Hello, my name is Susan Cookson, and I'm an infectious diseases physician and a tuberculosis specialist, and the research coordinator for the Emergency Response and Recovery branch at the US Centers for Disease Control and Prevention. In this video we will focus on respiratory diseases and emergency as well as take some time to talk about a chronic infectious diseases, tuberculosis, or TB. Acute respiratory infections, or ARIs, are a common cause of death and emergencies, especially among young children. ARIs are caused by viruses, bacteria, and atypical bacteria. And this is no exception in emergencies. The most common viruses are adenovirus, influenza, and parainfluenza, respiratory syncytial virus, or RSV, and human metapnemuovirus. In a 2007 to 2010 study among refugee children less than five years of age, in a camp in Kenya. The two most common virus groups, in about one of five children, were adenovirus and the combination of influenza and parainfluenza viruses, followed by RSV at about 13%. Of these, only influenza has a vaccine. For bacterial infections, streptococcal and Haemophilus influenza, including type b, are common among refugees, and again, especially among refugee children. And the atypical bacteria, also called walking pneumonia because they are not as several as tradition bacterial infections, and need different antibiotics than traditional bacterial infections. Atypical bacteria infections have also been found in about 1 in 20 children in the same refugee camp in 2006 through 2008. These bacteria have such names as Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella species. Pneumonias, or acute lower respiratory tract infections, are particularly dangerous. And account for 14% of deaths among children 1 to 59 months, or those less than 5 years, and 4% among those 1 to 27 days old. This is only second to sepsis as far as an infectious etiology of death in these very young children. The risk factors for pneumonia include low birth weight, malnutrition, poor breastfeeding practices, vitamin A deficiency, indoor air pollution, household over-crowding, and HIV. How many of these problems are existing within emergency crises? The answer is all of these are problems in emergencies. Additionally in emergencies, food insecurity and malnutrition, inadequate shelter, and cold exposure. Overcrowding at the community level, and even in the household. Decreased vaccine coverage, and lacks or delays in diagnosis and treatment, all increase the risk of pneumonia in emergencies. So how do we decrease the burden of ARI in general and in emergencies? To first understand this we must identify the main barriers to effective treatment of children. UNICEF and the World Health Organization, or WHO, calls pneumonia the forgotten killer of children. This is because effective case management of a child depends on care seeking behavior of the parents as well as access to health services. The three steps are, one, the parent must recognize the infection in the child. Two, the parent must have access to care, which is a real challenge in an emergency. And finally, the parent must accept the care that is available. If the clinic is run by a faction the parent is fleeing from, these parents will not accept the care even if it's offered. Once the parent gets the child to the clinic, case management depends on the training and supervision of health care workers, and the availability of antibiotics and supportive care, again, a potential problem in emergencies. The assumption underlying the WHO/UNICEF case management approach is that a high percentage of fatal pneumonia is bacterial. We learned early that this is not always the case, and in fact a good quarter of pneumonia can be due to viral etiologies, or causes. However, among the cases caused by bacteria, timely antibiotics can prevent death. Children with pneumonia can be identified by a simple algorithm, with healthcare workers using this and giving antibiotics or referring the children to the hospital. However, an ounce of prevention is worth a pound of cure so to say. In pneumonia, this is no exception. We need to modify risk factors such as improving general health conditions and establishing routine immunization as soon as possible. MSF, an international health organization, has actually provided Haemophilus Influenzae type b, or Hib, a pneumococcal vaccine in an emergency setting. In Yida County, South Sudan among camp base Sudanese, they provided both Hib and pneumococcal vaccines because of the high rate of in-patient acute respiratory infection, presumably pneumonia. We have done a cost effectiveness analysis using published data and providing supplemental immunization of Hib and pneumococcal vaccine in Somalia. It was found to be highly cost effective at just over the per capita gross domestic product of Somalia of $152 for two doses of each. Now, let's turn to a more chronic respiratory disease. My favorite disease, tuberculosis or TB, in emergency. The causative infectious agent of TB is Mycobacterium tuberculosis and it is transmitted in the air. Therefore, risk factors are especially at play in emergencies where there are overcrowding in camps. But TB is especially active when a person has malnutrition, or alcohol abuse, or is immune suppressed from co-infection with HIV. For people so affected, they have a greater risk of having active TB. For example, instead of the 10% lifetime risk of having TB if infected, a person with HIV has a 10% risk per year for every year that they are alive. Other risks include the disruption of control programs, which can lead to delays in diagnosis and in treatment. In addition to low TB case detection, we can see high rates of people stopping treatment, and low cure rates that can then increase the potential of chronic and multiple drug resistant cases. So, how do these risk factors play out in emergencies? What is the epidemiology? While more than 85% of refugees originate from or live in countries that are considered high TB burden countries. Few studies have looked at the burden among refugees. But 1985, in Somalia over 25% of adult's deaths were reportedly associated with tuberculosis. In Bosnia, in 1991 through 1995, there was a fourfold increase in new cases of TB detected. In a recent review of 51 reports, comparing crisis affected versus the reference population, the TB incident rate ratio was as much as 27 times higher, and the TB prevalence rate ratio was up 20 times higher. So given these risks and the epidemiology, what are the prevention and control methods in emergency? Avoid overcrowding in camps. Keep tents well ventilated. Prevent malnutrition, provide breastfeeding and micronutrients. And, if treatment is possible, ensure adequate case management. What is the TB control in emergencies? WHO worked with the UN Refugee Agency to develop an interagency field manual for TB care and control among refugee and displaced populations. This manual lays out the priorities to find prior patients on TB medication and assess the length of time that they had treatment interruption. If it was less than one month, they should try to restart the treatment. But if it was a month or longer, the program should try to determine if the patient is again infectious, by collecting sputum and examining it under a microscope. The paramount point is that treatment should not be restarted until the continuity of treatment can be guaranteed. So what is needed to guarantee TB control in treatment? WHO and the UN Refugee Agency have established criteria for implementing TB control programs. These are that, one, emergency phase is over, that the mortality rate is less than 1 per 10,000 per day. Two, the camp is expected to remain stable for greater than nine months. Three, that the basic needs of shelter, water, sanitation, food, are met. Four, that essential clinical services and medications exist for the large portion of the population. Five, that there is a commitment to controlling TB with sustained funding, which means longer than 12 months. And, that there is a good laboratory, standard treatment protocols, a good drug supply, and good monitoring system for quality control. So in summary, acute respiratory infections are the most common cause of disease and death in emergencies. Risk factors for respiratory infections, whether acute or TB, seen in emergency are a large contributor to these deaths. Tuberculosis is a greater problem in emergencies than previously recognized. And much of this excess morbidity and mortality is avoidable. These can be avoided or prevented by vaccination, timely treatment, and instituting control measures as soon as possible. Thank you.
