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International Notes Health Status of Displaced Persons Following Civil War -- Burundi, December 1993-January 1994

In Burundi (1990 population: 5.7 million), located in central-east Africa, seasonal epidemics of dysentery caused by Shigella dysenteriae type 1 (Sd1) have been documented each year since 1980. The assassination of the president of Burundi on October 21, 1993, resulted in widespread violence involving major tribal groups. By December, an estimated 130,000 persons had become displaced within the country, and approximately 683,000 persons had fled to Rwanda, Tanzania, or Zaire. Many displaced persons fled from rural areas to villages and towns; sanitation in these areas became inadequate as a result of the rapid influx of many persons. Because the civil war disrupted government services, the national routine disease surveillance system ceased to function in November. To assess the health status of displaced persons, rapid surveillance systems were established at sentinel sites throughout Burundi and in refugee camps in Rwanda. This report summarizes findings from these surveillance activities during December 1993- January 1994. Burundi

In December 1993, the Burundi Ministry of Health (MOH) established a sentinel disease reporting system which included the selection of one rural outpatient clinic in each of the 15 provinces. A one-page reporting form was designed to record for each week the number of new cases of seven diseases with epidemic potential (i.e., cholera, dysentery, and other diarrhea; lower respiratory tract infections; malaria; measles; and meningitis), intentional injuries, and the total number of new clinic visits. Standard case definitions developed by the MOH were disseminated to participating sites. Completed surveillance forms were sent weekly to the MOH; nongovernmental organizations (NGOs) collected and transported surveillance forms. The MOH then issued a weekly surveillance report for distribution to staff in health centers and hospitals, MOH officials at the national level, and NGOs involved with relief activities.

Because the populations of sentinel clinic catchment areas were not available to calculate disease incidence rates, the analysis of surveillance data focused on calculation of weekly proportional morbidity (i.e., number of new visits for a reported disease divided by total number of new visits for all diseases). Data were analyzed from the 12 sites reporting complete information for December 13, 1993-January 9, 1994. Dysentery and malaria (defined as diarrhea with visible blood and fever without another apparent cause, respectively) were the most common causes of morbidity, accounting for 29% and 28% of all new visits to health centers, respectively. In comparison, during December 14, 1992- January 10, 1993, national surveillance data indicated that dysentery and malaria accounted for 6% and 23% of all new visits to health centers. Lower respiratory tract infections and nonbloody diarrhea accounted for 3% of all new visits during the crisis; meningitis, measles, intentional injuries, and cholera each accounted for less than 1% of all new visits. Weekly estimates of proportional morbidity for dysentery and malaria and counts of the total number of new visits for any cause were stable during the 4-week period. The MOH and collaborating organizations used these sentinel data to establish dysentery and malaria as priority health problems and to mobilize resources. Rwanda

By October 31, 1993, an estimated 300,000 refugees from Burundi had settled in Rwanda. Health posts were established by Medecins Sans Frontieres (MSF) in each of four refugee camps (total population: 54,921) in the commune of Kibaye. Standard case definitions were used to collect surveillance information during all health post visits. Camp populations were determined by census. Mortality surveillance was conducted by counting the numbers of burial shrouds distributed, the numbers of new graves dug, the numbers of deaths reported to health posts by families, and daily visits by health workers to tents and shelters.

During December 1, 1993-January 17, 1994, the most commonly reported causes of new visits to health posts were malaria, dysentery, nonbloody diarrhea, and lower respiratory tract infections, accounting for 38%, 14%, 7%, and 6%, respectively, of all new visits to health posts. The mean weekly dysentery attack rate during this period was 3.8 cases per 100 persons; the rate was highest for children aged less than 5 years (5.8 cases per 100 children).

During this period, the average daily crude mortality rate was 3.0 deaths per 10,000 persons -- an annualized rate of approximately 10%. Of the total 765 deaths, 433 (57%) were attributed to dysentery (estimated case-fatality rate=3.2%). Other causes of mortality were malaria (19%), acute lower respiratory tract infections (6%), and malnutrition (6%).

Based on these findings, MSF emphasized treatment of dysentery with a complete course of nalidixic acid and improvement of basic sanitation and hygiene. The weekly number of dysentery cases in these camps peaked during late November and rapidly decreased during December. Reported by: JS Kidasi, Ministry of Health, Burundi. C Paquet, Epicentre; A Sasse, W Jansen, Medecins Sans Frontieres/Belgium. M Clerc, J-Y De Lemps, Medecins Sans Frontieres/France. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Epidemiologic Support Br, Div of Technical Support, International Health Program Office, CDC.

Editorial Note

Editorial Note: The surveillance approaches described in this report demonstrate how simple, rapid reporting systems can provide decision-makers with useful information about the health status of populations affected by conflict and massive population displacement. In particular, weekly proportional morbidity and daily death rates can be used to identify priority disease-control activities, monitor trends, and evaluate the effectiveness of health interventions. Proportional morbidity may be especially useful as a means of monitoring health status when population estimates are not available and incidence rates cannot be calculated. Death rates are one of the most sensitive indicators of health status; the goal of emergency relief efforts should be to reduce the crude mortality rate to less than one death per 10,000 persons (1). Standardized clinical case definitions can reduce variability in reporting, particularly when there is rapid turnover in clinic staff.

Since 1991, dysentery epidemics caused by Sd1 have occurred in eight countries in southern Africa (Angola, Burundi, Malawi, Mozambique, Rwanda, Tanzania, Zaire, and Zambia). Epidemic dysentery is a particular problem among refugee populations in which crowding and poor sanitation facilitate transmission. In refugee and displaced populations, epidemic dysentery has been characterized by substantially higher incidence rates than in nonrefugee populations (2) and high proportional mortality -- a pattern underscored by the findings in Burundi. The proportion of dysentery-associated deaths among Burundian refugees in Rwanda (57%) was similar to that among Burundian refugees in Tanzania (50%) (3).

Treatment with an effective antimicrobial (e.g., ampicillin, cotrimoxazole, and some quinolone agents) can reduce the severity and duration of shigellosis if the organism is susceptible to the antimicrobial (4). Since 1993, Sd1 strains from Burundi have been resistant to ampicillin and cotrimoxazole and moderately susceptible to nalidixic acid; the case-fatality rate was lower among Burundian refugees in Rwanda treated with nalidixic acid (3%) than among patients in Burundi treated with cotrimoxazole before the crisis (10%) (5). However, because resistance to nalidixic acid among Sd1 isolates previously has been widespread in Burundi and is increasing again (5,6), the effectiveness of nalidixic acid as a treatment for Sd1 infections may diminish.

The problem of rapid acquisition of antimicrobial resistance in the treatment of Shigella dysentery in Africa underscores the need for identification of measures to prevent transmission of epidemic dysentery in refugee and internally displaced populations. For example, handwashing with soap and water can reduce secondary transmission of Shigella infections between household members; in Burundi, poor hygienic practices and lack of soap in the household are risk factors for acquiring dysentery (2). The most effective strategies to control transmission of Sd1 in refugee camps and among displaced persons may be distributing soap, ensuring access to water, promoting handwashing before eating or preparing food and after defecation, and properly disposing of fecal material.


  1. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 1990;263:3296-302.

  2. Birmingham ME, Lee L, Ntakibirora M, Deming M, Bizimana F. The epidemiology of dysentery in Burundi {Abstract}. In: Program and abstracts of the Epidemic Intelligence Service 42nd annual conference. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1993.

  3. Varaine F, Fouveaud C. Dysentery outbreak in Burundian refugee camps, Kibundo District, Tanzania {Trip report}. Paris: Epicentre/Medecins Sans Frontieres, December 1993.

  4. Salam M, Bennish ML. Antimicrobial therapy for shigellosis. Rev Infect Dis 1991;13:S332-S341.

  5. Murray JCS, Ntakibirora M, Manirankunda L, Lee L, Deming M, Birmingham M. Mortality from dysentery in Burundi {Abstract}. In: Program and abstracts of the Epidemic Intelligence Service 43rd annual conference. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

  6. Ries AA, Wells JG, Olivola D, et al. Epidemic Shigella dysenteriae type 1 in Burundi: panresistance and implications for prevention. J Infect Dis 1994;169:1035-41.

+------------------------------------------------------------------- ----+ |             | | Erratum: Vol. 43, No. 38 | | ======================== | | SOURCE: MMWR 44(35);654 DATE: Sep 08, 1995 | |             | |             | | On page 702 of the article "Health Status of Displaced Persons | | Following Civil War -- Burundi, December 1993-January 1994," in the | | "Reported by:" section, S Nkurikiye should be listed first, and the | | affiliation of JS Kidasi should be U.S. Agency for International | | Development. | +------------------------------------------------------------------- ----+

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