a registration system. To estimate the amount of basic needs required (food.e. health resources). These estimates might exist from a prior registration exercise or census.Public health guide for emergencies I 225 6 Indicator Examples Programme process Access. community health. This estimate must be valid since it provides the basis for all planning in humanitarian programmes. inconclusive and inaccurate information and data. Acute emergency situations This can be most challenging since many decisions have to be made on incomplete. donors. which can only be carried out several weeks or months after the relief operation has been established.000 litres of water are consumed in one day and individual water usage is Epidemiology and surveillance . However. It requires very experienced professionals to lead the operations. over-stated or understated especially during disasters with major displacements. they might be grossly unreliable e. To have a census for planning and political reasons (required by host authorities. etc. water. To draw budgets for relief programmes and estimate needs in recovery phase. coverage.). To calculate the value of indicators for programme monitoring and evaluation. peripheral clinics/second and tertiary facilities Estimating population size A reliable estimate of the total population size including age and sex distribution is important for the following reasons: To be aware of the true population that is at risk of death and disease including the host population. To plan long-term solutions including contingencies and future mitigation.g. Epidemiological procedures can be used to get better estimates of the population size and structure. interview a sample of people at their household or water collecting point to estimate the average amount of water used by each individual: If 200. and quality of the following services: General food distribution and supplementary feeding Potable water supply Latrine construction Immunisation Reproductive Health Health services at all levels i. the following surveys or sampling methods can be used for the rapid assessment: Water Usage: Determine the total amount of water the whole population in the dispersed population/camps consumes in one day. shelter. the population of children aged less than five years or women of child-bearing age etc. media. Then. Different methods for estimation Estimates of the total population. One might either accept the best available data or apply current epidemiological knowledge about the effects of similar disaster situations on the population structure. The most critical denominator is the estimate of the total population. represent critical denominators that are required for calculating indicators.

However. If possible. Make a rough estimate of the population size using this information or continue to step 4. these estimates should be interpreted carefully since food rations may be collected for sale or families may collect more than one ration. The key landmarks (e. the varying population density within the location(s) should be shown. Figure 6-1: Map of catchment area Note: The legends (symbols and colours representing structures and boundaries) should be consistent and recognisable for all maps. To estimate the number of households in the entire location. multiply the estimated fraction of under-fives by five to estimate the fraction of the total population for the total population estimate. Maps of sub-catchment areas might also be drawn to show varying target groups for different primary health care services.g. The population might either be settled in its own camps or integrated within the host population. Determining the population’s size and composition: Divide the entire map into sections containing approximately equal numbers of households.000/20 = 10.6 226 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance estimated as 20 L/person/day. one can either take a photograph of the settlements while flying or manually sketch maps to locate the affected population. where many landmarks are hard to find. Nutrition Screening: Screen and count a specified fraction of children under five years. the number of women.g. children and elderly is very high. use the cut-off height for all children aged less than five years as 110 cm.. Such maps and pilot charts are used by military and civil aviation. Note: Aerial mapping is indeed useful. the total population in the dispersed population/camps should be 200. A map can be used for sampling people from various ethnic and socio-economic groups for interviews or for sampling households for rapid surveys and for planning and evaluating programmes. lake). without appropriate scaled maps and their coordinates. it will not work. If no maps exist. . Carry out convenience sampling and select a reasonable number of households (e. If birth records are not available. count the number of households (shelters or cooking fires) in a typical section and multiply this by the total number of sections. the roads and any Primary Health Care facilities around the catchment area should be included in the map (see Figure 6-1 below). In emergencies. river. Note: Mass immunisation campaigns can be used to estimate the population size in a similar manner assuming that the immunisation coverage is 90% or more. Begin with a tour around the boundary of the location(s) to define its approximate shape and the maximum and minimum length and width. but in floods. Assuming that the under-five children make up about 20% of the total population. However. Aerial Mapping: Maps are useful tools for gathering additional information. A Global Positioning System (GPS) is convenient. Note: The total food distributed and individual food baskets may be used to estimate the total population in the same way as water usage.000 people.

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Note: The above-mentioned convenience (or non-probability) sampling is useful for making crude estimates of the population size/composition and possibly for identifying the immediate health needs during the rapid assessment. Results from convenience sampling are biased and not representative of the entire population. They cannot be used for comparison with results from other surveys. Where possible, probability sampling surveys should be organised as soon as possible to obtain more reliable results. See the section on population surveys for details about probability sampling methods.

Post-emergency situations
To estimate population size during post-emergency situations, other techniques can be used if the information from census or registration exercises is unreliable: Participatory mapping of the catchment area can be done by inviting a group of the affected population to sketch a map of the entire community on the ground or on large paper. They should first be asked to define the physical boundaries of the location of the affected community (see Figure 6-1 above) and the location of all key landmarks (e.g. rivers or lakes, roads, health facilities/services, water pumps, cemeteries etc). Distances should be shown as accurately as possible. They should be asked to identify where different ethnic communities and the most vulnerable group(s) (e.g. the poorest or most malnourished) are located in the map of the catchment area. Note: The above approach can easily capture the population in camp settings. However, when the affected community is dispersed within a host population, it is important to invite members from the disaster affected as well as the host population to either separately or jointly participate in the mapping exercise depending on the level of hostility between the two groups. Household registration: If the information from the census or registration exercises is unreliable or more information is required as dispersed population/camps services are set up, household and dispersed population/camps registers should be developed. Reviewing existing administrative records or interviewing key persons can help in designing the registers and in determining the target groups for emergency health services. Community health workers can be trained to visit all households and gather the required information e.g. record the households on the map and register each household member’s personal details (name, age, sex) and any existing risk factor (malnutrition, illness and disability). Household registers can later be used by health workers to locate vulnerable individuals who are most at risk of disease or death and to target them for specific primary health care interventions. Dispersed population/camps registers can be developed from summaries of household registers. They are useful for identifying the priority health needs of the population in the dispersed population/camps. Examples of dispersed population/camps and household registers are shown in the following table.

International Federation refugee camp Photo: International Federation

Epidemiology and surveillance

fifty) that can be easily reached. Record the number of persons living in each household including their age and sex breakdown. Calculate the average number of persons per household and multiply this by the total number of households. The agesex pyramid can be plotted to show the estimated population structure (see data analysis section for an example an of age-sex pyramid).



I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies

Table 6-2: Camp register

Epidemiology and surveillance



# Households

Camp leader

CHW volunteer

Health problems Priority Addressed

Access to health facility

Available transport







sanitation Immunisation Immunisation Malnutrition

no yes

10 km

Donkey carts

Water source not reliable Easily floods in rainy season






yes no

5 km


Table 6-3: Community health worker household register
Registration date: Prior occupation: Camp/zone: Health problem Date of death 23/7/68 Teacher Omega/blue

Household ID: 02/90/12 Head of household: Aladdin Ali

Relation to HoH





Risk factor







local beliefs

son father

Sinbad Ali Baba

3 months 58


diarrhoea TB 20/6/68

not breastfeeding

Poor access to formal health care, low literacy

Caution: Keely et al. (2001) cite several potential reasons for the overestimation of the number of beneficiaries.19 These include hiding people who are not Internally Displaces Persons (IDPs) or legitimate refugees, registering more than once to increase food rations, under-reporting of out-migrations and deaths and when members of the local population can attempt to register to access services provided to IDPs or refugees. On the other hand, under-estimations might result if IDPs or refugees who settle outside camps in the local population are hard to find and count, or if persons who are sick or malnourished do not access services that are being used to count beneficiaries.

Calculating rates, ratios and proportions
The most readily available data is usually in the form of absolute numbers (e.g. the total number of measles cases, the total number of diarrhoea cases). Absolute numbers can be used to report on the health of a specific population in a confined area over a short period. However, they cannot be used to compare events within the same population between population groups of different sizes or at different locations because absolute numbers can lead to invalid conclusions. For example, no conclusion can be drawn from reports of twenty-one deaths in Refugee Camp A and fifteen deaths in Refugee Camp B. To understand the significance of these reports and compare the death toll in the two camps, the frequency of deaths must be expressed as fractions such as rates, ratios, or proportions (percentages). These fractions contain a numerator and the best estimated population size as the denominator.

Rate = x/y x factor

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The Crude Mortality Rate is the total number of deaths per day and the number of under-five deaths. As with determining population data, counting the number of deaths in an emergency is difficult. It is even harder to count events among beneficiary populations that are not living in camps. Deaths often do not happen at or get reported to service sites such as health facilities or feeding centres. As a result, two additional approaches that can be used to estimate the number of deaths include retrospective mortality surveys and community-based surveillance. Standardised methods for retrospective mortality surveys (such as SMART) are being developed.11 Community-based methods include having volunteers and making home visits to ask about recent deaths, hiring grave watchers to count the number of burials or counting the number of shrouds or other burial material distributed.11 Note: Checchi and Roberts provide an easy to read description of both retrospective mortality surveys and community-based mortality surveillance in ‘Interpreting and using mortality data in humanitarian emergencies: a primer for non-epidemiologists.’ This paper can be downloaded from the Humanitarian Practice Network. It provides information on sample sizes, sampling methods, question procedures and interpretation of retrospective mortality surveys. These surveys provide relatively good quality information about past mortality experience. However, they should be led only by very experienced people. For prospective, community-based surveillance, Checchi and Roberts recommend a system whereby trained home visitors go to homes within assigned sectors daily or weekly. During their visits, the home visitors inquire about deaths (day of death, age, gender). Home visitors can also use this opportunity to help update information about the size of the beneficiary population (total size, under-five count and eventually age and gender distribution). This system requires substantial supervision and a significant number of home visitors, however. The authors recommend at least one home visitor for every 1,000 beneficiaries. Checchi and Roberts site potential problems with an alternative community-based method: grave-watchers hired to watch burials sites twenty-four hours a day. The potential problems they cite include the difficulty distinguishing new from old graves especially after rain, incomplete knowledge of all burial sites (e.g. some newborn deaths might be buried within or near shelters) and difficulty distinguishing graves of members of the local population from those of the refugee population.21 The notes below show how to calculate these rates assuming there is an existing surveillance system that documents the number of deaths occurring after identifying the total number of the population at risk of death. Both numbers are needed to make the calculation. Note: Retrospective surveys are a good source of information for the number of deaths and the population at risk of death. Experienced persons are needed, however, to calculate the precision of the rates derived from surveys.

Epidemiology and surveillance

This formula expresses the likelihood that a particular event, case, or episode (x) will occur in a specified period of time among a population at risk (y). Examples of rates include the crude mortality rate, cause-specific mortality rate and incidence rate. These are described in greater detail below.

000 # of days in time period = # deaths/10. dysentery. Other causes of death typically requested in many emergencies include pneumonia. The formula for this calculation is provided below: Total number of deaths during the time period Total population at midpoint of time period that is at risk of death X 10. monitor and evaluate health interventions. that is.000 persons in the population. The Sphere handbook includes sample weekly mortality surveillance reporting forms that can be used until a standard is defined by the lead health authority. this rate is most commonly presented as the number of deaths (among < 5s) per 10.000 persons/day Crude Mortality Rate and the Under-Five Mortality Rate (U5MR) are typically calculated on a population level. obtaining rates on a population-basis for specific causes of death and disease is costly to do on a regular basis.6 230 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Crude Mortality Rate (CMR): The rate of death in the entire beneficiary population (includes both sexes and all ages). As with the CMR. cholera treatment centres and feeding centres. malaria and meningitis.17 Note: Calculate rates for the causes of death requested by the lead health authority and include on standard mortality reporting forms.1 Any enquiry on specific deaths needs to include diseases of epidemic potential such as acute watery diarrhoea. Cause-specific mortality rates: This rate looks at the number of deaths due to a specific disease or other cause during a specified time period. This is because information about the trends in rates (as opposed to population-based rates) is often sufficient for disease control. The formula for this calculation is provided below: Total number of deaths in children < 5 years of age during the time period Total number of children less than five years in the population at mid-point of time period that is at risk of death X 10. The population size most commonly used in the calculation is the estimated population size at the mid-point of the time period---the time period that the number of deaths represent (say the number of deaths during a month or a week or a day).000 # of days in time period = # deaths/10.1 The most commonly used expression of CMR is the number of deaths per day per 10. the total number of deaths in the population is counted (surveillance) or estimated (surveys). In contrast to CMR and U5MR.000 persons per day. The following rates described below are considered key rates for health information systems to collect and utilise. . injury as well as maternal and neonatal illnesses that kill scores worldwide (between 7 to 10 million per year depending on sources). This information is used to select. The rate is reported as the number of deaths due to a specific cause per 1.000 persons/day Under-5 mortality rate (U5MR): The rate of death among children below 5 years of age in the beneficiary population. the numerators for other key rates of mortality and morbidity are often based on information collected only at service sites such as health facilities. measles. Daily reporting should be considered during an epidemic. cholera.000 individuals in the population during the time period (weekly during emergency or monthly in the post-emergency phase).1 This is a type of age-specific mortality rate.

000/day = 4. injury. dysentery. and eye diseases.1 The specified events may include diseases of epidemic potential such as acute watery diarrhoea.000 = # events/1.000 x 7 15 x 10.6 deaths/10.000 people) as follows: Crude mortality rate (CMR) Number of deaths x factor Total mid-interval population x time period 21 x 10.000/day = (indicates a stable situation) 4.000 x 7 0. The weekly reporting formula for this calculation is provided below: Total number of event during the week Total population at mid-point of the week that is at risk of having the event * x 1. the crude death rate can be calculated for each camp based on the estimated total population—A (50.014 deaths/1. monitor and evaluate health interventions. Incidence rates: The Sphere handbook includes sample weekly morbidity surveillance reporting forms that can be used until case reporting is standardised by the lead health authority.000 persons/week Epidemiology and surveillance .000 persons/week* Meningococcal meningitis is usually calculated per 100.3 10 x 30 = 0.000 = 5. During the initial phase of the emergency. From the above example: 4. death rates may be analysed once a month using a factor of 1. Assuming they all occurred over a seven-day period. The post emergency phase begins once the Crude Mortality Rate (CMR) drops below one death/10.3 deaths per 10.000 is used for calculating daily death rates in order to detect sudden changes.000 to calculate monthly death rates.000/day indicates an acute emergency phase. cholera. sexually transmitted infections including AIDS. To convert CMR expressed as deaths/10. a factor of 10. divide the daily CMR by ten and then by the total days in a month. Thereafter. Other events typically requested include pneumonia. measles.) during a time period in a population at risk for the event. 1000.000 people) and B (5.000/day into deaths/1000/month.000 = 50.000/month Incidence rates for common causes of mortality and morbidity is the number of new occurrences of an event included on standard morbidity reporting forms (disease.3 deaths/10. malnutrition. scabies etc. injury. or 10. skin diseases.000 can be used to convert calculated rates into whole numbers. A crude death rate of one death/10.000 per = day (indicates a critical situation) = Crude mortality rate for population A Crude mortality rate for Population B Note: A factor of 100.Public health guide for emergencies I 231 6 Example: The significance of twenty-one deaths in Camp A and eighteen deaths in Camp B depends on the period that they occurred and the size of the population at risk. This information is used to select.000/day. malaria and meningitis.

it may indicate inadequate access to health facilities. The maximum acceptable CFRs are as follows: cholera (1%). it is often difficult to do. it may suggest over-utilisation due to a specific public health problem (e.1 No effort is made here to distinguish new from repeat consultations.1 Ta used to calculate the weekly case fatality rate is provided below. typhoid (1%). this rate is a reflection of the quality of care provided in health facilities.’1 While it is recommended that new visits be counted separately from old visits. Otherwise. . Shihe formulgella dysentery (1%). Total number of visit in one week X 52 weeks = # visits/persons/year Total population at mid-point of the week Consultation rates per clinician per day: This looks at the total number of patients seen by each clinician per day on average. The rate is converted to an annual rate even if the time period during which the information is collected on visits is less (usually one week). CFR: If cases on a disease arrive at a health facility shortly after the onset of the disease. If the rate is lower than expected. Health facility utilisation rate: ‘Among displaced populations. Total number of people dying from the disease during the last week Total number of people who had the disease during the last week x 100 = X% Health facility utilisation rate looks at the number of out-patient visits per person. an average of 4.6 232 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Case-Fatality Rates (CFR) is the proportion of persons with a disease in a specified period that dies from the disease. infectious disease outbreak). meningococcal meningitis (varies. 268). during an emergency the total number of visits is typically counted. If the rate is higher.. It is reported as a percent such as ‘the case-fatality rate of persons with cholera in the last week was 35%’.g.0 new consultations/per person/per year may be expected. up to 20% during outbreaks). or under-estimation of the target population (pg. this rate is a reflection of the effectiveness of outbreak control measures. The formula used to calculate this rate on a weekly basis is provided below.

such as a physician. the ratio of males to females Total number of males Total number of females = 8. and one person works ½ day six days per week. Proportionate mortality is not a rate by definition. This number represents full-time staffing. Example: If the estimated size of the displaced population is 20. this is 3.000 with 8.: Male: Female = 2/2:3/2 = 1:1. this is one full-time equivalent.000 12.000 males and 12. If two persons each work all day three days per week. . Proportionate mortality looks at the proportion of all deaths in a population during the period due to a certain cause (the denominator is the same as for the Crude Mortality Rate). where x need not be part of y. nurse.000 = 2:3 This ratio is better interpreted by dividing each side of the equation by the value on the left side i.’1 Note that Primary Health Care workers (non-physicians) can often see more patients than physicians because physicians tend to manage more complicated cases. during one week period.e.5 full-time equivalents.5 full time equivalents. monitor and evaluate health interventions. where x is part of y. If one person works ½ day six days per week. Clinical staff is defined as a ‘formally trained clinical provider. The formula used to calculate this rate on a weekly basis is provided below. If three persons each work all day six days per week. Ratio = x/y This formula expresses a relationship between a numerator (x) and a denominator (y). Consider a clinic that is open six days per week. The decision to hire additional clinical staff should be triggered if this threshold is regularly exceeded.000 females: Then. this is 0.5 Proportion = x/y This formula expresses the relationship between a numerator (x) and a denominator (y). clinical officer or medical assistant (page 267). For example. Epidemiology and surveillance Number of consultations per clinician per day: The Sphere standard is that clinicians are not required to regularly consult more than fifty out-patients per day.Public health guide for emergencies I 233 6 Total number of patient in one week Number of FTE clinicians in health facility * * ÷ Number of days health facility open per week = # consultations/ clinician/day FTE = Full-Time Equivalent. we might find that cholera was responsible for 70% of all deaths in that week. This information is used to select.

a Crude Mortality Rate (CMR) of >1.20) Unknown baseline: 0.000 per day U5MR: 1 per 10.000 per day U5MR: 1 per 10.25 (0.4) Unknown baseline: 1.000 per day Emergency if: CMR ≥1 per 10.0) .4) South Asia: 0. When baseline rates are unknown. Former Soviet Union: 0.5 per 10.000/day or U5MR of >2. Table 6.4. of children aged 12-23 months who got immunised) (Total number of children aged 12-23 months) Interpretation of epidemiological data The main uses of the Crude Mortality Rate and Under-Five Mortality Rate (U5MR) are to (1) Decide if humanitarian assistance is needed.000 per day: ‘major catastrophe’ (double for U5MR thresholds) Emergency if CMR (U5MR): Sub-Saharan Africa: 0.0 (2.6 (0.0/10.19) South Asia: 0. of beneficiaries of a service = x 100 Total target population Immunisation (%) Coverage = (No.000 per day: ‘very serious’ CMR > 2 per 10.44 (1.5 (1.5 per 10. Need for humanitarian assistance: Mortality rates that are double the expected baseline levels are an indicator of significant excess mortality and a justification for initiation or continuation of humanitarian assistance.3) Latin America: 0.3 (0.16 (0. Academia UNHCR Fixed at: CMR: 0. Former Soviet Union: 0. and (3) Advocacy. Médecins Sans Frontièrs Epicentre.000 per day: ‘out of control’ CMR > 5 per 10. The Sphere thresholds are provided in Table below. Mortality thresholds used to define emergency situations11. Agencies Assumed baseline Emergency thresholds Centres for Disease Control.2) Eastern Europe. (2) Decide if humanitarian assistance is adequate or should change.30 (0.0/10.6 234 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Example 1: If the 21 deaths in camp A were of patients diagnosed with malaria during the same month: Proportional mortality (%)from malaria in hospitals = Number of deaths due to a certain disease x 100 Total deaths during that period x 100 = 21 x 100 100 = 21% Example 2: Coverage is also calculated as a proportion as follows: No.9 (2.000 per day CMR > 1 per 10. We recommend the use of Sphere standard thresholds for initiation/continuation of humanitarian assistance as these reflect the doubling of expected baseline levels.000 per day U5MR ≥ 2 per 10.59) Eastern Europe.0) Sphere project Context-specific CMR (U5MR): Sub-Saharan Africa: 0.5 (1.14) Latin America: 0.000/day are used.000 per day Fixed at: CMR: 0.

If we only use group discussions. CMR. By using several data collection methods (review of secondary information. interviews with individuals.7 By including persons with diverse perspectives and backgrounds on the assessment team. Some deaths can be missed by any surveillance system especially if death reports are limited to what is collected at service sites. There are specific guides addressing issues of bias. For example.) the bias that the information only represents the interests of a narrow group of people can be overcome. beneficiaries. which is available for download from the Humanitarian Practice Network. judge whether or not the population size is likely to be overor under-estimated. service provider. Analyze how this might affect the true rates. Triangulation: Confidence in the data collected can be improved by cross-checking in various ways: (1) by different sources. such as the one by Checchi and Roberts discussed previously in this chapter. mortality studies can be used to raise awareness and apply pressure for adequate humanitarian assistance. Triangulation might be performed to improve the quality of findings as described in the table below. or if other interventions such as food distribution. Quality of mortality data can vary depending on whether surveillance or surveys are the source. if we only use observation we may never learn about what people do when not observed.g. the analysis or conclusions might not be accurate.or under-estimate and how this might affect the true rates.21 Judging the quality of mortality surveillance data should only be used by persons with significant experience and expertise should lead or conduct mortality and those who are able to consider the following when interpreting survey data: The Crude Mortality Rate (CMR) and Under-Five Mortality Rate (U5MR) calculations are very sensitive to the number used to estimate the population size (denominator). a single death can be recorded twice if several sources of data are used to count deaths. Advocacy: When the needs of populations in crisis are being ignored by media and political leaders. water and sanitation need improving. important but sensitive information might not be shared. By collecting data about and from persons with diverse characteristics (gender. before disseminating or using any assessment data. consider the sources of the death reports (e. group discussions. observations) the biases that come with particular methods can be overcome.) can be overcome.11 . its quality should be examined for potential biases. the potential bias that the information exclusively represents a limited point of view (e. U5MR and other indicators are less reliable and ‘jump’ within days. When interpreting the data. With small populations. Use available information about causes and age of deaths to decide how current health interventions need to change. outsider perspective only.Public health guide for emergencies I 235 6 However. it might be expected that people might change their behaviour during observation. Epidemiology and surveillance Need to change humanitarian interventions: Sites with ongoing CMR or U5MR at emergency level should consider re-prioritizing the health interventions provided (see Standard 1 for Health Systems and Infrastructure). If we rely only on interviews.g. etc.. or both) and judge whether or not the number of deaths is likely to be an over. leadership role. (2) about different persons and (3) using different methods. supplementary feeding. ethnicity etc. When interpreting the data. Similarly. views of one technical area or gender. To judge the situation requires experience and a great deal of common sense. community-based surveillance. we may miss important but complex information that can be picked up by observation. Because health needs assessments are done rapidly. facility registers only.

such as the need for intervention and the type and size of the intervention. They must be carefully reviewed and adapted to the local situation. Local representation is absolutely essential and teams made up of expatriates must be avoided. get the proper authorisation (work permits. The assessment should be started within a short time frame. Select how and in what order the information will be gathered. Inform all departments within the organisation that need to be directly involved with the assessment—logistics. Try to confirm all information with the UN. the population affected and any political factors. what the plans are. data processing tools. A rapid needs assessment is carried out to determine: The magnitude of the emergency and population size affected. Assign specific tasks and responsibilities to each member of the assessment team. . personnel) for each stage of the assessment. Unfortunately. Based on the nature of the emergency. Design or adapt the forms for recording and analysing the information collected. precise and reliable data often require weeks to organise. finance. What the government or military is doing.6 236 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Rapid health assessment Epidemiology and surveillance Objectives of rapid health needs assessment Key decisions in a health emergency. ideally within the first three days after the event. must be made rapidly. government and military and assessments. If a multidisciplinary assessment team cannot be recruited locally. Before the field assessment.) for additional personnel from outside the country. The methods used are more complex. water and shelter. This means that some decisions must be made using less precise and less reliable data. Also collect the pre-emergency health data and information on the existing health system. human resources etc. Coordinate with other organisations. coordinate with other agencies. plans and activities of international or local organisations. collect background information about the emergency situation’s geographic location. Identify the person at headquarters who can be contacted from the field during the assessment. Availability of food. the host government and other NGOs. Estimate the time frame and the resources needed (stationery. 3. vaccinations etc. determine the priorities to be considered. All should use the same checklists. If existing assessment checklists are to be used. This includes the following steps: 1. collecting and analysing data. and Critical upcoming hazards. Preparing for rapid health needs assessment Adequate preparations are needed before a rapid assessment can be made. The vulnerable population groups with high risk of death or disease. 4. like winter conditions. Presence. The assessment team should then plan the field assessment as follows: Define the terms of reference and the objectives of the assessment. Environmental conditions. All should agree on how and when the information will be reported. What are the present health priorities and potential public health problems. Whether or not external support or intervention is needed. travel permits. such as training field staff and volunteers. collect and analyse. 2. clinics and hospitals. 5.

accommodations and meals. Appoint a team leader to co-ordinate the assessment with the host government. Health related sectors like shelter. culture) or speciality-specific skills (epidemiologists. logisticians. Determine the average family size in selected households of some sections and apply findings to the entire map. Be aware of the common mistakes that can occur during any assessment. Table 6-5: Preventing common errors during a rapid health needs assessment Common errors Preventive action The assessment is poorly coordinated between various NonGovernmental Organisations (NGOs) and excludes the host government and the affected community. Try to prevent errors by using the actions shown in the following table. environmental engineers). relief needed. Discuss plans with local authorities. 8. first aid kits etc. The assessment team lacks the expertise needed. More data is collected than is needed or used. Plan the field assessment: define the objectives. water and sanitation. yet often time is limited. survival gear and GPS as deemed important. are not duplicated and ensure future support of relief activities.. Collect only data that can be processed. Collecting information requires time. Ensure that one of the main objectives for carrying out the needs assessment is setting up an information system. including drawing conclusions from the local response and outstanding needs.Public health guide for emergencies I 237 6 7. The needs assessment is conducted too late. the relevant information needed and methods for collecting data. . The assessment report does not consider the affected population’s perceived needs. public health nurses. physicians. Strengthen disaster preparedness by establishing an early warning system for detecting humanitarian emergencies. The estimated size of the target population—the critical denominator—is unreliable. Collect essential equipment. apart from maps. the affected community’s leaders. language. site-specific (geography. Check the security situation in the field and make contact with local authorities and other organisations. Ensure there is someone based locally to arrange the assessment team’s transportation. Make better estimates by mapping the location and dividing it into sections. Follow epidemiological procedures when carrying out population-based surveys. Epidemiology and surveillance 6. and other agencies so that the results are shared. The data collected is not linked to an ongoing information system. All members must have double communication means. community representatives and other agencies. Select members of the team with disaster-specific (prior experience). Involve representatives from the affected population at every stage of the assessment. The survey sample does not accurately represent the affected population. communication. The data collected is often incomplete (due to poor access) or inappropriate (does not cover all the important areas). 9. Psychological trauma and reproductive health are often not assessed.

children. including the presence of armed forces or militias. review field reports. Table 6-6: Sample checklist for rapid health needs assessment13 Preparation Obtain available information on the disaster-affected population and resources from host country and international sources. Determine the average household size and estimates of female. e. Thus. Assessment checklists should not be considered as simple exercises for filling out data forms.) so that the assessment proceeds smoothly. Many checklists for rapid assessments have been developed. fire. Obtain demographic and health data from host country and international sources. members of certain ethnic or social groups. Determine the existing social structure. women. and Internet/Medline. disabled persons.and child-headed households. Determine how much access humanitarian agencies have to the affected population. Determine age and sex breakdown of the population. Preventive action Collect background information: interview former staff. Discuss before assessment when and how to share common planning and priority settings. and the media. etc. local authorities. older people.6 238 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Common errors Causes of death are incorrectly attributed to the disaster even for slow-onset disasters. Determine the overall security situation. disease epidemics. Identify groups at increased risk. Security and access Determine the existence of ongoing natural or human-generated hazards. the assessment period is extended and serious delays in vital action can occur. people living with HIV. It can also help to identify the sources of information to be contacted on arrival at the site. Checklists that are used should first be adapted to the context and culture of the specific emergency. police) to take care of the injured and limit harm from hazards (fire.g. They are supposed to guide assessment teams in thinking about the information they might want to collect in the rapid needs assessment as well as to ensure that they have covered the key issues. some of which classify indicators under different data categories. Defining the information needed Defining in advance what information is needed about the emergency can improve the coverage and quality of the needs assessment. country profiles. . including positions of authority/influence and the role of women. such as drought and famine. other agencies and clusters. Arrange for a local emergency response team (health. Assessment team members do not complete their tasks as they are drawn into establishing initial activities. Information is not shared with government. Not all the information in the checklist might be needed or be relevant for every assessment. there is insufficient time for accurate assessments. Obtain available maps and aerial photographs. Demographics and social structure Determine the total disaster-affected population and proportion of children under five years old.

use standard guidelines and forms. Expanded Programme on Immunisation (EPI). especially as they relate to procurement. Determine the status of the existing Health Information Systems (HIS). make recommendations for what should be done if none exists. Determine the capacity and functional status of existing public health programmes.g. Determine the status of existing referral systems. Determine age. functional status and access. Calculate the Under-Five Mortality Rate (U5MR) which is the age-specific mortality rate for children under five. . Determine the numbers and skills of available health staff. supplies and equipment. maternal and child health services. Morbidity rates Determine incidence rates of major diseases that have public health importance. Determine the capacity of existing logistics systems. e. Mortality rates Calculate the Crude Mortality Rate (CMR). communication. as this is usually common. Ascertain disease epidemiology in country of origin. Identify existing risks to health. Calculate cause-specific mortality rates. vaccines and other supplies. Identify pre-existing health problems and priorities in the country of origin if refugees are involved. Ascertain local disease epidemiology. Before carrying out the assessment. When possible. Consider data from other relevant sectors Nutritional status.g. Determine the availability of standardised protocols. check with the lead health agency in the emergency to identify if a standard assessment form is being recommended. vaccines and medical supplies. use the standard assessment form and process. Determine the status of national health facilities including total number. essential drugs. If so. Determine the strengths and coverage of local public health programmes in refugees' country of origin. Identify previous sources of health care. potential epidemic diseases. and include information about other sectors.and sex-specific incidence rates of major diseases where possible. Food and food security. distribution and storage of essential drugs. Environmental conditions. physical status. Epidemiology and surveillance Background health information Identify pre-existing health problems and priorities in the disaster-affected area prior to the disaster. classification and levels of care provided. fuel and storage of food. Available resources Determine the capacity of and the response by the Ministry of Health of the country or countries affected by the disaster. e.Public health guide for emergencies I 239 6 Logistics Assess transport.

surveys. reproductive health needs. Ask specifically about children to identify if the beneficiaries have problems utilizing health services. multi-lateral agencies (e. reports. needs and available resources. Background information. surveys (e. Selected beneficiaries should be from diverse backgrounds such as age. review registers. How the data will be collected during field assessment depends on the nature of the emergency and the time and resources available for the assessment including the skills of the assessment team.and postdisaster community health information. environmental conditions. consult texts listed under references and suggested readings). focus groups. future prospects. Possible sources and methods of collecting data in emergencies are summarised in the table below.. pre-/post-disaster demographic and health status data. demographic profile of local and displaced population. key informant interviews. * Refer to the previous checklist for full details. such as norms and attitudes regarding gender and gender based violence. reports. future prospects.g. needs and available resources.. media. internet web sites Background information. . review registers. existing protection and response systems and the nature of gender based violence in the community. surveys. health policies.g. look at specific items. Morbidity and nutritional status. UN). patient narratives. As above for local (and perhaps displaced) populations. interviews. If records are poor or not available (e. Interviews. The dispersed population/camps administrator and health workers are also important sources of information. focus group discussions and surveys. NGO) Humanitarian agencies (international and local). it might only be feasible to collect age-specific data about under fives and for those above five (<5 years and >5 years). establish the commonly perceived causes of mortality and morbidity by interviewing local health workers and health officials.g. review registers. Review available health records at health facilities to determine the major causes of death and illness during the initial assessment. Background information. Sources and methods for collecting data Good sources of information for the initial assessment can be identified according to the background information and the type of information needed. future prospects. destroyed by floods). environmental conditions. Interviews. pre. Mapping. To minimise bias. reviewing existing records. This also helps involve beneficiaries in the design of health services from the outset. needs and available resources. situation reports. gender. Observation. review census and survey reports (e. Data can be collected using quantitative and qualitative methods such as observation. observation. needs and available resources.6 240 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Depending on the situation. Surveys. needs and available resources. and ethnicity. (For details about qualitative research methods. demographic health survey). Initially. the beneficiary population can also be consulted during the initial assessment or shortly after. private. Demographic Health Survey). interviews. mapping.g. interviews. Table 6-7: Sources of information and methods of data collection for a rapid health needs assessment Source * Information to be collected Method of data collection Affected population Host government authorities Health authorities (local/central ministry of health (MOH)) Health facilities (MOH.

planning a follow-up assessment if necessary. the estimated number of people involved. Identify individuals or groups of people in life-threatening situation. Assess the environment and extent of the disaster’s damage and population displacement. the following steps may provide a logical approach to a field assessment: 1.g. food supply. local organisations. or building). health status including immunisation status and priority health problems of the affected population. after collecting the background information. How much normal life and the social structure has been disrupted. Similarly. the displaced and the host populations’ health status. health workers and the affected community (leaders of different ethnic groups. and health facilities) including maps. the affected populations’ coping mechanisms and any other issues of secondary priority such as reproductive health needs and mental health. 2. Some areas might be more densely populated than others for various reasons. health services and the level of insecurity. a walk-through tour may help provide insight on their distribution. Review existing records at the local or national level (host country. Note: where the disaster affected community is widely dispersed within a host population. the existing services’ function and capacity (e. water supply. the local infrastructure and the resources. taking their history (interviews and review existing records). in order to: Confirm or update background information on the health needs and local response. The more populated areas might have worse living conditions.Public health guide for emergencies I 241 6 Conducting the rapid health needs assessment A needs assessment can be carried out by following the same logical sequence as individual patient assessments. tree. 3. interim diagnosis. from the top of a hill. Preliminary observations should be done if possible when approaching the site by vehicle or aircraft. women) etc. volunteers.g. Examples include snowballing technique (locating the first subject and enquiring for Interviewing affected community members in Guatemala Photo: International Federation Epidemiology and surveillance . 5. The living conditions and access to sanitation. agencies. 4. the public health sector. physical examination. Rapid surveys: Conduct rapid surveys using convenience or cluster sampling of households to estimate the demographic profile. media. Whether the host government will accept intervention. which includes: briefly observing patients on arrival. relevance of the health information system). aerial photos. census health data etc. Detailed visual inspection: walk around the displaced community and surrounding areas to investigate rumours and gather valid impressions about the following: The layout of the camp or settlement (from the highest level e. This helps establish baseline information on demography. Innovative methods of sampling can be adopted to sample enough displaced persons per cluster where a disaster affected community is dispersed within a host population setting. Interview officials from the local government.

diarrhoea measles. dressing/injection) Referrals Manage minor injuries Referral of emergency conditions and injuries Temporary field unit if poor access to referral hospital Expanded Programme on Immunisation programme (measles. meningitis).6 242 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance information on the next subject with similar characteristics) or measuring the proportion of displaced persons among all the subjects surveyed within a cluster and projecting this number to estimate the entire disaster affected population. Growth monitoring Curative (acute respiratory infection. Table 6-8.g. Prepare a basis for ongoing health information: Use the assessment findings to set up a health information system.). skin infections. the evolving disaster situation and the available resources. adequate sanitation. referral for danger signs. selective feeding. and plotting graphs. The table below summarises emergency and post-emergency interventions as recommended by the Sphere Humanitarian Charter. Initial interventions often focus on the prevention and control of diseases of epidemic potential (such as acute respiratory infection. calculating percentages. cholera prevention and control. Priority health services in emergencies by phase Health service Emergency phase Post-emergency phase Child health Curative care Immunisation (measles. Key results must be compared to normal reference values or standards to improve understanding and conclusions regarding the disaster situation and help determine the appropriate response. shelter as well as provision of basic clinical and reproductive health services (Minimum Initial Services Package). malaria. TB) Treatment of TB and other chronic diseases (diabetes mellitus. Population surveys can be organised soon after the assessment to: Provide valid base-line information if missing. This requires a more comprehensive Health Information System. referral. 7. food aid and food security. polio. 6. disease surveillance. Assessment findings help guide the identification of priority actions for the acute emergency phase. arthritis) Surgery for chronic conditions such as hernia or uterine prolapse Surgery . the range of services can expand according to the needs of the affected population. hypertension. Basic health care (triage. Priority interventions can include the provision of a sufficient and safe water supply. outpatient. the skills or the resources to carry out a detailed analysis may not exist. rates. Determine the priorities for the programme (e. Vitamin A). and distribution of bed nets. malaria. For more details. diphtheria. As the situation stabilises. frequency tables. Ongoing collection and analysis of information over time will refine the findings of the initial assessment. However. measles immunisation. inpatient. diarrhoea. including summarising statistics. whooping cough. Simple analysis procedures may be performed in the field. measles. measles immunisation. please refer to the annex on data analysis. anaemia). etc. Preliminary analysis: A timely and careful analysis of the assessment findings is necessary to provide a basis for programme planning.

The affected population. please refer to the relevant chapters. disease surveillance. Possibly blood transfusions Community-based programme for the emotionally traumatised Ongoing surveillance Population-based surveys Periodically review and update HIS Community mobilisation for disease control activities Tertiary care for physical disability Health Information System (HIS) Initial assessment Establish surveillance system using simple indicators Preventive health Community based activities include: IEC. STI/HIV Prevention and treatment ‘Pull’ system for ordering drugs Essential drugs supply Standard treatment protocols Basic laboratory investigations (malaria. The disaster situation. helminths. HIV test). The local response and capacity. sputum smear.Public health guide for emergencies I 243 6 Health service Emergency phase Post-emergency phase Reproductive health Minimum Initial Service Package (MISP): Pharmacy ‘Push’ system for drug kits New Emergency Health Kit Laboratory Mental health Initially clinical diagnosis or referral of specimens. blood sugar. write an assessment report as soon as possible about the key findings and recommendations under the following headings: The assessment methodology. The external resources needed. haemoglobin. gram stain. 8. population estimates For more detailed descriptions about specific interventions for the acute emergency and post-emergency phase. Comprehensive reproductive health care: Antenatal care. Family planning. The recommended actions. Report findings: After the analysis. dysentery or meningitis) or high drug-resistance (malaria. Seek to provide tests for detection of outbreaks (cholera. Epidemiology and surveillance . ORT. dysentery) Prepare plans. emergency operations centre. prenatal care.

g. 10.6 244 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Vital assessment data or findings can be immediately transmitted via the Internet. The affected population. by voice or SMS. before and after flight). camp A and camp B. . the time for recovery and return to any sense of normalcy will become a bigger problem for future governments because many continue to spend large proportions of the health care budget (even 60 to 80%) on higher level of care. As disasters become more frequent. The report should include information about the following: The assessment. Person for calculating age-specific and sex-specific rates to identify the population subgroups at increased risk. which in-depth assessments are required urgently. The external resources needed. Place for comparing different sites. All findings and analysis must be shared with government authorities. Special considerations during response: The findings should have some bearings on future surveillance and intervention in recovery and long term rehabilitation efforts. The local response and capacity. These challenges must be considered during the emergency response in most developing countries: how to set up emergency operations with incompetent health care systems.. coordinating body and/or cluster and other agencies to ensure full coordination and preparation for a unified and prioritised set of interventions. Many health care systems are disrupted after major disasters. Surveillance Surveillance is defined as the ongoing.g. or with host population). Facilities left standing might be only operating at a reduced capacity especially at the disaster’s peripheral level mainly due to the lack of resources and mismanagement. systematic collection analysis and interpretation of health data. The following information about the assessment must be clearly stated in the report: Time for monitoring trends by mapping when events happened. 11. (e. The recommended actions. Objectives of surveillance include: Monitoring a population’s health and identifying priority immediate and long-term health needs. This health care gap will likely widen over time with a brain-drain of doctors and nurses from the periphery. Setting up a surveillance system A surveillance system for emergency health care should be started from the initial needs assessment. linked with giving feedback to people at all levels of the data collection system as well as applying the information to disease prevention and control measures. (e. Assisting in planning and implementing health programmes. Dissemination: Give feedback to everyone who participated or has a stake in the assessment. The goal of surveillance is to give timely information about health problems so that diseases and outbreaks can be detected early and health services respond more effectively. 9. Recommendation for follow up surveys: Try to indicate as early as possible. Following disease trends for early detection and control of outbreaks. The disaster.

Monitoring the quality of health care. Design and monitor programmes. analysis and reporting procedures. Reportable disease list Comprehensive. food distribution. water and sanitation. Observation by walking around Reduce mortality rates From the first month(s) onward Regular population-based surveys. (Emphasises public health approach) Main Priority Type of data collection Defining population Size Case definition Mostly active collection. analysing and reporting data are limited particularly in the acute emergency phase. Programme process indicators estimate the coverage of immunisation. Used to assess quality. Addresses less urgent issues. The following indicators should be included in surveillance systems for all phases of an emergency: Demographic indicators estimate the total population. vulnerable groups and in-andout migration.Public health guide for emergencies I 245 6 The capacity and use of surveillance will vary according to the phase of the disaster. Table 6-9: Surveillance systems in emergency and post-emergency phases Emergency phase Post-emergency phase Duration Method of data collection 1-4 months Screening initial assessment. Watch for measles. health services. cholera Simple. Because the time and resources for collecting. Evaluating the coverage and effectiveness of programme interventions. A few common conditions Informal. Epidemiology and surveillance Ensuring resources are targeted to the most vulnerable groups. More in number Formal with process in place. morbidity rate and nutritional status. For longer term health needs. Data needed for immediate actions Outbreak investigation Surveillance and use of data Indicators and sources of information Good surveillance requires standard data collection. More quantitative Census and supplemental surveys May include lab confirmation. Ongoing Health Information System Detect disease outbreaks. The following table defines specific indicators and potential sources of information commonly used in emergency surveillance systems. Largely qualitative Sample survey methods Simple clinical signs and symptoms. Health Status indicators estimate mortality rate. . The sources and methods of gathering information should be carefully selected. The following table presents differences between surveillance systems set up in the acute emergency and post-emergency phases. Monitor quality of programmes Both passive and active collection. Simple surveys. only the most essential indicators should be selected based on practical use.

Burial contractors. hiring graveyard monitors. measuring this critical indicator during emergency situations may be difficult because data from health facilities’ death registers might be incomplete. other methods of data collection must be. cases with nonspecific illnesses) Facility records. >5) Cause-Specific Mortality Case Fatality Rate (CFR) Registration records. Burial shroud distribution. Religious leaders. monitor against diarrhoea incidence) Immunisation coverage Reproductive Health (Ante natal care attendance. quality. departures) Identification of vulnerable groups Births Crude Mortality Rate (CMR) Age-specific Mortality Rate (<5. STI/HIV prevalence) Outpatient and inpatient attendance ORS distribution Community based mental health care (number of people reached. Graveyards. Community health worker records Nutrition surveys MCH clinic records Feeding centre records Birth registers Camp administration Morbidity 1. Population census. therefore.6 246 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-10: Surveillance indicators and sources of information Epidemiology and surveillance Surveillance Indicators Sources of Information Demographic Mortality* Total population Population structure (age. However. Death rates in acute emergency situations have been known to exceed five to sixty times that of normal situations. Traditional birth attendant records *Note: The mortality or death rate is the most important indicator of serious stress affecting a displaced population. . Laboratories Feeding centre(s) records.g. considered (e. Immunisation surveys (annual). sex) Rate of migration (new arrivals. deliveries. Routine 2. CHW reports Volunteers Hospital death registers. access. interviewing grave-diggers and shroud distributors as well as doing community surveys). Each method or source of gathering information should be evaluated for quality and reliability. family planning uptake. Community reporters (including Community Health Workers). Camp administration Outpatient and admission records. Outbreaks (daily) Incidence rate (new cases) Prevalence rate (total existing cases) Age-/sex-specific morbidity rate Proportional morbidity rate Nutrition (Frequent surveys while malnutrition rate is high) Programme process Global malnutrition rate Severe malnutrition rate Rate of weight gain/loss in MCH clinics Incidence of micro-nutrient deficiency disorders Incidence of low birth weight Average daily ration Delayed age of menarche Shelter coverage (link with incidence of ARI) Feeding centre enrolment and attendance Water and sanitation (quantity.

new cases with a common disease).Public health guide for emergencies I 247 6 Alternatives to surveillance Surveillance systems are often biased because they collect information passively. All patient and hospital records must be monitored regularly to ensure that the recorded diagnosis accurately represents the patient’s condition. Broad case definitions can help community outreach workers to recognise and refer all possible cases to health facilities. For details on surveys. The table below gives examples of case definitions that may be appropriate for workers at different levels of a primary health care programme. Other methods of collecting information will follow. Community-based surveillance In community surveillance. which may require laboratory confirmation.e. Key differences between surveys and surveillance are described in the following table. Note: Cases diagnosed at different levels of care should be analysed separately. refer to the next section on population surveys. community health volunteers and extension health workers to recognise and manage cases according to their diagnostic skills. i. This might require training volunteers. Qualified health workers in higher levels of the emergency health system can be trained to use more specific (but less sensitive) case definitions. Table 6-11: Case definitions from home to hospital Diagnosis level of care Possible case home Probable case first level facility Definite case hospital Malaria Fever only Fever + periodic shaking + chills Fever + rash Rapid diagnostic test or Positive slide for malaria parasites Fever + rash + cough or Koplik’s spots Measles Fever only Disease surveillance can be improved by encouraging the use of standard case definitions for diagnosing and managing patients and recording data in health facility registers. Epidemiology and surveillance . Surveys Sometimes it is necessary to organise focused assessments to gather information that is not immediately available through the existing surveillance system. a limited amount of health information is gathered directly from the community (e.g. Other methods of gathering information are necessary for detecting health problems and cases occurring outside the existing facilities. they mainly focus on people who use existing services. This will ensure the surveillance system does not miss any person that is a probable or definite case with a communicable disease.

As much data analysis as possible must be done at the field level where it can be used. focused assessments that collect population-based health data (active). Expanded Programme on Immunisation. syphilis. chancroid) HIV/AIDS Analysing and reporting surveillance data For a surveillance system to be useful. mortality. mortality. but is a one-time cost only. births. nutritional (micro-nutrient deficiencies). therefore not representative of all needy groups. health services and environmental health indicators.6 248 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-12: Differences between surveys and surveillance Epidemiology and surveillance Surveys Surveillance Intermittent. and use of health services). reproductive health. Staff responsible for analysing and reporting surveillance data need to do the following: . Ongoing. allows for filling of information gaps in communitylevel data. analysis. genital ulcer disease. Collect information on demography. Less costly since integrated within routine services and the existing system. plotting simple graphs and comparing all information with earlier information. May be limited to concerned agency/facility. This can be achieved by training all data collectors to recognise cases with reportable diseases.. Collect information on demography. systematic collection. With appropriate sampling. All reports should prompt immediate action by the appropriate health authorities beginning with a preliminary investigation to confirm whether there really is an outbreak. Captures those who attend facility-based services. Table 6-13: Examples of diseases that can cause outbreak Reportable diseases Diseases of public health importance Measles Cholera Meningitis Hepatitis Tuberculosis Yellow fever Haemorrhagic fever Rabies Tetanus Sexually transmitted infections (gonorrhoea. Should involve all health agencies and facilities. the information that is gathered should be analysed and reported in a timely manner. nutritional status (acute malnutrition) and programme indicators (e. calculating rates. Requires more time and resources to organise. and interpretation of facility-based data (mainly passive). This will improve the programme’s effectiveness. Data analysis includes summarising data into frequency tables. morbidity. morbidity. They should also be given guidelines for immediate reporting of a suspected disease outbreak. Outbreak investigation A surveillance system should be sensitive enough to pick up the first few cases with diseases that have epidemic potential (see table below). chlamydia.g. (Refer to the section on outbreak investigation for further details).

Refer to the data analysis section for further details. Indicators should mean the same to data collectors at a particular level. In detecting any outbreak (might depend on the frequency of reporting data) Information is gathered in a standard manner (case definition. e. the case definition for malaria is the same for all community health workers Performs repeated measurement of the same indicator to detect trends.g. the district health office should be notified immediately. . The analysis and interpretation of all health information should be linked with feedback to the data collectors. not Weight-For-Age to assess for acute malnutrition. the most senior person at each health facility should be held responsible for performing simple data analysis (e. Ensure information is passed promptly to decision-makers in a manner they can easily understand. Can adapt to new health problems or sudden programme changes. procedure) and can be reproduced.) Evaluating a surveillance system A surveillance system can be evaluated and updated from time to time.g. To both the affected population and to the authorities. At the project office level. e. when a potential disease outbreak.g. tools. however. Copies of the surveillance reports must also be forwarded to the district and national health offices (either on a weekly or monthly basis). Timely Reliable Standardised Continuous Acceptable Flexible Epidemiology and surveillance Focus on mortality rates and key causes of illness. Display disease trends in form of graphs.g. use Weight-ForHeight. e. is suspected. (For more details. Give feedback to the data collectors after analysing and interpreting the information. transparent manner. Limited to relevant public health information that can and will be acted upon. the health co-ordinator might perform additional data analysis and interpretation before reporting the findings to the headquarter level and lead agency. prevalence of intestinal worms is not a priority indicator of health status during the acute emergency phase. Indicators used are in line with the defined problem. please refer to the section on data analysis and reporting at the end of this chapter. The following table describes the criteria for evaluating surveillance systems: Table 6-15: Criteria for evaluating the function of a surveillance system Criteria Description Simple Representative Relevant Data is easily collected and recorded in a logical. sorting and summarising data and calculating rates) and forwarding it to the health co-ordinator.Public health guide for emergencies I 249 6 Table 6-14: Example of a 2x2 Frequency Table Cases with ARI Males Females Age of patients Total Under five years Over five years Total a c a+c b d b+d a+b c+d a+b+c+d Since the main sources of information are health facilities..

They gather information that is not routinely collected by the existing information systems (e. water. focused assessments carried out to collect additional health data from a population. Procedures for making inquiries and for direct reporting of epidemics.g. Delegates from the International Federation are also taking part in the assessment visits. relief workers might first confirm that the survey information is not available from all possible sources and that a survey is the best way of obtaining it. Use of surveillance findings in decision-making and action. Well-designed sample surveys can provide more valid information about the entire population than interviewing each member of the population. South Phyongan and South Hamgyong provinces to make further assessments on the impact of the floods and monitor the distribution of relief packages to the affected people. to find out if the displaced population has access to food. manpower and create many errors.6 250 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance The following indicators might also be used for evaluating the surveillance system: Percentage of cases or deaths reported as ‘Unknown’ or ‘Other’.). Who gets and who uses the surveillance data. Surveys can investigate the entire population or only a fraction of the target population (sample surveys). Most health related surveys are sample surveys. Suitability and use of standard case definitions. Relief workers will encounter many situations where they might have to carry out a survey. The DPRK Red Cross has dispatched teams of specialists to Kangwon. Basic principles There are two types of surveys —exhaustive surveys that study the entire population and sample surveys that study a subset of the population. health care etc. The following table outlines the necessary steps for planning and organising surveys: . Ways of disseminating findings from surveillance. money. Because surveys consume many resources (staff. Population surveys Surveys are defined as periodic. time and money). Exhaustive surveys might involve too much time.

Public health guide for emergencies I 251 6 Table 6-16: Checklist for conducting surveys Planning Organising 1.g. graphs. Cluster and systematic random samples are most common. Train the supervisors and interviewers (and translators) To sample respondents as needed To keep their respondents interested during the interview To ask each question in a standard way To take measurements correctly and record data on the questionnaires Practice sessions may help identify problems in understanding questionnaire by data collectors and households. under-five population may be assessed for malnutrition Decide on sampling method and calculate the sample size. key lessons learned in the process Programme changes resulting from the survey Effectiveness of revised programme in addressing health problem and needs identified under step 1 Epidemiology and surveillance . rates. Make any corrections to the questionnaire or the training before starting the survey 8.g.g. and survey data collectors Incorporate data and feedback into health information system Develop recommendations and action plan from survey results and feedback (no survey without action) 11. Graph and tabulate analysis results Nutrition measures may be tabulated and analysed using computer software such as Epi-Info (from CDC/Atlanta) Interpret results in light of other information 10. Outline the logistical plan for sampling 5. computers. methods. conduct the survey and analyse data Arrange for four to five survey teams. stationery 3. write up the background and the survey methodology Work out the main end-results expected from the analyses in form of ‘dummy tables’ Draw an outline of the survey report: section headings. other NGOs. height boards. e. Analyse and interpret the data Manually tabulate the data (tables. Translate and back-translate the questionnaire using different persons. each with a local supervisor and two interviewers Arrange for equipment and supplies: e. Survey report Write a survey report and present findings to and receive feedback from the community. compass. percentages. 4. Design the survey questionnaire Select indicators and limited number of questions according to defined objectives. Plan how results will be analysed and reported Before the survey begins. Plan the survey Identify the health problem and its importance Determine what additional information is required to solve the identified health problem Establish why a survey is the best way of obtaining the necessary information 2. etc. tables. Keep key terms in local languages Pilot test the questionnaire.. Survey design Define survey objectives. GPS. Sampling Define the population to be surveyed and their location based on the survey objectives. etc. Conduct the survey Involve community members and leaders Arrange for supervision and regular discussion Review completed questionnaires with the interviewers 9. equipment and analysis procedure 6. to determine the prevalence of malnutrition in children below five years List the main questions the survey should answer to achieve the survey objectives Outline methods and instruments for gathering data Estimate at least two weeks to train staff. MOH. Prepare the community Inform the community leaders about the purpose and method of the survey Get their agreement and co-operation 7. Evaluate the survey If survey objectives were achieved.. frequencies) Calculate averages. e.

These will depend on the main problems affecting a displaced population. a survey may help determine whether the presence of anaemia is related to hookworm infection. define the main questions that the survey will try to answer. After setting the objectives. customs. To learn about local beliefs. as shown below. To estimate the coverage or use of specific services such as immunisation and outpatient clinics. anaemia). To test a hypothesis (an educated guess or theory) about the link between risk factors (e. To measure past events such as mortality rate during a certain period. hook worm infection) and presence of a health condition (e. practices etc. To identify groups at increased risk of specific conditions (vulnerable populations) that should get treatment or referral to health services. such as malnutrition. For example. relating to health.g. ‘Dummy Tables’ are useful for summarising survey findings. Objectives for the population survey can be selected from the following: To measure the incidence or the prevalence of a disease or health condition.g.6 252 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Survey design Epidemiology and surveillance A population survey is carried out to achieve particular objectives. Figure 6-2: Examples of ‘Dummy tables’ for a hookworm survey Distribution of hookworm infected people by age and sex Age of patients Cases with hookworm infection Males Females Total Under five years Over five years Total Distribution of hookworm-infected cases by levels of haemoglobin Hookworm infection Haemoglobin level Present Absent Total % with hookworm Less than 10 g% 10g % or more Total % with anaemia . for a population with high levels of anaemia. Planning the analysis and reporting How information from a population survey will be analysed and reported needs to be determined early in the planning stage. These questions can be compiled into a questionnaire to be used for gathering the required information.

000 is usually adequate to assess for a common condition. Note: Sample size tables in standard statistics textbooks can be used to determine the actual sample size needed.Public health guide for emergencies I 253 6 Estimating sample size Table 6-17: Estimating sample size Estimating sample size for sample random or systematic sampling Estimating sample size for cluster sampling N = Z2pq d2 N = size of sample Z = level of statistical certainty chosen. manage epidemiological databases and perform statistical calculations. In general. A sample size of 100 to 200 randomly selected individuals from a population of up to 20. Therefore. including sample size calculations and data analysis. maternal deaths). Epidemiology and surveillance .96. Doubling would maintain the same degree of precision as simple random sampling: N = 2 X 96 = 192 WHO immunisation coverage survey uses a minimum of 7 subjects per cluster (7 x 30 clusters = 210. However.96): N = (1. N = 2 (Z2pq) d2 Because this type of sampling has some degree of selection bias. a larger sample size is needed when greater accuracy is required or to investigate conditions that have a low prevalence (e. It does not give sufficiently accurate estimates for rare conditions.96)2 (0. The above calculations can easily be performed using the STATCALC function on Epi-Info2.) q=1–p Example: To calculate the largest sample within a 10% margin of error and confidence limits of 95% (z = 1. Epi-Info is a public domain software package that can be used to process questionnaires. The above table shows formulas for calculating the appropriate sample sizes for different sampling methods. or confidence interval: 95 % => Z = 1.5) 2 = 3. one should approximately double the sample size.84 x 0.1) 2 Note: Confidence interval is the range of values obtained from the sample survey between which we are 95% confident that the true value in the overall population exists. which is greater than 192).01 (0. the larger the sample. The rapid KPC 30-cluster survey (of Child Survival Projects) uses a sample size of 300 (10 per cluster) to ensure that sub-samples are large enough to obtain management type information within statistical margins adequate for making management and programme decisions. 90% => Z = 1. but not so large that it wastes limited resources. Note: A cluster sample is recommended for collecting information on condition that is common. use 50% for maximum sample size.25 = 96 0.68 value of z usually rounded to 2 d = degree of accuracy desired = half the confidence interval p = estimated level/prevalence/coverage rate being investigated. the more reliable the estimated results of the entire population will be. (When in doubt.g. the size of a selected sample should be large enough to give reliable estimates.

g. Cluster sampling Cluster sampling begins with a list of clusters (community or administrative subdivisions.g. e.e. based on the cumulative frequency distribution of a population. Results from these surveys can also be compared with results of similar surveys performed in another time.) from which the sample is to be drawn. The starting sub-unit (e.g.. the characteristics of the sampled population (study population) are similar to the population from which it is drawn (reference population). every person in the target population has the same known (and non-zero) chance of being included in the survey. Determine the direction line by spinning a bottle on the ground. household) is randomly selected by picking a random number between one and the total number of households along the direction line between the geographical centre (e. divided by the required number of subjects per cluster. Note: This method is more likely to produce a representative sample.6 254 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Sampling methods Epidemiology and surveillance Sampling is the selection of a specified number of persons in a population for study with the hope that they are representative. Systematic sampling Begin by randomly selecting the starting unit to fulfil statistical requirements in systematic selection. seven). mosque. Note: A systematic sample can be drawn without an initial listing (e. market. For the second stage. List every sampling unit (persons.g. etc. village. The selection continues until all the required subjects per cluster have been interviewed. a certain number of clusters (usually thirty) are randomly selected. The following are probability sampling methods. . (e. select the next household in the same direction.g. Note: Consider the following points when selecting subjects in a cluster: If the suitable subject in a selected household is not available. sub-location. Probability sampling therefore enables the collection of reliable information at a minimal cost. child younger than five) is sampled and examined if present... church) and the cluster boundary. Simple random sampling Begin by constructing the sampling frame. household.. a specific number of sub-units (a minimum of seven) are randomly selected within each selected cluster. plot etc. Subsequent households might either be the nearest household from the entrance of the one just sampled or every nth household (where the sampling frequency might be the total number of households along the direction line. Randomly select the required number of units from the sampling frame by drawing lots or using a table of random numbers. In probability sampling. i. For the first stage. In each selected household. zone. twenty and fifty depending on the sample size relative to the total population) to the starting unit. a suitable subject (e. village. ten. choose from a line of people or according to the time patients enter a clinic. It allows investigators to form conclusions about a reference population based on information collected only from a subset of the population.). The next sampling units are systematically selected by adding a certain number ‘n’ (e. but it can be expensive and difficult to make a sampling frame where a population is scattered. place or population.g.g.

Garissa District Development Plan: 1997-2001). However. The investigating team identified one individual in each household for recruitment into the study. Exhaustive sampling Sometimes. the survey team for that cluster should go to the next nearest house in the next nearest cluster.022 distributed among twelve divisions and eighty-four sub locations (Office of the President. three children less than five-years-old). Sampling was done among the non-refugee population using multi-stage cluster sampling. Whenever possible. If the last household has more than one suitable subject present (e.Public health guide for emergencies I 255 6 The following figure shows an example of cluster sampling. This figure does not include the 120. When a map with a prior census is available. subjects can be selected using simple random sampling or systematic sampling. The following table describes the main differences between these two methods. Figure 6-3: Example of cluster sampling (WHO)16 Sampling method The estimated population of Garissa District for 1998 is 231. each cluster included one child aged two to nine years. The target sample size was 210 individuals.g.g. Thirty sub locations were selected as clusters. The most commonly used sampling methods are systematic sampling and cluster sampling. when investigating a disease outbreak or selecting only a group of people for the study can create a strong feeling of discrimination in the population. Choosing a sampling method The type of sampling method selected depends on whether a sampling frame—a list of individual people from which a sample is to be drawn—exists. a ‘second-best’ cluster sampling procedure is the only option where a population has not been settled in an orderly manner (as is the case in many refugee camp settings). . the entire population must be surveyed e.000 Somali refugees living in camps at Dadaab. Seven households were chosen in each cluster by random sampling. The number of clusters selected per division was based on population distribution by division. Epidemiology and surveillance If there are not enough subjects in the cluster. include the other children in the survey. Sub location clusters were selected randomly from each division. five individuals aged ten to fortynine years and one individual fifty years or older to reflect the age distribution of the RVF and HF cases already identified in this outbreak.

disease) being studied is clustered within the population. Key steps for designing questionnaires The following steps outline the process for designing a questionnaire: 1.g. because of the design effect. Survey is faster because people are grouped together. focus group discussions can be used to develop the first draft.. Ensure there is a logical flow of questions in each section. Develop questions that produce the required information for each indicator. Whenever possible. Ensure each question is clear. Place instructions for the interviewers at the beginning of each section. Provide enough space between questions for recording responses. 6. narrative response) or closed (i. requires a larger sample. Potential for errors if the variable (e. Begin with general questions and end with the more sensitive questions. 10. is needed. Although designing a questionnaire might look simple. The sample size formula is used but.6 256 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-18: Systematic sampling and cluster sampling Epidemiology and surveillance Systematic sampling Cluster sampling Ideal where shelters are arranged in an orderly manner. Pictures are useful for illustrating questions that are difficult to state in words or for illiterate data collectors. Test new questions on dummy tables (see planning the analysis and reporting section) to confirm that they will assess the selected indicators.e. 8. 11. coded). Less effort because only a simple sampling frame. 9. To develop complete questionnaires. Systematic selection may not necessarily produce a random sample. Keep only those questions that provide the most essential information. Requires more effort to construct a detailed list of individual subjects (from census or registration) as a sampling frame. Identify the easiest method for assessing each indicator. 7. Designing a questionnaire Questionnaires are useful for collecting information that may be difficult to obtain in any other way. Develop new questions for any additional information. lists of clusters (e. it is in fact difficult. use pre-tested questionnaires from the local or international organisations (such as the host ministry of health. . therefore. 2. Translate the questionnaire into the local language and then translate it back to the original language to identify any mistakes. Demographic and Health Survey (DHS). 5. villages) with population estimates. Expanded Programme on Immunisation information can also be referred to as a useful data collection and analysis software. simple. 3. Check each question against the survey objectives. including definition of cases and events. Define indicators that meet the survey objectives. short and easy to ask. WHO. Provides more precise estimates of the reference population from a similar sample size.e. ‘n’ is multiplied by two. 4. Decide whether to make the questions open-ended (i. Less precise. Most suitable method when the site is not arranged in an orderly manner and the population is large and spread out in groups.g.

g. weighing scales. Leading questions—ensure questions are neutral. Interviewees might be concerned about the nature of the questions and who will be informed of their responses. Consider all problems encountered during the pilot test of the questionnaire and make final changes. Which of the health problems do you think was the cause of death in your child? __________________________________________________________________ 7. tape measures) in an area that is not to be surveyed. Which other symptoms did the child have? _______________________________ ______________________ 6. etc. A full explanation about the survey should be given prior to the interview with strong reassurances about the confidentiality of their participation and use of the information.Public health guide for emergencies I 257 6 13. Did the child visit the health post during the week before he/she died? (Yes/No) __________________________________________________________________ Common problems with questionnaires The following are common problems with questionnaires: Too many questions—after questions on personal details (name. Figure 6-4: Sample questionnaire for a childhood mortality survey Questionnaire for childhood mortality survey 1. In general. Check that no essential information has been left out and the interview is short (less than twenty minutes). The questionnaire is constructed in one language but administered in another. how many? ________________________________________________ 2. how many? ________________________________________________ 3. Pilot test (try out) the questionnaire and other survey instruments (e. sex. Do not suggest that a particular answer is correct. .). How old was each child at the time of death? ______________________________ 4. Use pre-coded answers or record exactly what the subject says. age. Have any children less than five years of age in this household died during the past year? (Yes/No) __________________________________________________________ If yes. Epidemiology and surveillance 12. People are asked about events that they cannot recall. Did the child have any of the following during the week before death: Fever with cough? Fever without cough? Diarrhoea? Fever with rash? Accident? 5. Are there any children less than five years of age currently living in this household? (Yes/No) _________________________________________________ If yes. the maximum recall period that can be relied upon is two weeks (except for major events such as admission to hospital or death). add another ten to fifteen questions to limit the interview to a total of ten to twenty questions. Interviewers are left free to interpret the answers.

It might be transferred into dummy tables and simple calculations performed in the field by hand or with the help of a pocket calculator. They should be trained to ask questions in a neutral way and refrain from giving advice. For example. In the early phase of a disaster. Even if samples are carefully selected. For the best possible common analysis and coordinated and prioritised action. a survey done during the day might miss young men and women who have gone to work. information sharing with all agencies. Following up all non-responders at least once. surveys’ results can still mislead. the information in the completed questionnaires must be processed and analysed to be meaningful.6 258 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Training and supervising interviewers Epidemiology and surveillance Train all interviewers to administer the revised questionnaire in a standard way otherwise they might influence how interviewees respond to the questions. STDs and HIV/AIDS. Observer error can arise in commonly occurring inaccuracies because the interviewers recorded faulty measurements rather than because of faulty instruments or unreliable subjects. . Table 6-19: General outline for a survey report Outline for a full survey report Introduction Purpose of survey Survey area Dates of survey Methodology Indicators Sampling frame Questionnaire used Survey results Highlights Graphs with charts and tables Conclusions and recommendations Significant findings Problem areas Potential actions Further investigations Analysing and reporting survey findings After carrying out the survey. Checking instruments daily and adjusting the zero reading on weighing scales. In many cultures it is important that women interview women and men interview men particularly for sensitive subjects like family planning. People might not be willing to answer sensitive questions. The following table shows a general outline of a report to present the data to programme decision-makers in a way that they can understand. A shorter report focusing on the survey results and recommendations from the survey must be sent to the affected community. Non-response bias can be minimised by the following: Ensuring that at least 80% of the original sample population responds during the survey. Checking that interviewers follow standard guidelines when taking and recording measurements. Interviewers should be closely supervised to prevent the following: Non-response bias can occur if a high proportion of the sample population is missing or did not answer the questions. cluster and government is absolutely vital. vital data and information must be transmitted immediately because the next day things might look different. Further analysis might only be possible at the project office and the ministry of health levels. Observer errors can be reduced by the following: Making all interviewers sign their names on each questionnaire they administer.

Cause of death: inquiries were made about the presumed cause of each death. Sampling The sampling method selected for the mortality and nutritional assessment was systematic random sampling. MUAC is expressed to the nearest millimetre. Two data entries were recorded: yes proven by vaccination card or no if a vaccination card could not be produced. health. Methods Survey population Eleven camps in Montserrado and Bong counties were included in the assessment. For adults. A baseline assessment was organised to determine the magnitude of the problem. the existing resources and the existing gaps so that all problems could be tackled. Mortality: mortality data was collected from interviews with the head from all the selected households including households with no children aged between six to fiftynine months.Public health guide for emergencies I 259 6 In May 2002. Nearly 70. Reproductive health care: any pregnant woman found in a selected house was asked if she had visited a health clinic for her pregnancy since her arrival to the camp. Any woman that had given birth since arriving at the camp was asked if she had gone with her child to the clinic to be checked within the first ten days of her delivery. reported and registered as stated by the respondent. particularly for the under fives. sanitation and food aid. age was registered in years. Data included the number of people living in the household and number of people that had died in the household between their arrival to the camp and the date of the assessment.000. Nutritional status for at risk populations in all the camps and sites. A minimum sample size for the mortality survey was calculated based on the June population estimate and a sampling interval of one in ten houses was defined. Anthropometric assessment: Mid Upper Arm Circumference (MUAC) was measured at the midpoint between the shoulder and elbow of the left arm while the arm was relaxed. Epidemiology and surveillance Case study: health survey among an internally displaced population in Liberia22 Background . while the remaining six camps in Bong county had an estimated population of 39. Five of the camps were located in the Montserrado County with an estimated population of 77. Measles vaccination: the mother was asked if the child had been vaccinated against measles and was asked to show the vaccination card or other official document proving the child had been vaccinated.000. All displaced persons were distributed in fourteen camps and sites located in Montserrado and Bong Counties. was not assessed. The full extent of the mortality and morbidity status in all camps following the forced migration in May was not well known. Deaths since interviewees arrived to the camp were recorded and the month and year of death identified using the events calendar. Crude Mortality Rate and Under Five Mortality Rates were calculated for the month of July. thousands of Liberians were forced to flee as a result of clashes between government forces and dissidents.000 people were displaced including Internally Displaced Persons (IDPs) previously living in the camps. This last wave of displacement created additional needs for shelter. Survey questionnaire Age: the age of a child under five was noted in months and determined as accurately as possible using a calendar of local events.

mortality and nutritional data was condensed in a spreadsheet designed for this purpose. febrile illness (11%). Constructed and occupied with occupants present at the time of the visit. one team met with key informants to draw a map of the camp that identified how displaced people were distributed at the time of the survey. and respiratory infection (10%). the following house in the sampling interval was visited. respectively.0 and 8. Data processing and analysis Demographic. condense key information gathered and address any problems the other team members might encounter during data collection. interviewers asked about basic demographic information. the first household of a block was selected using random numbers. Once all blocks in the camp were identified. Each team met with block leaders or members to establish each block’s limits.2. 8. The team leader and interviewers held two separate focus group interviews with clients at the health facility: one with women and another with men to identify better the key health priorities and possible solutions as well as the resources needed to address them. Five three-member teams administered the questionnaires after attending four-day training for the survey. Once established. A local calendar of events was used to determine household members’ ages and dates of death. every tenth house was visited until the block was completed. The major causes of death were diarrhoea (18%). Constructed but unoccupied. Before initiating data collection in each camp. Houses selected for the survey were grouped into four categories: Under construction with no one living in them. The main causes of morbidity were malaria (43%) and ARI (18%). in Mont Serrado County.2% had moderate malnutrition when measured using mid-upper arm circumference as an indicator of malnutrition. mortality and nutritional data and a fourth for health services assessment were made in consultation with the International Rescue Committee health team in Liberia. A team leader was appointed for each team to scrutinise the record forms for errors and omissions. all of them were measured. Whenever a house was found under construction or unoccupied the next house in the sampling interval was visited. Mid-upper arm circumference (MUAC) measurement was performed using a standard measuring tape. Appropriate biostatistical and epidemiological programmes were used to process and analyse the data. Constructed and occupied with occupants not present at the moment of the visit. water source and mortality for the data.6 260 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Data collection Four data collection questionnaires for demographic. At each house. Whenever children were not found in a house. When occupants where not present at the time of the visits they were revisited twice. If two or more eligible children for measurement were found. The survey instrument was pre-tested in habitats and modifications done accordingly. Dummy tables were constructed beforehand for the analysis of each of the variables. the child was referred to the clinic for further assessment. For children under five. Health services data was condensed in a spreadsheet and dummy tables were constructed beforehand to facilitate analysis. they were divided among the teams. One team collected health services data on morbidity and data from existing registers in the health facilities. Results The study found crude and under-five mortality rates of 3. . When a child’s MUAC child was found to be below 135. After the first house was selected.

Using RDTs or microscopy.17 Using this approach.Public health guide for emergencies I 261 6 IDPs in the Liberia camps are facing a critical health situation: crude mortality rates are two times over the emergency threshold. For the purpose of a rapid survey. Record the total number of outpatients seen at the clinic while the survey is being done. calculate the total number of patients at the clinic and fever cases. Determine the proportion of fever cases among all outpatients. Up to 100 patients should be tested. outpatient clinics. Record the age. The mortality rates for children under five years old are three times over the emergency threshold. Analysis and interpretation of survey results Data analysis and interpretation can yield important information about malaria transmission. results can be presented by week and age group. preferably one to three days. test all febrile patients attending selected high-volume. RDTs give quick and reliable results. Conducting the survey Table 6-20: Key steps in rapid clinic-based fever survey for malaria Conducting the survey Choose either microscopy or Rapid Diagnostic Tests (RDT) as a diagnostic method. Rapid clinic-based fever survey for malaria Clinic-based fever surveys generate information about the prevalence of parasitaemia among symptomatic patients who seek care at health facilities. ‘fever’ should be defined as patients with fever or a history of fever over the past forty-eight hours. but may be of poor quality. Repeat the survey weekly during the acute phase and monitor trends at least once every month. Calculate the proportion of confirmed malaria among those with fever. The results of a clinic-based survey on fever at health facilities are presented below. or positive Rapid Diagnostic Tests rate. the proportion of febrile patients with malaria parasites can be quickly determined in emergency settings. Host population Age group Proportion of parasites in fever cases Interpretation of malaria transmission All children and adults Children under ten years Less than 10% More than 50% Low transmission High transmission Epidemiology and surveillance Conclusions . pregnancy status and place of origin of tested patients. Data can be interpreted as follows for the host and displaced populations. microscopy remains the gold standard for malaria diagnosis. Using the survey data. Patients have ‘confirmed malaria’ if there is a presence of malaria parasites in their blood. Using proper staining techniques. For ease of interpretation. slide-positivity rate. Ensure that sufficient staff is available and trained in the selected method. sex. Conduct all testing within a short time period. This proportion can be represented as the parasite rate.

one person to . High malaria endemic going to another area with high malaria endemic Travelled through high malaria endemic areas The immunity acquired in the area of origin might not have the same protective capacity in the new area. Scenario Interpretation of malaria transmission High local malaria transmission If incoming population is non-immune. over time an epidemic may start. children and pregnant women are most at risk. Define the study population. See the population survey section above. identifies groups (e. See the population survey section above. Source: WHO Community cross-sectional malaria prevalence survey The population survey approach can be applied when information about the prevalence of malaria in a displaced population is needed.6 262 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Children over ten years and adults More than 50% Possible onset of outbreak Epidemiology and surveillance Displaced population Among the displaced population. then over time there will be fewer and fewer malaria cases in the health care facilities. Determine the sample size. The purpose of the community crosssectional malaria prevalence survey documents the baseline prevalence of malaria among an affected population. the plasmodia are sometimes slightly different.g. The following table outlines possible interpretations for high proportions of positive malaria among febrile members of a displaced population. children under five) at particular risk for malaria. See the population survey section above. particularly during the first few weeks of settlement. interpretation of survey results is more complex. determines information about treatment-seeking behaviour. high morbidity and mortality rates will be recorded in all age groups. As above. as only those who brought it from their home area will have it. Conducting the survey Steps in conducting the survey are outlined here. these rapid surveys take three to six days to complete. If incoming population is semi-immune. Recruit and train survey team. However. Information collected from community surveys can help distinguish between low (well under 10% of the population is infected) and medium/high malaria endemic (10% or more of the population is infected). if the area where people are relocated to is receptive to the type of malaria the incoming population is bringing with them. Choose a sampling method. High malaria endemic in area of origin If the incoming population comes from an area where malaria is often found but the local area is not receptive to malaria transmission. Similar results might suggest different situations.17 Generally. and uses this information to guide and monitor interventions. showing high morbidity and mortality rates. The team should include a community member to explain the procedure and obtain informed consent from households.

8 . RDT or microscope and slides for smears).and hyperendemic Hypoendemic Very high Low or zero High (>50%). one person to take auxiliary temperature and conduct the RDT or make a malaria smear on a slide. lancets. funds to pay for transport to the clinic. For areas where high transmission exists all year. Essential supplies include diagnostic equipment (e. cotton wool. always higher than spleen rate Software programmes such as Epi-Info can be used for further data analyses. one person to check for presence of an enlarged spleen. anti-malarial drugs for treatment (if administered on the spot) and. Special attention should be paid to prevalence among children under age five. alcohol for swabbing skin. consent and record forms. one person to administer treatment and advise about danger signs and follow-up. the survey can be repeated several weeks after the start of interventions to monitor their impact. but lower than spleen rate Low Low (<10%) ≤ 10%.Public health guide for emergencies I 263 6 Ensure adequate supplies. pens and pencils. Analysis and interpretation of survey results At least the following two indicators should be calculated and interpreted from the collected data: Prevalence of malaria can be calculated by determining the proportion of people from the entire population with fever or history of fever and who have a positive RDT result.g. Finally in areas with annual peaks in transmission.17 Table 6-21: Classification of malaria endemicity Spleen rate Malaria endemicity Under five years Over five years Parasite rate Under five years Over five years Meso. rubber gloves. it will be helpful to repeat the survey after twelve months to assess effectiveness of interventions. Epidemiology and surveillance register participants. Community cross-sectional malaria prevalence surveys should be repeated in different seasons because malaria transmission varies between dry and wet seasons. The following table offers interpretations of these calculations. record auxiliary temperature. The data should be analysed by age. if needed. the Rapid Diagnostic Tests (RDT) result and information on treatment-seeking behaviour. clinic referral forms. sex and pregnancy status. Malaria Endemicity can be determined by calculating the proportion of the entire population with a positive RDT (or slide result) or the proportion of the entire population who have splenomegaly.

Among children over 10 years and adults. What Determines the proportion of treatment-seeking febrile patients with malaria. then interpret as high malaria transmission. More costly and requires more personnel. test all febrile patients attending selected high-volume. continuous Used to determine levels of malaria transmission at the community and sub-population level. Among all children and adults. Periodic. if proportion of fever cases with parasites is more than 50%.g. then consider outbreak onset. Malaria is hypoendemic if the overall spleen rate in the population is low (<10%) or the overall parasite rate is low (≤ 10%) and higher than the spleen rate. outpatient clinics. before implementing intervention) and used to guide and monitor interventions. Community cross-sectional prevalence survey To document the baseline prevalence of malaria among an affected population in the community. Malaria is meso. determining the sample size and sampling methods. Use population survey methods by defining and selecting the population.g. When How Using rapid diagnostic tests or microscopy. Requires a five member team (see above). Can be conducted by clinic staff and administrators. if proportion of fever cases with parasites is less than 10%. Cheap and requires less personnel.or hyper-endemic if a) spleen rate among under 5 years is very high or among over 5 years is low or zero or b) parasite rate among under 5 years is high (>50%) or among over 5 years is low. conducting the survey and testing participants in the community.6 264 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-22: Distinguishing between rapid clinic-based fever survey and community cross-sectional malaria prevalence survey Epidemiology and surveillance Rapid clinic-based fever survey Why To gather quickly information about malaria prevalence among symptomatic patients seeking care at health facilities. Up to 100 patients should be tested. if proportion of fever cases with parasites is more than 50%. To identify groups (e. children under five) at particular risk from malaria. Ongoing. intermittent. Among children less than 10 years. interpret it as low malaria transmission. Typically conducted at baseline (e. Cost Who Interpretation For host population: .

Epidemiology and surveillance Outbreak investigation .and sex. 2. Describe the outbreak in terms of time. Look for links or interaction between relevant factors (e. Calculate the age. 4. Please refer to the Control of Communicable Diseases chapter for more details about epidemic thresholds.g. the clinical presentation and disease outcome. Be sure to coordinate efforts with the national health authorities as well as inter-governmental investigations (e. floods increasing the Aedes mosquito population and reducing access to health care resulting in an outbreak of dengue fever). Analyse what caused the outbreak. Collect population data for the communities at risk (more denominators). WHO). Graph reported dates of disease onset for all cases to establish the timing (incubation period) and the source of disease (single or multiple sources). Confirm the outbreak. Key steps Table 6-23: Checklist for an outbreak investigation Key step Description 1.specific rates to identify who is most vulnerable.. Provide essential information on the affected sites. 3.000 people in a two-week period).Public health guide for emergencies I 265 6 Disease outbreaks or epidemics occur when many people in a community or region develop a similar illness—in excess of normal expectations—through a common source or carrier. An outbreak can be declared following the detection of a single case in a nonendemic area (such as cholera or measles) or after the number of reported cases reach the threshold incidence rate of a particular disease (e. the time period.g. Objectives of investigating an outbreak The following may be defined as objectives for investigating an outbreak: To identify the cause(s) and risk factors for the disease.g. Notify and coordinate with the host and international health authorities. To provide a foundation for developing public health policy. place and person. Define a ‘case’ and count the number of reported cases (the numerator): Is the disease known? Are the causes partially understood? Define the denominator: What is the population at risk of developing the disease? Calculate the attack rates. Review previous levels of disease and local knowledge of disease outbreaks. threshold for meningitis is fifteen cases per 100. the frequency and profile of cases. To identify the appropriate prevention and control measures that will reduce the impact of the disease. a possible diagnosis and suspected source of infection. To determine the extent of the disease. Map the residence of all reported cases to identify the most affected areas and the direction of the disease spread (see spot map in the data analysis section).

a report should be written and shared with all concerned. and set up special surveillance for new cases.) might be invited to support the local team. based on the analysis of the outbreak. 8. Identify important differences between the cases and non-cases to define the individuals/groups at increased risk of contracting the disease. the geographic distribution and the clinical presentation among cases. The causative agent and probable routes of transmission. personal and environmental hygiene. Prepare a report on the outbreak that covers the following points: Even though different disease outbreaks might occur. The most effective ways of controlling the spread of disease should be initiated as soon as possible. The epidemiologists might help organise a case-control study that compares risk factors among people with and those without the disease. For example: in suspected cholera outbreaks. Collect specimens from cases and non-cases for laboratory investigation. faecal contamination and toxic chemicals. vector control. isolate cases. and nutrition).6 266 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance 5. 7. Investigate for vectors. if necessary. If the outbreak seems to be spreading and causing many deaths rather than phasing out naturally. there are key steps to be carried out in most outbreak investigations. conduct additional studies. microbiologists etc. Interview cases with disease and non-cases to identify possible sources and methods of disease transmission (common source or person-to-person). epidemiologists. there is not enough information for identifying either the cause of the outbreak or the appropriate control measures. appropriate disease control measures must be initiated at the beginning before identifying the cause or risk factors for disease. At the end of the investigation. Source reductions (treat cases and carriers. The reason for the outbreak. These steps are summarised in the table above. Protect vulnerable people (immunisation. personal protection. Prevent transmission (health education. Initiate prevention and control strategies. Recommendations for prevention of future outbreaks. The order of the steps might depend on the nature of the outbreak and the existing knowledge about the disease. Disease control measures that were introduced. Sometimes. restrict movements). When investigating an outbreak. If necessary. 6. the first step is to confirm that there really is an outbreak. and control animal reservoirs). Continue surveillance: maintain routine reporting. . Determine the proportion of cases and non-cases that had possible exposure to infection.g. a special team of investigators (e. A local public health team might be capable of doing this and sometimes even identifying the possible causes and risk factors. chemo-prophylactics. Assess the environment. follow-up suspects. Description of the trend in the disease outbreak. entomologists.

organisation and supervision. Train interviewers to ask questions in a standard way and to practice using the survey’s questionnaires and equipment before the investigation. Standardise the sequence of data collection procedures. collect any required laboratory specimens (blood. speedy carrying out of the investigation may be critical. At the end of the investigation.). Planning the investigation Consider access to the site and the willingness of the community to help the investigation. Finally. Epidemiology and surveillance . If the disease is spreading rapidly. organise a final meeting with all supporters and participants to thank and give them feedback about the investigation and recommend any long-term measures to prevent and control future outbreaks. Most investigations involve epidemiological. the daily family activities and the migration patterns when scheduling the time for data collection.’ Prepare incentives to maintain community participation during the investigation. it needs careful planning. Remember. Perform a physical examination after the interview. Evaluate the collection and processing of laboratory specimen for quality control. Design appropriate questionnaires based on how the information will be analysed. Conduct frequent staff meetings to identify and address any problems. Organising the investigation Involve local authorities for security clearance. stool etc. Key procedures must be followed. Sketch an organisational chart that shows the lines of authority.Public health guide for emergencies I 267 6 Carrying out the investigation Because investigating a disease outbreak involves many people. the roles of different teams and the link between functions. Supervising the investigation Supervise field workers by checking how they conduct interviews during the survey and their accuracy in recording data. Arrange for translators and chaperones to be present during interviews if needed. Consider the local climate. Preserve all laboratory specimens appropriately. publicity and introduce the investigation team to the affected community. ‘no survey without services. Data should be collected as follows: Collect information directly from the affected person or family member where necessary. clinical. This might include providing some medical services or essential drugs. Carry out and check data entry daily and perform simple calculations. and laboratory procedures.

252 cases of suspected cholera were reported (WHO. Additional data was collected from an emergency surveillance system that began operation on August 25. The number of persons treated for cholera increased sharply in early June and stool cultures confirmed the presence of Vibrio cholerae O1. unlike other health facilities that provided services in Monrovia during the 2003 outbreak. This centre.746 hospitalized patients with illnesses consistent with a diagnosis of cholera.000 Internally Displaced Persons (IDPs) settled in private homes with family members. an estimated 300.8%) patients died. From June to August. Between June 2 to September 22.e. 3. The number of persons treated per week peaked in mid-July at 935. In June. Because of fighting between June and July. Three choleratreatment centres operated by Médecins sans Frontières (MSF) reported that during June 2 to September 15. Joseph Catholic Hospital in Monrovia from stool specimens obtained from six patients during June 9 to 13.969 (1. During the week ending October 20.000 IDPs in Monrovia (1). a total of 1. Because cholera transmission was probably attributable to an acute shortage of clean water. 37 (0. out of 4.8%) hospitalized patients had severe dehydration. international and Liberian organisations attempted to supply IDP settlements with sufficient potable water and began chlorinating wells. To estimate the magnitude of the outbreak in August. The epidemic began in June (see the figure below) and was associated temporally with increased fighting and the movement of IDPs. cases of cholera were confirmed by international nongovernmental organisations. After August 25. WHO conducted a retrospective review of data collected by health organisations between June and August 2003 but did make a report to MoH. public buildings and in other sites. of an estimated one million permanent residents and 172. the normal collection of health data by the Liberian Ministry of Health (MoH) was interrupted. compared with 450 to 655 patients during comparable periods in the previous four years. the case-fatality ratio in cholera-treatment centres was <1%. MoH.6 268 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance Case study: cholera outbreak investigation after the civil conflict in Liberia20 In June 2003 at the height of Liberia’s civil war as rebel forces approached the capital city of Monrovia. unpublished data. . a total of 2. Cases most closely approximating the standard WHO recommended case definition for use in cholera outbreaks (i.352 between September 16 to-22. poor sanitation and crowded living conditions. declined to 387 in the last week in July. the majority of facilities that reported data to the emergency surveillance system used a case definition that included acute watery diarrhoea in children aged two to four years. the last week for which data was available.073 (64. has treated cholera patients for the previous four years. V. 2003). the number of persons treated for cholera increased from forty-nine to 426 per week. cholerae O1 was isolated in the laboratory of St. acute watery diarrhoea in a person aged > five years) were included in retrospective case counts. Data from the cholera treatment centre operated at JFK Hospital by MSF Belgium were used to compare the outbreak in 2003 with the number of reported cholera cases in previous years. 16. In June. During this period.648 cholera patients were treated in this facility.4%) persons sought medical care for an illness consistent with the surveillance case definition for cholera. and increased again to 2.

All data collected by whichever means—routine information system. Summarising data into frequency Results of data analysis should be carefully interpreted and presented as tables and graphs. Expanded Programme on Immunisation INFO see www. surveillance systems. perform basic and advanced data analysis and print results. Note: This step may have been done when planning for the data collection. Analysing data can be simple and straightforward. Most of it can be done with a pocket calculator. an outbreak investigation or a survey – needs to be processed.who. time and resources needed to analyse data should be planned in advance. To improve the quality of programmes. Performing summary statistics (for numerical data). store databases. To develop an action plan for dealing with problems. water supply and sanitation. analysed and presented in a form that decision-makers can easily understand. Where staff members lack the knowledge and skills for analysing data. To investigate further to verify the actual causes of a problem.html a public domain software might be used to set up questionnaires. The following steps might be used to analyse data in the field: Define the major end-results expected from the analysis These are mortality and morbidity rates. Where computers and staff with computer skills are available. Projects can save time and effort by analysing only the priority problems being tackled by the project. The methods. Basic data analysis and interpretation Data should be analysed and interpreted in a logical sequence.Public health guide for emergencies I 269 6 Objectives of data analysis The following are objectives of analysing data: To identify the possible root causes of problems. on-the-job training should be organised with follow-up supervision. coverage and access to food ration. which are easier to understand. Basic data analysis includes the following steps: Sorting the data records. Calculating percentages and rates. Process all data Data on people attending health facilities or feeding centres is usually recorded directly from individual patient cards into facility registers on a daily basis. Data in these registers will usually be summarised as shown in the following table: Epidemiology and surveillance Appendix: Data analysis and presentation . To define needs that has not been met.

. Date Zone Age Sex Weight ARI infection 1 2 3 4 5 6 7 8 9 10 .g. Analyse categorical data. + Data from surveys is usually received in individual questionnaire forms. Table 6-25: Examples of two-way tally sheets Example of a two-way tally sheet showing age and gender Male Female Total Example of a two-way tally sheet showing ARI cases by age ARI + ARI Total <5 >5 Total \\\\\ \\\\\ \\\\\ \\\\\ \\\\\ 25 \\\\\ \\\\\ \ \\\\\ \\\\\ \\\\ 25 26 24 50 <5 >5 Total \\\\\ \\\\\ \\\\\ 15 \\\\\ \\\\\ \\\\\ \\\\\ \\\\\ \\\\ \\\\\ 35 30 20 50 . 3 F F F F M M F M M F . . The information must be recorded onto a summary sheet similar to the one shown above. 200 TOTAL 1/1 1/1 1/1 1/1 2/1 2/1 2/1 2/1 2/1 3/1 . etc. S 4 6 8 3 4 4 11 2 2 1 . occupation. Ensure that no observation is recorded more than once and that all the observations are contained in the table.). Note: All data received should be inspected for inconsistencies or for missing data and appropriate actions should be taken (e. location. . must first be tabulated as follows: Hand-tally data from the above registers or summary sheets of observations into the corresponding box as shown below. omit. . . F 20 25 30 15 15 20 40 12 8 7 . sex. Categorical data such as age. . 7/1 R Q S Q Q P P Q R R . These questionnaires must be sorted by record number and date from the earliest to the most recent. verify. etc. .6 270 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-24: Summary sheet for ARI survey data on 200 displaced people in camp A Epidemiology and surveillance Record No. 10 + + + + + .

male with female. % ARI Female No. These comparisons can also be illustrated with graphs.7 40. under-five with total population.3 6. See presenting data for an example of a spot map. please refer to the standard statistical texts. Two-way tables might be used to classify data by PERSON (age and gender or other characteristics).g. Epidemiology and surveillance Classify data into frequency tables: Transfer total counts from tally sheets into corresponding cells (intersection of a row and a column) of empty but labelled dummy tables which should be prepared during the planning stage.7 60. of ARI cases Male Female Total No. One-way tables might be appropriate for classifying data by PLACE. the above results of Acute Respiratory Infection (ARI) distribution in one camp can be compared to results of another camp whose population size and structure is similar otherwise the conclusions drawn might not be valid. . A spot map is easily created by pushing pins on a map of the study areas. Table 6-27: Example of calculating percentage of observations ARI Male No. By place: compare frequency tables for different camps or population settlements. % < 5 years > 5 years Total 50 10 60 33.). For all comparisons.3 26. For details about how to compare populations with a different structure or size. These might be one-way or two-way frequency tables.0 100 50 150 66.0 50 40 90 33. Compare frequencies and percentages as follows: By person: compare frequency tables for gender/age (e. Information about the one-way frequency table is better understood on a spot map that shows where the disease distribution is greatest. Percentages might be expressed to one decimal point or rounded to a whole number.4 100 Tables of categorical data can be used later for comparison with other data for the presentation of graphs or to carry out statistical tests. of ARI cases 10 30 70 40 150 < 5 years > 5 years Total 50 10 60 50 40 90 100 50 150 Calculate percentage of observations: Divide the count in each cell by the grand total and multiply the result by 100. For example. etc. ensure the population size and structures in the frequency table are similar. By time: compare frequency tables with baseline or the previous month’s frequencies to follow trends.Public health guide for emergencies I 271 6 Table 6-26: Examples of one-way and two-way frequency tables A one-way frequency table: Distribution of ARI cases by location CAMP P Q R S Total A two-way table: Distribution of ARI cases by age and sex No. % ARI Total No.6 33.

Note: The median is referred to as the mean when the data is biased or tends to lie in one direction. + 10 + 11)/11 = 80/15 = 5.6. 3. Figure 6-5: Applying standard deviation After a nutritional survey of displaced children. 2. haemoglobin levels.1.4. weight.3 years set Standard Deviation (SD) describes the scatter of observations around their mean.3. please refer to standard statistical texts. 10.10} —can begin with a disorganised data {1. The range is the difference in values between the lowest and the highest observed values. age. A large SD implies a wide scatter in the observed data while a small SD implies a narrow scatter with little difference between the observations. Table 6-28: Examples of summary statistics Data set for ages of 15 people with ARI infection Original data set Sort data set: Age range: Median age: Mode: Mean age: Percentage: {2.1. 4. 1.21.g.2.3 years 10/15 = 66. In emergencies. 2. the Weight-For-Height (WFH) data for all children surveyed might be plotted on a graph and compared with WFH data for a standard population of children. 6. 21} 1 – 21 years 3 years 2 years (1+ 2 + 3 + 3…. 4. For details on calculating standard deviation. the SD is commonly used to estimate the prevalence of malnutrition or to show the normal range of laboratory tests. 8. 2.6 272 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Analyse numerical data Epidemiology and surveillance (e.7% of people with ARI are below the mean age of 5. 2. height.g. The fraction of displaced children with WFH more than –2 SD below the mean standard WFH is judged as wasted (shaded area under the curve for displaced children). Median—-sort the data in each category from the lowest to the highest value and note the middle value that divides the data set into two equal halves. 11. birth weight) and dividing the total sum by the number of observations. etc.) Descriptive Analysis: Summarise data by defining the following: Range—-scan the data set in each category. .. Percentage—-define the proportion of subjects above or below particular data categories. Mode—scan the data set to identify the most common observation. 8. Mean—-calculate the mean also known as average by summing all the data in a category (e.11. 3.

The percentages can be applied to a total population estimate to define the estimates of population sub-groups when data about the displaced population is lacking or unreliable. children less than five etc. of females Total < 5 years 5-14 years 5-14 years 50+ years Total 20 45 45 10 90 20 35 35 10 110 40 80 80 20 200 Analyse indicators Calculate rates. 50+ years.g. but after the survey. 5-14. mortality etc. dummy tables for a survey might have been drawn for two class intervals for age (< 5 years and > 5 years). Epidemiology and surveillance Classify numerical data into frequency tables: Frequency tables can be used to classify numerical data under suitable class intervals. By place: to compare indicators for several locations or settlements. underfive mortality) with those of the total population or if data is available. Demographic indicators—-The following table lists the population structure of a typical developing country in percentages and ratios. the vulnerable population can also be estimated (e. mortality etc. For example.). compare indicators for two sub-groups (e. of males No. . compare indicators (incidence. all pregnant women. By time: to follow trends. the analysts might feel that they can draw better conclusions by classifying age as < 5.g. 15-49. ratios and proportions: Data for numerators and denominators for selected indicators can be obtained from frequency tables developed according to the previous steps. Compare selected indicators: Ensure the indicators being compared represent a similar population size and time period. morbidity of male and female or of two different ethnic groups in the camp). Interpret data Consider normal reference values or targets when interpreting health indicators. Depending on the information in the demographic table available.) as demonstrated earlier in this chapter.Public health guide for emergencies I 273 6 Table 6-29: Population distribution by age and gender Age No.) with baseline values or those from the previous week or month. The population pyramid might also be drawn to display the age and sex compositions of a population (see the table and figure below). Calculate the values of each indicator (disease incidence. Follow trends to determine if the situation is improving. The class intervals in dummy tables might have to be revised after data collection according to the observed range of data.g. By person: to compare indicators for a sub-group of the population (e.

6 274 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-30: Population structure of a developing country Epidemiology and surveillance Population composition p Total population Infants (0-1 year) Children 0-5 years Sex ratio Women of child-bearing age Pregnant women Expected births 100% 4% 18% 1:1 24% 5% 4.000/day within four to six weeks after starting a basic support programme that has provided sufficient food and water. For well run relief programmes. The baseline CMR from the initial assessment might be compared later with other CMRs to determine the effectiveness of the relief efforts. sanitation and health care. A CMR >1 death/10. Mortality: The table below shows how Crude Mortality Rates (CMRs) can be used to assess the status of an emergency situation. . The crude mortality rate of displaced populations is expected to fall below 1. CMR should not exceed 1.000/day implies an acute emergency situation.4 cent Figure 6-6: Example of a population pyramid Health status indicators: Ensure the indicators being compared represent a similar population size and time period.0 deaths/10.5 times those of the host population. Note: Cut-off values for the under-fives CMR are almost double the CMR for the whole population.

000 / day Normal for stable situations in developing countries. Note: See the nutrition chapter for details about calculating WFH.000/ day CMR > 1. Note: The presence of oedema indicates severe malnutrition regardless of the Weight-for-Height (WFH) indicator.000 / day CMR > 2. There are several anthropometric indicators. Epidemiology and surveillance .5 /10. skin changes (scaling.5 12.0 /10.000/ day CMR > 2. Finding even as few as 1% of children with a Z-score below -3 SD indicates the need for immediate nutrition interventions. prevalence. Two types of indicators can be used: Clinical indicators of malnutrition include detection of oedema (excess fluid in tissues of lower extremities). relief organisations should consider that a nutritional emergency exists if more than 8% of children sampled have a Z-score below -2 SD.Public health guide for emergencies I 275 6 Table 6-31: Classifying emergency situations by crude mortality rates Benchmarks for crude mortality rate Indication Total Population CMR 0. Whether the control measures being implemented locally are effective for reducing the disease incidence.0 / 10.000/ day Age under Five Years CMR 0. Whether the condition is potentially life-threatening or disabling (severity). For developing countries with lower ‘normal’ nutritional intake levels. Emergency out of control.3-0. hair changes or signs of micronutrient deficiency disorders. Must be investigated. Thus. Very serious situation.0 / 10. Morbidity: Determine the importance of identified diseases in the following terms: How common each disease is and what the risk factors are.0 /10. median or Z-score.000 / day CMR > 4. severity or death from the disease.7-1. The following table shows the MUAC and WFH cut off values for global and severe acute malnutrition: Table 6-32: Cut-off values for MUAC and WFH for acute malnutrition WFH MUAC Percentile Z-score Severe malnutrition Global malnutrition 11. Anthropometric indicators are based on measurements of age. Clinical indicators must be interpreted against anthropometric indicators. baggy skin). but the ones most commonly used for measuring malnutrition in children are WFH and Mid-Upper-Arm-Circumference (MUAC). Nutritional status: A displaced population’s nutritional status might be projected from the nutritional status of children less than five years of age. Whether the existing disease surveillance system is capable of detecting and monitoring the disease or if new indicators for the disease should be added. sex. WFH might be interpreted as a percentile. Demands immediate actions.0/10. weight and height.5 <70 <80 < -3 SD < -2 SD Take are when interpreting findings from anthropometric surveys. up to 5% of children might have a Z-score below -2 Standard Deviation (SD) when compared to the reference population.

. check whether: Enough stocks are maintained and that the use of supplies is monitored. Local skills and resources (including traditional healers) are fully used (e. To assess the adequacy of inputs.g.) by comparing the actual values of the process indicators to pre-defined targets or standards. Programme input indicators To assess availability of inputs consider the following: Availability of essential drugs. etc. The table below identifies where the practices and/or coverage of immunisation fall short of what would be desired or expected.g. it is essential to interpret these rates against the following factors: Morbidity and mortality rates for children under five. most of the critical jobs should be assigned to the affected population). Table 6-33: Comparing standards to current practices Actual practice and coverage Set standard Conclusion 80% access to immunisation 90% immunisation coverage No drop-out 80% Compliance Latrine coverage: 1 per family Global malnutrition rate less than 8% DPT1 coverage = 82% DPT3 coverage = 70% DPT1 – DPT3 = 12% Measles = 50% Fully immunised = 45% 1 per 20-25 people 10-15% of children have Zscore < -2 SD of reference mean Good practices and coverage Mixed practices and coverage Mixed practices and coverage Poor practices and coverage Good practices and coverage Mixed practices and coverage Graphs can also show the trends over time of the gaps between the actual practices and the set standards. Time of year (e. Minimum standards are being followed. Trends in food security.6 276 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Epidemiology and surveillance After determining the global and severe malnutrition rates for a displaced population. e. Daily staff attendance. pesticides being sprayed are safe for the user and the environment. Quality and use of food rations (food basket monitoring). Food availability and consumption.g. harvest or planting season). Expenditures compared to budgeted amounts. health services. Possible solutions can then be found to address the causes of gaps in service. immunisation. sanitation. Programme process indicators Identify any gaps in coverage and quality of services provided (food and water supplies.

g. Do not generalise findings from a small area to the whole population: they might not be representative (e. Advanced data analysis Sometimes.g. reporting or information bias. more advanced data analysis might be needed to determine the following: Relative Risk (RR) Relative risk compares the probability of disease in two different study populations: one with a risk factor and the other without. One purpose of the survey was to determine whether people who use Insecticide Treated bed Nets (ITN) have a lower risk for contracting malaria. if all children who were interviewed were weighed. after carrying out special investigations or surveys. not the entire population). Some of these patterns might become more obvious after graphing the data. and indicators) as follows: Check that the results are: . Unbiased—-search for systematic error at any stage of the study that produces results systematically differing from the true estimate due to selection. consider the following data obtained from a survey of incident malaria following a period of high malarial transmission. graphs. tables. hospital morbidity reports only represent those who use the services. Also consider the possibility of interaction between indicators (e. reduced water supply and under-five mortality. Epidemiology and surveillance Before drawing conclusions about the data. Relative risk can be calculated by determining the ratio of the proportion of exposed individuals with the event of interest out of the total exposed divided by the proportion of unexposed individuals with the event out of the total number of unexposed. Convincing—-findings should be consistent with existing scientific knowledge of disaster experiences. check from the summary statistics and tables whether there are more ARI cases among underweight children compared to those with normal weight. Relative risk is usually applied to longitudinal (cohort) studies. etc. scan all analysis results (summary statistics.). The following table and example illustrate the concept: Table 6-34– Calculation of relative risk and odds ratio Status Diseased Non-diseased Total Exposed Unexposed Total A C a+c B D b+d a+b c+d T Relative risk is: Relative risk = [a / (a + b)] / [c/(c + d)] For example. Look for patterns among data variables: For example.Public health guide for emergencies I 277 6 Scan all analysis results Consistent—-cross-check data gathered by different sources/methods to build a more accurate understanding of the results. increased malaria incidence with season of the year.

etc. Sensitivity. Odds ratio is usually calculated for case-control studies in a representative sample with results applied to the entire population.6 278 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Table 6-35 – Calculation of relative risk for malaria among ITN Users versus non-ITN users Epidemiology and surveillance Status Malaria + Malaria - Total Use ITN Do Not Use ITN Total 20 40 60 30 10 40 50 50 100 Relative risk is: Relative risk = [20/(20 + 30)]/[40/(40 + 10)] = 0. Table 6-36 – Calculation of odds ratio for age less than five among those with and without malaria Status Malaria + Malaria Total Age < 5 Age ≥ 5 Total 40 20 60 10 30 40 50 50 100 Odds ratio is: Odds ratio = (40 × 30) / (20 × 10) = 6. consider the following data obtained from a community-based malaria prevalence survey. The odds of malaria are six times greater among those less than five years of age when compared to those aged five or older.0 This odds ratio can be interpreted as follows. specificity and predictive values These tools assess whether a screening test or procedure can sufficiently detect a condition or if further tests are needed (e. Alternatively. clinical diagnosis of anaemia.5 This relative risk can be interpreted as follows. One purpose of the survey was to determine whether people with malaria are more likely to be under the age of five compared to those without malaria.). Odds Ratio can be calculated by determining the odds of a risk factor among individuals with the event of interest divided by the odds of a risk factor among individuals without the event of interest. Odds Ratio (OR) Odds ratio is used to compare the probability of having a risk factor in two different study populations: one with and the other without the disease. The risk of malaria among those who use ITNs is one-half the risk of malaria among those who do not use ITNs. . Table above calculates odds ratio as a cross-product ratio: Odds ratio is: Odds ratio = (a × d) / (b × c) For example. The odds of being less than age of five years are six times greater among those with malaria compared to those without malaria. pneumonia. odds ratio can be interpreted in the following way.g.

Although not shown here. Results will be expressed as a statistical probability. as calculated above. a resulting P-value of less than 0.g. we can say that the odds of malaria is six times greater among those less than five years compared to those greater than five with a 95% CI of 2.74 in 95% of all surveys conducted in a similar way among the same population. Chi2 test) are performed to establish whether two quite different factors. and SE (estimate) is the standard error of the relative risk or odds ratio.0 × e-[1. following a malaria survey.96 × √(1/40 + 1/10 + 1/20 + 1/30)] Employing basic algebraic techniques.74 Using these confidence limits. standard error for the relative risk can be calculated as follows. This means that true population’s odds ratio would fall between 2.96 × √(1/40 + 1/10 + 1/20 + 1/30)] = 2. However. the 95% Confidence Interval (CI) for odds ratio calculated above using table 4-33 is: 95% CI (log odds ratio) = log odds ratio ± [1. For example. or whether the apparent relationship might have only occurred by chance.Public health guide for emergencies I 279 6 Confidence limits The 95% confidence interval can be calculated using the following general formula: Point estimate ± [1. The chi-squared statistic (X2) for a two-by-two contingency table can be calculated by hand as follows: X2 = (ad – bc) 2 (a+b+c+d) (a+b) (c+d) (b+d) (a+c) with (r-1)(c-1) degrees of freedom.0 × e [1. we can calculate the 95% CI for odds ratio: 95% CI (odds ratio) = exp [log 6. the diagnosis of anaemia and hookworm infection could be statistically associated. similar calculations can determine the 95% confidence limits for Relative Risk using the standard error formula given above.44 to 14. the lower 95% confidence limit = 6. there is a 95% probability that the prevalence for the whole population will lie between (20–5) = 15% and (20 + 5) = 25%..0 ± [1.05 implies association. Significance tests Significance tests (e. where a P-value less than 0. in the logarithmic scale: SE (log odds ratio) = √(1/a + 1/b + 1/c + 1/d) Thus.g. e. For example.74.05 would indicate that there is a real difference between the spleen rates of males and females that is not due to chance factors from sampling.44 and 14.96 × √(1/40 + 1/10 + 1/20 + 1/30)] = 14. this finding should be interpreted against existing scientific knowledge about malaria transmission before drawing the final conclusion of confirming the finding or repeating the survey in another population.96 × √(1/40 + 1/10 + 1/20 + 1/30)]] Thus.96 × SE (estimate)] Where the point estimate is the relative risk or odds ratio. Epidemiology and surveillance Confidence limits indicate the probability (usually 95%) that the estimate obtained from the sample will not differ from the true population rate by more than the range defined by the confidence limit. standard error for the odds ratio can be calculated as follows. in the logarithmic scale: SE (log relative risk) = √[b/(a(a+b))] + [d/(c(c+d))] Referring to table 6-33. Referring to table 6-33.44 Thus. the upper 95% confidence limit = 6. Significance tests can also be used to establish whether the observed differences between different study populations are real or due to chance alone. . in a sample of 100 individuals in which a prevalence rate of 20% is observed.

please refer to standard statistical texts for full details. Present only the most essential features in graphs. With a chi-squared value of 16. This makes graphs easier to understand. This means that the obtained Odds Ratio (6. the obtained p-value would be less than or equal to 0. the simplicity and clarity of the information is destroyed. Otherwise. Presenting data Data can be presented in the form of tables or graphs because they create a clearer impression than numbers alone. the significance of this value can be determined. Incidence of ARI in Alpha camp by age and sex 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% <5 >5 Males Females . basic rules should be followed when drawing and presenting graphs and tables.0) is statistically significant.667 and 1 degrees of freedom (df). Limit the number of graphs. Each presentation should be of reasonable size—-not too big or too small.6 280 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies The following X2 can be calculated for table 6-33: Epidemiology and surveillance X2 = [(40×30 – 10×20)2 (40 + 10 + 20 + 30)]/[(40 + 10)(20 + 30)(10 + 30)(40 + 20)] = 16. Otherwise. etc. the higher malaria risk obtained among individuals less than five years of age compared to those aged five or more in this population is real and not due to chance. tables.667 The degrees of freedom (df) are (2 – 1) (2 – 1) = 1 Using a distribution table of chi-squared values (available in appendices in many statistical texts). it can be used to perform these tests. such as: Neatly draw and label all presentations and include a description of the data. A few tables were shown in the previous section on analysing and interpreting data. Note: Carrying out the above-described statistical analysis procedures in detail is beyond the scope of this book. Graphs are very useful because they help define patterns in the data. The figures below show examples of graphs: Histogram—to show the frequency distribution of large samples of quantitative data. Use different colours/shadings/lines to increase contrast between data categories. If EPI-INFO is available.001. However. because too many can be confusing. In other words.

Prevalence of diarrhoea among displaced population in Alpha camp 1995 80% 60% 40% 20% 0% Jan Feb Mar Apr May under five years over 5 years Age-group Epidemiology and surveillance . The time variable is usually placed on the x-axis and the frequency or rate on the y-axis. e. Time chart—to show trends and changes in health of the population and disease occurrence over time.g.Public health guide for emergencies I 281 6 Pie chart—to show proportions of different segments of a whole. specific causes of death.

16 .6 282 I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies Scatter diagram—to show relationship between a limited number of observations. Epidemiology and surveillance Average weight gain/day among under 5s enrolled in SFC at Alpha Camp 18 Ave weight gain (g/day 13 Females Total Males 0 2 4 6 8 Time (months) Spot map—to show distribution of cases within an area.

Decision makers at the national and international level so that appropriate control measures can be organised. Summary of report for those Community health workers so that they will be who gave support or helped to motivated to continue collecting data. collect data. Senior health workers responsible for data collection to improve diagnosis and management of disease cases. Agencies and service providers of similar programmes. The objective of surveillance. The objective is to improve how the relief programme is managed as well as provide feedback to data collectors so that they feel motivated. Very brief summary of the most important findings and conclusions. surveys. CHWs Displaced population Information in emergencies must flow two ways. The table below gives a summary of the reports and recipients of the information. General population to be aware of health risks and to improve how they manage their illnesses at home. Programmes also have a responsibility to distribute information to affected populations themselves. the results should be communicated in a form that everyone can understand. Table 6-37: Description of different reports and recipients Type of report Recipient Full detailed report for those in a position to improve situation and provide additional resources. Epidemiology and surveillance . After analysing data. outbreak investigations and health information is not simply to collect and report data.Public health guide for emergencies I 283 6 Communicating and using information Figure 6-7: Flow of information in emergencies International level National level Project level Health facility Community leaders.