Memorandum by the United Nations High
Commissioner for Refugees
1. UNHCR is very pleased to have the opportunity
to contribute to the Committee's review of the effectiveness of
action undertaken by international organizations in response to
the global spread of communicable diseases.
2. Because of his mandate and responsibilities
vis a vis the refugees and internally displaced persons, UNHCR
will limit its evidence to refugee communities assisted through
care and maintenance programs delivered mainly in camps.
3. UNHCR doesn't have an intergovernmental
approach and its progams are linked to an inter Agency perspective
mainly with its traditional partners in operations, WFP, UNICEF
and WHO.
4. UNHCR is not in a position to give appropriate
answers to most of the questions listed as issues in the Call
for Evidence and will present its Evidence by treating each of
the four main infectious diseases to be considered, Tuberculosis,
Malaria, HIV and Avian Influenza, separetely.
5. UNHCR delivers public health program
to Refugees accommodated in camps through medical implementing
partners, Non governmental Organizations, NGOs, for most of them,
having a medical presence and capacity at camp level. Public Health
programs implemented are always in full compliance with the objectives
and the policies of the National Health Plan elaborated by governmental
authorities in a given country.
6. Refugees and other Persons of Concern,
PoC, to UNHCR are unique groups which often have special needs
due to their circumstances (eg trauma and violence including sexual
violence, different languages and cultures, issues related to
durable solutions, dependancy upon external support and limited
economic opportunities). Existing policies, guidelines and protocols
for persons in resource-poor settings may need to be modified
accordingly and in some cases specifically developed.
TUBERCULOSIS
7. Tuberculosis (TB) is a major global public
health problem that causes an estimated two million deaths annually.
These deaths comprise 25% of all avoidable adult deaths in developing
countries. The incidence of TB globally is increasing by 1% per
year. Co-infection with HIV is a major contributing factor in
many countries, mainly those of sub-Saharan Africa. Today, TB
control is complicated by the emergence of multi drug-resistant
(MDR) TB, particularly in countries of the former Soviet Union.
However, substantial progress has been made in the implementation
of effective TB control programmes in a growing number of countries
worldwide.
8. Refugees and internally displaced persons
(IDPs) are at increased risk of developing TB and often have poor
access to anti-TB treatment. Conflict is the most common cause
of population displacement, which often results in relocation
to temporary settlements (camps). Malnutrition and overcrowding
in camp settings further increase their vulnerability. For example,
(a) In 1985, 26% of deaths among adult refugees
in Somalia and between 38-50% of all deaths among refugees in
camps in eastern Sudan were attributed to TB.
(b) In north-east Kenya in 1994, the incidence
of new infectious TB patients in camps was four times the rate
in the local population.
(c) In Ingushetia in 2000, the TB notification
rate for displaced Chechens was almost twice as high as the resident
Ingush population.
9. A TB control programme should be implemented
only if the security situation is sufficiently stable to enable
implementation of activities (especially short-term therapy) and
if no major movements of the camp or the population served are
anticipated in the near future; otherwise drug resistance may
occur. At a minimum, programme funding should be sufficient to
enrol patients for 12 months (although short term therapy is for
six months in many countries) and complete the treatment of all
members of this cohort—a minimum of 18 months.
10. To provide guidance to humanitarian
agencies (eg NGOs) on the implementation of effective TB programmes
for refugees and IDPs, WHO and UNHCR collaborated to produce an
interagency field manual (1st edition 1997, 2nd edition 2006).
Its aim is to encourage implementation of TB control programmes
in these populations wherever possible, while ensuring they meet
accepted standards of quality and outcome. Despite the challenges
of these settings, experience over the past 10 years in the implementation
of TB control programmes has shown that they can be effectively
diagnosed and treated among these vulnerable populations.
11. The basis of an effective TB control
programme is the WHO "Stop TB" Strategy. The goal is
to dramatically reduce the global burden of TB by year 2015 in
line with the Millennium Development Goals and Stop TB Partnership
targets. This new strategy has six components, one of which includes
five basic key elements—the most relevant in refugee and
IDP situations:
— Political commitment and sustained
financing.
— Case detection through quality-assured
bacteriology.
— Standardized short-course chemotherapy
with supervision and patient support.
— Effective drug supply and management
system.
— Monitoring and evaluation system,
and impact measurement.
12. TB activities in the refugee camps are
always implemented in line with the National TB Programme
(NTP). The NTP often provides medicines, other supplies and technical
support to the refugee programmes. In turn the refugee programmes
facilitate travel of NTP Officers. Similarly, urban refugees access
TB treatment from the national programmes, although language and
other barriers limit access of refugees to these services. The
characteristics of the NTP in the country of origin should also
be taken into consideration if refugees are likely to be repatriated.
Inter-country coordination in the planning stage is critical to
minimise the risk of patients interrupting treatment when camps
or populations are moved.
13. The priorities of a TB programme are
first to identify and treat infectious TB patients and those with
severe forms of the disease. The diagnosis and cure of infectious
TB cases is the most effective method of preventing TB transmission
and controlling the disease in the community. Due to limited investigation
capacity in the camps, admission of patients to the programme
is based on sputum testing. Clinical judgment is used for admission
of under-five children and for those with extra- pulmonary disease.
14. Many refugees and displaced persons
may come from, or seek refuge in, countries with a high prevalence
of infection with HIV. The prevalence of HIV among the refugees
in Kenya is lower than that of the surrounding population (5%
vs. 12%) while in Tanzania, it is similar to that of the surrounding
local populations (between 5-10%). Although accurate data are
not available, the incidence of TB has increased in the past several
years. Hence TB/HIV co- infection may be prevalent in these populations.
TB is among the leading cause of death among people infected with
HIV worldwide. In some countries, particularly sub-Saharan Africa,
up to 70% of TB patients are co-infected with HIV. Patients diagnosed
with TB should be offered and HIV test and conversely, those diagnosed
with HIV should be screened for TB. TB patients co- infected with
HIV respond well to standard anti-TB treatment. UNHCR HIV/AIDS
Strategy puts high emphasis in the coordination of HIV/AIDS and
TB control programmes.
15. Provision of food may be important in
TB programmes in malnourished populations and can serve a useful
function as an incentive to support adherence and treatment completion.
The treatment in the camps is based on directly observed therapy
(DOTs) strategy where patients are required to take the medications
under observation, at least during the intensive phase. To support
this policy, the refugee programmes provides supplementary food
to TB patients in the intensive phase.
16. Cure rates in the camps are generally
close to the national targets of 85% (the data available for 2006
shows a cure rate of 92% in Tanzania, 88% in Kenya, and 89% in
Ethiopia). However, case detection rates and smear positivity
rates are generally lower than the national targets, thereby,
reflecting the need for the refugee programme to improve these
areas and strengthen coordination and monitoring of these activities.
For example in Tanzania the number of cases detected in the camps
represents only the 50% of the ones expected. In Kenya the detection
rate could reach the 79%.
17. In camps, most patients are treated
and followed up as outpatients, while those who are severely ill
and cannot walk to clinics, and those who are smear positive with
bacteria count of 3+, are kept in the TB wards for a limited period
of time.
18. TB programmes continue to focus on treatment
of sputum positive patient, who transmit the disease to other
persons, and much less on sputum negative patients who might be
also suffering from TB. Chest X-rays are not routinely used for
diagnosis (because they are not available in most refugee and
IDP situations) and thus, clinical evaluation of the progress
of the patients is undertaken. Therefore, although the refugee
programme lacks behind the national target in the case detection
rate, the cure rate is quite commendable.
19. In West Africa, for the overall repatriation
activities of Liberian refugees, TB is apart of the repatriation
health plan. Returnees are accessing the TB national Program units,
as the rest of population. In 2006, the National Program in Liberia
treated 3,452 cases of TB (68% smear positive pulmonary TB). The
outcome of the cohort registered 9- 12 months earlier showed a
treatment success rate of 80%. In Ghana in 2006, a total of 168
cases were detected among refugees in the camps (90% smear positive
pulmonary TB). All of them were taken in charge by the National
TB Program. The outcome of the cohort registered 9- 12 months
earlier showed a treatment success rate more than 95%.
20. Programme implementation may be interrupted
as a result of unplanned population movements or breakdowns in
security. The unique problems of continuity faced by programmes
delivered under insecure circumstances must be taken into account;
firstly in the decision to institute a programme and secondly
in contingency plans adapted to the specific situation. For example:
(a) During a prolonged period of low intensity
war and recurrent insecurity in south Sudan in 2001, arrangements
were made to prepare for each patient at programme entry a "runaway
bag" containing one month's supply of anti-TB drugs. The
runaway bags could be rapidly distributed in the event of insecurity
when expected to last more than a few days. Contingency plans
were made to contact local staff on the ground and arrange regrouping
to resume treatment within a month.
(b) In Maela refugee camp in Thailand, a
TB programme began in 1997. To ensure treatment compliance, TB
patients were admitted to a "TB village" next to the
camp where they stayed with their family for the whole duration
of treatment. They were housed in bamboo huts similar to the ones
in the camp. Food was provided by the programme during the entire
duration of treatment. As for all health services, TB diagnosis
and treatment were free of charge. Regular health education messages
were provided. Treatment was given daily under strict supervision
by medical personnel.
21. Although most patients are expected
to complete treatment at the site in which they began the treatment,
a plan should be devised to deal with patients who transfer into
or out of the programme. It is very important that continuity
of treatment occurs during and post movement. Contact with the
new treatment centre should be made by the clinic staff, if possible,
prior to transfer. Forward planning and liaison between staff
is particularly important if a large population is being transferred.
For example, in 2003, Eritrean refugees on TB treatment who were
repatriating from Sudan were provided with 4 weeks of medications
and followed up by the NGO in Sudan, to be linked into the Eritrea's
NTP once they reached their final destination.
MALARIA
22. Malaria remains an important cause of
illness and death among refugee and displaced populations. The
majority of today's refugees live in malaria endemic areas, this
situation has not been reversed during the last years, in the
contrary, and some new factors as climate change, natural disasters
and population displacement have triggered changes in mosquito
behaviors and malaria epidemiological profiles in different countries.
Still of the almost 33 million persons of concern to the office
of the United Nations High Commissioner for Refugees (UNHCR),
almost two-thirds (63%) live in malaria endemic areas.
23. Many factors may promote vulnerability
to malaria illness and death among refugees. Pregnant women and
young children are particularly at risk of severe illness and
death: women of child bearing age and children make up the majority
of the population in many refugee situations. Refugee camps are
often sited on marginal lands that promote breeding sites for
malaria vectors. Refugees may be malnourished, particularly in
the phase immediately following flight. Travel may take refugees
through or to areas of higher malaria endemicity than their place
of origin. Control programmes may have broken down (associated
with the conflict that caused population flight) or never been
implemented.
24. A significant change in approach to
malaria control, particularly in Africa, has taken place over
the last decade. Funds for malaria control have become available
on a scale not seen since the days of the eradication campaign
50 years ago. These new resources are being used largely to support
a supply of artemisinin combination therapy to replace ineffective
chloroquine and sulphadoxixne pyrimethamine for first line treatment
of malaria and for the provision of long-lasting, insecticide
treated bednets.
25. Intermittent preventive treatment in
pregnancy (IPT) has been shown to be of significant benefit in
reducing potential malaria-related pregnancy complications in
moderate to high transmission settings. The AIDS epidemic interacts
with malaria: HIV infection increases susceptibility to malaria
and has an adverse effect during pregnancy. Malaria may increase
the viral load of HIV infections.
26. The globally-accepted "best practices"
for malaria control incorporating a mix of the SPHERE[48]
common standards for intervention and WHO-endorsed malaria specific
interventions,[49]
are reflected in the eight key strategic objectives.
The key objectives are as follows:.
(a) Protection: To protect the right of UNHCR's
Populations of Concern (PoCs), with specific reference to malaria.
(b) Coordination, Integration, and Partnership:
To effectively coordinate and integrate malaria control policies
and programmes in a multi-sectorial approach for PoCs by strengthening
and expanding strategic partnerships with key stakeholders, including
implementing partners.
(c) Advocacy: Increase awareness, knowledge,
and recogntion within UNHCR, governments, donors, and other decision
makers on the negative impact of inadequate malaria control on
the survival, development, and quality of life of PoCs. To mobilize
resources, internally and jointly with partners, with an emphasis
on non-traditional UNCHR donors to enable achievement of the multi-year
objectives of this strategic plan.
(d) Access to Early Diagnosis, Prompt and
Effective Treatment, and Prevention: To ensure that UNHCR PoCs
living in the malaria endemic areas have access to prevention,
early diagnosis, and prompt and effective treatment, according
to international standards.
(e) Durable Solutions: To develop and incorporate
malaria control strategies and interventions into policies and
programmes for durable solutions.
(f) Capacity Building: To build and strengthen
specific malaria-related knowledge and skills as well as to provide
necessary technical tools to PoCs and those staff working with
them.
(g) Assessment, Surveillance, Monitoring
and Evaluation, Operational Research: To regularly monitor and
report on the status of malaria within the PoC population to inform
programmatic planning and implementation in a timely manner. To
evaluate programme performance and achievements using a results-based
management approach. To develop and carry out operational research
on new approaches and technologies in malaria control.
(h) Participation: To promote beneficiary
participation in malaria control programmes.
HIV/AIDS
27. There are an estimated 20.8 million
refugees and displaced persons globally, many of whom reside in
countries heavily affected by AIDS. Approximately four million
of these persons live in sub Saharan Africa. Displacement as a
result of conflict or other disasters can increase vulnerability
to HIV by reducing access to HIV prevention services, information,
and commodities. Basic HIV-related health care may not be available
and people may become vulnerable to HIV infection. In addition,
social support networks are often disrupted, exposure to sexual
violence may be increased, and poverty may lead to the exchange
of sex in return for food or shelter.[50]
However, displacement may reduce the transmission of HIV due to
reduced mobility to high prevalence areas; isolation and inaccessibility
of some displaced populations; and in some circumstances, especially
in the post-emergency phase, the availability of better protection
and other HIV-related services than in countries or areas of origin.
The extent to which UNHCR's POCss are adversely affected by HIV
has been increasingly examined in recent years. There is now adequate
evidence demonstrating that in many situations HIV prevalence
among populations affected by conflict and displacement is not
necessarily higher than that of the surrounding host population;
on the contrary it is lower in many settings.
28. To support and promote HIV and AIDS
policies and programmes in order to reduce morbidity and mortality
and to enhance the quality of life among refugees, IDPs, returnees
and other POCss to UNHCR, Eight HIV/AIDS Strategic Objectives
have been identified:
— Protection—To ensure that the
human rights of UNHCR's POCss are protected in HIV/AIDS prevention,
treatment, care and support programmes.
— Coordination, integration and partnerships—To
coordinate and effectively integrate HIV/AIDS policies and programmes
in a multi-sectoral approach for POCss by strengthening and expanding
strategic partnerships with key stakeholders.
— Advocacy—To advocate for UNHCR's
POCss to be integrated into HIV-related policies and programmes
within UNHCR, Government, donors and by other decision makers.
— Prevention—To reduce HIV transmission
and morbidity through scaling up effective prevention interventions
to UNHCR's POCss with an emphasis on community participation,
especially among women, children and people with special needs
to ensure they have access to HIV prevention information and services.
— Care, support and treatment—To
ensure that POCss living with HIV and AIDS have access to timely,
quality and effective care, support and treatment services including
access to anti-retroviral therapy at a level similar to that of
the surrounding host populations.
— Durable Solutions—To develop
and incorporate HIV/AIDS strategies and interventions into policies
and programmes for durable solutions in order to mitigate the
long term effects of HIV and AIDS.
— Capacity Building—To build
and strengthen HIV/AIDS knowledge and skills as well as to provide
necessary technical tools to POCss and those staff working with
them.
— Assessments, surveillance, monitoring
and evaluation, operational research—To ensure that data
on UNHCR's POCss are reflected in national HIV surveillance, monitoring
and evaluation systems, to monitor and report on a regular basis
POCs's access to HIV prevention and treatment programmes in camp
situations, to evaluate programme performance and achievements
using a results-based management approach, and to conduct operational
research on new approaches to providing HIV prevention and treatment
services to refugees and displaced populations.
AVIAN INFLUENZA
29. UNHCR has the mandate and humanitarian
responsibility to ensure preparedness and pandemic mitigation
for refugees and other persons of concern (eg refugees, internally
displaced persons (IDPs), asylum seekers and returnees). A majority
of these persons in camps are hosted by countries where the management
and response to the avian and human influenza (AHI) pandemic threat
is already an enormous task to meet the needs of the national
population. While it is possible that urban refugees will be included
in national plans, extension of planning and implementation of
preparedness and mitigation measures to camps is unlikely. It
will be incumbent on UNHCR to be the convening agency in such
refugee settings to ensure timely and efficient management of
the situation.
30. Taking into account the environment
as well as in many cases the poor living conditions and access
to general services, refugees and populations displaced by conflict
may be particularly vulnerable to a human influenza pandemic,
especially in countries which have weak infrastructure to deal
with such a pandemic.
31. High population densities in refugee
settings combined with close habitation with livestock and poor
nutrition, barriers to accessing health facilities, high prevalence
of other communicable diseases, poor sanitation, remoteness of
locations (many within active conflicts), poor links to national
disease surveillance systems and the lack of trained staff to
investigate and detect clusters could result in higher infection
and mortality rates than in other populations.
32. In the event of a pandemic, limited
resources for infection control and disease management are unlikely
to be directed towards refugees and other persons of concern to
UNHCR. Communication efforts may not take into account specific
linguistic and cultural needs. Refugees and other persons of concern
risk being stigmatised or blamed for diseases transmission. Restriction
of population movements and quarantine of whole camps may follow,
without logical or understandable justifications. Without strong
advocacy, refugees, IDPs and other persons of concern to UNHCR
risk being excluded from national and regional AHI preparedness
planning.
33. UNHCR, together with the host Government,
will be responsible for protection and assistance activities of
refugees if an influenza pandemic occurs. Although UNHCR normally
seeks to implement there programmes through an implementing partner,
there are circumstances in which it may be necessary or clearly
in the interest of refugees for UNHCR to assume greater operational
responsibility.
34. In order to limit the negative impact
of a potential AHI pandemic, the UNHCR Country Offices, in coordination
with national governments and UN country teams, are already actively
working on the preparation of country-level contingency plans
dealing with both staff and beneficiaries.
1 February 2008
48 Sphere Project, Humanitarian Charter and Minimum
Standards in Disaster Response, The Sphere Project, Geneva, 2004. Back
49
World Health Organization (2005) Malaria control in complex
emergencies: an inter-agency field handbook. Geneva: World Health
Organization. Back
50
UNAIDS and UNHCR (2005) Strategies to support the HIV related
needs of refugees and host populations, Geneva. Back
|
