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TYPHOON YOLANDA HEALTH CLUSTER BULLETIN November 26, 2013

TYPHOON YOLANDA HEALTH CLUSTER

NOVEMBER 26, 2013

HIGHGLIGHTS

As of 26 November 2013, the National Disaster Risk Reduction Management Council (NDRRMC) of the Philippines reported 5 240 deaths, 25 615 injured, and 1 613 missing. A total of 9 927 335 have been affected with 3 393 940 displaced. Of the displaced, 240 377 are currently living in 1 092 evacuation centres.

Health needs have shifted

from immediate trauma care

to broader public health is-sues. The five main causes of illness currently are acute respiratory infection, fever, diarrhea, hypertension and skin disease.

A total number of 55 regis-

tered Foreign Medical Teams (FMTs) are in the af-fected areas composed of more than 1 100 medical staff as of 26 November 2013. There are an addition-al 12 medical teams in coun-

try that have not yet regis-tered. Forty-seven of the field hospitals established are type 1. There are 6 teams with type 2 hospitals and two teams with a type 3 hospital. There are five more teams on standby outside of the country. An additional 103 national and local medi-cal teams have also been deployed to the affected are-as.

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Inside this bulletin:

Affected population and areas Main public health concerns Public health risks, needs, and gaps

Health cluster action Next steps Funding status of action plan

ISSUE #3

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AFFECTED POPULATION AND AREAS

As of 26 November 2013, the National Disaster Risk Reduc-tion Management Council (NDRRMC) of the Philippines reported 5 240 deaths, 25 615 injured, and 1 613 missing. A total of 9 927 335 have been affected with 3 393 940 dis-placed. Of the displaced, 240 377 are currently living in 1 092 evacuation centres (Table 1). The government is beginning the process of registration and profiling of the population movements, during which pro-cess the vulnerabilities, mobil-ity and protection issues in-cluding the risk of child and human trafficking are record-ed. Between 17 and 21 No-

vember, Department of Social Welfare and Development (DSWD) and IOM registered 1015 persons. It was noted that the majority of the house-holds were incomplete and were missing family members. Many are moving without reg-istration thus the profiling is still not comprehensive. In ad-dition, 3.39 million people are living with host families or in damaged/destroyed houses. The Camp Coordination and Camp Management (CCCM) cluster reports that 33% of sites in Tacloban city lack a camp management structure. Only 35 sites have latrines while 77% have no solid waste removal system. There

is on average 1 latrine per 61 persons, and 44% of the sites report having to leave the site location to find clean water. This increases the risk of out-breaks - an increase in the diarrhea cases have already been reported from the affect-ed areas. In Cebu, temporary shelters are being created in anticipation of further arrivals in the near future. In Guiuan an estimated 600 – 700 per-sons are leaving the Eastern Samar province per day, by bus and plane, headed mainly to Manila. Reception centers for the displaced have been established in Manila.

Table 1: AFFECTED POPULATION

(NDRRMC, 26 November 2013) Number of af-

fected popula-tion

% of total popula-tion of the area*

Number of Dis-placed Popula-

tion % of internally

displaced

Region IV A 27 076 0.2 - 0.00

Region IV B 425 903 15.5 3 028 0.11

Region V 656 239 23.7 - 0.00

Region VI 2 748 780 38.7 2 353 287 33.13

Region VII 2 601 503 38.3 2 386 0.04

Region VIII 3 397 959 82.9 1 035 239 25.24

Region X 19 592 0.5 - 0.00

Region XI 5 220 0.1 - 0.00

Caraga 45 063 1.9 - 0.00

Total 9 927 335 21.0 3 393 940 7.58

Humanitarian Case Load according to Flash Appeal

12 900 000 29.84%

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PUBLIC HEALTH RISKS, NEEDS, AND GAPS

General Issues

Assessment and validation of affected sites are of primary concern as more information is needed to plan for ade-quate response. In Cebu, the evacuation sites for victims coming from Sa-mar and Leyte provinces have reduced from 6 to 3. Each site can cater to 300 individuals. As more population move-ment is expected in the com-ing days, the city together with the Red Cross is plan-ning to create a tent city next week. In Ormoc, the regional DoH has designated 22 municipali-ties as priority areas based on the level of damage to the communities, health system and access. In Region VIII, in view of the extensive destruction to the health services and as a means to sustain the provi-sion of health services, the regional DoHs are encourag-ing organizations that are able to commit for longer periods to “adopt” a municipality, and provide services and assist with coordination of actors in their adopted municipality.

Morbidity

To date, the five main causes of morbidity identified include acute respiratory infection, fever, diarrhea, hypertension and skin disease. In Tacloban, the number of cases needing surgery and in-patient care is decreasing while need for primary health care especially treatment of chronic diseases (e.g. TB, hypertension) is increasing.

Additional needs include dis-ease prevention, mental health and psychosocial sup-port, and water and sanita-tion. There is an increased report-ing of disease events from the affected areas through the SPEED (Surveillance in Post Extreme Emergencies and Disasters), Event-based sur-veillance and response (ESR) system and the Philippines Integrated Disease Surveil-lance and Response (PIDSR) system. Based on the reports, the rumours are verified and the updated information is provided. There are also increasing numbers of cases with Acute Respiratory Infection (ARI), dog bites and wounds related to debris clearing and recon-struction of houses. Some cases of chicken pox and lep-tospirosis have been reported and verification is currently taking place. Other areas of concern as reported by the medical teams include treat-ment of spinal injuries and tetanus. Treatment protocols and tetanus immunoglobulin have been dispatched. In Tacloban city, between 24 and 26 November, the follow-ing cases of note were report-ed: Suspect leptospirosis cas-

es (1 each) from Palo and Tacloban City were admit-ted to Eastern Visayas Medical Center (EVRMC)

Suspect tetanus cases (4 in total) from Tacloban city, Tolosa, and Leyte were admitted to Eastern Visayas Medical Center (EVRMC)

Functionality of health facilities

DoH reports of initial rapid assessments of health facili-ties show that 1 150 of 2495 health facilities have been af-fected. This includes 833 BHS, 235 RHUs and 81 hos-pitals as well as one CHD-EV. The assessment reports are being compiled by the DoH to be used as a basis for recov-ery planning. Although further in-depth as-sessment of the health facili-ties are needed to determine specific needs and costing, the current analysis gives a good picture of the situations at health facilities by Region. Reports of more detailed as-sessment of health facilities by health cluster partners have also been received. For example, in Tacloban, assessment shows that there are currently 5 health facilities operational including one pub-lic tertiary level hospital and four private hospitals. All five are being supported by public health workers and foreign medical teams that are co-located at the facilities. A sec-ondary level field hospital is operational at the Tacloban airport supported by the Aus-tralian government and anoth-er field hospital run by a Ger-man-Belgian team has been set up at Palo in Leyte prov-ince. Overall in Leyte and Sa-mar provinces the operations of health facilities, cold chain system, communications, and other support infrastructure is beginning to be reestablished. Humedica (NGO) has also conducted a rapid structural assessment of Mother Mercy Hospital. Results show that the 4-storey hospital is serv-ing about 130 – 200 out-

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patients per day from the community. Part of the ground floor has been converted to a minor surgery centre. The major damage was loss of about 40% of the roof sheet-ing and the roof structure. This damage has resulted in water ingress into the first and second floors making these floors unusable, particularly with the frequent rains. A similar rapid structural as-sessment of Bethany Hospital conducted by MSF France in Tacloban shows minor dam-age to windows and door in one of the operating rooms. One of the three operating theatre remains completely untouched and will be func-tional for internal fixation sur-gery once a generator is in-stalled. One of two-storey buildings of the hospital was severely damaged. Over 50% of the roof structure was de-stroyed in the Typhoon and numerous windows were damaged on the 2nd storey. This has made the entire up-per floor unusable. AECID has supported the DoH to develop a referral sys-tem for transfer of patients in Tacloban. A specific reporting form for surgical referrals and needs will be developed as part of the system. As of 26 November, surgical cases are to be referred to EVRMC, the Australian FMT and Divine World health facility, dialysis patients are to be referred to RTR, patients needing venti-lators to be referred to the Australian FMT and all other referrals including for obstetric care are to be referred to EVRMC. Additional transpor-tation mechanisms are need-ed to support this system. Currently the Red Cross am-bulances stations at EVRMC

are the main point of call for transportation of patients. In north Cebu, Daan-bantayan district hospital (with 10 beds), Bantayan Hospital (with 25 beds) and Camotes Island hospital (with 25 beds) are fully functional although Camotes Island hospital has suffered damages to the infra-structure. In Ormoc, there are 2 opera-tional health facilities. Cariga-ra Hosptial, originally a level 2 hospital, is only partially func-tional and is unable to provide essential surgical care ser-vices including caesarean. The Ormoc District Hospital is partially functional and is able to deliver emergency surgical care including obstetric sur-gery, but not all operating rooms are functional and those that do function are do-ing so under marginal condi-tions. ICRF and Mercy Malay-sia are providing assistance to the hospital in order to im-prove the situation. The Or-moc Maternity and Children’s Hospital is fully functional ex-cept for surgical referral. A few private facilities are also functional, with one that is well supplied and has suf-fered little damage, but only on a paid basis. All hospitals have reduced admission lev-els due to lack of electric and difficult operating conditions, and one private health facility is planning to close complete-ly to conduct full repairs on its facility. Essential health services

An assessment conducted by IMC shows that almost 10% of the typhoon-affected population is in need of reproductive health services. Some of the rural health units (RHU) are

able to handle deliveries, but many are referring patients to urban health care centres. This issue is compounded by the lack of proper supplies and clean delivery kits. In Leyte province, although there is good coverage of health care service in most of the affected areas, there is still limited presence of medical teams along the eastern coast. There is also a need to educate the public on the free health care being provided in order to increase access to health care. The need for trauma care teams has decreased and there is now an increase in the need for public health teams that can provide preventive care including prophylaxis and immunization services, as well as health promotion and psy-chosocial support.

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HEALTH CLUSTER ACTION

Health Cluster coordination

The Department of Health is the lead of the Health Cluster, with WHO as co-lead. In addition to the national Health Cluster in Manila, sub-national Health Cluster Coordi-nation teams have been estab-lished in the following areas: Tacloban City for coordinat-

ing health response in re-gion VIII

Cebu city for coordinating health response in region VII

Roxas City for coordinating health response in region VI

Ormoc City for coordinating health response in region VIII in collaboration with the cluster in Tacloban City

Borongan for coordinating health response in region VI covering Guiuan

In Ormoc city, the local DoH and city DoH have set up an Incident Command System (ICS) for coordination and the health cluster is liaising closely with this system. Assessment Reports from the field show that medical support provided by international and local teams need to increase in geo-graphical area and scope of services beyond the current hubs. As the situation evolves, the need for emergency trauma care is decreasing, and the need for primary health care is increasing, including for essen-tial medical and surgical care as well as preventive health services.

It is estimated that 3.2 million women and girls of child-

bearing age are affected by the crisis. An estimated 233 697 pregnant and 155 798 lactating women need specialized ser-vices for prenatal, postnatal, child health, health promotion and family planning, including 7 973 pregnant and 4 716 lactat-ing women. Daily, an estimated 865 births take place in the af-fected communities, of which 129 will experience potentially life-threatening complications. Priority Setting The health cluster has used the following indicators to identify priority areas of focus: Status of health facilities

(structural and non-structural)

Health facility functionality (services)

Availability of health human resources

Status of health service de-livery (clinical)

Availability of public health services

Availability of medical sup-plies including cold chain

Vulnerability of population, including morbidity data

Eight provinces were identified for primary focus. The eight will be prioritized into high (Red), medium (Orange), and low pri-orities (Green) based on further analysis of the above men-tioned criteria. The main public health risks have been identified as follows: Disruption in the health sys-

tem including lack of health facilities, primary and sec-ondary health care delivery and the subsequent disrup-tion to universal access to health care

Communicable diseases especially in view of the

disruption to the surveil-lance system and problems related to water and sanita-tion, overcrowded living conditions and low vaccina-tion coverage prior to the event especially for mea-sles. Cholera, dengue and leptospirosis are endemic in many of the affected areas, increasing the risk of out-breaks of these diseases in view of the increased vul-nerability of the affected population.

Chronic diseases including interruption of treatment for disease needing long term treatment. This is an in-creasing problem as chron-ic diseases including hyper-tension and diabetes ac-count for a large number of morbidity and mortality

Reproductive health – high number of pregnant women about to deliver, low capaci-ty of health facilities to de-liver obstetric and surgical care

Disruption in cold chain and medical provisions

Lack of water and low sani-tation level, and low capaci-ty for waste management, including medical waste

Based on this the main areas of public health response are as below. For areas of high pri-ority (Red) all these public health responses are deemed to be required. For other areas (Orange and Green) the public health response will be adopt-ed locally to the needs. Restoration of primary, sec-

ondary and tertiary care as per the health systems. Particular attention should be given to maternal and child health services and obstetric care. This is to

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ensure sustainability and universal access to health care services, with the aim of rebuilding towards safer health facilities. (Health Systems Approach)

Health care waste man-agement

Increasing services for mental health and psycho-social support

Maternal and Child Health (MCH) care especially for children under 5

Care for non-communicable disease patients with a spe-cific focus on continuation of treatment for chronic dis-eases (hypertension, TB, diabetes etc.)

Restoration of mechanisms for outbreak control includ-ing restoring the surveil-lance and early warning system, cold chain, labora-tory and immunization

Inter-cluster coordination mechanisms are also func-tional and in particular with the Water and Sanitation

(WASH), nutrition and pro-tection clusters. A Multi-cluster Initial Rapid Assess-ment (MIRA) was conduct-ed and is currently being analysed. Public Risk com-munication

Implementation of a nutri-tion programme including referral to and from health care facilities for severe malnutrition

Referral from health care facilities, including patient tracking with specific focus on child protection and re-sponding to gender based violence.

Response Health Care Services A total number of 55 registered Foreign Medical Teams (FMTs) are in the affected areas com-posed of more than 1 100 med-ical staff as of 26 November 2013 (map). There are an addi-tional 12 medical teams that have not yet registered. Forty-

seven of the field hospitals es-tablished are type 1.

There are 6 teams with type 2 hospitals and two teams with a type 3 hospital. There are five more teams on standby outside of the country. An additional 103 national and local medical teams have also been deployed to the affected areas. All FMTs are required to be completely self-sufficient for the duration of their stay as re-sources are limited. Provision of fuel remains the main chal-lenge. A guidance note has been is-sued by DoH on the entry and exit strategy of FMTs in light of the evolving situation and the subsequent shifting of priorities from immediate trauma care to primary and surgical care as well as public health issues.

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Essential drugs and supplies The DoH has provided a list of needs for supplies which was transmitted to health cluster partners. The needs are evolving based on the in-puts from health cluster part-ners to fill the gaps. In Cebu sufficient drugs and supplies exist to date. The remaining items in Cebu have been moved to Region VIII to support on-going response activities. This includes 16 solar refrigerators donated by the UK government (DfID) for use in the vaccination cam-paigns. Following requests for addi-tional antibiotics for use in treatment of wounds and in-fections, Hope (NGO) has im-ported large amounts of ap-propriate antibiotics. Plans are on-going for further distri-bution of the drugs to the are-as where they are needed. Vaccination and cold chain The mass vaccination cam-paign for measles, polio and vitamin A dosage started to-day in Tacloban. The cam-paign is supported by WHO, UNICEF and other health cluster partners. Patients with wounds have been provided with tetanus toxoid as the risk of tetanus still exits. Vaccines are sup-plied mainly through local pro-curement but additional dona-

tions from international enti-ties are still welcome. Whilst cold chain was brought from other sites for Tacloban to start the campaign, shortages still exit to continue the vac-cinations in other parts of Re-gion VIII. UNICEF, in support of DoH, is conducting cold chain assess-ments for regions VI, VII and VIII. Surveillance and communi-cable disease control There are currently two main surveillance systems in oper-ation, SPEED and PIDSR, to assist in detection of outbreak prone diseases. SPEED is widely promoted as a system for emergency situations. The system is currently functioning in region VII, however, infor-mation received still remains patchy (Table 2). From infor-mation received to date, verifi-cation has been undertaken for several events including acute respiratory illness and diarrhea. However, no out-breaks have been reported to date. The Health Emergency Man-agement unit of DoH, with the support of UNICEF, has pro-vided an orientation on SPEED to medical teams leaving from Manila to the affected areas in order to sen-sitize them with the aim to in-crease the use of the system. WHO is also supporting the DoH to strengthen surveil-

lance through training of pub-lic health staff in Borongan on SPEED and provision of SMART sim cards to 17 RHUs in Capiz which will al-low those working in remote locations to send information to a central hub for uploading data into SPEED. Such sup-port will increase the reporting rate to SPEED even from lo-cations with low communica-tion access. In addition, sen-ior public health officers are being deployed to all hubs to support the local DoH in sur-veillance activities (starting with Borognan and Roxas). Maternal, Newborn and Child Health Currently UNFPA and Merlin have provided reproductive health kits which have been sent to Palo and Cebu. The kits include items for manage-ment of rape survivors. Addi-tionally, three hospital units with reproductive health equipment have been ordered and one obstetrical surgical unit is on standby for ship-ping. UNFPA will second a senior reproductive health specialist to the health cluster to support the DoH. If needed, two-day “refresher” trainings to midwives and health work-ers on the use of items in the reproductive health kits can be provided. Dead Body Management In the absence of facilities for receiving the dead and under-taking examination, WHO has

Table 2: Summary of SPEED Reporting in Typhoon Yolanda affected Areas

Region Provinces (#)

Municipalities (#)

Health Facilities and Reporting Sites (#)

VI 2 5 5

VII 1 10 21

VIII 1 5 7

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developed a kit of materials and equipment for a tempo-rary mortuary to receive bod-ies in which the forensic staff can undertake a preliminary examination. The kits will be deployed to Tacloban (Baspar and Suhi) and one more loca-tion, to be determined. A fo-rensic pathology team of three persons from the Uni-versity of Manila is also on site to support dead body management. Water, Sanitation and Hygiene (WASH) and Environmental Health Following reports of diarrhoea from Bantayan, Cebu, and Region VII the WASH cluster has coordinated the chlorina-tion of shallow wells dug by

the cluster. Laboratory tests are being conducted to test for the adequacy of the level of chlorination. Environment health assessment in health care facilities is being con-ducted this week by a DoH and WHO in Eastern Samar. Mental Health and Psycho-social Support A rapid assessment by IMC shows that mental health is a significant concern for affected populations and the current response measures are insufficient to meet all the needs. The government is discussing the means to train national health professionals on delivering mental health and psychosocial care to the affected population. A mental

health expert from WHO is in Manila to help coordinate the actions in support of the DoH. Planning The DoH has developed a plan to identify short and long-er terms needs. The health cluster partners are putting together a similar plan for identifying short (6 weeks) and longer term needs. The possible areas of support and focus include health facilities strengthening to ensure equity and strengthen health care service provision, pre-vention and control of com-municable diseases, coordi-nation with other clusters as well as within the health sec-tor to ensure seamless deliv-ery of services.

NEXT STEPS Assessments, tracking and mapping will be continue to: Estimate amount of infra-

structure damage and health service availability in detail

Better define affected pop-ulations and needs, in-cluding for pregnant and lactating women and pa-tients with chronic dis-

ease, evacuee locations and needs of displaced people

Evaluate resources cur-rently available and what will be required in the short to mid term

Refine understanding of health partners’ location and activities including availability of logistics and supplies

Better understand the needs for longer term re-lief and recovery in the next 6 to 12 months

FUNDING STATUS OF ACTION PLAN As of 26 November 2013, the action plan is 28% funded for the health sector (table 3). The percentage covered has decreased compared to the last bulletin due to the addi-tion of 2 projects.

As of 26 November 2013, WHO received firm commit-ments from Australia, Cana-da, Norway, Japan, the Unit-ed Kingdom and the UN Cen-tral Emergency Response

Fund (CERF) for a total of US$10.7 million. Rapid de-ployment of staff and medical supplies has been made pos-sible thanks to contributions made earlier in 2013 to en-hance WHO’s surge capacity for acute emergencies from the governments of the Rus-sian Federation, Sweden and the United States of America, and from the European Com-mission Humanitarian Aid and Civil Protection (ECHO).

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Table 3: FUNDING STATUS OF ACTION PLAN FOR HEALTH (US$) Project Appealing

Agency Amount Required

Funding % Covered

Saving Pregnant Women and Newborn lives and support to Super Typhoon Haiyan affected provinc-es of Leyte, Capiz, Iloilo and Aklan

Save the Children

570 310 0 0%

Adolescent and Sexual Reproductive Health in Emergency Services and Support to typhoon Haiyan affected provinces of Leyte, Samar, Iloilo, Aklan and Capiz

Save the Children

1 926 000 800 000 42%

Ensuring Access to Reproductive Health Services for IDPS affected by Typhoon Haiyan

UNFPA 3 000 000 592 077 20%

Provision of emergency health services to Typhoon affected populations

WHO 15 000 000 8 816 481

59%

Emergency Health for Children and Families Affect-ed by Super Typhoon Haiyan in the Philippines

Save the Children

1 070 000 206 612 19%

Providing Mental Health and Psychosocial support to children and pregnant and lactating women and Primary Health Care Interventions in population affected by Typhoon Haiyan (Yolanda)

ACF-Spain

3 000 000 0 0%

Provision of life-saving interventions for health to children 0-59 months affected by Typhoon Haiyan (Yolanda) emergency

UNICEF 13 500 000 182 041 1%

TOTAL 38 066 310 10 597 211

28%

http://fts.unocha.org/reports/daily/ocha_R32_A1043___26_November_2013_(03_00).pdf

Health Cluster Partners National- Manila: AECID, Americares, Australian Aid, CDN- DART, CFSI, Child Fund, DFID, DOH, FPOP, Handicap International, HuMa, ICRC, IFRC, IHP -UK, ILO, IMC, IOM, IRC, ISAR-Germany, JICA,MERLIN, MDM, MSF, National Bureau of Investigation , PHE, Philippines Red Cross, Relief International, Plan International, Project Hope, PU-AMI, SCI, UNFPA, UNICEF, USAid, US Forces, WHO, World Vision. Sub-national- Tacloban: AECID, ACF, ACTED, Action PompiersUzgenceInlanaVionus, ARC, ASEAN, ASYA SAR/KYM, B-FAST, AUs, BomberosUnidos SP, Care, Christian Aid, DFID, DOH, ECHO, Emergency.LU, Ericsson Response, EUCPT, First Relief Fund, First Response Radio, Fuel Relief Fund, German Embassy, German Red Cross, Globalmedic, GOAL, Good Neighbours Intl., Good People Intl., HUMEDICA,IFRC, International Disaster Relief, Internews, IOM, IsraAid, JICA, KIHI, KOICA, Leger Foundation, Miral Welfare Foundation, MSF/F, OCHA, Oxfam, Philip-pine Red Cross, PompiersHumanitaires France, PUI France, Samaritan 119 Korea, SC, SCDN, Solidarities International, Spanish Red Cross, TGCFI, RTR hospital, UNDAC, UNDP, UNFPA, UNICEF, USAID, US OFDA, Vodafone foundation, WFP, WHO, WISAR, World Vision. Sub-national- Cebu: AmeriCares, ASB Germany, Canadian Emergency Response Unit, Canadi-an Medical Assistance Teams, CFSI, ChildFund, DOH, Embassy of Israel, Eversly Child Sanitari-um, GOAL, ICRC, IFRC, International Medical Corps, JICA, MDM, Med Japan, Merlin, MSF, NYC Medics, PNA, Samaritan Purse, SC, SCI, Spanish Red Cross, Saint Anthony Mother and Child Hospital, Talisay District Hospital, UNICEF; Vicente Sotto Memorial Medical Center, WHO Sub-national- Roxas: ACF, Action Aid International, Canada DFAT, Child Fund, CRWRC, DoH, GOAL, IOM, Japan Heart Foundation, Philippine Rural Reconstruction Movement, MSF-Swiss, NETHOPE, Save the Children, UNDAC, UNICEF, Welt Hunger Hilfe, WFP, WHO, World Vision International

http://fts.unocha.org/reports/daily/ocha_R32_A1043___26_November_2013_(03_00).pdf

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Health Cluster Contacts National- Manila: [email protected] Sub-national- Tacloban: [email protected]; [email protected] Sub-national- Cebu: [email protected] Health Cluster Website:http://www.wpro.who.int/philippines/typhoon_haiyan/en/

Please send any information on potential disease outbreaks to: [email protected]

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