What Is the Immunization Plan for an Internally Displaced Person from a Natural Disaster?

Patient Presentation
A 10-month-old female came to clinic with a mild cough, runny nose and a fever for 2 days.
The child has recently relocated from the New Orleans area because Hurricaine Katrina had devastated their home.
She was drinking and urinating well, was playful and had no specific ill contacts.
The past medical history revealed a healthy female who had received routine health care up to 6 months of age.
Her immunizations were current.
The pertinent physical exam revealed a playful female with a normal temperature and no tachypnea. She had mild clear rhinorrhea anda small amount of fluid behind her tympanic membranes bilaterally with no injection. Her throat and lungs were normal.
The diagnosis of a viral upper respiratory illness was made. Her parents were told to give symptomatic care and to monitor symptoms. The parents asked what they should do about their child’s immunization schedule because of the hurricaine and the lack of vaccine documentation.
The parents were told that the Centers for Disease Control website had recommended that health care providers assume that patients without documentation of immunization would have had all of their vaccinations and to continue the regularly schedule vaccines at the proper time. They were offered Influenza vaccine in a few weeks when it became available.

Discussion
A humanitarian emergency generally can be described as “an acute situation affecting a large population where through disruption or displacement neither the population nors it’s government is capable of providing for all of the basic needs.”
There can be various inciting events including natural disasters (e.g. hurricanes, droughts, famines, earthquakes, etc.) or manmade disasters (e.g. terrorist attacks, bombings, nuclear explosions, civil war, etc.). The United Nations High Commission for Refugees refers to the individuals affected as “persons of concern.”These persons of concern are either refugees (people who leave and cross an international border to another country) or internally displaced persons (IDPs, people who leave their homes but do not cross an international border and enter another country).
Refugees sometimes maybe better off than IDPs because once a border is crossed then international treaties and laws often apply to their treatment. This is not true for IDPs as a sovereign government needs to accept aid for what is considered an internal problem.

The most vulnerable individuals in humanitarian emergencies are the youngest and oldest of a population. Orphaned and unaccompanied children are even more vulnerable. Women and women-headed households often have less access to relief services. Pregnant and lactating women are also vulnerable because of their increased nutritional needs.

The appropriate emergency response must always be tailored for the disaster.
Ten essential emergency relief measures to evaluate and institute are:

  • Rapid assessment of the situation and the affected population
  • Provide adequate shelter and clothing
  • Provide adequate food – minimun 1900 kcal/person/day
  • Provide elementary sanitation and clean water 3-5 liters/person/day
  • Institute diarrhea control program
  • Immunize against measles and provide Vitamin A supplements
  • Establish primary care medical treatment
  • Establish disease surveillance and a health information system
  • Organize human resources – victims themselves, community leaders, interpreters, surrogates for unaccompanied minors
  • Coordinate activities with local authorities, relief organizations, government agencies, military etc.

Learning Point
The Centers for Disease Control (CDC) has issued recommendations for immunization implementation plans for IDPs of the Hurricaine Katrina and Rita disasters that occurred in the fall of 2005 (see To Learn More). Many medical records were destroyed in these disasters.

  • If medical records are available and the patient has current vaccines, then the patient should continue to receive the proper vaccines on the regular schedule
  • If medical records are available and the patient is missing vaccines, then the patient should receive the proper vaccines on the catch-up schedule.
  • If no medical records are available, then the recommendations are based upon age:
    • <10 years – the patient is assumed to have current vaccines and should receive the proper vaccines for their age based upon the current schedule and state immunization practices. Varicella vaccine should be given unless there is a reliable history of disease.

    • 10-18 years – the patient should receive the adult formulation of diphtheria toxoids and acellular pertussis (Tdap), meningococcal conjugate vaccine (ages 11-12, and 15 years only) and Influenza vaccine if in high risk Tier 1 category.
    • > 18 years – the patient should receive adult formulation of diphtheria toxoids and acellular pertussis (Tdap) if 10 years or more since last tetanus, Pneumococcal vaccine for adults > 65 years, and Influenza vaccine if in high risk Tier 1 category.

It is important for health care providers not only to document the immunizations given, but also to document that the decision for the immunization plan was based upon the natural disaster recommendations from the CDC or other agency. This can prevent possible confusion in the future for the other health care providers who may not know of these recommendations and to prevent unnecessary vaccine duplication.
As for school requirements, the CDC has stated,”States affected by Hurricane Katrina had immunization requirements for school and daycare and it is likely that children enrolled prior to the disaster would be vaccinated appropriately. It is not necessary to repeat vaccinations for children displaced by the disaster, unless the provider has reason to believe the child was not in compliance with applicable state requirements.”

People living in crowded group conditions should be immunized for Influenza, Varicella, MMR and Hepatitis A according to the CDC guidelines.

Questions for Further Discussion
1. What are some of the mental health needs of refugees and IDPs?
2. What is the relationship between governmental agencies and non-governmental organizations in disasters?
3. What is your own role in providing help during a local diaster?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Traveling with Small Children and Colds / Upper Respiratory Infection (URI)

To view current news articles on this topic check Google News.

Uniformed Services University of the Health Sciences, Department of Pediatrics. Military Medical Humanitarian Assistance Course. October 2003. pp. 3-24.Available from the Internet at http://www.pedsedu.com/course_manual.htm (rev. 9/8/05, cited 10/17/05).

Centers for Disease Control. Interim Immunization Recommendations for Individuals Displaced by Hurricane Katrina.
Available from the Internet at http://www.bt.cdc.gov/disasters/hurricanes/katrina/vaccrecdisplaced.asp (cited 10/17/05).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 31, 2005