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Source: World Health Organization (WHO)
22 January 2009


1. Context

The Gaza Strip, on the eastern Mediterranean coast between Israel and Egypt has been the setting for a protracted humanitarian crisis. It has a population of 1.5 million with the sixth highest population density in the world, and a very young demographic with 18% of the population under 5 years of age (274 000 children). Recent events have resulted in a severe exacerbation of the chronic humanitarian crisis.

As of 18 January, over 50 896 people had been newly displaced and were residing in 50 shelters organised by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). It is estimated that there may be an additional tens of thousands of displaced people, mainly sheltering with host families. As of 18 January, the Ministry of Health of the Palestinian Authority (MoH) reported that 1 300 people had been killed since 27 December, of whom at least 410 were children and 104 women. Over 5 300 were reported injured, including 1 855 children and 797 women.

Vital infrastructure has been severely compromised or destroyed, resulting in lack of shelter and energy sources, sudden deterioration of water and sanitation services, food insecurity, overcrowding and severely curtailed access to health services. Since 27 December 2008, at least 16 health facilities and 16 ambulances have been reported damaged and as of 14 January, 21 out of 57 MoH health facilities and 3 out of 18 UNRWA health facilities were closed (OCHA).

Those facilities that remain operational face a number of challenges, including (i) low staffing levels due to insecurity, especially in Gaza City; (ii) electricity for only a few hours per day from emergency generators; (iii) uncertain supply lines; and (iv) inaccessible health care services for most of the catchment area population, with attendance rates reported to have fallen by more than 50%.

2. Priority health issues

The risk of excess morbidity and mortality is primarily from traumatic injury or from the discontinuation of treatment for chronic conditions due to poor access to health care services. Diarrhoeal diseases currently represent the most important risk of excess morbidity and mortality from communicable diseases. The priorities below may change should the crisis continue for an extended period.

The current overwhelming health concern is timely access to appropriate care for those who are injured. The nature of presenting injuries includes open wounds, blunt trauma and burns. Delays in provision of trauma and emergency surgical care and rehabilitation for the injured can increase the likelihood of complications including disability, or of death.

An adequately functioning pre-hospital emergency medical service (EMS), such as an ambulance service, and emergency rooms that are adequately staffed and equipped can significantly improve survival rates among those with life-threatening injuries and surgical conditions.

Given the context (reduced staffing, treatment delays, interruptions to electricity and limited water supplies), the risk of wound infection is high (for guidelines on surgery, and wounds and injuries, see section 5). Tetanus is of particular concern as vaccination coverage among adults is low. Health care workers should ensure they are suitably protected including with all appropriate vaccinations.

The stress and losses that occur during emergencies are a risk factor for a wide range of mental disorders, including mood and anxiety disorders (such as post-traumatic stress disorder). WHO projects that the long-term effects of emergencies can increase the number of people with severe mental disorders by an average of 1% above baseline and those with mild and moderate mental disorders by an estimated 5-10% above baseline. Much of the affected population is also likely to be burdened by a wide range of symptoms of distress and other psychosocial problems caused by severe trauma, loss and social and living conditions.

Prior to recent events, non-communicable disease was the leading cause of death in the Gaza Strip. Surveys indicate a 9% prevalence of diabetes mellitus among the adult population. In 2007, UNRWA treated approximately 34 000 hypertensive and 23 000 diabetic patients in the territory (a total of 45 000 patients taking into consideration an overlap of the conditions), with a prevalence in the adult population of 17% and 12% respectively. Among these patients, about 7 000 were receiving insulin therapy and 22 000 were taking hypertension drugs; 23% of patients with hypertension and/or those with diabetes (10 000) were considered to be at high risk of complications and death. Among these patients, the two groups considered to be at highest risk are the young insulin dependent diabetic patients with severe hypertension, and those on renal dialysis. These patients are only able to tolerate an interruption of therapy for 4-5 days in the first case and a maximum of one week in the second.

Risk of diarrhoeal disease outbreaks may increase with protracted disruption to water and sanitation services. Risk of outbreaks of vaccine-preventable diseases is currently low, given high reported vaccine coverage, with the exception of tetanus vaccination among adults. However this may change if vaccination programmes are disrupted for protracted periods.

3. Priority communicable diseases

The risk of outbreaks of waterborne and foodborne diseases is currently high and will increase if water, sanitation and food control services are not restored, or are allowed to deteriorate further. The main pathogens of concern are Campylobacter, Salmonella, Shigella, Leptospira, rotavirus, as well as other enteropathogens such as Entamoeba histolytica and hepatitis A and E1. Typhoid fever, reports of which increased in the Gaza Strip in 20072, is also a concern. Cholera has not been reported in the territory since 1992.

Currently, 55 out of 145 wells in the Gaza Strip are not functioning and 80% of the water supply in the territory is estimated to be unsafe for drinking (OCHA). Sewage treatment has been disrupted and sewage has been reported in the streets of Beit Hanoun and Beit Lahiya. Monitoring of water quality has stopped since 4 January 2009, following the closure of the Public Health Laboratory.

Vaccination programmes have ceased as of 27 December 2008. However, given the high reported routine vaccination coverage prior to that date (Table 1), with the notable exception of tetanus coverage in adults, the risk of measles, polio, diphtheria, and pertussis outbreaks is currently low.

The main risk is from tetanus resulting from trauma (inadequately treated wounds and burns) and from maternal and neonatal tetanus (MNT) following unsafe deliveries. Tetanus vaccination coverage in adults is low and protection is known to wane with age. The incubation period is usually 3–21 days, and the case-fatality ratio (CFR) is 70–100%. (For prevention and management of tetanus, see Section 5).

Currently there are about 1 200 births per week in the Gaza Strip (UNFPA - OCHA Field Update 16/01/09). Many of the newborns are not receiving routine vaccinations in line with Expanded Programme on Immunization (EPI) schedules. Un-immunized children will require catch-up vaccination doses once the EPI activities are able to resume. If disruption to EPI services is of short duration (i.e. a few weeks), it is unlikely that vaccination coverage will dip below the herd immunity thresholds. However, the Gaza Strip is a very densely populated area which requires greater levels of herd immunity, and therefore higher vaccination coverage, than less densely populated areas. If vaccination programmes are suspended for a protracted period, accumulating birth cohorts of un­immunized children will result in lowered vaccination coverage levels, placing the entire community at risk of outbreaks of vaccine-preventable diseases.

Children and newborns are particularly at risk from ARI and have an increased risk of death from pneumonia. The main risk factors include crowding, poor ventilation, indoor smoke, malnutrition and lack of breast-feeding. The disruption of EPI services also means fewer babies receive supplements of vitamin A, a highly effective preventive intervention against ARI. Acute malnutrition is a major contributing factor to morbidity and mortality from communicable diseases such as ARI, particularly in children. Micronutrient deficiencies, especially iron deficiency anaemia and vitamin-A deficiency, remain public health problems in the Gaza Strip3.

Between 20 and 25 new TB cases are reported annually from the Gaza Strip. Untreated active pulmonary TB carries a case fatality ratio (CFR) of 65% within 5 years. In the acute phase of this emergency, the main concern for TB programmes is the continuation of treatment which is likely to be hampered by drug supply problems and loss of contact with patients.

Highly pathogenic A(H5N1) was reported in poultry in the Gaza Strip in 2006. No human cases have been reported to date.

The prevalence of HIV in the Gaza Strip is low. No new AIDS cases were reported in 20074.

There is no risk of malaria in the Gaza Strip.
A functioning communicable disease surveillance system was in operation prior to June 2006. This has since deteriorated and ceased functioning as of 27 December 2008.

4. Priority interventions

    Interventions to reduce morbidity and mortality in the Gaza Strip are fundamentally dependent on patients' ability to access health care, which is at present severely compromised.

    · Provide emergency medical and surgical care for traumatic injury, burns and life threatening surgical conditions. Ensure appropriate wound management including tetanus prophylaxis.

    · Ensure the continuation of treatment of chronic conditions for those on medications including TB, hypertension, diabetes and kidney disease. Where feasible, decentralization of care will increase treatment coverage given the restrictions on movement.

    · Provide support for mental health and psychosocial disorders.
      o Include specific psychological and social considerations in provision of general health care;
      o provide psychological first aid to people with severe, acute anxiety;
      o ensure continued access to care for people with severe mental disorders.

    · Provide sufficient safe water, sanitation and reinforced hygiene measures for infection control.

    · Establish and maintain an effective mechanism for communicable disease surveillance and response to detect and respond to outbreaks, with particular focus on diarrhoeal diseases.

5. Information Sources
WHO headquarters and WHO Regional Office for the Eastern Mediterranean/EMRO
Communicable Disease Surveillance and Response, WHO/EMRO

Disease control in humanitarian emergencies (DCE), WHO/HQ Health Action in Crises (HAC), WHO/HQ
Avian and Pandemic Influenza
Avian influenza Pandemic influenza preparedness and mitigation in refugee and displaced populations. Second edition May 2008.(pdf -550 kb)
Child health in emergencies
Emergencies documents Pocket book of hospital care for children Acute respiratory tract infections in children IMCI Chart Booklet (WHO; UNICEF, 2006)
Diarrhoeal diseases
Acute diarrhoeal diseases in complex emergencies: critical steps. Cholera outbreak: assessing the outbreak response and improving preparedness First steps for managing an outbreak of acute diarrhoea. Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1 Oral cholera vaccine use in complex emergencies: What next? Report of a WHO meeting. Cairo, Egypt, 14–16 December 2005. [pdf-3200kb] Background document: the diagnosis, treatment, and prevention of typhoid fever (WHO, 2003) [pdf­230kb]
Drug donations
Guidelines for Drug Donations (WHO, revised 1999) [pdf-270kb]
Environmental health in emergencies
Guidelines for drinking-water quality, third edition, incorporating first addendum Environmental health in emergencies and disasters: a practical guide WHO Technical notes for emergencies Frequently asked questions in case of emergencies Four steps for the sound management of health-care waste in emergencies
Food safety
Ensuring food safety in the aftermath of natural disasters Prevention of foodborne disease: Five keys to safer food Guideline for the safe preparation, storage and handling of powdered infant formula (WHO, 2007)
Gender & gender-based violence
IASC Guidelines for Gender-based Violence Interventions in Humanitarian Settings (2005) [pdf- 1900kb] IASC Gender Handbook in Humanitarian Action Women, Girls, Boys and Men Different Needs – Equal Opportunities (2006) [pdf-3200kb]
Clinical management of rape survivors: Developing protocols for use with refugees and internally displaced persons. 2004 - Revised edition (WHO/UNHCR) mngt rapesurvivors/

Hepatitis A

Hepatitis E
Guidelines for HIV/AIDS interventions in emergency settings: Interagency Standing Committee guidelines
Laboratory specimen collection
Guidelines for the collection of clinical specimens during field investigation of outbreaks (WHO, 2000)
Nutrition in emergencies publications Communicable diseases and severe food shortage situations (WHO, 2005) [pdf-250kb] The management of nutrition in major emergencies.(WHO, 2000) [pdf-12 800kb] Infant feeding in emergencies - guidance for relief workers in Myanmar and China Guidelines for the inpatient treatment of severely malnourished children (WHO, 2003) [pdf-400kb] Community-based management of severe malnutrition Management of the child with a serious infection or severe malnutrition: guidelines at first referral level in developing countries (WHO, 2000) Guiding principles for feeding infants and young children during emergencies (WHO, 2004) [pdf- 1800kb]
Infant and young child feeding in emergencies. Operational guidance for emergency relief staff and programme managers (IFE, 2007) [pdf-870kb] (in English and Arabic) 1-english-01 0307.pdf 1 .pdf
Gaza Alert - Media Guide on Infant and Young Child Feeding in Emergencies (in English and Arabic)
Management of dead bodies
Management of dead bodies after disasters: a field manual for first responders (2006) [pdf-1 100kb] Management of dead bodies in disaster situations (WHO, 2004) [pdf-780kb]
WHO/UNICEF Joint Statement on reducing measles mortality in emergencies (WHO/UNICEF, 2004)
WHO measles information Measles fact sheet
Medical waste in emergencies
Medical wastes in emergencies Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies (WHO, 1999) Four steps for the sound management of health-care waste in emergencies (WHO, 2005)
Mental health in emergencies
Mental heath in emergencies IASC Guidelines on Mental Health and Psychosocial support in Emergency settings (2008) English [pdf-800kb] Arabic [pdf-1 .1 Mb] IASC Guidelines on Mental Health and Psychosocial support in Emergency settings: Checklist for field use (2008) [pdf-4 MB]
Control of epidemic meningococcal disease. WHO practical guideline, 2nd edition (WHO, 1998)
Outbreak Communications
WHO Outbreak communication guidelines
WHO-recommended surveillance standard of poliomyelitis
Surgery - emergency surgical care
Integrated Management for Emergency and Essential Surgical Care (IMEESC) tool kit

Maternal and Neonatal Tetanus. M Roper et al. Lancet 2007; 370: 1947-59.
http :// _and _neonatal _tetanus _Seminar.pdf
Tetanus Immunization: Maternal and Neonatal Tetanus (MNT) elimination

Surgical Care at the District Hospital (2003)
Travel advice
Guide on Safe Food for Travellers
Tuberculosis care and control in refugee and displaced populations. An interagency field manual (2007). [pdf­960kb]
Vaccines and biologicals
Vector control
Integrated vector management Pesticides and their application for the control of vectors and pests of public health importance ( WHO,2006)
Wounds, injuries and trauma care
Prevention and management of wound infection [pdf-40kb] Guidelines for essential trauma care (2004) [pdf-764kb] Prehospital trauma care systems (2005) [pdf-566kb] Integrated Management for Emergency and Essential and Surgical Care (IMEESC) tool kit Best Practice Guidelines on Emergency Surgical Care in Disaster Situations [pdf-2254kb]
White Phosphorous: Systemic Agent Surgical Care at the District Hospital (2003) WHO generic essential emergency equipment list [pdf-1 11kb]
Zoonotic diseases

1 Exclusive breastfeeding should be encouraged. The most appropriate alternative for infants dependent on a breast milk substitute (BMS) is ready-to-use infant formula is most appropriate as it does not require mixing with water.
2 UNRWA Health Report 2007.
3 UNRWA Health Report 2007.
4 UNRWA Health Report 2007.

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