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International Notes Surveillance of Health Status of Kampuchean Refugees -- Khao I-Dang Holding Center, Thailand, December 1981-June 1983
In November 1979, the Khao I-Dang Holding Center (KIDHC) was opened to house some of the thousands of Kampuchean refugees who fled into Thailand (1,2). The average monthly KIDHC population between December 1981 and November 1982 was approximately 42,700. A census in December 1982 showed a population of 40,134. Subsequently, an additional large number of refugees were transferred to the camp after closure of other Khmer holding centers by Thai authorities. As of mid-June 1983, approximately 57,500 Kampuchean refugees were still living at KIDHC; twenty-one agencies and 1,377 workers (including 1,287 Kampuchean and 18 Thai workers) have supported their health, nutritional, and other needs.
During the 12 months beginning in December 1981, 2,323 births were recorded in KIDHC (3); 1,682 (72.4%) of these infants were born in the hospital, representing a crude birth rate of 54.4/1,000 population. Mean birth weight was 2,980 g for 118 consecutive live infants born in the KIDHC hospital during early January 1983. Of these, 11 (9.3%) weighed less than 2,500 g.
During the same 12-month period, 182 resident deaths were reported (Table 1) (3), for a crude resident death rate of 3.97/1,000 residents. Ninety-nine resident deaths occurred among children under 1 year of age, for an infant mortality rate of 42.6/1,000 live births.
Under 1 month of age, prematurity (23 cases), sepsis (19), and congenital anomalies (7) were the most common causes of death, accounting for 75.4% of 65 deaths in this age group. The most common categories in the 1- to 11-month age group were "unknown" (12 cases) and congenital anomalies (4). In the 1- to 4-year age range, pneumonia (6) and sepsis (4) together accounted for 71.4% of all deaths. Eight accidental deaths in all age groups were recorded. Nine adults died of malignancies. In addition, 206 deaths occurred among other Kampuchean refugee patients referred for medical care from refugee camps on the Kampuchean border (Table 1). More deaths occurred among non-resident young adults than among neonates and older adults (45 years or older).
A total of 4,345 hospital discharges of KIDHC residents occurred during this recording period, most of which--1,609--were normal or complicated births. Serious pediatric infections (pneumonia and cellulitis, 249 cases) and gynecologic problems (188) were the second and third most common causes for hospitalization. The annual hospitalization rate was 101.8/1,000 residents.
Two hundred eighty-seven Plasmodium vivax malaria cases and 78 P. falciparum malaria cases were reported among KIDHC residents during 1982. Most, if not all, of the P. falciparum cases occurred among persons transferred to KIDHC when another holding center, located in a malaria-endemic region was closed.
In October 1982, a health and nutrition survey (4) of a random sample of children under 5 years old in KIDHC revealed evidence of acute malnutrition in five (1.5%) of 328 children (5).* Evidence of chronic malnutrition was found in 22 children (6.7%).** Conjunctival xerosis or other ophthalmologic signs of recent or healed vitamin A deficiency were seen in 14 children (4.3%). All surveyed children less than 1 year old (75) were breastfed. Of 63 children 12- to 17-months-old, 58 (92.1%) were breastfed; 41.1% of 56 of 18- to 23-month-olds were breastfed.
During the latter half of 1982, increases in the numbers of beriberi (vitamin B((1)) deficiency) cases were noted by health workers. In addition, several children were admitted to the hospital during that time with corneal involvement compatible with severe vitamin A deficiency.
Because of these problems, undermilled rice was introduced in March 1983 as a total substitute for white rice in the KIDHC food distribution system. Also, as of June 1983, all non-breastfeeding children 6 months to 5 years of age and all lactating women attending the maternal- and child-health centers were given 200,000 International Units of vitamin A. Younger children received 100,000 International Units. Neither beriberi nor vitamin A deficiency are currently reported to be prevalent problems at KIDHC.
The current childhood immunization recommendations in the camp include one dose of measles vaccine and three doses each of trivalent oral polio vaccine and diphtheria-tetanus-pertussis vaccine. A survey in the maternal- and child-health facilities in December 1982 showed that 84% of the population had complete immunizations. No outbreaks of vaccine-preventable diseases were reported in 1982 or thus far in 1983. A major catchup immunization program was undertaken in May 1983 to complete immunizations of all residents.
Including patients transferred to KIDHC from other recently closed refugee camps, 303 newly diagnosed tuberculosis (TB) patients were placed on therapy in 1982. Of the 298 who left the TB treatment program during the same period, 226 (75.8%) did so because they had completed the prescribed course of four-drug therapy (streptomycin and pyrizinamide for the initial 2 months plus rifampin and isoniazid for all 6 months). Another 41 (13.8%) were transferred on medication and with records to other refugee processing centers; seven (2.3%) died, and 24 (8.1%) are assumed to have defaulted from their treatment program because of departure to refugee camps nearer the Kampuchean border where adequate follow-up is more difficult. Of those with smear-positive pulmonary TB completing the treatment regimen, 96% had favorable outcomes, as judged by persistence of smear-negativity over the final 3 months of treatment; 3% had uncertain bacteriologic response, and 1% appeared resistant to the above drug combination.
As of February 1983, four traditional medicine centers and 31 Krou Khmer (traditional healers) were serving the camp population. Including follow-up visits, nearly 3,000 patients per day were being seen in these facilities at this time. Cooperation and cross-referrals between Western trained health workers and traditional healers were reported.
In addition to training for provision of basic health care, current training programs for KIDHC residents include water jar and soap production, bread making, carpentry, woodcarving, sewing, weaving, fish farming, blacksmithing, tinsmithing, rice milling, classical Khmer ballet and music, and theater. Reported by A Holloway, M Gorman, J Shout, D Bass, MD, L Boyer, R Dewey, R Dexter, V Dietz, MD, M Lyna, S Kim Seath, M Im, L Wiesner, International Rescue Committee. H Rieder, MD, Thai/Swiss Red Cross TB Program. JP Hiegel, MD, Sovereign Order of Malta. B Thompson, MSc, C Eldridge, J Borton, Cooperative for American Relief Everywhere. Khmer Public Health Association. AG Rangaraj, MD; A Ahmad, Office of the United Nations High Commissioner for Refugees. International Health Program Office; Div of Nutrition, Center for Health Promotion and Education, CDC.
Editorial Note: The original health surveillance system at KIDHC was organized in 1979 by staff of the International Committee of the Red Cross (ICRC) with the assistance of several volunteer agencies, primarily the International Rescue Committee.
Although the ICRC is no longer involved at KIDHC (except for the hospital surgical ward) and volunteer agency staffs have changed several times since the holding center opened, the surveillance system has continued to evolve and to function efficiently. Kampuchean health workers have taken over much of the responsibility for the surveillance system. In June 1983, information gathered by Krou Khmer was included in the KIDHC surveillance report for the first time.
Although the population of KIDHC has fluctuated as some refugees continue to enter and as others depart for resettlement or return to Kampuchea, these and other recent data suggest that general health conditions have improved since KIDHC opened: the current mean birth weight of 2,980 g was greater than that of 2,810 g noted among the first 154 infants born at KIDHC from November 16, 1979, to January 11, 1980 (2), and the crude mortality rate of 3.0/1,000 residents/year (3) is lower than the rate noted at KIDHC in 1979 and early 1980 and is lower than what is generally observed in many developing countries (6). This low rate is probably due to the relatively low infant mortality rate, usually a major component of overall (crude) mortality, and deaths before their arrival at KIDHC of many among this population who might otherwise have died in 1982 (e.g., the elderly, the chronically ill).
These data and observations indicate that a relatively simple, population-based surveillance system can function over several years border area. Ill or premature neonates in this environment are not often candidates for referral. The large proportion of deaths among young adult non-residents is partly due to a large number of injuries from land mines or other weapons.
These data and observations indicate that a relatively simple, population-based surveillance system can function over several years in a refugee camp environment, providing information needed by administrators and health workers to maintain or improve health conditions in the camp.
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