WHO Library Cataloguing-in-Publication Data
Public health risk assessment and interventions: tropical cyclone Pam, Vanuatu 1. Cyclonic storms. 2. Disaster planning. 3. Risk management. 4. Vanuatu. I. World Health Regional Office for the Western Pacific.
ISBN 978 92 9061 749 5 (NLM Classification: WA 295)
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
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conTenTsAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1. Background and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.1 Tropical Cyclone Pam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2 Priority areas for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2. Priority areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Trauma and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Interruption of critical infrastructure:
water, sanitation and hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3 Diseases associated with overcrowding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.4 Vector-borne diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
2.5 Loss of health infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
2.6 Food security and malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
2.7 Existing medical conditions and other health threats . . . . . . . . . . . . . . . . . . . . . .17
3. sPecific Priority interventions for immediate imPlementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
3.1 Water and sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
3.2 Shelter and site planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
3.3 Prevention and management of malnutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
3.4 Essential health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
3.5 Early warning and response network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
3.6 Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
3.7 Vector control and personal protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
4. staff health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
4.1 Vaccination recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
4.2 Malaria prophylaxis and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
4.3 Other precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
5. risk communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Annex 1: Health Services in Vanuatu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Annex 2: Communications messages (specific health issues) . . . . . . . . . . . . . . . . . . . . . . . .39
Annex 3: EWARN case definitions – Cyclone Pam, Vanuatu . . . . . . . . . . . . . . . . . . . . . . . . . .41
Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
iv
abbreviaTions
afr acute fever and rash
aPi annual parasite incidence
alri acute lower respiratory tract infection
ari acute respiratory infection
art antiretroviral therapy
Bms breast-milk substitute
dhP dengue haemorrhagic fever
ePi Expanded Programme on Immunization
evm Effective Vaccine Management
eWarn Early Warning and Response Network
glean Global Leptospirosis Environmental Action Network
hBv hepatitis B Virus
hev hepatitis E
iehk Interagency Emergency Health Kits
ili influenza-like illness
imci Integrated Management of Childhood Illness
irn indoor residual spraying
JmP Joint Monitoring Programme
llin long-lasting insecticidal net
mch maternal and child health
misP Minimum Initial Service Package
mou Memorandum of Understanding
ncd noncommunicable diseases
ndmo National Disaster Management Office
PeP post exposure prophylaxis
Plhiv people living with HIV
Pmtct prevention of mother to child transmission
soP standard operating procedures
stis sexually transmitted infections
tB tuberculosis
tig tetanus immune globulin
unhcr Office of the United Nations High Commissioner for Refugees
unicef United Nations Children’s Fund
vBd vector-borne disease
vhW village health worker
vhW village health workers
vPd vaccine-preventable disease
Who World Health Organization
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
This public health risk assessment provides health professionals in United Nations
agencies, nongovernmental organizations, donor agencies and local authorities
working with populations affected by the Cyclone Pam emergency in Vanuatu,
with baseline health information and up-to-date technical guidance on the major
public health threats. A related document, Public Health Risk Assessment and
Interventions – Typhoon Haiyan, Philippines 16 November 2013 was used as a
template for this document [1].
The health issues and risk factors addressed have been selected on the basis
of the known burden of disease in Vanuatu, and their potential impact on
morbidity, mortality, response and recovery.
Public health threats represent a significant challenge to those providing health-
care services in this evolving situation. It is hoped that this risk assessment will
facilitate the coordination of activities between all agencies working among the
populations affected by the crisis.
preface
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
The Republic of Vanuatu was hit by a Category 5 cyclone on 13 March 2015,
causing widespread destruction and damage to buildings, infrastructure and
loss of communication [2]. Early reports indicate several fatalities and more than
3000 people were evacuated to emergency shelters [2].
Baseline health profile: Prior to the emergency, Vanuatu’s under-resourced health
services had critical health worker shortages [3]. Vaccination rates for measles and
other vaccine-preventable diseases (VPDs) have been suboptimal, and much of the
population has very limited access to health services [4]. Children under-5 require
special attention as natural disasters put children at increased risk of infections such
as gastroenteritis and acute respiratory infections.
Priority areas for public health: • Trauma and Injury
• Interruption of critical infrastructure
• Disease associated with overcrowding
• Increased communicable disease transmission and potential for outbreaks of diseases
• Increased exposure to vector-borne disease
• Loss of health infrastructure
• Nutrition and food security concerns
• Existing medical conditions and other disease threats.
execuTive summary
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
Immediate priorities:• Provision of food, safe drinking-water, appropriate sanitation, shelter,
and other essential non-food items including fuel for cooking
• Trauma care for the wounded with tetanus prevention
• Provision of medicines and medical supplies
• Establishment of emergency primary and secondary care for medical,
surgical and obstetric emergencies
• Risk communication to the public
• Measles vaccination in high-risk areas
• Establishment of an early warning system for early detection and response
to outbreaks
• Infection control in health-care settings including safe blood transfusion,
medical waste management and adequate water supply and sanitation
• Management of acute malnutrition including medical complications
• Continuity of treatment for chronic diseases and chronic infections such
as tuberculosis (TB).
Short-term priorities:• Re-establishment of essential health-care services (primary, referral
and hospital care)
• Emergency mental health care and psychosocial support
• Waste management
• Vector control and provision of personal protection against vector-borne
diseases.
Medium-term priorities:• Post-surgical care and management of disabilities
• Routine immunization
• Health of victims who have migrated and potential returnees.
A national list of case definitions for likely conditions has been defined for
clinical and epidemiological purposes. Laboratory diagnostic support is limited
and clinical definitions are therefore essential for disease management.
Background and risk factorsThe Republic of Vanuatu (Vanuatu) is an archipelago in the South Pacific Ocean,
comprising 83 islands, of which approximately 65 are inhabited, with a total land
area of 12 189 square kilometres, spanning a distance 900 km in length [5].
Vanuatu has an estimated population of 271 000, of which approximately 37% are
under the age of 15 years. Locals are predominantly of Melanesian origin, known as
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
ni-Vanuatu (98.5% population). The national language is Bislama (pidgin). English
and French are widely spoken and are also official languages. There are more than
105 local Melanesian languages and dialects.
The country has six provinces:
Torba, Sanma, Penama, Malam-
pa, Shefa and Tafea. There are
two urban centres: in the cap-
ital, Port Vila, on the island of
Efate (population of 44 039);
and Luganville, on the island of
Espiritu Santo, (population of
13 156 people) [3]. The majority
of the population (74%) lives in
rural areas [6], although rural to
urban movement is increasing,
leading to overcrowding in ur-
ban centres.
The annual per capita income
is US$ 3130 with 6.5% living
in extreme poverty and 35%
vulnerable to poverty. The
Human Development Index
ranking for Vanuatu is 125 out
of 187 [4]. Life expectancy is
70 years for males and 74 years for females [7]. Under-5 mortality has improved
over the past 13 years from 33 deaths per 1000 live births in 1990 to 17 deaths per
1000 live births in 2013 [7]. Infant mortality (death before 1 year of age) in 2010
was estimated to be 28 deaths per 1000 live births – comprising a relatively lower
neonatal mortality rate (12 deaths per 1000 deaths within the first month) compared
to higher post-neonatal mortality (16 deaths per 1000 deaths in months 2–12) [6].
An estimated 20% of the population have no access to health services [3].
The Vanuatu economy is driven by exports of copra, timber, beef and cocoa (20% of
gross domestic product (GDP)), tourism (20% GDP) and foreign aid contributions [3].
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
1. bacKGrounD anD risK facTors
1.1 Tropical cyclone Pam
OIn the evening of 13 March 2015, at approximately 23:00 local time, Tropical
cyclone Pam struck Vanuatu, hitting Port Vila as an extremely destructive
Category 5 cyclone [2]. The cyclone tracked along the length of eastern side of
the Vanuatu archipelago, with the cyclone’s eye passing close to Efate Island,
before heading south directly over the southern islands. Winds were estimated
to have reached more than 250kmph. This caused serious damage to
infrastructure, left debris strewn across the capital and damaged an estimated
90% of structures. The southern-most islands of Tafea Province (population
32 540), were directly struck by the eye wall [2].
While the extent of the damage continues to be assessed, there are reports
of several deaths and serious injuries, many homes have been damaged or
destroyed, and access to health services, food and clean water is limited or
unavailable in many places. On 23 March 2015, the National Disaster Manage-
ment Office (NDMO) had confirmed 11 fatalities. An estimated 3300 people
have been displaced in 37 evacuation centres. The provinces of Shefa, Tafea,
Malampa and Penama are emerging as the worst impacted areas [8].
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
The cyclone has blocked roads with debris, knocked down bridges and caused
flooding. Electricity was out in many places and communication systems were
down or were unreliable, but are slowly being restored. Radio and telephone
communication with the outer islands has been cut off. In Port Vila, commercial
flights that were initially grounded, resumed on 15 March 2015 and access
to water and electricity started to be restored, although an estimated 80% of
power lines were damaged or down [8]. The main hospital in Port Vila was badly
damaged, including the Children’s ward, kitchen and Central Medical Store.
The morgue is unserviceable [8].
In the face of this disaster, the Government of Vanuatu has declared a state of
emergency and requested help from the international community. The Vanuatu
National Disaster Management Office provided the following situation update
on 27 March 2015:
• 166 000 people affected on 22 islands
• 15 000 homes destroyed or damaged
• 75 000 people in need of emergency shelter
• 110 000 people in need of clean drinking-water
• 8700 children vaccinated against measles.
1.2 Priority areas for public health
• Trauma and Injury
• Interruption of critical infrastructure
• Disease associated with overcrowding
• Increased communicable disease transmission and potential for disease
outbreaks
• Increased exposure to vector-borne disease
• Loss of health infrastructure
• Nutrition and food security concerns
• Existing medical conditions and other disease threats.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
2.prioriTy areas
2.1 Trauma and injuries
Wounds and injuries are frequently associated with the immediate post-cyclone
g period due to strong winds, collapsed structures and debris or from near-
drowning. The management of all injuries may be complicated by delays in
presenting for care and limited access of skilled personnel to the affected areas.
Complications of untreated injuries are death, infections, tetanus and long-term
disability.
2.1.1 TetanusTetanus (“lock-jaw”) is a disease caused by a toxin produced by the bacterium,
Clostridium tetani, affecting the nervous system. Clostridium tetani bacteria
are found in dust and animal faeces. Infection may occur after minor injury
(sometimes unnoticed punctures to the skin that are contaminated with soil,
dust or manure) or after major injuries causing tetanus prone wounds such
as open fractures, dirty or deep penetrating wounds, and burns. Neonatal
tetanus can occur in babies born to inadequately immunized mothers, especially
after unsterile treatment of the umbilical cord stump. Neonatal tetanus has
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
a case fatality rate of 70–100% without medical treatment and is globally
underreported. The incubation period is usually 3 to 21 days.
The tetanus vaccination coverage in Vanuatu was reported in 2013 as 75%
(DTP3), and the Vanuatu Demographic Health Survey conducted in 2013 which
collected information from all children under-5 years, reported coverage in
under-5 year olds of only 55% [6]. The vaccination coverage for all Expanded
Programme on Immunization (EPI) vaccines has varied greatly in past years,
meaning some age groups will be inadequately vaccinated. Maternal and
neonatal tetanus is assumed to have been eliminated from Vanuatu.
The management of wounds needs to consider the probability of tetanus.
Health-care workers operating in disaster settings should be alerted by the
occurrence of cases of dysphagia (difficulty swallowing) and trismus (facial
muscle spasm), often the first symptoms of the disease. A boosting dose of
tetanus vaccine and tetanus immune globulin should be given to patients with
tetanus prone wounds. Patients should also systematically receive prophylactic
antibiotics.
2.2 Interruption of critical infrastructure: water, sanitation and hygiene
Estimates from the Joint Monitoring Programme (JMP) for Water Supply and
Sanitation are that in 2014, 91% of Vanuatu’s population uses an improved
drinking-water source, and 25% of the population will have piped water to their
home [9]. The JMP reports that 58% of the population have improved sanitation
facilities, 20% have shared facilities, 20% unimproved facilities and 2% practise
open defecation [9]. Prior to the cyclone, rural and remote communities were
less likely than urban residents to have an improved drinking-water source and
improved sanitation.
With severe windstorms, water sources can become unsafe for drinking due
to the incursion of floodwaters, faecal contamination caused by overflow of
latrines, inadequate sanitation and upstream contamination of interconnected
water sources. Population displacement, crowding, poor access to safe drinking-
water, inadequate hygiene and toilet facilities, and unsafe practices in handling
and preparing food may cause outbreaks of diseases such as acute watery
diarrhoea, typhoid fever, shigellosis, viral enteritis and hepatitis A and E.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
2.3 Diseases associated with overcrowding
Population displacement caused by flooding can result in overcrowding in reset-
tlement areas, increasing the risk of transmission of many communicable diseas-
es. Acute respiratory infection, measles, diphtheria, and pertussis are transmitted
from person to person through respiratory droplets during coughing and sneez-
ing. The risks are increased when shelters are overcrowded and inadequately
ventilated. The transmission of meningitis, water-related and vector-borne dis-
eases also increases in such conditions.
Overcrowding leads to an increase in the potential for communicable disease
transmission and outbreaks of diseases such as:
• acute respiratory infections
• measles and other vaccine-preventable disease (VPD)
• diarrhoeal disease (bacterial and viral)
• hepatitis A and E
• leptospirosis
• meningococcal disease.
2.3.1 Acute respiratory infection (ARI)In 2014 there were 6219 cases of influenza-like-illness (ILI) reported. From Jan-
uary 2015 to 8 March 2015, there were 1142 cases of ILI reported [7]. A major
concern is acute lower respiratory tract infection (ALRI), such as pneumonia,
bronchiolitis and bronchitis, particularly in children under-5. WHO estimates that
11% of deaths in children under-5 years in Vanuatu are caused by pneumonia.
ALRI kills more children globally than any other disease. Low birth weight, mal-
nourished and non-breastfed children, and those living in overcrowded condi-
tions are at higher risk of acquiring pneumonia as well as of experiencing more
severe disease and death from pneumonia. Exclusive breastfeeding, adequate
nutrition, and immunization can help reduce infection rates.
Early detection and case management of pneumonia and other common illness-
es, guided by Integrated Management of Childhood Illness (IMCI), will prevent
morbidity and mortality in children under-5. Trained health workers should refer
to the national IMCI guidelines during and after the emergency [10].
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
2.3.2 Diarrhoeal diseaseThe risk of diarrhoeal disease in Vanuatu has increased due to overcrowding,
inadequate sanitation and limited access to safe drinking-water. Acute gas-
troenteritis (bacterial or viral) is often highly contagious. Transmission occurs
through contaminated food and water and directly from person to person.
Bacillary dysentery is the most important cause of acute bloody diarrhoea in
the post-disaster setting. It is caused by bacteria of the genus Shigella – of which
S. dysenteriae type 1 causes the most severe disease and the largest outbreaks.
Bacillary dysentery is endemic in most low- and middle-income countries. Without
prompt, effective treatment the case fatality rate can be as high as 10%.
Rotavirus outbreaks are well documented in the Pacific, and small children in
particular are at high risk of developing severe dehydration, which can lead to
death if not treated promptly with oral or intravenous fluids. Vanuatu does not
vaccinate against rotavirus. During the 2013 Demographic and Health Survey,
around 12% of children under age 5 years were reported to have had diarrhoea
in the previous two weeks; and 1% reported bloody diarrhoea [6].
Large post-disaster outbreaks of diarrhoea have been documented in the Pacific
in the context of floods. In 2014, Solomon Islands experienced a very large post-
flood diarrhoea epidemic that resulted in more deaths than the initial flash-flood
emergency. In that emergency, as is consistently reported, children under 5-years
bore the greatest burden both in terms of morbidity and mortality: children
under-5 years were almost 20 times (versus eight times at baseline) more likely
to suffer from diarrhoea than those five-years of age and older (personal
communication, Dr E Nilles, WHO).
2.3.3 Hepatitis Hepatitis B is endemic in the adult population in Vanuatu, with limited data
suggesting a prevalence of about 12%. Hepatitis B virus (HBV) immunization
success has been modest with childhood prevalence of around 3% and HBV-
vaccine birth dose coverage of about 80%. Hepatitis B birth dose is a priority
for all newborns within the first 24 hours of life, especially those born of HBV-
infected mothers, to prevent mother-to-child chronic hepatitis B transmission.
Hepatitis A can cause outbreaks but is considered less likely than other public
health risks in this context. In most low- and middle-income countries, hepatitis
exposure, infection and life-time immunity, occurs at a young age, when disease
severity is low. Although small clusters of hepatitis A disease may occur in the
disaster setting, large outbreaks are unlikely given high likelihood that most of
the population are immune due to prior infection. Vigilance in appropriate water
and food preparation techniques prior to consumption is, however, strongly
recommended.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
Hepatitis E (HEV) is usually a self-limiting disease but can progress to severe
disease and death. Pregnant women in particular are at high risk of severe disease
and death. Outbreaks can occur in settings with poor hygiene and sanitation
typically via contamination of food or water sources. Little robust data on
HEV in Vanuatu or the Pacific is available, but a sero-prevalance study in Papua
New Guinea, Kiribati and Fiji reported HEV sero-positivity rates of 15%, 9%,
and 2% respectively [11], demonstrating that this virus circulates in other Pacific
island countries and areas, and thus probably in Vanuatu also. Prior exposure
and immunity levels are not sufficient to prevent HEV outbreaks. There is no
globally available vaccine.
2.3.4 LeptospirosisLeptospirosis is a bacterial zoonosis present worldwide. Outbreaks of leptospi-
rosis commonly occur following flooding, due to the crowding of rodents, wild
and domestic animals and humans on shared dry ground. In this situation, the
disease is likely to be spread through indirect contact with water contaminated
with the urine of rodents, pigs, or other infected animals. Leptospirosis out-
breaks have occurred in the Pacific, sporadic cases are known to occur in
Vanuatu [13].
The Global Leptospirosis Environmental Action Network (GLEAN) has developed
preliminary set of recommendations for the control of disaster-related
leptospirosis outbreaks; these recommendations include: laboratory screening
of suspected cases, empiric treatment of probable cases, and prevention with
the use of barrier protection if there is a potential to come into contact with
contaminated water [14]. If individual exposure occurs when cleaning up after
disasters, the affected body areas should be immediately cleaned with soap and
clean bottled water. Use of mass chemoprophylaxis is not recommended, nor is
mass decontamination of water, however, there is evidence that pre-exposure
chemoprophylaxis decreases morbidity in controlled target populations including
individuals of high risk such as military workers, disaster relief workers, sewage
and sanitation workers [14].
2.3.5 Measles and other vaccine-preventable diseasesVanuatu provides immunization for children against vaccine-preventable diseases
(VPDs) including: tuberculosis, diphtheria, pertussis (whooping cough), tetanus,
hepatitis B, haemophilus influenza, polio and measles [6].
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In 2013, the Vanuatu Demographic and Health Survey, which conducted house-
hold surveys, found that only one in three (33%) children, aged 12–23 months
received all of the basic vaccinations (BCG, DPT, polio and measles) at some time
prior to the survey, and 7% were fully vaccinated [6]. The Vanuatu Joint Reporting
Form figures for vaccination coverage have greatly improved in the last few years
and show good coverage. However, wide variability in coverage rates in the last
15 years, indicates that a large proportion of children may not be adequately
covered for VPDs [12].
Measles vaccination coverage rates in children under-5 years was found to be
53%, and coverage rates for the third doses of DPT and polio vaccines in children
under-5 years were found to be 55% and 52% respectively [6].
During 2014, a measles outbreak affected the Blacksand area of Port Vila, the
first measles outbreak since 1997. In 2015, a second measles outbreak occurred.
In response, a catch-up campaign is being conducted on Efate. There are around
10 500 doses of monovalent measles vaccine in Port Vila and additional MR
vaccines are available in Suva, Fiji through the United Nations Population Fund
(UNICEF). Effective Vaccine Management (EVM) Assessment took place and
training of assessors started in the week of 8 March 2015.
On 17 March 2015, six teams were deployed to Port Vila for measles vaccination;
another six teams are to be trained for integrated measles response (with Vitamin
A and bed nets). Initial plans are to target Efate, Tanna and Sanma. Efate and
Tanna were both severely affected by the cyclone and although Santo was not
badly affected by the cyclone, they recently reported a large number of cases of
acute fever and rash (AFR) through syndromic surveillance.
There is a requirement to strengthen the early warning alert and response net-
work for AFR through the health centres in Port Vila and in the other affected
areas. Reports are starting to be received from sentinel sites outside Port Vila.
The Western Pacific Region was declared polio free in October 2000 and all
Pacific island countries have remained polio-free. The last reported polio case
(clinical) in the Pacific was in 1979. The case was not laboratory confirmed.
2.3.6 Meningococcal diseaseNeisseria meningitidis, the bacterium causing meningococcal disease, is spread
from person to person through respiratory droplets from infected people. There
are two classical clinical presentation of meningococcal disease: meningitis and
severe sepsis, although cases may present with overlapping features. Transmission
is facilitated by close contact and crowded living conditions. Health care workers
need to be vigilant for cases of meningococcal disease, and urgently report any
cases. The Case Fatality Rate of meningococcal disease is 5-10%, even with
appropriate and rapid antibiotic treatment.
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2.3.7 TuberculosisVanuatu, with an estimated tuberculosis (TB) incidence of 65 cases per
100 000 population in 2013 has a moderate TB burden. The notification rate
for 2013 was 44 cases per 100 000 population, with corresponding 126 TB cases
notified. The TB burden is higher among women compared to men, unlike in
the majority of countries. All age groups are affected, with a peak among the
14-24 age group among women, and in the over 65 years age group, for both
women and men. Provinces with higher notification rates are Taefa and Shefa,
although the lack of a patient-based national register does not allow a thorough
geographical analysis.
In the acute phase of this emergency, follow-up and continuity of treatment
of patients already on care should be maintained when feasible and for that
purpose stocks of anti-TB medicines shall be ensured. Due to the demonstrated
link between emergencies and TB, once response to trauma-related emergency
has been provided, service provision in terms of TB detection by smear
microscopy should be conducted to displaced communities to identify cases and
avoid TB transmission.
2.4 Vector-borne diseases
There is an increased risk of vector-borne diseases (VBD) such as dengue,
chikungunya, Zika and malaria. Flooding may initially flush out mosquito
breeding, which can restart when the waters recede. The lag time is usually
6-8 weeks before the onset of increased VBD transmission.
2.4.1 ChikungunyaChikungunya fever is of moderate risk and presents very similarly to dengue
usually with swelling and pain in large joints, although haemorrhagic
complications are rare. A significant proportion of patients develop a long-
term debilitating arthritis that lasts for months to years. Both infections are
transmitted by Aedes mosquitoes that breed in close proximity to human
settlements. Collections of water in debris and damaged houses can contribute
to increased mosquito breeding sites.
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2.4.2 DengueDengue is a viral disease transmitted by the Aedes mosquito, which is endemic
in the Pacific. In late 2013, a large outbreak of dengue fever occurred in Vanuatu,
with 1561 cases reported in December 2013. The outbreak continued into 2014,
however data was not available on the final numbers (Roth et. al 2014).
Dengue epidemiology is rapidly evolving, with outbreaks occurring more
frequently and expanding to areas that were previously unaffected. The risk
of transmission may increase among people living in inadequate shelters or
overcrowded conditions, particularly where fresh water is stored in unprotected
water containers and rainfall collects in other artificial containers, allowing
mosquitoes to proliferate.
Dengue causes a severe influenza-like illness. Occasionally a severe form of the
disease with potentially lethal complications including dengue haemorrhagic
fever (DHF) can occur. Severe dengue can affect all age groups. Mortality is highest
during the initial period of the outbreak or epidemic. Children are at particularly
high risk of mortality as a result of complications, especially if treatment is
delayed. Early detection and treatment of DHF can reduce the case-fatality ratio
from 20% to less than 1%. Supportive treatment supplies should be stockpiled.
2.4.3 MalariaMalaria is endemic in most islands of Vanuatu, which has an overall Annual
Parasite Incidence (API) of 13.2 cases per 1000 population (2012). Transmission
is generally higher in the northern provinces than the southern provinces, with
an API of 38.2 reported on Torba, and 20–21 per 1000 reported in Malampa,
Penama and Sanma in 2012. Shefa reported an API of 4.7 per 1000 and Tafea
reported an API of 0.4 per 1000 in 2012. The national API decreased from 74 per
1000 in 2003 to 13 per 1000 in 2012, and the virtual disappearance of confirmed
malaria-related deaths. Tafea achieved close to zero local malaria transmission in
2013 and is on track to achieve sub-national elimination by 2016.
The malaria programme is the most operationalized public health programme
in Vanuatu. Preventive intervention is based on using the insecticide treated
nets (long-lasting insecticide nets (LLIN)) and selective indoor residual spray in
elimination provinces (Tafea and Torba). The Demographic Health Survey in 2013
indicated that 83% of households (91% in rural areas) owned at least one LLIN.
The last mass distribution campaign of LLIN was in 2013 when over 90 000 long-
lasting insecticidal nets (LLINs) were distributed. Most health facilities including
aid posts provide malaria diagnosis using rapid diagnostic tests or microscopy
and recommended first-line regimen (Artemether-Lumefanthrin).
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To prevent and mitigate the risk of a malaria outbreak:
• ensure full replacement of lost, damaged or destroyed LLINs;
• malaria case management services should be restored and strengthened
as soon as possible to ensure adequate services are available and accessible;
• restore and maintain routine surveillance and surveillance of selective areas
(e.g. evacuation centres); and
• develop a recovery plan for preventive intervention through distribution
of LLINs to the affected areas.
2.4.4 ZikaZika virus is a newly emerging cause of outbreaks and usually results in a mild
disease characterized by low grade fever and rash. Recent outbreaks have been
reported in French Polynesia, the Federated States of Micronesia, New Caledonia
and Solomon Islands. As of 20 March 2015, six confirmed cases diagnosed in
New Caledonia have been said to have originated from Vanuatu. However,
there is no outbreak reported in Vanuatu.
2.5 Loss of health infrastructure
Government health services in Vanuatu comprise a four-tier system: referral
hospitals, health centres, dispensaries and community supported aid posts.
Vanuatu is divided into the northern and southern health-care directorates.
The Northern Health Care Directorate, based in Luganville, delivers curative and
preventive health services in Torba, Sanma, Penama and Malampa provinces.
The Southern Health Care Directorate coordinates health services for Shefa and
Tafea provinces [12].
Each province is made up of several islands which are then divided into zones.
Health facilities are distributed among these zones. There is a referral hospital in
each of the two Health Care Directorates. Community and preventive services
include: malaria control, environmental health, immunizations, reproductive
health, MCH/Reproductive Health/Family Planning, STIs and HIV/AIDS, TB/leprosy,
IMCI, nutrition and health promotion programmes. Appendix 2 describes the
type of services provided at each level [4].
A review of Human Resources for Health in Vanuatu in 2012 showed critical
health worker shortages [3]; Vanuatu has the third lowest health workforce
density in the Pacific region. The greatest shortages are in rural areas. It has been
estimated that 1261 health workers were employed in the public sector in 2012,
including 397 nurses and midwives, and 46 doctors [3]. This is equivalent to
1.77 health workers per 1000 population. This is considerably lower than the
WHO minimum recommended 2.3 health workers per 1000 population.
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2.6 Food security and malnutrition
Food security can be adversely affected by disruptions in the food system,
including spoilage, crop loss, the inability to replenish stock due to transport
constraints, and the inability to store and process foods. This may lead to limited
availability of safe and nutritious food and consumption of potentially unsafe
food and/or inadequate food consumption, with low dietary diversity and poor
nutrient quality. Vulnerable groups include children, particularly children under-
5 years, pregnant and lactating women and older people.
In 2007, the Vanuatu Multiple Indicator Cluster Survey showed that the
underweight prevalence for the under-5 age group was 15.9% and the stunting
prevalence (the percentage of children under-5 who have low height for their
age) was 20.1% [13]. During emergency situations such as Tropical Cyclone
Pam, disease and death rates among children under-5 are usually higher than
for any other age group; the younger the infant the higher the risk. Mortality
risk is particularly high because of the combined impact of a greatly increased
incidence of infectious diseases, diarrhoea and malnutrition.
Breastfeeding provides critical protection from infection in environments
without safe drinking-water supply and sanitation. In 2007, the initiation of
breastfeeding (within 1 hour of giving birth) was reported to be 71.9%, with the
exclusive breastfeeding rate among infants 0-5 months of 39.7% [13]. During
emergencies, it is even more critical to encourage and support mothers to
initiate breastfeeding within one hour after the delivery, to exclusively breastfeed
up to six months and for those with infants under 6 months who “mix feed”, to
revert back to exclusive breastfeeding if possible [14].
In accordance with internationally accepted guidelines, donations of infant
formula, bottles and teats, and other powdered or liquid milk and milk products
should not be made. Experience with past emergencies in other countries
have shown an excessive quantity of products, which are poorly targeted,
endangering infants’ lives. Any procurement of breast-milk substitutes (BMS)
should be based on careful needs assessment and in coordination with UNICEF.
Any distribution and use of BMS should be carefully monitored to ensure that
only the designated infants receive the product.
Basic interventions to facilitate breastfeeding include prioritizing mothers
with young children for shelter, food, security, and water and sanitation. This
will enable mother-to-mother support, specific space for skilled breastfeeding
counselling and support to maintain or re-establish lactation.
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The risk of foodborne disease outbreaks also increases during disaster situations.
Food contamination may occur at any point of the food chain. Inadequate
washing and cooking of food before consumption is often a prime cause of
inadvertent contamination. Similarly, power outage, limited access to safe
drinking-water and inappropriate cooking facilities increase the risk of food
contamination. There may also be improvised large-scale preparation of cooked
food and/or distribution of imported and locally produced food items. In this
context it is important that appropriate food safety measures are implemented
to ensure food safety during mass feeding operations as well as inspection of
pre-packaged food distributed to affected populations.
2.7 Existing medical conditions and other health threats
2.7.1 Noncommunicable diseasesDuring emergencies and disasters access to adequate nutrition and medicine
is an issue, making people with noncommunicable diseases (NCDs) more
vulnerable and at risk in developing acute complications. NCDs account for an
increasing proportion of the disease burden in Vanuatu, with the prevalence
of diabetes mellitus and hypertension in the adult population at approximately
20% and 28%, respectively [15]. Older people, who already comprise 6%
of the population, may be particularly at risk of and vulnerable to treatment
interruption, due to age-related barriers to access such as reduced mobility as
well as co-morbidities [16]. This group of diseases places a substantial burden
on health services and an impoverishing drain on families and communities. The
priorities during the acute phase of this emergency are to minimize treatment
interruptions. Identification of NCD patients on treatment; supply of essential
medicines, equipment and follow up are essential.
2.7.2 Skin infections Infestations, such as scabies and lice may occur and require treatment once they
occur. These infections occur due to overcrowding and as a result of a lack of
water and reduced hygiene.
2.7.3 Sexually transmitted infections including HIVSimilar to most Pacific island countries, Vanuatu’s HIV prevalence among
15-19 years old is still below 0.1%; with a cumulative total of 9 reported cases
from 2002 to December 2012. Four patients are currently on antiretroviral
therapy (ART) [17].
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With regards to other sexually transmitted infections (STIs), from 2011 to 2014
21% of 14 037 men and women tested were infected with Chlamydia; 5.6%
of 13 655 people tested had gonorrhoea; and 4.3% of 9831 people tested had
syphilis. During the same period, STI testing among pregnant women showed
infection rates of 23.5% (n = 336/1431) with Chlamydia; no cases of gonorrhoea
(while 2008 Second Generation Surveillance data revealed 3%); and 4.3%
(n = 19/1097) had syphilis [17].
During emergency situations, essential STI and HIV prevention, treatment, care
and support services are usually disrupted. Further, existing gender inequalities
make women and children, specifically girls, disproportionately more vulnerable
to STI and HIV infection. This increased vulnerability is a consequence of mass
displacement, separation from family members and/or loss of livelihood or lack
of employment opportunities that may force women and girls to resort to sex
work or be subjected to sexual exploitation.
People living with HIV (PLHIV) and other key populations at higher risk to HIV
(sex workers and men having sex with men) may require specific measures to
protect themselves from physical and sexual violence and discrimination.
The initial and essential response to the prevention and control of STI/HIV
transmission includes: provision of prevention information on STI and HIV,
including prevention of mother-to-child transmission (PMTCT); condom supplies
and information on correct condom use; availability of STI and antiretroviral
drugs to those who are already on treatment, for PMTCT and for post exposure
prophylaxis (PEP); and ensuring treatment adherence among those receiving
ART and STI treatment.
An expanded response can occur once the situation is better understood
and additional human and financial resources have been identified to support
implementation. Palliative and home-based care should also be quickly re-
established.
2.7.4 Gender and violence against women Violence against women is a major health issue; it is reported that women
have a 60% lifetime risk of experiencing physical and/or sexual violence by
an intimate partner. Of those women, 90% report severe violence, only
10% report moderate violence.
The same factors affecting vulnerability to STI and HIV, such as existing gender
inequalities, place women and girls at higher risk of experiencing physical and
sexual violence post-disaster. The initial and essential response includes ensuring
safety and security in evacuation centres (e.g. good lighting and ensuring the
privacy of women and girls) and putting in place mechanisms to collect evidence
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and file criminal complaints, monitor and respond to physical and sexual
violence. Clear steps on the health sector’s response to intimate partner physical
and sexual violence should be known to all health-service providers [18].
2.7.5 Mental health and psychosocial supportAny major loss (e.g. death of family, property) and stressful situation (e.g. short-
age of food, living in emergency shelter) will contribute to the increase of mental
health conditions. Incidence of any mental disorders such as depression, anxiety,
acute and post-traumatic stress, and psychosis is likely to increase, particularly
in vulnerable populations such as women, children, older people, poor people,
those from low-income households, displaced people.
2.7.6 Neonatal and reproductive healthThe fertility rate in Vanuatu is 4.2 children born per woman [6]; this has
not changed since the last population census in 2009, which was 4.1. The
Demographic and Health Survey in 2013 found that the crude birth rate (number
of births per 1000 population) was 32.5 per year (equating to approximately
8000 births in Vanuatu per year). In general, the birth rate is higher in rural
areas than in urban areas. At the time of the survey, nearly 17% of teenage
women, aged 15-19 years had started childbearing [6]. Although family planning
methods were recorded as high as 47%, only 34% used modern methods.
The maternal mortality rate is reported to be 110 deaths per 100 000 live births
[4], or approximately 6-7 deaths per year in Vanuatu.
The Vanuatu Demographic and Health Survey reported that in 2013, more than
76% of women received antenatal care from a skilled provider, although only
approximately 50% of women received the WHO recommended four or more
antenatal visits during an uncomplicated pregnancy [6]. Approximately 89% of
births were delivered in a health facility and were attended by a skilled provider.
Emergency reproductive services are available at two referral hospitals, Northern
District Hospital (Santo) and Vila Central Hospital (Efate) and at the Lenakel
Provincial Hospital (Tanna). The Demographic and Health Survey reported that
12% of births in the previous five years were delivered by caesarean section.
The Vila Central Hospital reports a lower rate for 2014 of approximately 8%.
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2.7.7 Environmental risks Safe drinking-water supply for communities
• Information on interruptions/insufficient water supply in communities
• Water is unchlorinated or insufficiently chlorinated (no chlorine smell or
taste in water at the tap) or is turbid (cloudy)
• Broken water pipes or uncovered or unsanitary water reservoirs.
Essential environmental health services at health-care facilities and hospitals
• Water supply
- Information on Interruptions/insufficient water supply at the facilities
- Water is unchlorinated or insufficiently chlorinated (no chlorine smell
or taste in water at the tap) or is turbid (cloudy)
- Broken water pipes or uncovered or unsanitary water reservoirs
• Waste management
- Insufficient or inadequate waste disposal containers
- No separation of wastes (e.g. sharps – organics – paper and plastics)
- Lack of fenced medical waste disposal area or medical wastes (needles,
dressings, drugs) observed in the facility and public spaces
• Infection control
- Lack of personal protective equipment (gloves, overalls, masks) for staff
- Lack of soap or handwashing posters at handwashing points
• Vector control
- Breeding sites (stagnant pools, food waste) in and/or around the facility
- Prepared food is unprotected from flies, other insects or rats
- Latest information on this is expected to be shared in the health cluster
bulletins issued by the Ministry of Health and WHO Country Office.
2.7.8 Dead body managementLarge numbers of dead bodies can be traumatic for viewers and require
urgent identification and proper burial. It is important to convey to all parties
that corpses do not represent a public health threat. For those involved in the
collection and burial of bodies, standard precautions for infection prevention and
control should be followed. In Vanuatu, following Cyclone Pam, early reports
regarding the damage at the hospital indicate that the morgue is non-functional,
meaning an alternative storage facility will need to be found.
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2.7.9 Drugs procurement and supply chain management In emergency situations, negotiated procurement may be used to purchase es-
sential medicines to expedite the process by foregoing formal advertising and
price competition. The selection of a contractor will be made to the best ad-
vantage of the Government, price and other factors considered. The aim of the
negotiated procurement during emergency situation is to ensure that shortages
of essential drugs over the next few months are minimized. The country has to
ensure that an effective supply chain management system is in place that will
ensure that the amount of inventory to be held at various locations or health
facilities is adequate.
2.7.10 Drug donationsDrug donations should be of maximum benefit and they must be based on
the needs of the recipient country. During an emergency, the Ministry of Health
informs donors of their needs, approves donations and coordinates receipt
and distribution.
Guidelines for medicine donation should be adhered to, conforming to the
following principles:
• Maximum benefit to recipient or country – donated drugs are very often not
relevant to the emergency situation or are donated in wrong quantities.
Donations should benefit the recipient to the maximum possible extent and
only essential medications that are part of the national essential drug list
should be sent.
• Respect for wishes and authority of the recipient – donor agencies often
ignore the existence of the local pharmaceutical industry and administrative
procedures for receiving and distributing pharmaceuticals and medical equip-
ment. Donations should comply with government and organizational policies.
• No double standards quality – many donated drugs arrive expired, unsorted
or labelled in languages unknown by local professionals. If the quality of
drug is not acceptable in the donor country and does not comply with its
standards, it is also not acceptable for the recipient. The date of expiration of
the drugs must be no less than one year from arrival in the recipient country.
• Effective communication between donor and recipient – donations are very
often sent without prior consultation or consent of the recipient. Donations
should be based on an expressed need.
In emergency situations, it is appropriate for a country to receive standardized
Interagency Emergency Health Kits (IEHK). The IEHK provide a complete
spectrum of essential drugs and medical supplies specifically adapted to
emergency situations.
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2.7.11 Storage and distributionEven essential drugs can be troublesome for a recipient country when sent in
excessive quantities. Local medical storage capacity is often insufficient to house
an enormous influx of drugs. Very often additional storage space has to be
rented at extra cost, or space in health-care facilities has to be re-purposed to
accommodate donations.
A well-designed and well-managed distribution system should:
• Keep medicines in good condition throughout the distribution process;
• Ensure medical supplies are distributed directly to health institutions in
affected areas;
• Minimize medicine losses caused by spoilage and expiry;
• Maintain accurate inventory records;
• Rationalize medicine storage points;
• Use available transportation resources as efficiently as effectively as possible;
• Reduce theft and fraud; and
• Incorporate a quality assurance programme.
2.7.12 Disposal of pharmaceuticals As the potential consequences of the influx of non-essential, expired or poorly
labelled drugs pose serious threat, most need to be disposed of. This adds
further costs for local governments. Constraints in funding for disposal of waste
pharmaceuticals necessitate cost-effective management. This can be achieved by
sorting the material to minimize the need for expensive or complicated disposal
methods.
It is not advisable to use damaged or expired products and should only be
collected ready for disposal. All medicines, which need to be disposed, should
be disposed of in line with the approved procedures and WHO Guidelines for
Safe Disposal of Unwanted Pharmaceuticals in and After Emergencies [19].
Disposal of drugs should be by high-temperature incineration (i.e. >1200ºC)
if facilities are available in which the cost of disposing of hazardous waste in
this way ranges from US$ 2000 to US$ 4000 per tonne.
In emergency situations, temporary burial of pharmaceutical and other wasted
medical supplies is an appropriate option until properly functioning incinerators
are in working order. Poorly-destroyed supplies in medium-temperature
incinerators are as great a hazard as landfills. If facing a huge amount of
damaged, expired or damaged labelled medicines, both liquid and solids, do
not dispose of them but keep them in a safe place until a reliable disposal
system is in place. Ensure these are not disposed of into rivers or seas.
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3. specific prioriTy inTervenTions for immeDiaTe implemenTaTion
Immediate priorities:1. Provision of safe and nutritious food, safe drinking-water, appropriate sanita-
tion, shelter and other essential non-food items including fuel for cooking
2. Trauma care for the wounded with tetanus prevention
3. Provision of medicines and medical supplies
4. Establishment of emergency primary- and secondary-care services for
medical, surgical and obstetric emergencies
5. Risk communication to the public
6. Measles vaccination in high-risk areas
7. Establishment of an early warning system for early detection and response
to outbreaks
8. Infection control in health-care units including safe blood transfusion,
medical waste management and adequate water supply and sanitation
9. Management of acute malnutrition including medical complications
10. Continuity of treatment for chronic diseases, such as diabetes, hypertension
and chronic infections such as TB and HIV.
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Short-term priorities:1. Re-establishment of essential health care services (primary, referral and
hospital care)
2. Emergency mental health care and psychosocial support
3. Waste management
4. Vector control and provision of personal protection against vector-borne
diseases.
Medium-term priorities:1. Post-surgical care and management of disabilities
2. Routine immunization
3. Health of victims who have migrated and potential returnees.
3.1 Water and sanitationProvision of essential environmental health services to affected populations
includes ensuring a minimal amount of clean water per day and safe disposal
of excreta and wastes. Ensuring uninterrupted provision of safe drinking-water
is the most important preventive measure in reducing the risk of outbreaks of
water-related diseases.
• The Office of the United Nations High Commissioner for Refugees (UNHCR),
WHO and the Sphere project recommend that each person be supplied with
at least 15–20 litres of clean water per day.
• Chlorine is the most widely available, easily used and affordable drinking-
water disinfectant. It is also highly effective against nearly all waterborne
pathogens.
- For point-of-use or household water treatment, the most practical forms
of free chlorine are liquid sodium hypochlorite, sodium calcium
hypochlorite and bleaching powder.
- The amount of chlorine needed depends mainly on the concentration
of organic matter in the water and must be determined for each situation.
After 30 minutes, the residual concentration of active free chlorine in
the water should be 0.5 mg/litre, which can be determined by using a
simple field test kit.
• The provision of appropriate and sufficient water containers, cooking pots
and fuel can reduce the risk of cholera and other diarrhoeal diseases by
ensuring that water storage is protected and that food is properly cooked.
• The need for good hygiene should be emphasized to the public.
• Adequate sanitation facilities must be provided in the form of latrines
or designated defecation areas.
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3.2 Shelter and site planning• Shelters for displaced or homeless people should be positioned with sufficient
space between them and, in accordance with UNHCR and Sphere standards
aimed at preventing diseases related to overcrowding.
• In shelter sites and during food distribution, attention and protection should
be given to women, older people, unaccompanied minors and people with
disabilities. Women should be included in planning and implementing shelter
and food-distribution activities.
• Waste should be disposed in a pit, away from shelters and protected from
rodents to reduce the exposure of the population to rodents, flies and other
vectors of disease.
• Shelters should be equipped with long-lasting insecticidal nets (LLIN) for each
sleeping space to prevent malaria transmission. Where housing conditions
allow, indoor residual spraying (IRS) can be carried out if less than 85% IRS
coverage of dwellings in the locality can be assured.
• Distribution of non-food items will be required, including blankets, water
containers, cooking materials.
3.3 Prevention and management of malnutrition• Infants should have skin-to-skin contact with their mothers within 30 seconds
of birth, and breastfeeding should start when the baby shows feeding cues
(usually within 90 minutes).
• Exclusive breastfeeding (with no food or liquid (including water) other than
breast milk) should continue until 6 months of age. The aim should be to
create and sustain an environment that encourages frequent breastfeeding
for children up to 2 years of age.
• Donations of milk-powder supplies usually increase in emergency situations
and contribute to a higher number of infants with diarrhoea and pneumonia.
These donations also exacerbate the low percentage of exclusively breastfed
infants. For those unable to be breastfed, the following hierarchy of feeding
should be followed: 1) expressed breast milk by mother; 2) breastfeeding
from surrogate donors and donor expressed breast milk. The few infants who
have no access to breast milk require an adequate supply of infant formula,
safe drinking-water and clean utensils. For those few cases, health-care
providers, including mothers, should be provided with guidance on the safe
preparation of infant formula products.
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• Many adults will have been or will now also be of borderline nutritional
status, and given that diarrhoeal disease may further compromise this,
attention must be paid to adequate and equitable distribution of food, and
maintaining nutrition of breastfeeding mothers.
• Bacterial infections are very common in severely malnourished children on
initial admission to hospital. Clinical management of severely malnourished
patients, including fluid management, must be thorough, carefully monitored
and supervised. Common problems encountered in severe malnutrition
include hypothermia, hypoglycaemia, dehydration and electrolyte
disturbances. Phases and principles of management of severely malnourished
children should be followed as outlined in WHO Guidelines on the
Management of Severe Acute Malnutrition in Infants and Children [20] [21].
• Populations dependent on food aid need to be given a food ration of
safe and adequate quantity and quality (ensuring dietary diversity, cultural
acceptability and covering all macro- and micronutrient needs). Infants from
six months of age onwards need hygienically prepared, and easy-to-eat,
digestible complementary foods that nutritionally complement breast milk.
Regular assessments of household access to adequate safe and nutritious
food (including market prices) needs to be undertaken and emergency food
aid needs to be adapted accordingly. Household access to facilities for the
safe preparation of food should also be assessed on a regular basis and
emergency supplies of necessary utensils and appropriate energy sources for
cooking should be adapted accordingly.
• After the acute phase of the emergency, efforts will be needed to improve
sustainable household access to food (e.g. seed distribution, land/crop
management, income generating activities) and to institute appropriate
child-feeding and caring practices, including diversifying diets and improved
hygiene.
• Poor hand hygiene exacerbates the spread of diarrhoeal diseases, even in the
presence of adequate nutrition.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
3.4 Essential health services
Access to health services is critical for affected populations, including case-man-
agement protocols, and medications and materials to treat likely high-burden
conditions (trauma/wounds, communicable and noncommunicable diseases and
emergency reproductive health services).
Standardized simple therapeutic proceduresTherapeutic procedures should be economical in terms of human and material
resources. Health personnel and supplies should support these procedures.
First line medical treatment should be simplified and aim to save lives and pre-
vent major secondary complications or problems. Use of standardized proce-
dures, such as extensive debridement, delayed primary wound closure or use of
splints instead of circular casts, can produce a marked decrease in mortality and
long-term impairment.
Redistribution of patients between hospitalsWhile health-care facilities within a disaster area may be damaged and under
pressure from mass casualties, those outside the area may be able to cope with a
much larger workload or provide specialized medical services such as neurosurgery.
The effective and equitable delivery of emergency medical treatment requires a
high level of coordination among national health services and partner agencies
that allows functioning hospitals to operate as part of a referral network. A net-
work of prehospital relief teams can coordinate referrals from the disaster area.
Essential medical and surgical carePriority must be given to providing emergency medical and surgical care to
people with traumatic injuries, which account for many of the health-care
needs among those requiring medical attention in the immediate aftermath of
the disaster. Falling structures cause crush injuries, fractures, and a variety of
wounds. Appropriate medical and surgical treatment of these injuries is vital to
improving survival, minimizing future functional impairment and disability and
ensuring as full a return as possible to community life. To prevent avoidable
death and disability, field health personnel dealing with injured survivors should
observe basic principles of trauma care:
• Patients should be categorized by the severity of their injuries and treatment
prioritized in terms of available resources and chances for survival. The under-
lying principle of triage is allocation of resources to ensure the greatest health
benefit for the greatest number.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
• Open wounds must be considered as contaminated and should not be closed.
Debridement of dead tissue is essential which, depending on the size of
the wound, may necessitate a surgical procedure undertaken in appropriate
(e.g. sterile) conditions. Any associated involvement of organs, neurovascular
structures or open fractures will also necessitate appropriate surgical care.
• After debridement and removal of dead tissue and debris, wounds should be
dressed with sterile dressings and the patient scheduled for delayed primary
closure.
• Patients with open wounds should receive tetanus prophylaxis (vaccine and/
or immune globulin depending on vaccination history). If the vaccination
history is unknown, both should be given. Antibiotic prophylaxis or treatment
will likely be indicated.
• Wherever possible, search and rescue workers should be equipped with
basic protective gear such as footwear and leather gloves to avoid puncture
wounds and exposure to diseases such as leptospirosis.
• HIV post-exposure prophylaxis kits should be available to health-care workers,
rescue and safety workers in case of accidental exposure to contaminated
blood and body fluids.
Reproductive health servicesAccess to comprehensive emergency reproductive health services and implemen-
tation of the Minimum Initial Service Package (MISP) for Reproductive Health in
Crisis Situations:
• A lead agency for reproductive health should be identified along with a repro-
ductive-health officer to ensure coordination, communication, and collabora-
tion in MISP implementation.
• Measures should be put in place to prevent sexual violence and to respond to
the needs of victims of sexual violence.
• HIV transmission should be prevented.
• Excess maternal and newborn morbidity and mortality should be prevented.
• Plans should be put in place for the transition to comprehensive reproductive
health services.
Communicable diseases• Heightened community awareness of the need for early treatment and rein-
forcement of proper case management are important in reducing the impact
of communicable diseases. The use of standard treatment protocols in health-
care facilities with agreed-upon first-line drugs is crucial to ensure effective
diagnosis and treatment for ARI, the main epidemic-prone diseases (including
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
dysentery, typhoid, dengue and DHF, leptospirosis, measles, malaria,
and meningitis) and STIs.
• Standard infection control practices should be in place in accordance
with national protocols.
• Malaria treatment:
- Uncomplicated-unconfirmed: Artemether-Lumefantrine
- Uncomplicated laboratory-confirmed P. falciparum infection:
Artemeter-lumefantrine + Primaquine (single dose)
- Severe malaria: Quinine + Tetracycline
- Uncomplicated P. vivax infection: Chloroquine + Primaquine (14 days).
• Tetanus: Appropriate management of injured survivors should be implemented
as soon as possible to minimize future disability and to prevent avoidable
death following disasters.
• Tuberculosis: maintenance of routine supply of TB drugs is essential.
Noncommunicable diseases• Continuation of treatment for people on medications for hypertension,
diabetes, cancer, chronic respiratory disease and kidney disease. Where
feasible, decentralization of care will increase treatment coverage given the
restrictions on movement.
• People who are in shelters can be checked for a history of diabetes and
high blood pressure. Management should include measuring blood pressure
and blood glucose and continuing provision of drugs. Shelters and centres
accommodating people should be made smoke free. Penicillin prophylaxis for
rheumatic heart disease should be maintained where feasible.
• Mental health and psychosocial support should be considered in the provision
of general health care. Psychological first aid should be given to distressed
people who have been exposed to a crisis event. Psychological first aid
involves:
- providing practical care and support, which does not intrude;
- assessing needs and concerns;
- helping people to address basic needs;
- listening to people, but not pressuring them to talk;
- comforting people and helping them to feel calm;
- helping people to connect to information, services and social supports; and
- protecting people from further harm.
• Continued access to care should be assured for people with severe mental
disorders. The mental health and wellbeing of the health-care workers also
needs attention [22].
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3.5 Early warning and response network
The Early Warning and Response Network (EWARN) aims to detect disease out-
breaks. Rapid detection of cases of epidemic-prone diseases is essential to ensure
rapid control. The EWARN is used to inform risk assessments of any disease
incident, allowing resources to be allocated proportionally and appropriately.
To be effective, EWARN needs to:
• focus on the communicable diseases most likely to occur in the disaster-
affected population;
• be simple to use, uniform in style and include standard case definitions and
reporting forms (see Annex 3 for EWARN diseases/syndromes under surveil-
lance with case definitions;
• ensure detailed outbreak response plans/standard operating procedures,
including for identification and training of rapid response teams and ade-
quate stockpiles of supplies (such as oral rehydration solutions, Zinc tablets,
ciprofloxacin for Shigella, amoxicillin and vitamin A for measles, Artemether-
Lumefanthrin for malaria, and intravenous (IV) solutions); and
• reinforce laboratory capacity: (i) to promptly test for the main communicable
disease threats; and (ii) to assure shipping supplies and protocols are in place
to facilitate international shipment for pathogen confirmation.
3.6 Immunization
• In evacuation centres or other crowded settings, vaccination using a measles
containing vaccine, together with vitamin A, should be an immediate
priority health intervention (at least 20% of children are vitamin A deficient).
Children aged 6-59 months (susceptibility profile based on prior coverage
through routine and supplementary immunization activities and immunity
gaps identified through prior measles surveillance) should receive the measles
vaccine, regardless of previous vaccination or disease history. Infants 6-11
months should receive 100 000 international unit (IU) of vitamin A and
children 12-59 months should receive 200 000 IU of vitamin A.
Re-vaccination of infants who received their first dose of measles vaccine
at 6-8 months of age is recommended once they reach 9 months; the
minimum interval between doses is one month.
• A single suspect measles case is sufficient to prompt the immediate imple-
mentation of activities to control measles.
• Mass tetanus vaccination programmes to prevent disease are not indicated.
• Wounds or lacerations may occur from objects submerged in floodwaters.
Tetanus vaccine (TT or Td) and tetanus immune globulin (TIG) is indicated for
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
those with open wounds who have never been vaccinated. TIG is indicated
for previously vaccinated people who sustain wounds (e.g. clean-up workers),
depending on their tetanus immunization history.
• Mass vaccination against influenza is not indicated.
• When the situation stabilizes, vaccinations routinely offered by the national
immunization programme should be made available.
• Hepatitis A vaccine is not recommended to prevent outbreaks in the affected
population.
• Typhoid vaccination, in conjunction with other preventive measures, may be
useful to control typhoid outbreaks, depending on local circumstances.
• Vaccination efforts should always be supplemented by health education and
improved sanitation. Special attention should be paid to the safe manage-
ment and disposal of waste from immunization activities to prevent the trans-
mission of bloodborne pathogens.
3.7 Vector control and personal protection
• Long-lasting insecticidal nets should be made universally available,
with priority given to pregnant women and children under-5 years.
• Refuse must be collected and appropriately disposed of to discourage
rodent and vector breeding.
• Water-storage containers should be closed or covered with mosquito-
proof lids.
• Space spraying and larviciding will control fly and mosquito populations,
and may be desirable around displacement centres.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
4. sTaff healThVaccinations and malaria prophylaxis are recommended for staff deployed to
Vanuatu.
Emergency settings differ vastly, including their epidemiological context. As such,
medical preparation must be as comprehensive as possible (within the limitations
imposed by departure at short notice) and tailored specifically for Vanuatu.
A minimum period of time is required following vaccination, to build up
protective levels of antibodies. A series of injections may be necessary. It is
advised that staff receive vaccinations two weeks in advance of departure if
possible (see Table 1 below). In the event of immediate departure, the duration
of the mission may influence the choice of vaccines.
Personal protection against mosquito bites, both during the day and at night is
important in preventing vector-borne diseases such as dengue, chikungunya,
Zika and malaria (long-sleeved clothes, repellents, mosquito nets, clean-up of
breeding sites).
Basic knowledge of first aid and stress management is important. Although not
always avoidable, good preparation can be useful in preventing and limiting
stress.
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4.1 Vaccination recommendations
Adult vaccination booster recommendations vary between countries so staff
should check their vaccination requirements with their local health provider
before leaving for the disaster area.
table 1. Vaccinations recommended for travel to Vanuatu
necessity vaccine validity comments
essential
Diphtheria 10 years Can be combined with tetanus
Tetanus 10 years Booster does is recommended if not taken in the last 10 years
Polio 10 years
Typhoid 3 years
Hepatitis A Life If there is no proof of immunity by vaccine or illness; can be combined with Hepatitis B
Measles Potential risk in emergency situation. If not fully immunized in childhood, obtain vaccination
optional Hepatitis B 15 years
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
4.2 Malaria prophylaxis and treatment
Malaria prophylaxis is recommended for all staff deployed in Vanuatu. The risk is
predominantly due to P. falciparum. The recommended drugs for prophylaxis are:
• Atovaquone 250 mg & Proguanil 100 mg (malarone): one day before expo-
sure, one tablet daily until 7 days after last exposure
• doxycycline 100 mg: one day before, one tablet daily until 4 weeks expo-
sure after last exposure
• mefloquine 250 mg: one week before exposure; one tablet weekly until 4
weeks after last exposure.
It is recommended that individuals carry supplies of reserve treatment for all
missions lasting longer than 8 days, in view of the potential difficulty in accessing
health services. The recommended treatment for malaria is Artemether-
Lumefantrine combination tablet (Coartem™).
4.3 Other precautions
Teams may consider bringing:
• medical kits including chlorine tablets for water purification
• Post-Exposure Prophylaxis Kit
• surgical masks
• gloves
• food and water: given that there will be an extreme shortage of basic food
and drinking-water.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
5. risK communicaTionsRisk communication is a critical tool for effective management of public health
emergencies. When the public is at risk of a real or potential health threat,
treatment options may be limited, direct interventions may take time to organize
and resources may be limited. Communicating advice and guidance, therefore,
is often the most important public health tool in managing a risk. Key risk
communications actions are:
• As soon as possible, assess public communication capacity and research
community understanding of the risks, population demographics, literacy
levels, languages spoken and socioeconomic and cultural backgrounds. This
will help inform an effective communications approach and messages that
resonate with target audiences.
• Review how the population consumes information and identify
communication partners, with appropriate language and media skills, to help
get the message out to those at risk. Ministry of Health counterparts are a
good place to start.
• Risks will also need to be communicated outside of the country, so identify
external channels of communication. Consider designating a spokesperson
– skilled at communicating using plain language – and seek opportunities
to communicate with the traditional media. Explore opportunities to
communicate messages regularly via social media.
• Coordinate closely with your communications partners to maintain consistent
and complementary messages and to build and maintain trust.
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annexes
annex 1: Health services in Vanuatu
table 2. Primary health services in Vanuatu (level of care, facility and description of services)
health Promotion and disease Prevention
Village health workers are minimally trained to work with communities to promote hygiene, good sanitation and disease prevention. Each province has a health promotion officer. Health Promotion Unit in the Ministry of Health provides overall policy direction, coordination and support to provinces.
UN agencies and other development partners support health promotion and community programmes in water and sanitation, health literacy, HIV/AIDS, reproductive health, alcohol tobacco and other drugs.
Primary care and community health services
Aid posts* Staffed by village health worker providing basic primary health care and referral to the nearest Dispensary or Health Centre. Services include dressings, malaria testing and treatment, family planning and community education. Under an MOU, the village health workers programme is outsourced to an international organization, Save the Children.
Dispensaries Serving a population of up to 5000 and staffed by a registered nurse and Nurse Aid providing essential primary health care through general outpatient consultations for common illnesses, MCH/RH services and with 2 to 4 inpatient beds. The main purpose of beds is for stabilization of patients before transfer to Provincial Hospital but also deliveries. Open from 8:00 to 17:00 with staff living nearby and on-call 24 hours.
Health centres
Serving a population of 5 to 8000 and staffed by Nurse Practitioner, Midwife, Registered Nurse and Nurse Aid possibly with a driver and vehicle providing essential primary health care through outpatient consultations, MCH/RH services with 10-15 inpatient beds for paediatrics, medical and maternity patients. The most common reason for admission is delivery. Open from 8.00 am to 5.00 pm with staff living nearby and on-call 24 hours. No pharmacist or other support services so rely on provincial hospital.
Municipal clinics
Primary and preventive care; coordination of hospital management for pa-tients in urban catchment areas; family planning Run by the Urban Councils in Port Vila (5 Clinics) and Luganville (3 Clinics) on a semi-private basis. Staffed by Nurse Practitioner and a registered nurse.
Private clinics and services
Include 6 medical clinics, 4 private pharmacists, 1 physiotherapy clinic, 1 dental clinic, 1 laboratory and 4 counselling centres run by NGOs. In addition there are traditional medical practitioners.
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table 3. Health services in Vanuatu (level of care, facility and description of services)
Private Pharmacies
Five located in urban centres provide over the counter and prescription medicines. Procure own medicines and stock a broader range of medical supplies than government-run pharmacies but are more expensive.
* Aid posts are community built and owned, with medicines and basic commodities supplied by government.
• Village health workers (VHWs) are volunteers who have received three months training in primary and preventive care, focusing on community education, treatment of minor ailments and prompt referrals.
• VHWs have limited training and may be presented with medical conditions beyond their level of expertise. VHWs need to work closely with dispensaries and health centres to refer such cases.
• The Ministry of Health has a Memorandum of Understanding with Save the Children to manage the VHW programme, but faces a challenge to effectively link the out-sourced VHW programme with the Ministry of Health primary-care facilities – especially dispensaries and health centres – and to maintain the focus of VHW activities on preventive health care and community education for healthy lifestyles rather than clinical services.
secondary care
referral hospitals Vila Central Hospital in Port Vila and Northern Provincial Hospital in Luganville are the two referral hospitals. Staffed by doctors, nurses and allied health professionals providing obstetric, medical, paediatric, surgical, inpatient and outpatient services and a range of specialist outpatient clinics. Open 24 hours. Inpatient services include: medical, surgical, maternity and neonatal, paediatric, infectious diseases, psychiatry, ear nose and throat, eye care. Allied health services include: laboratory, radiology, orthotics, nutrition, pharmacy, dental, physiotherapy. Patients referred overseas for services not available locally.
Provincial hospitals
Located in Torba (Torba mini-hospital), Penama (Lolowai Hospital), Malampa (Norsup Hospital) and Tafea (Lenakel Hospital) providing obstet-ric, medical, paediatric, surgical, an inpatient and outpatient services. The only doctor at Lenakel is an expatriate Canadian doctor on a six-monthly rotation basis. Norsup Hospital has one recently graduated junior doctor while Lolowai Hospital and Torba Mini Hospital are yet to be assigned doctors. In this case, the health service team comprises a nurse practi-tioner, a nurse and a midwife. The Pharmacist is responsible for medical supplies at each hospital.
Private hospital Vila Bay Health Centre is a private international health centre in Port Vila run by expatriates, offering primary and secondary care with capacity for medical evacuation and medical emergency.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
table 4 Health Services in Vanuatu by location
Pro
vin
ce
ho
spit
als
hea
lth
cen
tres
dis
pen
sari
es
aid
po
sts
tota
l fac
iliti
es
Pop
ula
tio
n (
2013
est
.)
faci
litie
s p
er 1
,000
po
pu
lati
on
an
nu
al o
utp
atie
nt
con
sult
atio
ns
p
er c
apit
a, 2
012
nu
mb
er o
f vi
llag
es
vill
ages
per
pri
mar
y ca
re f
acili
ty
TORBA 1 2 6 23 32 9,903 3.23 1.53 34 1.1
SANMA 1 7 6 38 52 49,242 1.06 1.59 403 7.8
PENAMA 1 6 8 42 57 32,227 1.77 2.20 129 2.3
MALAMPA 1 7 14 45 67 38,060 1.76 1.17 N/A —
SHEFA 1 3 7 42 53 87,789 0.60 0.61 N/A —
TAFEA 1 5 6 41 53 33,626 1.58 1.21 245 4.6
TOTAL 6 30 47 231 314 250,847 1.25 1.20 — —
Source: Vanuatu Health Service Delivery Profile (2012); updated using data from VHW Evaluation 2013 and VHW training programme records held by Save the Children Australia. 2012 consultations were derived from the health information system.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
annex 2: Communications messages (specific health issues)
Safe drinking-water• Even if it looks clear, water can contain germs. Under the present emergency
in Vanuatu, water in the affected areas should be assumed to be contaminated.
• Add drops of chlorine to the water, water purification tablets or boil, before
drinking or using for food preparation.
• Keep drinking-water in a clean, covered pot or bucket or other container with
a small opening and a cover. It should be used within 24 hours of collection.
• Pour the water from the container – do not dip a cup into the container.
• If dipping into the water container cannot be avoided, use a single cup or
other utensil with a handle and which is attached to the container.
Promote good hygienic practices• Wash hands with soap, ash or lime.
• Wash hands before cooking, before eating and before feeding children.
• Wash hands after using the latrine (toilet) or cleaning children after they have
used the latrine (toilet).
• Wash all parts of hands – front, back, between the fingers and under the
nails.
Avoid mosquito bites (once dwellings are re-established)• Sleep under an insecticide-treated bed net.
• Make sure your house or tent/shelter has been properly sprayed with
insecticide during the transmission season.
• Wear protective clothing at times when mosquitoes and other biting insects
are active.
• Stay indoors when outdoor biting mosquitoes are most active.
• Use insect repellents and mosquito coils if available.
• Remove, destroy or empty small rain-filled containers near the house or
tent/shelter.
Five keys to safer food • Keep clean (hand hygiene).
• Cook thoroughly, separate raw and cooked.
• Keep food at safe temperature (piping hot).
• Use safe drinking-water and raw materials.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
• Seek treatment early (once health services are established).
- Diagnosis and treatment of fever, diarrhoea and other illnesses should
be within 24 hours from observation of first signs of symptoms.
- For diarrhoea, oral dehydration salts made with safe (boiled and
chlorinated) water should be consumed.
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Public HealtH Risk assessment and inteRventions tRoPical cyclone Pam: vanuatu, maRcH 2015
annex 3: EWARN case definitions – Cyclone Pam, Vanuatu
syndrome case definitions
acute fever and rash (afr)
Sudden onset of fever (>380C) with acute non- blistering rash
Prolonged fever Any fever (>380C) lasting 3 or more days
Watery diarrhoea 3 or more loose or watery stools in 24 hrs (non- bloody)
Bloody diarrhoea Any episode of acute bloody diarrhoea
influenza-like- illness (ili)
Sudden onset of fever (>380C) with cough and/or sore throat
acute jaundice syndrome
Jaundice (yellow eyes or dark urine) AND severe illness with or without fever
suspected dengue
Fever (>380C) PLUS two of the following:
1. Aches and pains (headache, eye pain, muscle/joint pain),
2. Anorexia, nausea or vomiting,
3. Rash,
4. Tourniquet test positive,
5. Mucosal bleeding,
6. Abdominal pain,
7. Lethargy or restlessness
malaria Clinically suspected malaria PLUS positive RDT or Malaria Parasite Smear (MPS)
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For further information, please contact: Emergency Support Team World Health Organization – Regional Office for the Western PacificManila, Philippines Email: [email protected]
Division of Pacific Technical SupportWorld Health OrganizationSuva, FijiEmail: [email protected]; [email protected]