Health

Contents

Essential concepts in health
1. Health systems
2. Essential healthcare
  - 2.1 Communicable diseases
  - 2.2 Child health
  - 2.3 Sexual and reproductive health
  - 2.4 Injury and trauma care
  - 2.5 Mental health
  - 2.6 Non-communicable diseases
  - 2.7 Palliative care
Appendix 1: Health assessment checklist
Appendix 2: Sample weekly surveillance reporting forms
Appendix 3: Formulas for calculating key health indicators
Appendix 4: Poisoning
References and further reading

Essential concepts in health

Everyone has the right to timely and appropriate healthcare

The Sphere Minimum Standards for Healthcare are a practical expression of the right to healthcare in humanitarian contexts. The standards are grounded in the beliefs, principles, duties and rights declared in the Humanitarian Charter. These include the right to life with dignity, the right to protection and security, and the right to receive humanitarian assistance on the basis of need.

For a list of the key legal and policy documents that inform the Humanitarian Charter, including explanatory comments for humanitarian workers, ⊕ see Annex 1: Legal foundation to Sphere.

The aim of healthcare in a crisis is to reduce excess morbidity and mortality

Humanitarian crises have a significant impact on the health and well-being of affected populations. Access to life-saving healthcare is critical in the initial stages of an emergency. Healthcare may also include health promotion, prevention, treatment, rehabilitation and palliative care at any stage of the response.

The public health impact of a crisis can be both direct (injury or death from the crisis itself) and indirect (changes in living conditions, forced displacement, lack of legal protection or decreased access to healthcare).

Overcrowding, inadequate shelter, poor sanitation, insufficient water quantity and quality, and reduced food security all increase the risk of malnutrition and outbreaks of communicable diseases. Extreme stressors can also trigger mental health conditions. Eroding social support mechanisms and self-help systems can lead to negative coping mechanisms and reduced help-seeking behaviour. Reduced access to healthcare and interrupted medicine supply can disrupt ongoing treatment such as maternal healthcare and treatment for HIV, diabetes and mental health conditions.

The primary goal of a health response during a crisis is to prevent and reduce excess mortality and morbidity. Patterns of mortality and morbidity, and hence healthcare needs, will vary according to the type and extent of each crisis.

The most useful indicators to monitor and evaluate the severity of a crisis are the crude mortality rate (CMR) and the more sensitive under-five crude mortality rate (U5CMR). A doubling or more of the baseline CMR or U5CMR indicates a significant public health emergency and requires an immediate response ⊕ see Appendix 3: Formulas for calculating key health indicators.

In the absence of a known baseline, the following constitutes an emergency threshold:

CMR >1/10,000/day
U5CMR >2/10,000/day

Emergency thresholds must be decided at country level. Where a baseline U5CMR already exceeds emergency thresholds, for instance, waiting for it to double would be unethical.

Support and develop existing health systems

A health systems approach will progressively realise the right to health during the crisis and recovery so it is important to consider how to support existing systems. Hiring staff (national and international) will have short- and long-term implications for national health systems. Following analysis, well-planned health interventions can enhance existing health systems, their future recovery and their development.

In the first phase of a crisis, prioritise targeted health and multi-sectoral rapid assessments. Incomplete information and inaccessible areas should not impede timely public health decision-making. Undertake more comprehensive assessments as soon as possible.

Urban crises require a different approach to health responses

Urban responses must consider the population density, built environment policies, social structures and existing social services. Identifying people at risk or without access to healthcare is challenging. The scale of need can quickly outstrip what can be provided. People seeking refuge in towns and cities rarely know about existing health services or how to access them, risking a further increase in communicable diseases. Outreach will help people cope with new urban stresses such as inadequate access to shelter, food, healthcare, jobs or social support networks.

Rumours and misinformation spread quickly in cities. Use technology to immediately supply accurate information on healthcare and services. Secondary and tertiary healthcare providers are often more active in cities, so increase these providers’ capacity to deliver primary healthcare. Engage them in early warning and response systems for communicable diseases and increase their capacity to deliver their usual specialised services.

These Minimum Standards should not be applied in isolation

The Minimum Standards in this chapter reflect the core content of the right to adequate healthcare and contribute to the progressive realisation of this right globally. This right is linked to rights to water and sanitation, food, and shelter. Achieving the Sphere Minimum Standards in one area influences progress in other areas. Coordinate and collaborate closely with other sectors.

Coordinate with local authorities and other responding agencies to ensure that needs are met, efforts are not duplicated, and healthcare response quality is optimised. Coordination between healthcare actors is also important to meet needs impartially and ensure that people who are hard to reach, at risk or marginalised also have access to care. Cross-references throughout the Handbook suggest some potential linkages.

Where national standards are lower than Sphere minimums, work with the government to progressively raise them.

Priorities should be decided on the basis of sound information shared between sectors and be reviewed as the situation evolves.

International law specifically protects the right to healthcare

Healthcare must be provided without discrimination and must be accessible, meaning: available, acceptable, affordable and of good quality. States are obliged to ensure this right during crises ⊕ see Annex 1: Legal foundation to Sphere.

The right to healthcare can be assured only if the:

population is protected;
professionals responsible for the health system are well trained and committed to universal ethical principles and professional standards;
health system meets Minimum Standards; and
state is able and willing to establish and maintain safe and stable conditions in which healthcare can be delivered.

Attacks, threats and other violent obstructions of the work of healthcare personnel, facilities and medical transport are a violation of international humanitarian law. These protections are derived from the basic obligations to respect and protect the wounded and sick.

Humanitarian organisations should carefully consider the nature of any threat and how to address it. For example, an attack by a national army may be treated differently from a threat from the local community ⊕ see Special considerations to protect healthcare below.

Links to the Protection Principles and Core Humanitarian Standard

Healthcare actors must care for the wounded and the sick humanely, delivering impartial care without distinction, based on need. Ensuring confidentiality, data protection and privacy is crucial to protect individuals from violence, abuse and other problems.

Medical staff are often first responders in cases of violence against individuals, including gender-based violence and child abuse and neglect. Train staff to identify and refer cases to social welfare or protection actors using confidential communication and referral systems. An unaccompanied or separated child in need of critical healthcare but without a legal guardian to consent poses a particular protection challenge. Consult with the child and relevant local authorities if possible. The right to life and healthcare is essential to meet the child’s best interests and may outweigh the right to consent. Decisions must be sensitive to the context and to cultural norms and practices. International medical evacuation and the referral and movement of unaccompanied children requires stringent documentation as well as the involvement of protection services and local authorities.

Increasingly, healthcare must be provided at sea, including international waters, or once individuals are brought ashore. This brings specific protection challenges and political complexities and requires careful planning, preparedness and mitigation of protection risks.

Carefully evaluate civil–military cooperation, particularly in conflicts. Military and armed groups can be important providers of healthcare, even for civilians. Humanitarian agencies may – as a last resort – have to use military capabilities such as infrastructure support to re-establish power supplies to health facilities or provide logistics assistance such as transporting health items or medical evacuation. However, reliance on the military should be considered in the context of access to healthcare and perceptions of neutrality and impartiality ⊕ see Humanitarian Charter and Settings with domestic or international military forces in What is Sphere?

In applying the Minimum Standards, all nine Commitments in the Core Humanitarian Standard should be respected. Feedback mechanisms must be put in place during healthcare responses ⊕ see Core Humanitarian Standard Commitment 5.

Special considerations to protect healthcare

Preventing attacks on healthcare facilities, ambulances and healthcare workers requires sustained effort at international, state and community levels. The nature of threats will vary greatly by context and should be addressed and reported. To protect healthcare, health actors should consider the following issues in their work and in supporting ministries of health or other relevant parties.

During all emergencies – and especially during a conflict – health actors must present themselves as neutral and impartial and act according to these principles, as this may not be well understood by the parties to the conflict, the community or the patients.

When providing critical life-saving medical services, follow humanitarian principles and provide impartial healthcare based on need alone. To promote neutrality, care for the wounded and the sick without distinction, ensure patient safety and maintain confidentiality of medical information and personal data.

Acceptance from local communities, officials and parties to a conflict may help protect healthcare. Health actors should both educate those around them and maintain the perception of impartiality and neutrality. A healthcare facility’s standard of care, quality of services, and location (for example, if situated near a military camp) will also influence these perception.

Healthcare facilities typically apply a ‘no weapons’ policy, with weapons left outside a facility or ambulance. This promotes a neutral environment, can help avoid tensions or escalation of conflict within the facility, and can prevent the facility from becoming a target itself.

Take physical security measures to protect the facility and staff from hazards. At the same time, understand how security measures can affect the general public’s perception and acceptance of the healthcare facility.

Humanitarian organisations must consider the risks and advantages in how they profile their services and how this affects community trust and acceptance. Keeping a low profile (for example by not branding assets or locations) may be appropriate in some operations, while in others it might be better to display large logos on assets or locations.

1. Health systems

A well-functioning health system can respond to all healthcare needs in a crisis so that even during a large-scale health crisis such as an Ebola outbreak, other healthcare activities can continue. Easily treatable conditions will still be treated, and maternal and child health primary care programmes will continue, reducing excess mortality and morbidity. Any actor promoting, restoring or maintaining health contributes to the overall health system. The health system encompasses all levels, from national, regional, district and community to household carers, the military and the private sector.

In a crisis, health systems and the provision of healthcare are often weakened, even before demand increases. Healthcare workers may be lost, medical supplies interrupted or infrastructure damaged. It is important to understand the impact of the crisis on health systems to determine priorities for humanitarian response.

Humanitarian actors rarely operate in an emergency where there is no pre-existing health system. Where a system is weak, it will need to be strengthened or developed (for example through referral pathways, health information collation and analysis).

The standards in this section address five core aspects of a well-functioning health system:

delivery of quality health services;
a trained and motivated healthcare workforce;
appropriate supply, management and use of medicines, diagnostics material and technology;
appropriate financing of healthcare; and
good health information and analysis.

These aspects affect each other in many ways. For instance, insufficient healthcare workers or lack of essential medicines will affect service delivery.

Leadership and coordination are vital to ensure needs are addressed in an impartial manner. The ministry of health (MoH) usually leads and coordinates the response and may request support from other health actors. Sometimes the ministry lacks capacity or willingness to assume the role in an efficient and impartial manner, so another agency should take this responsibility. If the MoH does not have access or would not be accepted in all areas of the country, humanitarian actors should seek to support the accepted existing system, especially in an acute emergency. Carefully determine how to work with non-state actors and others, and their ability to provide or coordinate healthcare for the population.

Access to the population is important but must be considered with a clear understanding of the humanitarian principles and implications for impartial and neutral assistance. Coordination should occur at and between all levels of healthcare from national to community and with other sectors such as WASH, nutrition and education, as well as with cross-sectoral technical working groups such as mental health and psychosocial support, gender-based violence (GBV) and HIV.

Health systems standard 1.1:
Health service delivery

People have access to integrated quality healthcare that is safe, effective and patient-centred.

Key actions

1
Provide sufficient and appropriate healthcare at the different levels of the health system.
- Prioritise health services at country level or at the closest operational level in acute emergencies, based on type of crisis, epidemiological profile and health system capacity.
- Identify different types of care that should be available at different levels (household, community, healthcare facility and hospital).
2
Establish or strengthen triage mechanisms and referral systems.
- Implement protocols for triage at healthcare facilities or field locations in conflict situations, so that those requiring immediate attention are identified and quickly treated or stabilised before being referred and transported elsewhere for further care.
- Ensure effective referrals between levels of care and services, including protected and safe emergency transport services and between sectors such as nutrition or child protection.
3
Adapt or use standardised protocols for healthcare, case management and rational drug use.
- Use national standards, including essential medicines lists, and adapt to the emergency context.
- Use international guidelines if national guidelines are outdated or not available.
4
Provide healthcare that guarantees patients’ rights to dignity, privacy, confidentiality, safety and informed consent.
- Ensure safety and privacy so that everyone may access care, including people with conditions often associated with stigma, such as HIV or sexually transmitted infections (STIs).
5
Provide safe healthcare and prevent harm, adverse medical events or abuse.
- Implement a system to report and review adverse medical events.
- Establish a policy to report any abuse or sexual violence.
6
Use appropriate infection prevention and control (IPC) measures, including minimum WASH standards and medical waste disposal mechanisms, in all healthcare settings.
- During disease outbreaks such as cholera or Ebola, seek comprehensive guidance from specialist bodies such as the World Health Organization (WHO) UNICEF and Médecins Sans Frontières (MSF).
7
Manage or bury the dead in a safe, dignified, culturally appropriate manner, based on good public health practice.

Key indicators

Percentage of population that can access primary healthcare within one hour’s walk from dwellings
- Minimum 80 per cent
Percentage of healthcare facilities that deliver prioritised health services
- Minimum 80 per cent
Number of inpatient beds (excluding maternity beds) per 10,000 people
- Minimum 18
Percentage of population requiring a referral seen at the next level of healthcare
Percentage of patients referred in adequate time

Guidance notes

Access to healthcare depends on availability of healthcare, including physical reach, acceptability and affordability for all.

Availability: Healthcare can be delivered through a combination of community-level, mobile and fixed healthcare facilities. The number, type and location of each will vary by context. A broad guideline for planning coverage of fixed healthcare facilities is:
- One healthcare facility per 10,000 people; and
- One district or rural hospital per 250,000 people.
These do not ensure adequate healthcare coverage in all settings, however. In rural areas, a better target may be one facility for 50,000 people, combined with community case management programmes and mobile clinics. In urban areas, secondary healthcare facilities may be the first point of access and therefore cover primary care for a larger population than 10,000.

Providing surge capacity for healthcare is critical in emergencies. Avoid duplicating existing services, which can waste resources and reduce trust in existing facilities. People need to confidently return to those facilities when temporary facilities close.

Monitor the utilisation rate of services. Low rates may indicate poor quality, direct or indirect cost barriers, preference for other services, overestimation of the population or other access problems. Higher rates may suggest a public health problem or underestimation of the target population, or may indicate access problems elsewhere. All data should be analysed by sex, age, disability, ethnic origin and other factors that may be relevant in context. To calculate utilisation rate ⊕ see Appendix 3.
Acceptability: Consult with all sections of the community to identify and address obstacles to accessing services by different parts of the community and all sides in a conflict, especially at-risk groups. Work with women, men, children, people living with and at high risk of HIV, persons with disabilities, and older people to understand health-seeking behaviour. Engaging with people in the design of healthcare will build patient engagement and improve timeliness of care.
Affordability: ⊕ See Health systems standard 1.4: Health financing.
Community-level care: Primary healthcare includes household and community care. Access to primary healthcare may be through community health workers (CHWs) or volunteers, peer educators, or in collaboration with village health committees to increase patient and community engagement. Care may range from prevention programmes to health promotion or case management and depends on context. All programmes should establish links with the nearest primary healthcare facility to ensure integrated care, clinical supervision and programme monitoring. If CHWs are screening for acute malnutrition, referral to nutrition services at healthcare facilities or other locations is needed ⊕ see Food security and nutrition assessments standard 1.2: Nutrition assessment. Integrate care with community programmes in other sectors such as WASH and nutrition ⊕ see WASH hygiene promotion standard 1.1 and Food security and nutrition – management of malnutrition standard 2.1.
Emergency referral systems with pre-determined, safe and protected transport mechanisms should be available 24 hours a day, seven days a week. There should be a clinical handover between referrer and receiving healthcare provider.
Patients’ rights: Design healthcare facilities and services to ensure privacy and confidentiality, such as with separate consultation rooms. Seek informed consent from patients or their guardians before medical or surgical procedures. Address any special considerations that can influence informed consent and safety, such as age, gender, disability, language or ethnicity. Establish patient feedback mechanisms as early as possible. Protect patient data ⊕ see Health systems standard 1.5: Health information.
Appropriate and safe facilities: Apply rational drug-use protocols and safe management of medicines and devices ⊕ see Health systems standard 1.3: Essential medicines and medical devices.
Ensure that facilities are suitable, even in emergencies. Ensure private spaces for consultations, organised patient flow, a 1-metre space between beds, ventilation, a sterilisation room (not open air) for hospitals, sufficient energy supply to support critical equipment, and adequate WASH structures. During disease outbreaks, review infrastructure requirements and guidance including, for example, triage, observation and isolation zones.
Devise measures to make healthcare facilities safe, protected and accessible during a crisis such as flooding or conflict.
Infection prevention and control (IPC) is key in all settings to prevent disease and antimicrobial resistance. Even in a non-crisis setting, globally 12 per cent of patients will develop an infection while receiving healthcare, and 50 per cent of infections after surgery are resistant to well-known antibiotics.
Core IPC components include producing and implementing guidelines (on standard precautions, transmission-based precautions and clinical aseptic techniques), having an IPC team in each setting, training healthcare workforce, monitoring programmes and incorporating detection of healthcare-associated infections and antimicrobial resistance into surveillance systems. Healthcare settings should have appropriate staffing and workload, bed occupancy (not more than one patient per bed), built environment and should maintain safe hygiene practice ⊕ see Health systems standard 1.2: Healthcare workforce, ⊕ see Appropriate and safe facilities above, WASH infrastructure and equipment, ⊕ see WASH standard 6: WASH in healthcare settings.
Standard precautions are a part of IPC measures and include:
- Prevention of injuries from sharps: Handle needles, scalpels and other sharps with care, for example when cleaning used instruments or disposing of used needles. Anyone with a sharps injury should be offered post-exposure prophylaxis (PEP) for HIV within 72 hours ⊕ see Essential healthcare – sexual and reproductive health standard 2.3.3: HIV.
- Use of personal protective equipment (PPE): Provide appropriate PPE based on risk and the task to be performed. Assess the type of exposure anticipated (for example, splash, spray, contact or touch) and the category of transmission of disease, the durability and appropriateness of the PPE for the task (such as fluid-resistant or fluid-proof), and the fit of the equipment. Additional PPE will depend on the type of transmission: contact (for example, gown or gloves), droplet (surgical masks need to be worn when within 1 metre of the patient) or airborne (particulate respirators). ⊕ See WASH standard 6: WASH in healthcare settings.
- Other measures include hand hygiene, healthcare waste management, maintaining a clean environment, cleaning medical devices, respiratory and cough hygiene, and understanding principles of asepsis ⊕ see WASH standard 6: WASH in healthcare settings.
Adverse events: Globally, 10 per cent of hospital patients suffer an adverse event (even outside a humanitarian crisis), mostly from unsafe surgical procedures, medication errors and healthcare-associated infections. An adverse events register should be maintained at every healthcare facility and audited to promote learning.
Management of the dead: Use local customs and faith practices to respectfully manage the dead and identify and return remains to families. Whether an epidemic, natural disaster, conflict or mass killing, management of the dead requires coordination between health, WASH, legal, protection and forensic sectors.
Dead bodies rarely represent an immediate health risk. Certain diseases (for example cholera or Ebola) require special management. Recovery of the dead may require PPE, equipment for recovery, transportation and storage, as well as documentation. ⊕ See WASH standard 6: WASH in healthcare settings.

Healthcare systems standard 1.2:
Healthcare workforce

People have access to healthcare workers with adequate skills at all levels of healthcare.

Key actions

1
Review existing staffing levels and distribution against national classifications to determine gaps and under-served areas.
- Track staffing levels per 1,000 people by function and place of employment.
2
Train staff for their roles according to national standards or international guidelines.
- Recognise that staff in acute emergencies may have expanded roles and need training and support.
- Introduce refresher training where turnover is high.
3
Support healthcare workers to operate in a safe working environment.
- Implement and advocate for all possible measures to protect healthcare workers in conflicts.
- Provide occupational health training and immunisations for hepatitis B and tetanus for clinical workers.
- Supply adequate IPC and PPE to carry out staff duties.
4
Develop incentive and salary strategies that minimise pay differences and inequitable distribution of healthcare workers between MoH and other healthcare providers.
5
Share healthcare workforce data and readiness information with MoH and other relevant bodies locally and nationally.
- Be aware of displacement and departure of healthcare workers during conflict.

Key indicators

Number of community health workers per 1,000 people
- Minimum 1–2 community health workers
Percentage of births attended by skilled personnel (doctors, nurses, midwives)
- minimum 80 per cent
Number of skilled birth attendant personnel (doctors, nurses, midwives) per 10,000 people
- minimum 23 per 10,000 people
All health staff performing clinical work have received training in clinical protocols and case management

Guidance notes

Availability of healthcare workers: The healthcare workforce includes medical doctors, nurses, midwives, clinical officers, laboratory technicians, pharmacists and CHWs, as well as management and support staff. The number and profile of workers should match the population and service needs. Understaffing can result in excessive workloads and unsafe healthcare. Integrate existing healthcare workers into the emergency response.
When recruiting and training local staff, follow national guidelines (or international if national are unavailable). International staff recruitment should follow national and MoH regulations (for example evidence of qualifications, especially for clinical practice).
Consider care for people in hard-to-reach rural and urban areas, including those close to conflict. Staff must provide care to people of all ethnicities, languages and affiliations. Recruit and train lower-level healthcare workers for community outreach, case management in mobile teams or health posts, and develop strong referral mechanisms. Incentive packages may be needed to work in difficult areas.
Community health workers (CHWs): Community programming with CHWs (including volunteers) increases access to hard-to-reach populations, including marginalised or stigmatised populations. If there are geographical constraints or acceptability issues in diverse communities, one CHW may only practically be able to serve 300 people rather than 500.
CHWs’ work will vary. They may be trained in first aid or case management or may conduct health screening. They must be linked to the nearest healthcare facility to ensure appropriate oversight and integrated care. Often CHWs cannot be absorbed into the health system once the emergency subsides. In some contexts, CHWs may usually work only in rural settings, so a different model may be needed in urban crises.
Acceptability: Meeting people’s sociocultural expectations will increase patient engagement. Staff should reflect the population’s diversity with a mix of different socioeconomic, ethnic, language and sexual orientation groups, and an appropriate gender balance.
Quality: Organisations must train and supervise staff to ensure their knowledge is up to date and their practice is safe. Align training programmes with national guidelines (adapted for emergencies) or agreed international guidelines.
Include training on:
- clinical protocols and case management;
- standard operating procedures (such as IPC, medical waste management);
- security and safety (adapted to the level of risk); and
- codes of conduct (such as medical ethics, patients’ rights, humanitarian principles, child safeguarding, protection from sexual exploitation and abuse) ⊕ see Essential healthcare – sexual and reproductive health standard 2.3.2: Sexual violence and clinical management of rape and Protection Principles.
Regular supervision and quality monitoring will encourage good practice. One-off training will not ensure good quality. Share records of who has been trained, in what, by whom, when and where with the MoH.

Health systems standard 1.3:
Essential medicines and medical devices

People have access to essential medicines and medical devices that are safe, effective and of assured quality.

Key actions

1
Establish standardised essential medicine and medical device lists for priority healthcare.
- Review existing national essential medicines and medical device lists early in the response and adapt to the emergency context.
- Pay special attention to controlled medicines that may require special advocacy to ensure availability.
2
Establish effective management systems to ensure availability of safe essential medicines and medical devices.
- Include transport, storage and cold chain for vaccines as well as for the collection and storage of blood products.
3
Accept donations of medicine and medical devices only if they follow internationally recognised guidelines.

Key indicators

Number of days essential medicines are not available
- Maximum 4 days out of 30 days
Percentage of health facilities with essential medicines
- Minimum 80 per cent
Percentage of health facilities with functional essential medical devices
- Minimum 80 per cent
All medicines dispensed to patients are within the expiry date

Guidance notes

Managing essential medicines: Essential medicines include drugs, vaccines and blood products. Good medicine management ensures availability but also prohibits unsafe or expired medicines. The main management elements are selection, forecasting, procurement, storage and distribution.
Selection should be based on the national essential medicines list. Advocate to close any gaps such as for non-communicable diseases, reproductive health, pain relief for palliative care and surgery, anaesthesia, mental health, controlled drugs (see below) or others.
Forecasting should be based on consumption, morbidity data and context analysis. National medicine supplies may be disrupted if local manufacturing is affected, warehouses are damaged or international procurement is delayed, among other factors.
Procurement methods should adhere to national laws, customs regulations and quality assurance mechanisms for international procurement. Advocate for improved mechanisms if delays occur (through the MoH, lead agency, national disaster management authority or humanitarian coordinator). If systems do not exist, procure prequalified products, within expiry date and in the language of the country and healthcare workforce.
Storage: Medicines should be safely stored throughout the drug supply cycle. Requirements vary between products. Medicines should not be stored directly on the floor. Ensure separate areas for expired items (locked), flammable products (well ventilated, with fire protection), controlled substances (with added security) and products requiring cold chain or temperature control.
Distribution: Establish safe, protected, predictable and documented transport mechanisms from central stocks to healthcare facilities. Partners may use a push (automatic supply) or pull (supply on demand) system.
Safe disposal of expired medicines: Prevent environmental contamination and hazards to people. Comply with national regulations (adapted to emergencies) or international guidance. Ultra-high temperature incineration is costly, and pharmaceutical stockpiling works only in the short term ⊕ see WASH standard 6: WASH in healthcare settings.
Essential medical devices: Define and procure necessary devices and equipment (including laboratory reagents, larger machines) at each level of healthcare that are nationally or internationally compliant. Include assistive devices for persons with disabilities. Ensure safe use of devices, including regular maintenance and spare parts supply, preferably locally. Decommission devices safely. Distribute or replace lost assistive devices and provide clear information on use and maintenance. Refer to rehabilitation services for appropriate size, fitting, use and maintenance. Avoid one-off distribution.
Prequalified kits are useful in the early stages of a crisis or in pre-positioning for preparedness. They contain prequalified essential medicines and medical devices and vary according to health intervention. WHO is the lead provider for Interagency Emergency Health Kits and non-communicable disease kits, in addition to kits to manage diarrhoea, trauma and others. The United Nations Population Fund (UNFPA) is the lead provider of sexual and reproductive health kits.
Controlled drugs: Medicines for pain relief, mental health and post-partum bleeding are usually controlled. As 80 per cent of low-income countries do not have access to adequate pain relief medicines, advocate with the MoH and government to improve availability for controlled drugs.
Blood products: Coordinate with the national blood transfusion service, where it exists. Only collect blood from volunteers. Test all products for HIV, hepatitis B and C, and syphilis as a minimum, with blood grouping and compatibility testing. Store and distribute products safely. Train clinical staff in the rational use of blood and blood products.

Health systems standard 1.4:
Health financing

People have access to free priority healthcare for the duration of the crisis.

Key actions

1
Plan for user fees to be abolished or temporarily suspended where they are charged through government systems.
2
Reduce indirect costs or other financial barriers to reach and use services.

Key indicators

Percentage of healthcare facilities that do not charge user fees for priority healthcare (including consultations, treatment, investigations and provision of medicines)
- Target 100 per cent
Percentage of people not making any direct payment when accessing or using healthcare (including consultations, treatment, investigations and provision of medicines)
- Target 100 per cent

Guidance notes

User fees: Requiring payment for services during an emergency impedes access and may prevent people from seeking healthcare.
Suspending user fees for government healthcare providers will necessarily cause financial strain. Consider supporting MoH facilities or those of other responsible providers with staff salaries and incentives, extra medicines, medical devices and assistive devices. If user fees are temporarily suspended, ensure users get clear information about the timing and reasons, and monitor accessibility and service quality.
Indirect costs can be minimised by providing adequate services in communities and using planned mechanisms for transport and referral.
Cash-based assistance: The Universal Health Coverage 2030 targets state that people should receive healthcare without undue financial hardship. There is no clear evidence that using cash-based assistance specifically for health responses in humanitarian contexts has a positive impact on health outcomes, as of this edition ⊕ see What is Sphere? including Delivering assistance through markets.
Experience suggests that using cash-based assistance for health responses may help if:
- the emergency has stabilised;
- there is a predictable service to support, such as ant-enatal care or chronic disease management;
- there is existing positive health-seeking behaviour and high demand; and
- other critical household needs such as food and shelter have been met.

Health systems standard 1.5:
Health information

Healthcare is guided by evidence through the collection, analysis and use of relevant public health data.

Key actions

1
Strengthen or develop a health information system that provides sufficient, accurate and up-to-date information for effective and equitable health response.
- Ensure the health information system includes all stakeholders, is simple to implement and simple to collect, analyse and interpret information to steer response.
2
Strengthen or develop disease Early Warning, Alert and Response (EWAR) mechanisms for all hazards that require an immediate response.
- Decide which priority diseases and events to include based on the epidemiological risk profile and context of the emergency.
- Incorporate both indicator- and event-based components.
3
Agree on and use common operating data and definitions.
- Consider denominator figures, such as population, family size and age disaggregation.
- Establish administrative areas and geographic codes.
4
Agree standard operating procedures for all health actors when using health information.
5
Ensure mechanisms to protect data to guarantee the rights and safety of individuals, reporting units and/or populations.
6
Support the lead actor to compile, analyse, interpret and disseminate health information to all stakeholders in a timely and regular manner, and to guide decision-making for health programmes.
- Include coverage and utilisation of health services, and analysis and interpretation of epidemiological data.

Key indicators

Percentage of complete Early Warning, Alert and Response (EWAR)/surveillance reports submitted on time
- Minimum 80 per cent
Frequency of health information reports produced by the lead health actor
- Minimum monthly

Guidance notes

Health information system: A well-functioning health information system ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status. Data may be qualitative or quantitative and collected from various sources such as census surveys, vital registration, population surveys, perceived needs surveys, individual records and healthcare facility reports (such as health management information systems). It should be flexible enough to incorporate and reflect unexpected challenges such as outbreaks or the total collapse of the health system or services. Information will identify problems and needs at all levels of the health system.
Collect missing information through further assessment or surveys. Consider cross-border movement of people, and the information needed or available. Provide regular analysis on who is doing what and where.
Health management information systems (HMIS) or routine reporting use health information generated from healthcare facilities to assess healthcare delivery performance. An HMIS monitors delivery of specific interventions, treatment of conditions, resources such as tracer drug availability, human resources and utilisation rates.
Health surveillance is the continuous and systematic collection, analysis and interpretation of health data. Disease surveillance specifically monitors different diseases and patterns of progression and is often captured in HMIS reporting.
Early Warning Alert and Response (EWAR) is part of a routine health surveillance system. It detects and generates an alert for any public health event that needs an immediate response, such as chemical poisoning or epidemic prone diseases ⊕ see Essential healthcare – communicable diseases standard 2.1.2: Surveillance, outbreak detection and early response.
Standard operating procedures: Establish common definitions and ways of conveying information across geographical locations, levels of care and health actors. As a minimum, agree on:
- case definitions;
- indicators of what to monitor;
- reporting units (such as mobile clinics, field hospitals, health posts);
- reporting pathways; and
- frequency of data submission, analysis and reporting.
Disaggregation of data: Health information data should be disaggregated by sex, age, disability, displaced and host populations, context (such as camp/non-camp situation) and administrative level (region, district) to guide decision-making and detect inequity for at-risk groups.
For EWAR, disaggregate mortality and morbidity data for children under and over age five years. The aim is to quickly generate an alert; less detailed data is acceptable. Outbreak investigations data, contact tracing, line listing and further monitoring of disease trends must have disaggregated data.
Data management, security and confidentiality: Take adequate precautions to protect the safety of the individual and the data. Staff should never share patient information with anyone not directly involved in the patient’s care without the patient’s permission. Give consideration to persons with intellectual, mental or sensory impairment that may affect their ability to give informed consent. Be aware that many people living with conditions such as HIV may not have disclosed their status to their close family members. Treat data that relates to injury caused by torture or other human rights violations, including sexual assault, with care. Consider passing such information to appropriate actors or institutions if the individual gives informed consent ⊕ see Protection Principle 1 and Core Humanitarian Standard Commitment 4.
Threats to healthcare: Threats to healthcare workers, or any violent incidents involving healthcare workers should be reported using agreed local and national mechanisms ⊕ see Essential concepts in health (above) and References and further reading (below).

2. Essential healthcare

Essential healthcare addresses the major causes of mortality and morbidity in a crisis-affected population. Coordinate with the ministries of health and other official health actors to agree on which services to prioritise, when and where. Base priorities on context, risk assessment and available evidence.

A crisis-affected population will have new and different needs, which will continue to evolve. People may face overcrowding, multiple displacements, malnutrition, lack of access to water, or continuing conflict. Age, gender, disability, HIV status, linguistic or ethnic identity can further influence needs and may be significant barriers to accessing care. Consider the needs of those living in under-served or hard-to-reach locations.

Agree on priority services with the MoH and other health actors, focusing on those risks most likely to occur and cause the greatest morbidity and mortality. Health programmes should provide appropriate, effective care, taking into account the context, logistics and resources that will be needed. Priorities may change as the context improves or deteriorates further. This exercise should be conducted regularly, based on available information and as the context changes.

Once mortality rates have declined or a situation has stabilised, more comprehensive health services may be feasible. In protracted settings this may be an essential package of health services, defined at country level.

This section outlines the essential minimum healthcare in key areas of emergency response: communicable diseases, child health, sexual and reproductive health, injury and trauma care, mental health, non-communicable diseases and palliative care.

2.1 Communicable diseases

A humanitarian crisis, whether caused by a natural disaster, conflict or famine, often brings increased morbidity and mortality from communicable diseases. People moving into crowded communal settlements or shelters means that diseases such as diarrhoea and measles spread easily. Damage to sanitation facilities or a lack of clean water means that water- and vector-borne diseases are transmitted rapidly. Reduced population immunity results in increased susceptibility to disease. A breakdown of health systems can interrupt long-term treatment, such as for HIV and tuberculosis (TB) provision of routine immunisations, and treatment of simple conditions such as respiratory infections.

Acute respiratory infections, diarrhoea, measles and malaria still account for the largest morbidity in crisis-affected populations. Acute malnutrition worsens these diseases, especially in children under age five years, and in older people.

The objective in a crisis is to prevent communicable diseases from the beginning, to manage any cases, and to ensure a rapid and appropriate response if there is an outbreak. Interventions to address communicable diseases should include prevention, surveillance, outbreak detection, diagnosis and case management, and outbreak response.

Communicable diseases standard 2.1.1:
Prevention

People have access to healthcare and information to prevent communicable diseases.

Key actions

1
Determine the risk of communicable diseases in the affected population.
- Review pre-existing health information if available and surveillance data as well as nutritional status and access to safe water and sanitation.
- Conduct risk assessments with the affected population, including local leaders and health professionals.
2
Work with other sectors to develop general prevention measures and establish integrated health promotion programmes at community level.
- Address specific fears, rumours and common beliefs that could undermine healthy behaviour.
- Coordinate with other sectors performing outreach, such as hygiene promoters or community nutrition workers, to ensure harmonised messaging.
3
Implement vaccination measures to prevent disease.
- Determine the need for vaccination campaigns for specific communicable diseases based on risk, feasibility and context.
- Resume delivery of routine vaccination via pre-existing immunisation programme as soon as possible.
4
Implement disease-specific prevention measures as needed.
- Provide and ensure all inpatients use long-lasting insecticide-treated nets (LLINs) in any malaria zone.
5
Implement infection prevention and control (IPC) measures at all levels of healthcare according to risk ⊕ see Health systems standard 1.1 and WASH support in WASH standard 6: WASH in healthcare settings.

Key indicators

Percentage of people who adopt key practices promoted in health education activities and messages
Percentage of affected households who report that they have received appropriate information on communicable disease-related risks and preventive action
Percentage of affected households who can describe three measures they are taking to prevent communicable diseases
All inpatients in healthcare settings use long-lasting insecticide nets (LLINs) in malarial zones
Incidence of major communicable diseases is stable or not increasing against pre-crisis level

Guidance notes

Risk assessments: Conduct risk assessments with the affected population, local leaders and health professionals. Analyse risks posed by the context and environment, such as in crowded communal settlements and urban areas. Actively consider different segments of the population for disease-specific factors, low immunity or other risks.
Inter-sectoral prevention measures: Develop general prevention measures such as appropriate hygiene, waste disposal, safe and sufficient water and vector management. Adequate shelter, spacing of shelters and ventilation can help reduce transmission. Exclusive breastfeeding and access to adequate nutrition contributes directly to health status ⊕ see Core Humanitarian Standard Commitment 3, WASH hygiene promotion standard 1.1, WASH water supply standards 2.1 and 2.2, WASH solid waste management standards 5.1 to 5.3, Shelter and settlement standard 2 and Food security and nutrition – infant and young child feeding standards 4.1 and 4.2.
Health promotion: Engage communities to provide information in formats and languages that are accessible for older people, persons with disabilities, women and children. Take the time to test and validate messages on sensitive issues.
Vaccination: The decision to implement a vaccination campaign will be based on three factors:
- An assessment of general risk factors such as malnutrition, high burden of chronic disease, overcrowding, inadequate WASH conditions, and disease-specific risks such as geography, climate, season and population immunity.
- The feasibility of a campaign, based on an assessment of the characteristics of the vaccine, including availability, efficacy, safety, whether it is single or multiple antigens, oral or injection, and its stability. Consider operational factors such as access to population, time constraints, transport, material requirements, cost and the ability to gain informed consent.
- The general context, including ethical and practical constraints such as community opposition, inequities due to lack of resources and political or security constraints, or known threats against vaccinators.
⊕ See Essential healthcare – child health standard 2.2.1: Childhood vaccine-preventable diseases and Vaccination in Acute Humanitarian Crises: A Framework for Decision Making, WHO, 2017, which covers 23 antigens, including cholera, meningitis, measles and rotavirus.
Prevention of malaria: Where there is high to moderate malaria transmission, provide LLINs to severely malnourished people and households, pregnant women, children under age five years, unaccompanied children and people living with HIV. Then prioritise people in supplementary feeding programmes, households with children under age five and households of pregnant women. Give pregnant women chemoprophylaxis according to national protocols and resistance patterns. In areas with high malnutrition and measles mortality, consider targeted seasonal malaria chemoprophylaxis.
Aedes mosquito-transmitted diseases: Dengue fever, chikungunya, Zika virus and yellow fever are spread by the Aedes mosquito. Prevent disease through integrated vector management. Individuals should wear clothing to prevent being bitten, and households should use good water and waste management practices and repellents or LLINs for young children and infants sleeping during the day ⊕ see WASH vector control standard 4.2: Household and personal actions to control vectors.

Communicable diseases standard 2.1.2:
Surveillance, outbreak detection and early response

Surveillance and reporting systems provide early outbreak detection and early response.

Key actions

1
Strengthen or establish a context-specific disease Early Warning Alert and Response (EWAR) mechanism.
- Decide priority diseases and events to be included, based on epidemiological risk.
- Train healthcare workers at all levels about priority diseases and mechanisms to notify health authorities and generate an alert.
- Disseminate weekly EWAR reports to all stakeholders to take necessary action.
2
Establish outbreak investigation teams.
- Ensure actions are triggered rapidly when an alert is generated.
- Initiate remote investigation where teams do not have access to the affected populations, such as in active conflict areas.
3
Ensure samples can be tested by rapid diagnostic tests or laboratories to confirm an outbreak ⊕ see Essential healthcare – communicable diseases standard 2.1.3: Diagnosis and case management.

Key indicators

Percentage of alerts being reported within in 24 hours
- 90 per cent
Percentage of reported alerts being verified within 24 hours
- 90 per cent
Percentage of verified alerts being investigated within 24 hours
- 90 per cent

Guidance notes

Early Warning Alert and Response (EWAR): In coordination with all stakeholders, including MoH, partners and community, strengthen or establish an EWAR system representative of the affected population ⊕ see Health systems standard 1.5: Health information. The system should be able to capture rumours, unusual events and community reports.
Surveillance and early warning: Strengthen the EWAR system with partners, and agree on reporting units, data flow, reporting tools, data analysis tools, case definitions and frequency of reporting.
Alert generation and reporting: Alerts are unusual health events that may signal the early stages of an outbreak. Define alert thresholds specific to each disease and report as quickly as possible. Use event-based immediately notifiable reporting by healthcare workers or analyse indicator-based reports (weekly or more frequently). Log all alerts immediately and relay them to outbreak investigation teams to verify.
Alert verification: Verify the alert information within 24 hours. Verification can be done remotely, such as by phone, and involves collecting further data and analysing the case(s) based on symptoms, date of onset, place, sex, age, health outcomes and differential diagnoses.
Outbreak detection: If an alert is verified, conduct a field investigation within 24 hours. Ensure teams have sufficient skills to verify alerts, perform field investigation, detect a suspected outbreak and take laboratory samples. The investigation will confirm an outbreak if an epidemic threshold has been reached or determine whether the alert reflects sporadic cases or seasonal peaks.
Review cases, take samples and conduct a risk assessment. Possible outcomes are:
- it is not a case;
- a case is confirmed, but it is not an outbreak; or
- a case is confirmed and an outbreak is suspected/confirmed.
Some outbreaks can only be confirmed by laboratory analysis; however, even suspected outbreaks may still need immediate action.

Alert and outbreak thresholds

Alert threshold

Outbreak threshold

Cholera

2 cases with acute watery diarrhoea and severe dehydration in people age 2 or above, or dying from acute watery diarrhoea in the same area within one week of each other
1 death from severe acute watery diarrhoea in a person age 5 or above
1 case of acute watery diarrhoea, testing positive for cholera by rapid diagnostic tests in an area

1 confirmed case

Malaria

Decided at country level depending on context

Decided at country level depending on context

Measles

1 case

Defined at country level

Meningitis

2 cases in one week (in a population <30,000)
3 cases in a week (in a population of 30,000–100,000)

5 cases in a week (in a population of <30,000)
10 cases per 100,000 people in a week (in a population of 30,000–100,000)
2 confirmed cases in one week in a camp

Viral haemorrhagic fevers

1 case

1 case

Yellow fever

1 case

1 case

Outbreak investigation and early response: Investigate further if an outbreak is confirmed or suspected. Determine the cause/source, who has been affected, modes of transmission and who is at risk, in order to take appropriate control measures.
Perform descriptive epidemiology investigations, including:
- cases, deaths and person, time and place of onset, to develop an epidemic curve and spot map;
- line listings which follow each case and analyse the extent of outbreak, for example number of hospitalisations, complications, case fatality rate; and
- calculating attack rates based on agreed population figures.
Develop a hypothesis that explains exposure and disease. Consider pathogen, source and route of transmission.

Evaluate the hypothesis and agree an outbreak case definition. This may be more specific than a case definition used for surveillance. Once laboratory investigations have confirmed an outbreak from numerous sources, follow the outbreak case definition; there may be no need to continue to collect samples.

Communicate and update findings promptly and regularly. Implement population-based control measures as soon as possible.

All of these activities may occur at the same time, especially during an ongoing outbreak ⊕ see Essential healthcare – communicable diseases standard 2.1.4: Outbreak preparedness and response.

Communicable diseases standard 2.1.3:
Diagnosis and case management

People have access to effective diagnosis and treatment for infectious diseases that contribute most significantly to morbidity and mortality.

Key actions

1
Develop clear messages that encourage people to seek care for symptoms such as fever, cough and diarrhoea.
- Develop written materials, radio broadcasts or mobile phone messages using accessible formats and languages.
2
Use approved standard case management protocols to provide healthcare.
- Consider implementing community-based case management such as for malaria, diarrhoea and pneumonia.
- Refer severe cases to higher levels of care or isolation.
3
Provide adequate laboratory and diagnostic capacity, supplies and quality assurance.
- Determine the use of rapid diagnostic tests or laboratory testing for pathogens, and at which level of healthcare it should be provided (for example, rapid diagnostic tests in the community).
4
Ensure treatment is not disrupted for people receiving long-term care for communicable diseases such as TB and HIV.
- Introduce TB control programmes only after recognised criteria are met.
- Coordinate with HIV programmes to ensure healthcare provision for those with HIV–TB co-infection.

Key indicators

Percentage of health centres supporting a crisis-affected population using standardised treatment protocols for a specified illness
- Use monthly record review to monitor trends
Percentage of suspected cases confirmed by a diagnostic method as determined by an agreed protocol

Guidance notes

Treatment protocols: Protocols should include a package of diagnosis, treatment and referral. If no such package is available in a crisis, consider international guidance. Understand local drug-resistance patterns (also considering displacement), especially for malaria, TB and typhoid. Consider clinically high-risk groups such as children under age two years, pregnant women, older people, people living with HIV and acutely malnourished children, who are at higher risk for certain communicable diseases.
Acute respiratory infections: In crises, vulnerability is increased by overcrowding, indoor smoke and poor ventilation, and malnutrition and/or vitamin A deficiency. Reduce case fatality rates through timely identification, oral antibiotics and referral of severe cases.
Diarrhoea and bloody diarrhoea: Control mortality rates through increased access to and use of oral rehydration therapy and zinc supplementation at household, community or primary healthcare level. Treatment can be at community oral rehydration points.
Community case management: Patients with malaria, pneumonia or diarrhoea can be treated by trained CHWs. Ensure all programmes are linked and overseen from the nearest healthcare facility. Ensure equitable and impartial access for all.
Laboratory testing: Establish a referral network of national, regional and international laboratory facilities to test specimens. Ensure rapid diagnostic testing for malaria, cholera and dengue fever, plus testing of blood haemoglobin level. Provide appropriate transport media for samples to be tested for other pathogens (such as Cary-Blair medium for cholera).
Train healthcare workers in diagnostic methods, quality assurance, and specimen collection, transport and documentation. Develop a protocol for definitive testing at reference laboratories nationally, regionally or internationally. Definitive testing includes cultures from specimens, serological and antigen testing or RNA testing for yellow fever, viral haemorrhagic fevers and hepatitis E. Establish protocols on safe transport mechanisms for pathogens, especially for viral haemorrhagic fever, plague or similar. Consider aviation regulations for transport of specimens by air.
Tuberculosis (TB) control is complex because of increasing drug resistance. Only establish programmes if continuous access to the population and provision of care is assured for at least 12–15 months. Multi-drug-resistant TB (MDR TB, resistant to two core anti-TB drugs, isoniazid and rifampicin) and extensively drug-resistant TB (EDR TB, resistant to four core anti-TB drugs) have been identified. Both these types require longer, more expensive and more complex treatments. In crises, it is often difficult to access the diagnostic and sensitivity testing necessary to ensure correct selection and use of TB medications.

Communicable diseases standard 2.1.4:
Outbreak preparedness and response

Outbreaks are adequately prepared for and controlled in a timely and effective manner.

Key actions

1
Develop and disseminate an integrated outbreak preparedness and response plan in partnership with all stakeholders and sectors.
- Focus training on key staff in high-risk areas.
- Pre-position essential medicines, medical devices, rapid tests, PPE and kits (such as for cholera and diarrhoeal disease) in epidemic-prone areas and areas with limited access.
2
Implement disease-specific control measures once an outbreak is detected.
- Determine the need for a targeted vaccination campaign.
- Scale up IPC measures, including providing isolation areas for cholera, hepatitis E or other outbreaks.
3
Create and coordinate outbreak-specific logistic and response capacity.
- Ensure transport and storage capacity for medicines and supplies, including cold chain for vaccines.
- Add healthcare facility capacity, such as cholera or meningitis tents.
- Ensure access and transport to laboratories at local, national and international levels to test samples.
4
Coordinate with other sectors as needed, including child protection.

Key indicators

Percentage of health staff in high-risk areas trained on outbreak response plan and protocols
Case fatality rate is reduced to an acceptable level
- Cholera <1 per cent
- Meningitis <15 per cent
- Hepatitis E <4 per cent in general population, 10–50 per cent in pregnant women in third trimester
- Diphtheria (respiratory) <5–10 per cent
- Pertussis <4 per cent in children aged one year, <1 per cent in those aged one to four years
- Dengue <1 per cent

Guidance notes

Outbreak preparedness and response plan: Develop this with health partners, MoH, community members and leaders. WASH, nutrition, shelter and education partners, the host government, prisons and military (if relevant) should also be involved. Ensure that other critical health services are not compromised when responding to the outbreak.
The plan should define:
- outbreak response coordination mechanism at national, subnational and community level;
- mechanisms for community mobilisation and risk communication;
- strengthening EWAR: disease surveillance, outbreak detection, outbreak (epidemiological) investigation;
- case management;
- control measures specific to disease and context;
- cross-sectoral measures;
- protocols on safe transport and referral pathways of samples for laboratory investigation;
- contingency plans for scaling up services at different levels of care, including establishing isolation areas in treatment centres;
- outbreak control team capacities and surge healthcare worker requirements; and
- availability of essential medicines, vaccines, medical devices, laboratory supplies and PPE for healthcare workers, including international procurement (for example, global stockpile of vaccines).
Outbreak control relies on adequate risk communication and dedicated outbreak control teams. Contain the outbreak comprehensively so it does not spread to new areas and to reduce the number of new cases where an outbreak is occurring. This will require active case finding and prompt diagnosis and case management. Provide isolation areas as needed (for example, for cholera or hepatitis E). Improve vector control to reduce exposure to infection, use LLINs and improved hygiene behaviour.
Vaccination campaigns
Meningitis: Serogroups A, C, W and Y can cause outbreaks in crises. Vaccines for A and C are available for use in epidemics. Routine vaccination in crises is not recommended and not possible for serogroups C and W. Target vaccination at specific age groups based on known attack rates, or at those aged six months to 30 years. Given the need for lumbar puncture for a definitive diagnosis, establish a clear case definition.
Viral haemorrhagic fever: The management and diagnosis of viral haemorrhagic fevers, such as Ebola or Lassa fever, are based on stringent national and international guidelines. This includes protocols on new vaccines and innovative treatment methods. Effective community engagement during these outbreaks is vital.

Yellow fever: Mass vaccination is recommended once a single case is confirmed in a settlement for displaced and host populations. Combine this with Aedes vector control measures and strict isolation of cases.

Polio: Polio is included in the WHO Expanded Programme on Immunization (EPI), and vaccination should be restarted following the initial stages of an emergency. Initiate mass vaccination if a case of paralytic polio is detected.

Cholera: Clear treatment and outbreak protocols should be available and coordinated across sectors. Use cholera vaccines according to the WHO framework and complement existing strategies for cholera control.

Hepatitis A and E: These present a significant risk, particularly in refugee camps. Prevent and control outbreaks using improved sanitation and hygiene and access to safe water.

Measles: ⊕ See Essential healthcare – child health standard 2.2.1: Childhood vaccine-preventable diseases.

Pertussis or diphtheria: Pertussis outbreaks are common when people are displaced. Due to concerns about risks among older recipients of the whole-cell diphtheria, pertussis and tetanus (DPT) vaccine, be careful about a pertussis outbreak-related vaccination campaign. Use an outbreak to address routine immunisation gaps. Case management includes antibiotic treatment of cases and early prophylactic treatment of contacts in households where there is an infant or a pregnant woman. Diphtheria outbreaks are less common but still a threat in crowded settings with low diphtheria immunity. In camps, mass diphtheria vaccination campaigns with three separate doses of vaccine are not unknown. Case management includes the administration of both antitoxin and antibiotic.
Case fatality rates: The acceptable case fatality rate CFR for specific diseases varies with context and existing immunity. Aim to reduce case fatality rates as much as possible. High case fatality rates may indicate a lack of access to appropriate healthcare, late presentation and case management, significant co-morbidities in the population, or poor-quality healthcare. Monitor the case fatality rate frequently and take immediate corrective steps if higher than expected.
Care of children: During outbreaks, consider children to be a specific group when designing and implementing programmes. Coordinate and refer between the health and child protection sectors. Address the risks of separating children from their parents. The risks may be caused by morbidity and mortality of the parents or by programme design. Focus on preventing family separation and ensure parental or child consent for treatment. Take measures to keep education facilities open, being mindful of necessary control measures and health education.

2.2 Essential healthcare – child health

During crises, children are even more vulnerable to infections, diseases and other risks to their health and lives. Not only have living conditions deteriorated, but immunisation programmes are also interrupted. The risks are even higher for unaccompanied and separated children.

A concerted child-focused response is required. Initially this will focus on lifesaving care, but ultimately interventions must alleviate suffering and promote growth and development. Programmes should address the major causes of morbidity and mortality. Globally these risks are acute respiratory infections, diarrhoea, measles, malaria, malnutrition and neonatal causes of morbidity and mortality.

Child health standard 2.2.1:
Childhood vaccine-preventable diseases

Children aged six months to 15 years have immunity against disease and access to routine Expanded Programme on Immunization (EPI) services during crises.

Key actions

1
Determine whether there is a need for vaccinations, and the appropriate approach for the emergency.
- Base this on an assessment of risk (for example population, season), feasability of a campaign (including need for mutliple doses, availibility), and context (such as security, competing needs). This should be an ongoing process as a crisis evolves ⊕ see Essential healthcare – communicable diseases standard 2.1.1: Prevention.
2
Conduct a mass measles vaccination campaign for children aged six months to 15 years, regardless of measles vaccination history, when estimated measles coverage is less than 90 per cent or unknown.
- Include vitamin A for children age 6–59 months.
- Ensure that all infants vaccinated between six and nine months receive another dose of measles vaccine at nine months.
3
Re-establish the EPI defined on p.401 and 402 EPI as soon as possible.
- Aim for primary healthcare facilities or systems of mobile teams/outreach to offer the national immunisation schedule for vaccine-preventable diseases at least 20 days per month.
4
Screen children attending healthcare facilities or mobile clinics for vaccination status and administer any needed vaccinations.

Key indicators

Percentage of children aged six months to 15 years who have received measles vaccination, on completion of a measles vaccination campaign
- >95 per cent
Percentage of children aged six to 59 months who have received an appropriate dose of vitamin A, on completion of measles vaccination campaign
- >95 per cent
Percentage of children aged 12 months who have had three doses of DPT
- >90 per cent
Percentage of primary healthcare facilities that offer basic EPI services at least 20 days/month

Guidance notes

Vaccination: Vaccines are vital in preventing excess deaths in acute crises. National guidance may not cover emergencies or people who have crossed borders, so work without delay to determine needed vaccines and create an implementation plan that includes procurement processes. ⊕ See Essential healthcare – communicable diseases standard 2.1.1 for guidance on risk assessment and vaccination decisions and Health systems standard 1.3: Essential medicines and medical devices on the procurement and storage of vaccines.
Measles vaccination: Measles immunisation is a priority health intervention in crises.
- Coverage: Review coverage data for displaced and host populations to assess if routine measles immunisation coverage or measles campaign coverage has been higher than 90 per cent for the preceding three years. Carry out a measles campaign if vaccination coverage is less than 90 per cent, unknown or in doubt. Administer vitamin A supplementation at the same time. Ensure that at least 95 per cent of newcomers to a settlement aged between six months and 15 years are vaccinated.
- Age ranges: Some older children may have missed routine vaccination, measles campaigns and the measles disease itself. These children remain at risk of measles infection and can infect infants and young children, who are at higher risk of dying from the disease. Therefore, vaccinate up to the age of 15 years. If this is not possible, prioritise children aged 6–59 months.
- Repeat vaccinations: All children aged nine months to 15 years should receive two doses of measles vaccine as part of standard national immunisation programmes. Children between six and nine months who have received the measles vaccine (for example, in an emergency campaign) should receive a further two doses at the recommended ages according to the national schedule (usually nine months and 15 months in high-risk areas).
Polio: Consider polio campaigns where polio outbreaks or threats to eradication programmes exist, as determined in Vaccination in Acute Humanitarian Crises: A Framework for Decision Making ⊕ see Essential healthcare – communicable diseases standard 2.1.1: Prevention.
National EPI programme: Re-establish EPI promptly to protect children against measles, diphtheria and pertussis and reduce the risk of respiratory infections. National EPI programmes may need supplemental vaccines ⊕ see Essential healthcare – communicable diseases standard 2.1.4: Outbreak preparedness and response.
Vaccine safety: Ensure the safety of vaccines at all times. Follow the manufacturer’s instructions for storage and refrigeration ⊕ see Health systems standard 1.3: Essential medicines and medical devices.
Informed consent: Obtain informed consent from parents or guardians to administer vaccine. This includes an understanding of risks and potential side effects.

Child health standard 2.2.2:
Management of newborn and childhood illness

Children have access to priority healthcare that addresses the major causes of newborn and childhood morbidity and mortality.

Key actions

1
Provide appropriate healthcare at different levels (facility, mobile clinics or community programmes).
- Use ‘Newborn Health in Humanitarian Settings’ guidelines for essential newborn care ⊕ see References.
- Consider adopting integrated community case management (iCCM) and Integrated Management of Childhood Illness (IMCI).
2
Establish a standardised system of assessment and triage at all facilities that provide care for sick newborns or children.
- Ensure that children with danger signs (unable to drink or breastfeed, vomits everything, convulsions, and lethargic or unconscious) receives immediate treatment.
- Include assessment of trauma and chemical poisoning in contexts where there is increased risk.
3
Make essential medicines available in the appropriate dosages and formulations for treating common childhood illnesses at all levels of care.
4
Screen children for their growth and nutritional status.
- Refer all malnourished children to nutritional services.
- Provide facility-based treatment for children suffering from severe acute malnutrition with complications.
5
Establish an appropriate case management protocol for treating childhood and vaccine-preventable diseases, such as diphtheria and pertussis, in situations where the risk of outbreak is high.
- Use existing protocols where possible.
6
Design health education messages to encourage families to engage in healthy behaviour and disease preventive practices.
- Promote actions such as exclusive breastfeeding, infant feeding, handwashing, keeping infants warm and encourage early childhood development.
7
Design health education messages to encourage people to seek early care for any illness such as fever, cough or diarrhoea among children and newborns.
- Take steps to reach children who do not have an adult or parent caring for them.
8
Identify children with a disability or developmental delay.
- Provide advice on and referrals to care or rehabilitation services.

Key indicators

Under-five crude mortality rates
- Fewer than 2 deaths per 10,000 per day ⊕ see Appendix 3 for calculations
Effective anti-malarial treatment provided in a timely manner to all children under age five years presenting with malaria
- Within 24 hours of the onset of symptoms
- Exception for children under age five years experiencing severe acute malnutrition
Oral rehydration salts (ORS) and zinc supplementation provided in a timely manner to all children under age five years presenting with diarrhoea
- Within 24 hours of the onset of symptoms
Appropriate care provided in a timely manner to all children under age five years presenting with pneumonia
- Within 24 hours of the onset of symptoms

Guidance notes

Essential newborn care: Provide all newborns with skilled care at birth, preferably in a healthcare facility and according to the ⊕ see ‘Integrated Management of Pregnancy and Childbirth’ (IMPAC) and ‘Newborn Health in Humanitarian Settings’ guidelines. Whether the birth takes place with or without skilled care, essential newborn care consists of:
- thermal care (delay bathing, and keep the baby dry and warm with skin-to-skin contact);
- infection prevention (promote clean birth practices, handwashing, clean cord, and skin and eye care);
- feeding support (immediate and exclusive breastfeeding, not discarding colostrum);
- monitoring (assess for danger signs of infections or conditions that may need referral); and
- post-natal care (provide it at or close to home in the first week of life, with the first 24 hours being the most critical for a post-natal care visit; aim for three home visits in the first week of life).
Integrated management of childhood illness (IMCI) focuses on the care of children under age five years at a primary healthcare level. After establishing IMCI, incorporate clinical guidelines into standard protocols and train health professionals properly.
Integrated community case management (iCCM) is an approach to provide timely and effective treatment of malaria, pneumonia and diarrhoea to people with limited access to healthcare facilities, especially to children under age five years.
Management of diarrhoea: Treat children with diarrhoea with low osmolality oral rehydration salts (ORS) and zinc supplementations. Zinc shortens the duration of diarrhoea, and ORS prevents dehydration. Encourage caregivers to continue or increase breastfeeding during the episode, and to increase all feeding after.
Management of pneumonia: If children have a cough, assess for fast or difficult breathing and chest indrawing. If present, treat with an appropriate oral antibiotic. Refer those with danger signs or severe pneumonia for priority care.
Fast breathing rates are age-specific:

Birth – 2 months: >60/min 12 months: >50/min

1–5 years: >40/min 5 years: >20/min
HIV: Where HIV prevalence is greater than 1 per cent, test all children with severe acute malnutrition. Mothers and caregivers of HIV-exposed infants require adapted support and advice ⊕ see Food security and nutrition standards.
Feeding separated children: Arrange supervised feeding for separated or unaccompanied children.
Child protection concerns: Use routine health services to identify child neglect, abuse and exploitation. Refer cases to child protection services. Integrate identification and gender-sensitive case management procedures into routine health services for mothers and infants, children and adolescents.
Nutrition referrals: ⊕ See Food security and nutrition standard 3: Micronutrient deficiencies, and Management of malnutrition standard 2.2: Severe acute malnutrition.
Household air pollution: Consider providing alternative cooking stoves to reduce smoke and fumes and the respiratory illness they cause ⊕ see Shelter and settlement standard 3: Living space and standard 4: Household items.
Poisoning: ⊕ See Appendix 4.

2.3 Sexual and reproductive health

From the onset of a crisis, critical life-saving sexual and reproductive care must be available. Establish comprehensive services as soon as feasible.

These critical services are part of an integrated health response and aided by the use of reproductive health kits ⊕ see Health systems standard 1.3: Essential medicines and medical devices.

Comprehensive sexual and reproductive healthcare involves upgrading existing services, adding missing services and enhancing quality. Understanding the health systems architecture will help determine how to support this ⊕ see Health systems standards 1.1 to 1.5.

All individuals, including those in humanitarian settings, have the right to sexual and reproductive health. Sexual and reproductive healthcare must respect the cultural backgrounds and religious beliefs of the community while meeting universally recognised international human rights standards. Be sensitive to the needs of adolescents, older people, persons with disabilities and at-risk populations, regardless of sexual orientation or gender identity.

Emergencies elevate risks of sexual violence, including exploitation and abuse. All actors should work together to prevent and respond, in close coordination with the protection sector. Compile information safely and ethically. Share data only according to agreed protocols ⊕ see Protection Principles and Health systems standard 1.5: Health information.

Sexual and reproductive health standard 2.3.1:
Reproductive, maternal and newborn healthcare

People have access to healthcare and family planning that prevents excessive maternal and newborn morbidity and mortality.

Key actions

1
Ensure that clean and safe delivery, essential newborn care, and emergency obstetric and newborn care services are available at all times.
- Establish a referral system with communication and transportation from the community to the healthcare facility or hospital that functions at all times.
2
Provide all visibly pregnant women with clean delivery packages when access to skilled health providers and healthcare facilities cannot be guaranteed.
3
Consult the community to understand local preferences, practices and attitudes towards contraception.
- Involve men, and women, and adolescent boys and girls in separate and private discussions.
4
Make a range of long-acting reversible and short-acting contraceptive methods available at healthcare facilities based on demand, in a private and confidential setting.
- Provide counselling that emphasises informed choice and effectiveness.

Key indicators

Skilled care is available for emergency obstetrics and newborn care at all times
- Basic emergency obstetric and newborn care: minimum five facilities per 500,000 people
- Comprehensive emergency obstetric and newborn care: minimum one facility per 500,000 people
Percentage of births attended by skilled personnel
- Minimum target: 80 per cent
Referral system for obstetric and newborn emergencies available
- Available 24 hours/day and 7 days/week
Percentage of deliveries in health facilities by caesarean section
- Target: 5–15 per cent
All primary health centres report availability of at least four methods of contraception between three and six months after the onset of the crisis.

Guidance notes

Emergency obstetric and newborn care: About 4 per cent of any population will be pregnant women, and about 15 per cent of those will experience an unpredictable obstetric complication during pregnancy or at the time of delivery that will require emergency obstetric care. About 5–15 per cent of deliveries will require surgery such as caesarean section. Globally 9–15 per cent of newborns will require life-saving emergency care. About 5–10 per cent of newborns do not breathe spontaneously at birth and require stimulation, and half of those require resuscitation. The major reasons for failure to breathe include pre-term birth and acute intrapartum events resulting in severe asphyxia ⊕ see Essential healthcare – child health standard 2.2.2: Management of newborn and childhood illness.
Basic emergency obstetrics and newborn care includes parenteral antibiotics, uterotonic drugs (parenteral oxytocin, misoprostol), parenteral anticonvulsant drugs (magnesium sulphate), removal of retained products of conception using appropriate devices, manual removal of placenta, assisted vaginal delivery (vacuum extraction), and maternal and newborn resuscitation.
Comprehensive emergency obstetric and newborn care includes all of the above as well as surgery under general anaesthesia (caesarean section, laparotomy), and rational and safe blood transfusion with standard precaution measures. Post-abortion care is a life-saving intervention that is part of emergency obstetric and newborn care and aims to reduce death and suffering from the complications of miscarriage (spontaneous abortion) and unsafe abortions. Treatment includes managing bleeding (possibly through surgical intervention) and sepsis, and providing tetanus prophylaxis.

It is essential that both basic and comprehensive emergency obstetric and newborn care services are available at all times.

The referral system should ensure that women or newborns have the means to travel to and from a primary healthcare facility with basic emergency obstetric and newborn care and to a hospital with comprehensive emergency obstetric and newborn care.
Family planning: Engage with various groups in the community to understand preferences and cultural attitudes. Ensure the community is aware of where and how to access contraception. Share information in multiple formats and languages to ensure accessibility. Engage community leaders to disseminate the information.
Trained providers who understand the client’s preferences, culture and context should give contraceptive counselling. Counselling should emphasise confidentiality and privacy, voluntary and informed choice and consent, method effectiveness for medical and non-medical methods, possible side effects, management and follow-up, and guidance on removal if needed.
A range of contraceptive types should be available immediately to meet anticipated demand. Providers should be trained to remove long-active reversible contraceptives.
Other services: Initiate other maternal and newborn care as soon as possible, including ante-natal and post-natal care.
Coordination with other sectors: Coordinate with the nutrition sector to ensure that pregnant and breastfeeding women are referred to nutrition services as appropriate, such as for targeted supplementary feeding ⊕ see Food security and nutrition – management of malnutrition standards 2.1 and 2.2.

Sexual and reproductive health standard 2.3.2:
Sexual violence and clinical management of rape

People have access to healthcare that is safe and responds to the needs of survivors of sexual violence.

Key actions

1
Identify a lead organisation to coordinate a multi-sectoral approach to reduce the risk of sexual violence, ensure referrals and provide holistic support to survivors.
- Coordinate with other sectors to strengthen prevention and response.
2
Inform the community of available services and the importance of seeking immediate medical care following sexual violence.
- Provide post-exposure prophylaxis for HIV as soon as possible (within 72 hours of exposure).
- Provide emergency contraception within 120 hours.
3
Establish safe spaces in healthcare facilities to receive survivors of sexual violence and to provide clinical care and referral.
- Display and use clear protocols and a list of patients’ rights.
- Train healthcare workers in supportive communication, maintaining confidentiality and protecting survivor information and data.
4
Make clinical care and referral to other supportive services available for survivors of sexual violence.
- Ensure referral mechanism for life-threatening, complicated or severe conditions.
- Establish referral mechanisms between health, legal, protection, security, psychosocial and community services.

Key indicators

All health facilities have trained staff, sufficient supplies and equipment for clinical management of rape survivor services based on national or international protocols
All survivors of sexual violence state they received healthcare in a safe and confidential manner
All eligible survivors of sexual violence receive:
- Post-exposure prophylaxis within 72 hours of an incident or from exposure
- Emergency contraception within 120 hours of an incident or from exposure

Guidance notes

Prevention of sexual violence and rape requires action across all sectors ⊕ see WASH water supply standard 2.1 ⊕ see WASH excreta management standard 3.2 ⊕ see Food security and nutrition – food assistance standard 6.3 and Livelihoods standard 7.2; Shelter and settlement standards 2 and 3 ⊕ see Protection Principle 1 and Core Humanitarian Standard Commitments 4 and 8. ⊕ See Health systems standard 1.1 to 1.3 for further information on making healthcare facilities safe and providing safe care.
Clinical care, including mental healthcare and referral for survivors, must be in place in all primary healthcare facilities and mobile teams ⊕ see Healthcare systems 1.2 and Essential healthcare standard 2.5. This includes skilled staff to provide compassionate, timely and confidential treatment and counselling to all children, adults and older people on:
- emergency contraception;
- pregnancy testing, pregnancy options information and safe abortion referral to the full extent of the law;
- presumptive treatment of STIs;
- post-exposure prophylaxis to prevent HIV transmission ⊕ see Health standard 2.3.3: HIV
- prevention of hepatitis B;
- care of wounds and prevention of tetanus; and
- referral for further services, such as other health, psychological, legal and social services.
Ensure equal gender distribution of healthcare workers fluent in local and patient languages, and coach female and male chaperones and interpreters to provide non-discriminatory and unbiased services. Train healthcare workers on clinical care for survivors of sexual violence, focusing on supportive communication, history and examination, treatment and counselling. Where feasible and needed, provide training on the medico-legal system and forensic evidence collection.
Child survivors of sexual violence: Children should be cared for by healthcare workers trained in post-rape management of children. Allow children to choose the gender of the healthcare worker. Involve specialised protection actors quickly in all cases.
Community engagement: Work with patients and the community to improve accessibility and acceptability of care and to deliver prevention programmes throughout a crisis. Ensure confidential feedback mechanisms and swift feedback. Involve women, men, adolescent girls and boys, and at-risk populations such as persons with disabilities and LGBTQI groups.
Legal frameworks: Be aware of the national medico-legal system and relevant laws on sexual violence. Inform survivors of any mandatory reporting laws that could limit the confidentiality of the information patients disclose to healthcare providers. This may influence their decision to continue to seek care, but must be respected.
In many countries, induced abortion is legal under circumstances such as rape. Where this is the case, access or referrals should be provided without discrimination.
While addressing sexual violence is critical, forms of gender-based violence (GBV) such as intimate partner violence, child and forced marriage and female genital mutilation are also not only prevalent in humanitarian crises, but in some scenarios may increase during a crisis and have significant unique health impacts (physical, sexual, mental) on individuals that require specific responses. Other international guidelines are increasingly recognising not only sexual violence, but these other forms of GBV and their impacts on health ⊕ see IASC Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action.

Sexual and reproductive health standard 2.3.3:
HIV

People have access to healthcare that prevents transmission and reduces morbidity and mortality due to HIV.

Key actions

1
Establish and follow standard precautions and procedures for the safe and rational use of blood transfusion.
2
Provide anti-retroviral therapy (ART) to everyone who is already on it, including women in prevention of mother-to-child transmission programmes.
- Actively trace people living with HIV to continue treatment.
3
Provide lubricated male condoms and, where already used by the population, female condoms.
- Work with leaders and the affected population to understand local use, increase acceptance and ensure that condom distribution is culturally appropriate.
4
Offer testing to all pregnant women where HIV prevalence is greater than 1 per cent.
5
Initiate post-exposure prophylaxis (PEP) as soon as possible, but within 72 hours of exposure for survivors of sexual violence and occupational exposure.
6
Provide co-trimoxazole prophylaxis for opportunistic infections for:
1. patients living with HIV; and
2. children born to mothers living with HIV, at four to six weeks of age; continue until HIV infection is excluded.
7
Ensure primary healthcare facilities have antimicrobials and provide syndromic management to patients with symptoms of an STI.

Key indicators

All transfused blood is screened and is free of transfusion-transmissible infections, including HIV
Percentage of people previously on anti-retroviral therapy (ART) who continue to receive ART medicines
- 90 per cent
Percentage of women accessing health services who are tested for HIV, where HIV prevalence is greater than 1 per cent
- 90 per cent
Percentage of individuals potentially exposed to HIV reporting to health facilities who receive PEP within 72 hours of exposure
- 100 per cent
Percentage of HIV-exposed infants receiving co-trimoxazole at four to six weeks of age
- 95 per cent

Guidance notes

The key actions above should apply in all humanitarian crises, regardless of the local HIV epidemiology.

Involve the affected community and key populations (healthcare workers, leaders, women, LGBTQI people, persons with disabilities) in HIV service delivery, and ensure they know where to access anti-retroviral (ARV) medicines. If there is already an association of people living with HIV, consult with and involve them in programme design and delivery.

Community-led distribution of condoms within peer groups is useful. Key populations and adolescents will often know where their peers congregate, and volunteers can distribute to peers. Educate key populations with culturally appropriate messages about correct use and disposal of used condoms. Make condoms available to the community, aid agency staff, uniformed staff, aid delivery truck drivers and others.

Blood transfusion: ⊕ See Health systems standards 1.1 and 1.3.
Post-exposure care and treatment should include counselling, HIV exposure risk assessment, informed consent, assessment of the source, and provision of anti-retroviral medicines. Do not give PEP to a person known to be living with HIV. Although counselling and testing is recommended before starting PEP, if not feasible do not delay the initiation of PEP ⊕ see Essential healthcare – sexual and reproductive health standard 2.3.2: Sexual violence and clinical management of rape.
Comprehensive HIV-related activities in crises: Establish the following activities as soon as feasible:
HIV awareness: Provide accessible information to the public, particularly to populations at higher risk, about preventing HIV and other STIs.
HIV prevention: Provide high-risk populations with harm-reduction services such as sterile injecting equipment and opioid substitution therapy for people who inject drugs, where these services already existed ⊕ see Essential healthcare standard 2.5: Mental health care.

HIV counselling and testing: Provide (or re-establish) counselling and testing services linked to ART initiation. Priority groups for HIV testing are pregnant women and their partners, children with severe acute malnutrition where the HIV prevalence is greater than 1 per cent, and other at-risk groups.

Stigma and discrimination: It is crucial to ensure that strategies and programmes do not increase stigma. Aim to actively decrease stigma and discrimination in areas known to have high stigma index and discriminatory behaviours.

ART interventions: Extend anti-retroviral therapy to all who need it – not only those who were previously enrolled – as soon as possible.

Prevention of mother-to-child transmission: Test pregnant women and their partners and provide early infant HIV diagnosis. Provide ART to women who are already known to be positive for or who newly test positive for HIV. Refer infants who test positive to paediatric HIV services. Provide infant feeding guidance specific to women living with HIV, and retention and adherence support ⊕ see Food security and nutrition – Infant and young child feeding standards 4.1 and 4.2.

Services for HIV/TB co-infection: Provide TB screening and referral for people living with HIV. Provide TB treatment to people previously enrolled on a treatment programme ⊕ see Essential healthcare – Communicable disease standard 2.1.3: Diagnosis and case management. Link testing services for TB and HIV in high – prevalence settings and establish TB infection control in healthcare settings.

Note: Caritas Internationalis and its Members do not promote the use of, or distribute any form of, artificial birth control.

2.4 Injury and trauma care

In any crisis, a high burden of morbidity and mortality is attributable to injury. Increased demand for trauma care services is likely to quickly exceed the capacities of local health systems. To reduce the impact of injuries and the risk of health system collapse, provide systematic triage and mass casualty management alongside basic emergency, safe operative and rehabilitative care. This section addresses the health system response to physical injury. Specific guidance on poisoning, mental health and sexual violence are addressed elsewhere ⊕ see Appendix 4: Poisoning; Essential healthcare standard 2.5 and Essential healthcare – Sexual and reproductive health standard 2.3.2.

Injury and trauma care standard 2.4:
Injury and trauma care

People have access to safe and effective trauma care during crises to prevent avoidable mortality, morbidity, suffering and disability.

Key actions

1
Provide care for trauma at all levels for all patients.
- Quickly establish safe referral systems between facilities and from affected communities to facilities.
- Establish mobile clinics or field hospitals if care in fixed structures is not accessible to the population.
2
Ensure that healthcare workers have the skills and knowledge to address injuries.
- Include all levels from first responders to those providing definitive surgical and anaesthetics care.
3
Establish or strengthen standardised protocols for triage and injury and trauma care.
- Include referral systems for child protection, survivors of sexual violence, and those requiring mental health and psychosocial support.
4
Provide tetanus prophylaxis to anyone at risk of injury, to injured people with open wounds and those involved in rescue and clean-operations.
5
Ensure minimum safety and governance standards for all facilities providing trauma and injury care, including field hospitals.
6
Ensure timely access to rehabilitation services, priority assistive devices and mobility aids for injured patients.
- Confirm that assistive devices such as wheelchairs and crutches or other mobility aids can be repaired locally.
7
Ensure timely access to mental health services and psychosocial support.
8
Establish or strengthen the health information systems to include injury and trauma data.
- Prioritise basic clinical documentation such as individual medical records for all trauma patients.
- Use standard definitions to integrate injury into the health information system data sets.

Key indicators

Percentage of health facilities that have a disaster plan including management of mass casualties, reviewed and rehearsed on a regular basis
Percentage of health facilities with protocols for the acutely injured including formal triage instruments
Percentage of health facilities with staff that have received basic training in the approach to the acutely injured
Percentage of health facilities implementing quality improvement measures to reduce baseline morbidity and mortality according to available data

Guidance notes

Training and skills development for injury and trauma care should include:
- mass casualty management, for those responding and coordinating response;
- basic first aid;
- standardised triage in the field and at healthcare facilities; and
- early recognition, resuscitation, wound management, pain control and time-sensitive psychosocial support.
Standardised protocols should exist or be developed to cover the following:
- acuity-based triage classification for routine and surge situations that includes assessment, prioritisation, basic resuscitation and criteria for emergency referral;
- frontline emergency care at the point of access; and
- referrals for emergency and advanced care, including surgery, post-operative care and rehabilitation.
Minimum safety and quality standards: Even where trauma care is being provided in response to an acute event or ongoing conflict, Minimum Standards must be assured. Areas to be addressed include:
- the safe and rational use of medications, devices and blood products, including supply chain;
- infection prevention and control;
- sufficient power supply for lighting, communications and operating essential medical devices such as emergency resuscitation equipment and sterilisation autoclaves; and
- medical waste management.
Community-based first aid: Timely and appropriate first aid by non-professionals saves lives if done in a safe and systematic manner. All first aiders should use a structured approach to the injured. Basic wound management training, such as in cleaning and dressing, is vital.
Include household- and community-level first aid, and guidance on when and where to seek medical help. Raise awareness of context-specific risks such as unstable infrastructure or risk of injury during rescue attempts.
Triage is the process of categorising patients according to the severity of their injuries and their need for care. It identifies those who would most benefit from immediate medical intervention. Several triage systems exist. One widely used system applies five colours: red for highest priority patients, yellow for medium, green for lower, blue for patients beyond the technical capacity of the facility or who require palliative care, and grey for the deceased.
Frontline professional emergency care: All higher-level healthcare workers, such as doctors, should be skilled in a systematic approach to the acutely ill and injured ⊕ see the ABCDE approach in the IFRC International First Aid and Resuscitation Guidelines. Initial resuscitation and life-saving interventions, such as fluid and antibiotic administration, haemorrhage control and treatment of pneumothorax, can be delivered in many settings before transferring the patient to advanced services.
Anaesthesia, trauma and surgical care: Emergency, operative and rehabilitative care should be undertaken only by organisations with appropriate expertise. Providers should act within their professional scope of practice, with adequate resources to sustain their activities. Inappropriate or inadequate care may do more harm than doing nothing. Surgery provided without appropriate pre- and post-operative care and ongoing rehabilitation can result in a failure to restore functional capacities of the patient.
Field hospitals: The use of temporary field hospitals may be necessary, especially in acute crises, and should be coordinated with MoH or lead agencies and other health actors. Standards and safety of care should meet national and international standards ⊕ see References for further guidance.
Rehabilitation and social reintegration: Early rehabilitation can increase survival, maximise the impact of medical and surgical interventions and enhance quality of life for injured survivors. Medical teams with inpatient capacity must be able to provide early rehabilitation. Map existing rehabilitation capacities and referral pathways and understand the links between existing social welfare systems and cash-based assistance. Establish links with local rehabilitation centres or community-based rehabilitation organisations for ongoing care.
Prior to discharge, consider the ongoing needs of trauma and injury patients, including those with a pre-existing disability. Ensure medical and rehabilitation follow-up, patient and caregiver education, essential assistive devices (such as crutches or wheelchairs), mental health and psychosocial support, and access to other essential services. Establish multi-disciplinary care plans and teams including physical rehabilitation specialists and staff skilled in mental healthcare and psychosocial support. Mental health and psychosocial support for those with life-changing injuries should begin as when they are inpatients. Links to ongoing support services are essential ⊕ see Essential healthcare standard 2.5: Mental health care.
Special management considerations – pain control: Good pain management after injury reduces the risks of pneumonia and deep vein thrombosis and helps the patient start physiotherapy. It reduces the physiological stress response, leading to a reduction in cardiovascular morbidity, and reduces psychological stress. Acute pain from trauma should be treated following the reverse WHO pain ladder. Neuropathic pain resulting from nerve injury may be present from the outset and should be treated appropriately ⊕ see Health systems standard 1.3: Essential medicines and medical devices and Essential healthcare standard 2.7: Palliative care ⊕ see WHO pain ladder.
Special management considerations – wound management: In most crises, many patients will present for care more than six hours after injury. Delayed presentation greatly increases the risk of wound infection and associated mortality. Healthcare workers must know protocols to manage wounds (including burns) and prevent and treat infection, for both acute and delayed presentations. These protocols include providing appropriate antibiotics, surgical removal of foreign material and dead tissue, and dressing.
Tetanus: In sudden-onset natural disasters the risk of tetanus can be relatively high. Administer tetanus toxoid-containing vaccine (DT or Td – diphtheria and tetanus vaccines – or DPT, depending on age and vaccination history) to those with open wounds. Individuals with dirty or highly contaminated wounds should also receive a dose of tetanus immune globulin (TIG) if they are not vaccinated against tetanus.

2.5 Mental health

Mental health and psychosocial problems are common among adults, adolescents and children in all humanitarian settings. The extreme stressors associated with crises place people at increased risk of social, behavioural, psychological and psychiatric problems. Mental health and psychosocial support involves multi-sectoral actions. This standard focuses on actions by health actors ⊕ see the Core Humanitarian Standard and Protection Principles for more information on psychosocial interventions across sectors.

Mental health standard 2.5:
Mental health care

People of all ages have access to healthcare that addresses mental health conditions and associated impaired functioning.

Key actions

1
Coordinate mental health and psychosocial supports across sectors.
- Set up a cross-sectoral technical working group for mental health and psychosocial issues. It may be co-led by a health organisation and a protection humanitarian organisation.
2
Develop programmes based on identified needs and resources.
- Analyse existing mental health systems, staff competencies, and other resources or services.
- Conduct needs assessments, keeping in mind that mental health conditions may be pre-existing, induced by the crisis or both.
3
Work with community members, including marginalised people, to strengthen community self-help and social support.
- Promote community dialogue on ways to address problems collaboratively, drawing on community wisdom, experience and resources.
- Preserve or support re-initiation of pre-existing support mechanisms such as groups for women, youth and people living with HIV.
4
Orient staff and volunteers on how to offer psychological first aid.
- Apply the principles of psychological first aid to manage acute stress after recent exposure to potentially traumatic events.
5
Make basic clinical mental healthcare available at every healthcare facility.
- Organise brief training and supervise general healthcare workers to assess and manage priority mental health conditions.
- Organise a referral mechanism among mental health specialists, general healthcare providers, community-based support and other services.
6
Make psychological interventions available where possible for people impaired by prolonged distress.
- Where feasible, train and supervise non-specialists.
7
Protect the rights of people with severe mental health conditions in the community, hospitals and institutions.
- Visit psychiatric hospitals and residential homes for people with severe mental health conditions on a regular basis from early in the crisis.
- Address neglect and abuse in institutions and organise care.
8
Minimise harm related to alcohol and drugs.
- Train staff in detection and brief interventions, harm reduction, and management of withdrawal and intoxication.
9
Take steps to develop a sustainable mental health system during early recovery planning and protracted crises.

Key indicators

Percentage of secondary healthcare services with trained and supervised staff and systems for managing mental health conditions
Percentage of primary healthcare services with trained and supervised staff and systems for managing mental health conditions
Number of people participating in community self-help and social support activities
Percentage of health services users who receive care for mental health conditions
Percentage of people who have received care for mental health conditions who report improved functioning and reduced symptoms
Number of days for which essential psychotropic medicines were not available in the past 30 days
- Less than four days

Guidance notes

Multi-level support: Crises affect people in different ways, requiring different kinds of support. A key to organising mental health and psychosocial support is to develop a layered system of complementary supports that meets different needs, as illustrated in the diagram below. This pyramid shows how different actions complement each other. All layers of the pyramid are important and should ideally be implemented concurrently.
Pyramid of multi-layered services and supports (Figure 10)

Source: IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings (2010)
Assessment: Rates of mental health conditions are substantial in any crisis. Prevalence studies are not essential to initiate services. Use rapid participatory approaches and, where possible, integrate mental health in other assessments. Do not limit assessment to one clinical issue.
Community self-help and support: Engage community health workers, leaders and volunteers to enable community members, including marginalised people, to increase self-help and social support. Activities could include creating safe spaces and the conditions for community dialogue.
Psychological first aid: Psychological first aid needs to be available to people exposed to potentially traumatic events such as physical or sexual violence, witnessing atrocities and experiencing major injuries. This is not a clinical intervention. It is a basic, humane and supportive response to suffering. It includes listening carefully, assessing basic needs and ensuring they are met, encouraging social support and protecting from further harm. It is non-intrusive and does not press people to talk about their distress. After brief orientation, community leaders, healthcare workers and others involved in the humanitarian response can provide psychological first aid to people in distress. Although psychological first aid should be widely available, the overall mental health and psychosocial support response should not be limited to it alone.
Single-session psychological debriefing promotes venting by encouraging people to briefly but systematically recount perceptions, thoughts and emotional reactions experienced during a recent stressful event. It is at best ineffective and should not be used.
Other psychological interventions: Non-specialised healthcare workers can deliver psychological interventions for depression, anxiety and post-traumatic stress disorder when they are well trained, supervised and supported. This includes cognitive behaviour therapy or interpersonal therapy.
Clinical mental healthcare: Brief all health staff and volunteers about available mental healthcare. Train health providers according to evidence-based protocols such as the. Where possible, add a mental health professional such as a psychiatric nurse to general healthcare facilities. Arrange private space for consultations ⊕ see mhGAP Humanitarian Intervention Guide.
The most frequent conditions presented to health services in emergencies are psychosis, depression and a neurological condition, epilepsy. Maternal mental health is of specific concern because of its potential impact on care for children.
Integrate mental health categories into the health information system ⊕ see Appendix 2: Sample HMIS form.
Essential psychotropic medicines: Organise an uninterrupted supply of essential psychotropic medicines with at least one from each therapeutic category (anti-psychotic, anti-depressant, anxiolytic, anti-epileptic, and medicines to counter side effects of anti-psychotics. ⊕ See the Interagency Emergency Health Kit for suggested psychotropic medicines and Health systems standard 1.3: Essential medicines and medical devices.
Protecting the rights of people with mental health conditions: During humanitarian crises, people with severe mental health conditions are extremely vulnerable to human rights violations such as abuse, neglect, abandonment and lack of shelter, food or medical care. Designate at least one agency to address the needs of people in institutions.
Transition to post-crisis: Humanitarian crises increase the long-term rates of many mental health conditions, so it is important to plan for sustained increased treatment coverage across the affected area. This includes strengthening existing national mental health systems and fostering inclusion of marginalised groups (including refugees) in these systems. Demonstration projects, with short-term emergency funding, can provide proof-of-concept and create momentum to attract further support and funds for mental health system development.

2.6 Non-communicable diseases

The need to focus on non-communicable diseases (NCDs) in humanitarian crises reflects increased global life expectancy combined with behavioural risk factors such as tobacco smoking and unhealthy diets. About 80 per cent of deaths from NCDs occur in low- or middle-income countries, and emergencies exacerbate this.

Within an average adult population of 10,000 people, there are likely to be 1,500–3,000 people with hypertension, 500–2,000 with diabetes, and 3–8 acute heart attacks over a normal 90-day period.

Diseases will vary but often include diabetes, cardiovascular disease (including hypertension, heart failure, strokes, chronic kidney disease), chronic lung disease (such as asthma and chronic obstructive pulmonary disease) and cancer.

Initial response should manage acute complications and avoid treatment interruption, followed by more comprehensive programmes.

Mental health and palliative care are specifically addressed in ⊕ Essential healthcare standards 2.5: Mental healthcare and 2.7: Palliative care.

Non-communicable diseases standard 2.6:
Care of non-communicable diseases

People have access to preventive programmes, diagnostics and essential therapies for acute complications and long-term management of non-communicable diseases.

Key actions

1
Identify the NCD health needs and analyse the availability of services pre-crisis.
- Identify groups with priority needs, including those at risk of life-threatening complications such as insulin-dependent diabetes or severe asthma.
2
Implement phased-approach programmes based on life-saving priorities and relief of suffering.
- Ensure patients diagnosed with life-threatening complications (for example, severe asthma attack, diabetic ketoacidosis) receive appropriate care. If appropriate care is not available, offer palliative and supportive care.
- Avoid sudden treatment disruption for patients diagnosed before the crisis.
3
Integrate NCD care into the health system at all levels.
- Establish a referral system to manage acute complications and complex cases in secondary or tertiary care, and to palliative and supportive care.
- Refer patients for nutrition or food security responses where required.
4
Establish national preparedness programmes for NCDs.
- Include essential medicines and supplies in pre-positioned or contingency emergency medical supplies.
- Prepare individual patients with a backup supply of medications and instructions on where to access emergency care should a crisis occur.

Key indicators

Percentage of primary healthcare facilities providing care for priority NCDs
Number of days essential medicines for NCDs were not available in the past 30 days
- Less than four days
Number of days for which basic equipment for NCDs was not available (or not functional) in the past 30 days
- Less than four days
All healthcare workers providing NCD treatment are trained in NCD management

Guidance notes

Needs and risk assessment to identify priority NCDs: Design according to context and phase of emergency. This could involve reviewing records, using pre-crisis data, and conducting household surveys or epidemiological assessment with a cross-sectional survey. Gather data regarding specific NCD prevalence and incidence and identify life-threatening needs or severely symptomatic conditions.
Analyse pre-crisis service availability and use, especially for complex cases such as cancer or chronic renal disease, to assess expectations and health system capacity in the context. The medium- to long-term aim is to support and reinstate such services.
Complex treatment needs: Provide continuity of care for patients with complex needs such as renal dialysis, radiotherapy and chemotherapy, if possible. Give clear and accessible information about referral pathways. Provide referrals to palliative care support if available ⊕ see Essential healthcare standard 2.7: Palliative care.
Integration of NCD care into the health system: Provide basic treatment for NCDs at primary healthcare level in line with national standards, or in line with international emergency guidance where national standards do not exist.
Work with communities to improve early detection and referrals. Integrate CHWs into primary care facilities, and engage with community leaders, traditional healers and the private sector. Outreach services can provide NCD health services to isolated populations.
Adapt the existing health information system for the crisis setting, or develop a new one, to include monitoring of main NCDs: hypertension, diabetes, asthma, chronic obstructive pulmonary disease, ischaemic heart disease and epilepsy ⊕ see Health systems standard 1.5: Health information and appendix 2.
Medicines and medical devices: Review the national list of essential medicines and devices, including technologies and core laboratory tests, to manage NCDs. Focus on primary healthcare ⊕ see Health systems standard 1.3: Essential medicines and medical devices. If needed, advocate for the inclusion of key essential medicines and medical devices in line with international and emergency guidance on NCDs. Provide access to essential medicines and medical devices at the appropriate levels of care. NCD kits may be used in conjunction with inter-agency emergency health kits in the early stages of the crisis to increase availability of essential medicines and equipment. Do not use these kits to provide long-term supplies.
Training: Train all levels of clinical staff on case management of NCD conditions and train all staff in priority NCD management, including standard operating procedures on referral ⊕ see Health systems standard 1.2: Health care workforce.
Health promotion and education: Provide information about NCD services and where to access care. Information should be accessible to all, including older people and persons with disabilities, to promote healthy behaviours, modifying risk factors, and improving self-care and adherence to treatment. Healthy behaviours can include regular physical activity or reducing alcohol and tobacco consumption, for example. Work with different parts of the community to develop messages and distribution strategies so that they are age, gender and culturally appropriate. Adapt prevention and control strategies to the context, considering constraints such as limited food supply or overcrowding.
Prevention and preparedness plans: Include NCD management in national disaster and emergency plans, ensuring it is specific to the different types of healthcare facilities (for example, small health centres or major hospitals with dialysis units). Health centres in unstable or disaster-prone contexts should be prepared for NCD service delivery.
Form a registry of patients with complex conditions and critical needs and create standardised operating protocols for referring them if a crisis occurs.

2.7 Palliative care

Palliative care is the prevention and relief of suffering and distress associated with end-of-life care. It includes identifying, assessing and treating pain as well as other physical, psychosocial and spiritual needs. Integrate physiological, psychological and spiritual care based solely on patient or family request, and include support systems to help patients, families and caregivers. This end-of-life care should be provided regardless of the cause.

Palliative care standard 2.7:
Palliative care

People have access to palliative and end-of-life care that relieves pain and suffering, maximises the comfort, dignity and quality of life of patients, and provides support for family members.

Key actions

1
Establish guidelines and policies to support consistent palliative care.
- Include national or international guidelines for pain and symptom control at healthcare facilities.
- Develop triage guidelines based on the patient’s medical condition and prognosis and availability of resources.
2
Develop a care plan and provide palliative care to patients who are dying.
- Ensure pain relief and dignity in death in an acute emergency, as a minimum.
- Explore the patient’s or family’s understanding of the situation as well as their concerns, values and cultural beliefs.
3
Integrate palliative care into all levels of health system.
- Establish strong referral networks to provide continuity of support and care.
- Prioritise community-based management involving home-based care.
4
Train healthcare workers to provide palliative care, including pain and symptom control, and mental health and psychosocial support.
- Meet national standards, or international standards where national standards do not exist.
5
Provide essential medical supplies and equipment.
- Stock palliative medicines and appropriate medical devices such as incontinence pads and catheters at healthcare facilities.
- Be aware of controlled drugs regulations that may delay availability of essential medicines.
6
Work with local systems and networks to support patients, caregivers and families in the community and at home.
- Provide supplies for home care needs, such as incontinence pads, urinary catheters and dressing packs.

Key indicators

Number of days for which essential palliative care medicines were not available in the past 30 days
- Less than 4 days
Percentage of staff trained in basic pain and symptom control or palliative care in each health centre, hospital, mobile clinic and field hospital
Percentage of patients identified by the healthcare system as in need that have received end-of-life care

Guidance notes

Humanitarian health actors should be aware of and respect local ways of making medical decisions and local values related to illness, suffering, dying and death. Relief of suffering is important, and dying patients should receive comfort-oriented care, whether their illness is from fatal injuries, infectious disease or any other cause.

Developing a care plan: Identify relevant patients and respect their right to make informed decisions about their care. Provide unbiased information and take account of their needs and expectations. The care plan should be agreed and be based on patient preferences. Offer access to mental health and psychosocial support.
Availability of medicines: Some palliative care medicines such as pain relief are included in the basic and supplementary modules of the inter-agency emergency health kit, and in the Essential Medicines List. Inter-agency emergency health kits (IEHK) are useful for early phases of a crisis but are not suitable for protracted situations where more sustainable systems should be established ⊕ see Health systems standard 1.3: Essential medicines and medical devices and References and further reading.
Family, community and social support: Coordinate with other sectors to agree a referral pathway for patients and their families to have integrated support. This includes accessing national social and welfare systems or organisations that offer assistance in shelter, hygiene and dignity kits, cash-based assistance, mental health and psychosocial support, and legal assistance to ensure that basic daily needs are met.
Coordinate with relevant sectors to trace separated families so that patients may communicate with them.
Work with existing networks of community care, who often have trained home-based care facilitators and community psychosocial workers, to provide additional support for patients and family members and help provide home-based care if required (such as for people living with HIV).
Spiritual support: All support should be based on patient or family requests. Work with local faith leaders to identify spiritual care providers who share the patient’s faith or belief. These providers can act as a resource for patients, carers and humanitarian actors.
Orient local faith leaders on key principles of psychosocial support for patients facing major health issues.
Establish reliable mechanisms for bilateral referral between the healthcare system and spiritual leaders for any patient, caregiver or family member who requests it.

Ensure support for safe and dignified burial practices in collaboration with the local community, according to national or international guidance ⊕ see Health systems standard 1.1: Health service delivery.

Appendix 1
Health assessment checklist

Preparation

Obtain available information on the crisis-affected population.
Obtain available maps, aerial photos or satellite images, and geographic information system (GIS) data of the affected area.
Obtain demographic, administrative and health data.

Security and access

Determine the existence of the ongoing natural or human-made hazards.
Determine the overall security situation, including the presence of armed forces.
Determine the access that humanitarian organisations have to the crisis-affected population.

Demographics and social structure

Determine the size of the crisis-affected population, disaggregated by sex, age and disability.
Identify groups at increased risk, such as women, children, older people, persons with disabilities, people living with HIV or marginalised groups.
Determine the average household size and estimates of the number of female- and child-headed households.
Determine the existing social structure and gender norms, including positions of authority and/or influence in the community and the household.

Background health information

Identify health problems that existed in the crisis-affected area before the emergency.
Identify pre-existing health problems in the country of origin for refugees, or the area of origin for internally displaced persons.
Identify existing risks to health, such as potential epidemic diseases.
Identify pre-existing and existing barriers to healthcare, social norms and beliefs, including positive and harmful practices.
Identify previous sources of healthcare.
Analyse the various aspects of the health system and their performance ⊕ see Health systems standards 1.1 to 1.5.

Mortality rates

Calculate the crude mortality rate.
Calculate the age-specific mortality rates (such as under-five mortality rate).
Calculate cause-specific mortality rates.
Calculate proportional mortality rate.

Morbidity ratesc

Determine incidence rates of major health conditions that have public health importance.
Determine age- and sex-specific incidence rates of major health conditions where possible.

Available resources

Determine the capacity of the MoH of the country affected by the crisis.
Determine the status of national health facilities, including total number by type of care provided, degree of infrastructure damage, and access.
Determine the numbers and skills of available healthcare staff.
Determine the available health budgets and financing mechanism.
Determine the capacity and functional status of existing public health programmes such as Extended Programme on Immunisation.
Determine the availability of standardised protocols, essential medicines, medical devices and equipment, and logistics systems.
Determine the status of existing referral systems.
Determine the level of IPC standards in health facilities.
Determine the status of the existing health information system.

Data from other relevant sectors

Nutritional status.
Environmental and WASH conditions.
Food basket and food security.
Shelter – quality of shelter.
Education – health and hygiene education.

Appendix 2
Sample weekly surveillance reporting forms

2.1 Mortality surveillance form (aggregate)*

Site: .......................................................................................................................................................
Date from Monday: .......................................	To Sunday: ............................................................
Total population at beginning of this week: .............................................................................
Births this week: ............................................	Deaths this week: ..............................................
Arrivals this week (if applicable): ..............	Departures this week: ......................................
Total population at end of week: ..............	Total under 5 years population: ....................

<5 Years

≥5 Years

Total

Male

Female

Male

Female

Immediate cause

Acute lower respiratory infection

Cholera (suspected)

Diarrhoea – bloody

Diarrhoea – watery

Injury – non-accidental

Malaria

Maternal death – direct

Measles

Meningitis (suspected)

Neonatal (0–28 days)

Other

Unknown

Total by age and sex

Underlying cause

AIDS (suspected)

Malnutrition

Maternal death – indirect

Non-communicable diseases (specify)

Other

Total by age and sex

*This form is used when there are many deaths and therefore more detailed information on individual deaths cannot be collected due to time limitations.

–Other causes of mortality can be added according to context and epidemiological pattern.

–Age can be further disaggregated as feasible, for example 0–11 months, 1–4 years, 5–14 years, 15–49 years, 50–59 years, 60–69 years, 70–79 years, 80+ years.–

–Deaths should not be reported solely from health facilities, but should include reports from site and religious leaders, community workers, women’s groups and referral hospitals.

–Whenever possible, case definitions should be put on the back of this form.

2.2 Mortality surveillance form (individual records) *

Site: ........................................................................................................................................................
Date from Monday: .......................................	To Sunday: ............................................................
Total population at beginning of this week: .............................................................................
Births this week: ............................................	Deaths this week: ..............................................
Arrivals this week (if applicable): ..............	Departures this week: ......................................
Total population at end of week: ..............	Total under 5 years population: ....................

No

Sex (m, f)

Age (days=d, months=m, yrs=y)

Direct cause of death

Underlying causes

Acute lower respiratory infection

Cholera (suspected)

Diarrhoea – bloody

Diarrhoea – watery

Injury – non-accidental

Malaria

Maternal death – direct

Measles

Meningitis (suspected)

Neonatal (0-28 days)

Non-communicable dis. (specify)

Other (specify)

Unknown

AIDS (suspected)

Malnutrition

Maternal death (indirect)

Other (specify)

Date (dd/mm/yy)

Location in site (e.g. block no.)

Died in hospital or at home

1

2

3

4

5

6

7

8

*This form is used when there is enough time to record data on individual deaths; it allows analysis by age, location and facility utilisation rates.

–Frequency of reporting (that is, daily or weekly) depends upon the number of deaths.

–Other causes of death can be added as appropriate in the situation.

–Deaths should not be reported solely from site health facilities, but should include reports from site and religious leaders, community workers, women’s groups and referral hospitals.

–Whenever possible, case definitions should be put on the back of this form.

–Age can be further disaggregated as feasible, for example 0–11 months, 1–4 years, 5–14 years, 15–49 years, 0–59 years, >60 years.

2.3 Sample early warning alert and response (EWAR) early warning reporting form

This form is used in the acute phase of the crisis when the risk of public health events, such as trauma, poisoning, or outbreaks from epidemic-prone diseases, are high.

Date from Monday: ..................................................................	To Sunday: ..............................................................................
Town/village/settlement/camp: ..............................................................................................................................................
Province: ......................................................................................	District: ....................................................................................
Subdistrict: ..................................................................................	Site name: ..............................................................................
• Inpatient • Outpatient • Health centre • Mobile clinic
Supporting agency(ies): ..............................................................................................................................................................
Reporting officer & contact number: .....................................................................................................................................
Total population: .......................................................................	Total under 5 years population: ...

A. WEEKLY AGGREGATE DATA

New cases of:

Morbidity

Mortality

Total

<5 Years

5 Years and over

<5 Years

5 Years & over

TOTAL ADMISSIONS

TOTAL DEATHS

Acute respiratory infection

Acute watery diarrhoea

Acute bloody diarrhoea

Malaria – suspected/confirmed

Measles

Meningitis – suspected

Acute haemorrhagic fever syndrome

Acute jaundice syndrome

Acute flaccid paralysis (AFP)

Tetanus

Other fever >38.5°C

Trauma

Chemical poisoning

Others

Total

–More than one diagnosis is possible; the most important should be recorded. Each case should be counted only once.

–Include only those cases that were seen (or deaths that occurred) during the surveillance week.

–Write “0” (zero) if you had no case or death during the week for one of the syndromes listed in the form.

–Deaths should be reported only in the mortality section, NOT in the morbidity section.

–Case definitions for each condition under surveillance should be written on the back of this form.

–Causes of morbidity can be added or subtracted according to the epidemiology and risk assessment of disease.

–The purpose of EWAR surveillance is the early detection of public health events that need immediate response.

–Data on conditions such as malnutrition should be obtained through surveys (prevalence), rather than surveillance (incidence).

B. OUTBREAK ALERT

At any time you suspect any of the following diseases, please SMS or phone ……………….. or email ……………... with maximum information on time, place and number of cases and deaths: cholera, shigellosis, measles, polio, typhoid, tetanus, hepatitis A or E, dengue, meningitis, diphtheria, pertussis, haemorrhagic fever, trauma and chemical poisoning. This list of diseases will vary depending on the disease epidemiology of the country.

2.4 Sample routine health management information system (HMIS) surveillance reporting form

Site: .......................................................................................................................................................
Date from Monday: .................................................	To Sunday: ..................................................
Total population at beginning of this week/month: ..............................................................
Births this week/month: .......................................	Deaths this week/month: .....................
Arrivals this week/month (if applicable): ..................................................................................
Departures this week/month: ......................................................................................................
Total population at end of week/month: ..................................................................................
Total under 5 years population: ...................................................................................................

Morbidity

Under 5 years
(new cases)

5 years and over
(new cases)

Total

Repeat cases

Diagnosis

Male

Female

Total

Male

Female

Total

New cases

Total

Acute respiratory infection

Acute watery diarrhoea

Acute bloody diarrhoea

Malaria – suspected/confirmed

Measles

Meningitis – suspected

Acute haemorrhagic fever syndrome

Acute jaundice syndrome

Acute flaccid paralysis (AFP)

Tetanus

Other fever >38.5°C

HIV/AIDS

Eye diseases

Skin diseases

Acute malnutrition

Sexually Transmitted Infection

Genital ulcer disease

Male urethral discharge

Vaginal discharge

Pelvic inflammatory disease (PID)

Neonatal conjunctivitis

Congenital syphili

Non-communicable diseases

Hypertension

Ischaemic heart disease

Diabetes

Asthma

Chronic obstructive pulmonary disease

Epilepsy

Other chronic NCD

Mental Health

Alcohol or other substance use disorder

Intellectual disability and development disorders

Psychotic disorder (including bipolar disorder)

Dementia or delirium

Moderate-severe emotional disorder/depression

Medically unexplained somatic complaint

Self-harm (including suicide attempt)

Other psychological complaint

Injuries

Major head/spine injury

Major torso injury

Major extremity injury

Moderate injury

Minor injury

Total

Age can be further disaggregated as feasible, for example 0–11 months, 1–4 years, 5–14 years, 15–49 years, 50–59 years, >60 years

Appendix 3
Formulas for calculating key health indicators

Crude mortality rate (CMR)

Definition: The rate of death in the entire population, including both women and men and all ages.

Formula:

Under-5 mortality rate (U5MR)

Definition: The rate of death among children below five years of age in the population.

Formula:

Incidence rate

Definition: The number of new cases of a disease that occur during a specified period of time in a population at risk of developing the disease.

Formula:

Case fatality rate (CFR)

Definition: The number of people who die of a disease divided by the number of people who have the disease.

Formula:

Health facility utilisation rate

Definition: The number of outpatient visits per person per year. Whenever possible, draw a distinction between new and old visits. New visits should be used to calculate this rate. However, it is often difficult to differentiate between new and old visits, so they are frequently combined as total visits during a crisis.

Formula:

Number of consultations per clinician per day

Definition: Average number of total consultations (new and repeat cases) seen by each clinician per day.

Formula:

*FTE (full-time equivalent) refers to the equivalent number of clinicians working in a health facility. For example, if there are six clinicians working in the outpatient department but two of them work half-time, then the number of FTE clinicians = 4 full-time staff + 2 half-time staff = 5 FTE clinicians.

Appendix 4
Poisoning

Poisoning can occur when people are exposed to toxic chemicals through the mouth, nose, skin, eyes or ears or through ingestion. Children are at higher risk because they breath more quickly, have a large surface area relative to body mass, have more permeable skin, and are closer to the ground. Toxic exposures can affect a child’s development, including causing growth retardation and impaired nutrition, and can lead to illness or death.

Initial management

On presentation to the health facility, if the patient is known to have been exposed to or has signs and symptoms of chemical exposure:

take precautions for healthcare staff, including wearing appropriate personal protective equipment (PPE);
triage patients;
perform life-saving interventions;
decontaminate (for example, remove the patient’s clothes, or rinse affected areas with soapy water), ideally outside the health facility to prevent further exposures; then
follow further treatment protocols, including supportive treatment.

Treatment protocols

These may vary by country. In general, providing an antidote, and supportive treatment (such as for breathing), is needed.

The table below shows symptoms of chemical exposure and common antidotes given.

Symptoms of exposure to toxic chemicals and possible treatment

Class of toxic chemical

Common features of exposure

Antidotes (country guidelines will vary)

Nerve agents such as sarin, tabun or VX

Pinpoint pupils; blurred vision; headache; copious secretions; tight chest and breathing difficulty; nausea; vomiting; diarrhoea; muscle twitching; seizures; loss of consciousness.

Atropine
Oximes (pralidoxime, obidoxime)
Benzodiazepines (for seizures)

Blister agents such as mustard gas

Tearing; eye irritation; conjunctivitis; corneal damage; redness and blisters of the skin with pain; respiratory distress.

Supportive treatment +/- sodium thiosulphate
For example, eye irrigation, topical antibiotic, skin washing, bronchodilators,
Use sodium thiosulphate in severe cases

Cyanide

Gasping for air; asphyxiation; seizures; confusion; nausea.

Amyl nitrite (first aid)
Sodium thiosulphate and sodium nitrite or with 4 DMAP
or Hydroxocobalamin
or Dicobalt edetate

Incapacitating agents such as BZ

Dry mouth and skin; tachycardia; altered consciousness; delusions; hallucinations; hyperthermia; incoordination; dilated pupils.

physostigmine

Tear gas and riot control agents.

Stinging and burning of mucous membranes; lacrimation; salivation; runny nose; tight chest; headache; nausea.

Mainly supportive treatment

Chlorine

Eye redness and lacrimation; nose and throat irritation; cough; suffocation or choking sensation; shortness of breath; wheezing; hoarse voice; pulmonary oedema.

N acetylcysteine (NAC)

Thallium (rat poison)

Abdominal pain; nausea; vomiting; diarrhoea; constipation; seizures; delirium; depression; scalp and body hair loss; painful peripheral neuropathy and distal motor weakness; ataxia; neurocognitive deficits.

Prussian blue

Lead

Anorexia; vomiting; constipation; abdominal pain; pallor; inattentiveness; weakness; peripheral palsies.

Chelation

Organophosphates (includes some insecticides and nerve gas)

Salivation; lacrimation; urination; defaecation; gastric cramps; vomiting.

Atropine
Oximes (pralidoxime, obidoxime)

Modified from WHO, Environmental Health in Emergencies guidance.

References and further reading

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Overview and Latest update on iCCM: Potential for Benefit to Malaria Programs. UNICEF and WHO, 2015. www.unicef.org

Polio vaccines: WHO position Paper Weekly epidemiological record. WHO, 2016. http://www.who.int

Updates on HIV and infant feeding. UNICEF, WHO, 2016. http://www.who.int

Sexual and reproductive health

Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings. UNFPA and Save the Children, 2009. http://iawg.net

Inter-Agency Reproductive Health Kits for Crisis Situations, 5th Edition. UNFPA/IAWG, 2011. http://iawg.net

Inter-agency Field Manual on Sexual and Reproductive Health in Humanitarian Settings. IWAG on Reproductive Health in Crises and WHO, 2018. http://www.who.int

Medical eligibility criteria wheel for contraceptive use. WHO, 2015. http://who.int

Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations: A distance learning module. IWAG and Women’s Refugee Commission. 2011. http://iawg.net

Selected practice recommendations for contraceptive use, Third Edition. WHO, 2016. http://www.who.int

Safe abortion: Technical & policy guidance for health systems. WHO, 2015. http://www.who.int

Sexual violence and clinical management of rape

Clinical Care for Sexual Assault Survivors. International Rescue Committee, 2014. http://iawg.net

Caring for Child Survivors of Sexual Abuse Guidelines for health and psychosocial service providers in humanitarian settings. IRC and UNICEF, 2012. https://www.unicef.org

Clinical Management of Rape Survivors: Developing protocols for use with refugees and internally displaced persons, Revised Edition, pp.44–47. WHO, UN Population Fund, and UNHCR, 2004. www.who.int

Clinical Management of Rape Survivors: E-Learning. WHO 2009. http://apps.who.int

Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action, Reducing Risk, promoting resilience and aiding recovery. Inter-Agency Standing Committee, 2015. https://gbvguidelines.org

Guidelines for Medico-Legal Care of Victims of Sexual Violence. WHO, 2003. http://www.who.int

HIV

Consolidated Guidelines on the Use or ART Drugs for Treating and Preventing HIV Infection: Recommendations for a public health approach - Second edition. WHO, 2016. www.who.int

Guidelines for Addressing HIV in Humanitarian Settings. UNAIDS and IASC, 2010. http://www.unaids.org

Guidelines for the delivery of antiretroviral therapy to migrant and crisis-affected populations in Sub Saharan Africa. UNHCR, 2014. http://www.unhcr.org

Guidelines for management of sexually transmitted infections. WHO, 2003. www.emro.who.int

Guidelines on post-exposure prophylaxis for HIV and the use of Cotrimoxazole prophylaxis for HIV-related infections among adults, adolescents and children. WHO, 2014. http://www.who.int

HIV prevention in emergencies. UNFPA, 2014. http://www.unfpa.org

PMTCT in Humanitarian Settings Inter-Agency Task Team to Address HIV in Humanitarian Emergencies Part II: Implementation Guide. Inter-Agency Task Team, 2015. http://iawg.net

WHO policy on collaborative TB/HIV activities Guidelines for national programmes and other stakeholders. WHO, 2012. http://www.who.int

Injury and trauma care

American Heart Association Guidelines for CPR & ECC. American Heart Association, 2015 and 2017. https://eccguidelines.heart.org

Anaesthesia Handbook, Annex 3: ICRC Pain Management. Reversed WHO pain management ladder. ICRC, 2017. https://shop.icrc.org

Child Protection in Humanitarian Action Review: Dangers and injuries. Alliance for Child Protection in Humanitarian Action, 2016. https://resourcecentre.savethechildren.net

Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Minimum Technical Standards and Recommendations for Rehabilitation. WHO, 2016. http://apps.who.int

Disasters. WHO, 2013. http://www.who.int

eCBHFA Framework Community Based Health and First Aid. ICRC, 2017. http://ifrc-ecbhfa.org

EMT minimum data set for reporting by emergency medical teams. WHO, 2016. https://extranet.who.int

Guidelines for trauma quality improvement programmes. World Health Organization, 2009. http://apps.who.int

International First Aid and Resuscitation Guidelines. IFRC, 2016. www.ifrc.org

Interagency initiative comprising a set of integrated triage tools for routine, surge and prehospital triage allowing smooth transition between routine and surge conditions. WHO and ICRC. http://www.who.int

Recommended Disaster Core Competencies for Hospital Personnel. California Department of Public Health, 2011. http://cdphready.org

Technical Meeting for Global Consensus on Triage. WHO and ICRC, 2017. https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info

The European Resuscitation Council Guidelines for Resuscitation. European resuscitation council, 2015. https://cprguidelines.eu

The WHO Trauma Care Checklist. WHO, 2016. http://www.who.int

von Schreeb, J et al. Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan. Prehospital Disaster Med, NCBI, 2008. https://www.ncbi.nlm.nih.gov

War Surgery, Working with limited resources in armed conflict and other situations of violence. International Committee of the Red Cross, 2010. https://www.icrc.org

Mental health

A faith-sensitive approach in humanitarian response: Guidance on mental health and psychosocial programming. The Lutheran World Federation and Islamic Relief Worldwide, 2018. https://interagencystandingcommittee.org

A Common Monitoring and Evaluation Framework for Mental Health and Psychosocial Support in Emergency Settings. IASC, 2017. https://reliefweb.int

Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings. WHO and UNHCR, 2012. http://www.who.int

Building back better: sustainable mental health care after emergencies. WHO, 2013. http://www.who.int

Facilitate community self-help and social support (action sheet 5.2) in guidelines on Mental Health and Psychosocial Support in Emergency Settings. IASC, 2007. https://interagencystandingcommittee.org

Group Interpersonal Therapy (IPT) for Depression. WHO, 2016. http://www.who.int

Inter-Agency Referral Form and Guidance Note for Mental Health and Psychosocial Support in Emergency Settings. IASC, 2017. https://interagencystandingcommittee.org

mhGAP Humanitarian Intervention Guide: Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Settings. WHO and UNHCR, 2015. http://www.unhcr.org

Problem Management Plus (PM+): Individual psychological help for adults impaired by distress in communities exposed to adversity. WHO, 2016. http://www.who.int

Psychological First Aid: Guide for Field Workers. WHO, War Trauma Foundation and World Vision International, 2011. http://www.who.int

Psychological First Aid Training Manual for Child Practitioners. Save the Children, 2013. https://resourcecentre.savethechildren.net

Reference Group for Mental Health and Psychosocial Support in Emergency Settings in Mental Health and Psychosocial Support in Humanitarian Emergencies: What Should Humanitarian Health Actors Know. IASC, 2010. http://www.who.int

Non-communicable diseases

Disaster Risk Management for Health: Non-Communicable Diseases Fact Sheet 2011. WHO, 2011. http://www.who.int

Jobanputra, K. Boulle, P. Roberts, B. Perel, P. Three Steps to Improve Management of Noncommunicable Diseases in Humanitarian Crises. PLOS Medicine, 2016. http://journals.plos.org

Lozano et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systemic analysis for the Global Burden of Disease Study 2010. The Lancet, 2012. https://www.ncbi.nlm.nih.gov

NCD Global Monitoring Framework. WHO, 2013. http://www.who.int

NCDs in Emergencies – UN Interagency Task Force on NCDs. WHO, 2016. http://www.who.int

Slama, S et al. Care of Non-Communicable Diseases in Emergencies. The Lancet, 2016. http://www.thelancet.com

WHO Package of Essential Non-Communicable Disease Interventions, Tools for implementing WHO PEN. WHO, 2009. http://www.who.int

Palliative care

Caring for Volunteers Training Manual. Psychosocial Centre IFRC, 2015. http://pscentre.org

Disaster Spiritual Care Handbook. Disaster Services, American Red Cross, 2012. https://interagencystandingcommittee.org

Guidance for managing ethical issues in infectious disease outbreaks. WHO, 2016. http://apps.who.int

IASC guidelines on mental health and psychosocial support in emergency settings. IASC, 2007. http://www.who.int

IAHPC List of Essential Medicines for Palliative Care. International Association for Hospice and Palliative Care, 2007. https://hospicecare.com

Matzo, M et al. Palliative Care Considerations in Mass Casualty Events with Scarce Resources. Biosecurity and Bioterrorism, NCBI, 2009. https://www.ncbi.nlm.nih.gov

Powell, RA. Schwartz, L. Nouvet, E. Sutton, B. et al. Palliative care in humanitarian crises: always something to offer. The Lancet, 2017. http://www.thelancet.com

Palliative Care, Cancer control: knowledge into action: WHO guide for effective programmes. WHO, 2007. http://www.who.int

Silove, D. The ADAPT model: a conceptual framework for mental health and psychosocial programming in post conflict settings. War Trauma Foundation, 2013. https://www.interventionjournal.com

Nouvet, E. Chan, E. Schwartz, LJ. Looking good but doing harm? Perceptions of short-term medical missions in Nicaragua. Global public health, NCBI, 2016. https://www.ncbi.nlm.nih.gov

19th WHO Model List of Essential Medicines chapter 2 2, Medicines for pain and palliative care. WHO, 2015. http://www.who.int

Poisoning

Initial Clinical management of patients exposed to chemical weapons. WHO, 2015. http://www.who.int

Further reading

For further reading suggestions please go to www.spherestandards.org/handbook/online-resources

Further reading

Civil–military coordination

UN-CMCoord Field Handbook. UN OCHA, 2015. https://www.unocha.org/legacy/what-we-do/coordination-tools/UN-CMCoord/publications

Coordination

Global Health Cluster. http://www.who.int/health-cluster/en/

Health systems

Approach to Health Systems Strengthening. UNICEF, 2016. https://www.unicef.org/health/files/UNICEF_HSS_Approach_-_5Jun16.pdf

Health System Strengthening, from diagnosis to Planning. Action Contre Le Faim, 2017. https://www.actionagainsthunger.org/publication/2017/03/health-system-strengthening-diagnosis-planning

Monitoring the Building Blocks of Health Systems: A handbook of indicators and their measurement strategies. WHO, 2010. http://www.who.int/healthinfo/systems/monitoring/en/

Newbrander et al. Rebuilding and strengthening health systems and providing basic health services in fragile states. NCBI, Disasters, 2011. www.ncbi.nlm.nih.gov/pubmed/21913929

Strategizing national health in the 21st century: a handbook. WHO, 2017. http://www.who.int/healthsystems/publications/nhpsp-handbook/en/

van Olmen, J et al. Health Systems Frameworks in their Political Context: Framing Divergent Agendas. BMC Public Health, 2012. https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-774

Safety

Diagnostic Errors: Education and Training, Electronic Tools, Human Factors, Medication Error, Multi-morbidity, Transitions of care. WHO, 2016. http://apps.who.int/iris/bitstream/handle/10665/252410/9789241511636-eng.pdf?sequence=1&isAllowed=y

Hospital Safety Index Guide for Evaluators, 2nd ed. WHO, 2015. http://apps.who.int/iris/handle/10665/258966

Technical Series on Safer Primary Care: Patient engagement: Administrative errors. WHO, 2016. http://www.who.int/patientsafety/topics/primary-care/technical_series/en/

Medicines

Management of Drugs at Health Centre Level, Training Manual. WHO, 2004. http://apps.who.int/medicinedocs/en/d/Js7919e/

Medical devices including assistive devices

Global Model Regulatory Framework for Medical Devices including in vitro diagnostic medical devices. WHO, 2017. http://www.who.int/medical_devices/publications/global_model_regulatory_framework_meddev/en/

List of Prequalified in vitro diagnostic products. WHO, 2011. http://www.who.int/diagnostics_laboratory/evaluations/PQ_list/en/

Controlled medicines

Model Guidelines for the International Provision of Controlled Medicines for Emergency Medical Care. International Narcotics Control Board, 1996. www.incb.org/documents/Narcotic-Drugs/Guidelines/medical_care/Guidelines_emergency_Medical_care_WHO_PSA.pdf

Health financing

Doocy et al. Cash-based approaches in humanitarian emergencies, a systematic review. International Initiative for Impact Evaluation, 2016. http://www.3ieimpact.org/media/filer_public/2016/05/19/sr28-qa-sr-report-cash-based-approaches.pdf

Wenjuan Wang et al. The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda. Health Policy and Planning, NCBI, 2017. www.ncbi.nlm.nih.gov/pubmed/28365754

Health information

Checchi et al. Public Health Information in Crisis-Affected populations. A review of methods and their use for advocacy and action. The Lancet, 2017. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30702-X/abstract

Creating a master health facility list. WHO, 2013. http://www.who.int/healthinfo/systems/WHO_CreatingMFL_draft.pdf

Thierin, M. Health Information in Emergencies. WHO Bulletin, 2005. http://www.who.int/bulletin/volumes/83/8/584.pdf

Health needs assessments and prioritisation of health care services

Checchi, F et al. Public health in crisis-affected population. A practical guide for decision makers, Network Paper 61. Humanitarian Practice Network, December 2007. https://odihpn.org/resources/public-health-in-crisis-affected-populations-a-practical-guide-for-decision-makers/

Prioritising Health Services in humanitarian crises. Health and Education Research Team, 2014. http://www.heart-resources.org/2014/03/prioritising-health-activities-in-humanitarian-crises/

Waldman, R.J. Prioritising health care in complex emergencies. The Lancet, 2001. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04568-2/fulltext?_eventId=login

World Health Statistics, 2016: Monitoring for the SDGs. WHO, 2016. http://www.who.int/gho/publications/world_health_statistics/2016/en/

Communicable disease prevention

Vaccination in Humanitarian Emergencies, Implementation Guide. WHO, 2017. http://www.who.int/immunization/documents/general/who_ivb_17.13/en/

Outbreak detection and early response

Checklist and Indicators for Monitoring Progress in the Development of IHR Core Capacities in States Parties. WHO, 2013. http://www.who.int/ihr/publications/checklist/en/

Integrated Disease Surveillance and Response Community Based Surveillance Training Manual. WHO, 2015. http://www.afro.who.int/publications/integrated-diseases-surveillance-and-response-african-region-community-based

Outbreak preparedness and response

Key messages for social mobilization and community engagement in intense transmission areas, Ebola. WHO, 2014. http://www.who.int/csr/resources/publications/ebola/social-mobilization-guidance/en/

Child and newborn health

Disaster Preparedness Advisory Council, Ensuring the Health of Children in Disasters. Pediatrics. 2015. http://pediatrics.aappublications.org/content/early/2015/10/13/peds.2015-3112

Hoddinott, J. Kinsey, B. Child growth in the time of drought. Oxford Bulletin of Economics and Statistics. 2001. https://are.berkeley.edu/courses/ARE251/2004/papers/Hoddinott_Kinsey.pdf

Including children with disabilities in humanitarian action, Health Booklet. UNICEF, 2017. http://training.unicef.org/disability/emergencies/index.html

Revised WHO classification and treatment of childhood pneumonia at health facilities, evidence summaries. WHO, 2014. http://apps.who.int/iris/bitstream/10665/137319/1/9789241507813_eng.pdf

Injury and trauma care

Emergency Trauma Care. World Health Organization, 2017. http://www.who.int/emergencycare/gaci/activities/en/

EMT initiative. WHO, 2017. https://extranet.who.int/emt/page/home

Global guidelines for the prevention of surgical site infection. WHO, 2016. http://www.who.int/gpsc/ssi-prevention-guidelines/en/

Implementation Manual Surgical Safety Checklist, First Edition. WHO, World Alliance for Patient Safety, 2008 http://www.who.int/patientsafety/safesurgery/ss_checklist/en/

Joshi, GP et al. Defining new directions for more effective management of surgical pain in the United States: highlights of the inaugural Surgical Pain Congress™. The American Surgeon, NCBI, 2014. https://www.ncbi.nlm.nih.gov/pubmed/24666860

Malchow, Rj et al. The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Critical Care Medicine, NCBI, 2008. https://www.ncbi.nlm.nih.gov/pubmed/18594262

Providing Care for an Influx of Wounded. MSF, 2008. http://oops.msf.org/OCBLog/content/OOPSLOGV3/LOGISTICS/operational-tools/Pocket%20guide%20to%20Case%20Management%20of%20an%20Influx%20of%20Wounded%20OCB-v2.0-2008.pdf/Pocket%20guide%20to%20Case%20Management%20of%20an%20Influx%20of%20Wounded%20OCB-v2.0-2008.pdf

Mental health

Toolkit for the Integration of Mental Health into General Healthcare in Humanitarian Settings. International Medical Corps, 2018. http://www.mhinnovation.net/collaborations/IMC-Mental-Health-Integration_Toolkit

Non-communicable diseases

Action Plan for the global strategy for the prevention and control of non-communicable diseases 2008/2013. WHO, 2009. http://www.who.int/nmh/publications/9789241597418/en/

Demaio, A. Jamieson, J. Horn, R. de Courten, M. Tellier, S. Non-Communicable Diseases in Emergencies: A Call to Action. PLOS Currents Disasters, 2013. http://currents.plos.org/disasters/article/non-communicable-diseases-in-emergencies-a-call-to-action/

Global Status Report on Non-communicable diseases. WHO, 2010. http://www.who.int/nmh/publications/ncd_report2010/en/

The Management of cardiovascular disease, diabetes, asthma and chronic obstructive pulmonary disease in Emergency and Humanitarian Settings. WHO, 2008.

Palliative care

A faith-sensitive approach in humanitarian response: Guidance on mental health and psychosocial programming. The Lutheran World Federation and Islamic Relief Worldwide, 2018. https://interagencystandingcommittee.org/mental-health-and-psychosocial-support-emergency-settings/documents-public/inter-agency-faith

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. 2012. https://www.nap.edu/catalog/13351/crisis-standards-of-care-a-systems-framework-for-catastrophic-disaster

Ethics in epidemics, emergencies and disasters: research, surveillance and patient care: training manual. WHO, 2015. http://apps.who.int/iris/bitstream/handle/10665/196326/9789241549349_eng.pdf?sequence=1

Faith Leader Toolkit. Coalition for Compassionate Care in California, 2017. http://coalitionccc.org/tools-resources/faith-leaders-toolkit/

Knaul, F. Farmer, P.E. et al. Report of the Lancet Commission on Global Access to Palliative Care & Pain Control. The Lancet, 2017. https://www.ncbi.nlm.nih.gov/pubmed/29032993

Poisoning

Chemical Hazards Compendium. UK Government, 2013. https://www.gov.uk/government/collections/chemical-hazards-compendium

Emergency preparedness and Response, Fact Sheets on Specific Chemical Agents. Center for Disease control and prevention, 2013. https://emergency.cdc.gov/chemical/factsheets.asp

Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women. CDC, 2010. https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf

The Public Health Management of Chemical Incidents, WHO Manual. WHO, 2009. http://www.who.int/entity/environmental_health_emergencies/publications/Manual_Chemical_Incidents/en/index.html

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