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Myanmar

Communicable disease risk assessment and interventions - Cyclone Nargis: Myanmar, updated 27 may 2008

Attachments

WHO/HSE/EPR/DCE/2008.4.

1. BACKGROUND AND RISK FACTORS

Myanmar is the largest country in mainland South-East Asia, with a coastline of 2 400 km which largely forms the east coast of the Bay of Bengal. Three mountain ranges run north-to-south from the Himalayas forming natural divisions. The three main river systems, the Ayeyarwady (Irrawaddy), Sittaung and Thanlwin, flow between these barriers. The numerous tributaries of the three rivers in the delta regions make communication and transport challenging.

The country has three distinct seasons: rainy, cold and hot. The rainy season arrives with the south-west monsoon, which begins in mid-May, and lasts until mid-October.

Myanmar is divided into 14 primary administrative areas (7 divisions and 7 states) and each state or division is further subdivided into districts (65), townships (325), wards (2 781) and villages (64 910). It is a largely rural, densely forested (49%) country of 55.4 million people with an average density of 75 people / km2 that ranges from 595 / km2 in Yangon Division to 14 / km2 in Chin State, to the west of the country. The population is made up of 135 national groups, speaking over 100 languages and dialects. The population is predominantly Buddhist (89.4%) and the remainder are Christian, Muslim, Hindu and Animist. The majority of Burma's population lives in the Ayeyarwady valley, the area hit primarily by Cyclone Nargis.

The annual per capita income is USD 1691 with a ranking of 132/177 on the UNDP Human Development Index 2007 (HDI) and of 52/108 on the Human Poverty Index (HPI). The HPI measures severe deprivation in health by the proportion of people who are not expected to survive beyond the age of 40.

Early reports indicate the cyclone has affected five divisions and states (Ayeyarwady, Yangon and Bago Divisions; Kayin and Mon States) in total, mainly in the southern part of the country, as well as offshore islands (see Figure 1). The area which has been declared a State Disaster Area has a total population of 24 million.

Cyclone Nargis (Category 3-4) developed over the Bay of Bengal and made landfall at 16.00 hrs, on 2 May 2008 in the Ayeyarwady delta region with winds up to 200 km/hr and associated tidal surges, rain and flooding. Due to the complex of deltas on the coast, tidal surges are likely to have penetrated inland.

The cyclone tracked inland reaching Yangon (former capital city, 5 million inhabitants). The effects of the cyclone are reported to be significant in the coastal areas which are densely populated and in Yangon city where there is a large population of urban poor.

As of 16 May 2008, there were more than 77 000 dead and over 55 000 missing reported (Government of Myanmar). The number of affected population is estimated to be 2.5 million with about 100 000 displaced persons into settlements (OCHA).

A storm surge is reported to have destroyed the vast majority of domestic dwellings in seven townships, also causing severe storm and flood-damage to roads, communication links and other essential service infrastructure, especially water and power supplies. Such damage will hinder and complicate assessment and response efforts and increase the risk of infectious diseases.

Access to the public health system, which was already inadequate, has also been severely affected, and the capacity of the surveillance system to detect and respond to epidemics has been further weakened.

The areas devastated by the cyclone and flooding produce 65% of the country's rice, 80% of the aquaculture, 50% of poultry and 40% of pig production (FAO). Damage to these industries may have a longer term effect not only on domestic supply but also on importing countries which purchase rice from Myanmar such as Bangladesh and Sri Lanka.

The Government of Myanmar has formed an Emergency Committee and announced that the priorities of its relief operations are to provide adequate food, safe drinking-water and shelter to the affected people. Health issues are of major concern in districts affected by the cyclone.

The WHO Regional Office for South-East Asia and the WHO Country Office in Myanmar are actively involved in the response. A crisis room has been activated in the WHO Country Office in Yangon. The WHO Country Office in Myanmar is working with the Myanmar Ministry of Health, UNICEF and other partners on damage and needs assessments to assist the local health authorities. International health partners are expanding their activities in the affected areas. Since 19 May, WHO and health partners have procured emergency health kits to cover 70 000 people, medicines to treat 100 000 cases of diarrhoea, and 13 metric tones of essential medicines. WHO is also supporting the implementation of a surveillance/early warning and response system for epidemic-prone diseases.

Major health problems in Myanmar, which are most likely to be exacerbated by this crisis, relate predominantly to communicable diseases (malaria, dengue, measles) and malnutrition, especially in children. As of 2003, 40% of children under five were assessed as being stunted, indicating chronic malnutrition and 10% as being wasted (acute malnutrition) (UNICEF). Major causes of death are usually due to malaria, respiratory and diarrhoeal diseases.

Given the structural damage caused by the cyclone and flooding of water supplies there is an additional risk of waterborne diseases affecting large numbers of the urban, rural and displaced populations. In addition, extensive damage to infrastructure and distribution systems, as well as power supplies, will make it virtually impossible to prepare food safely, posing an additional risk of foodborne diseases. Chlorine powder, water purification units, plastic sheeting for shelter, cooking utensils, ready-to-eat survival food rations, essential medicines, cholera kits, rehydration fluids, antimalarial drugs, long-lasting insecticidal nets (LLIN) and supplies for the management of corpses are urgently needed.

Guidance for donors on donations of drugs and medical supplies has been developed by WHO in consultation with over 100 humanitarian organizations and experts. (see Sections 2.6, ix, and 4, Guidelines for Drug Donations). Adhering to these guidelines will ensure that the effect of donations is maximized for the people of Myanmar and will help to prevent stockpiling of unwanted medicines and medical supplies.

Risk factors for increased communicable disease burden

1. Interruption of safe water, sanitation and cooking facilities due to disruption of electricity and fuel supplies. The populations displaced by the cyclone are at immediate and high risk of outbreaks of water/sanitation/hygiene-related and foodborne diseases such as cholera, typhoid fever, shigellosis due to Sd1, and hepatitis A and E.

2. Population displacement with overcrowding. Populations in the affected areas and relief centres are at immediate and high risk of measles and at increased incidence of acute respiratory infections (ARI). Increased risk of meningitis is also associated with overcrowding.

3. Increased exposure to disease vectors. Displacement of populations will result in increased exposure to disease-carrying vectors, increasing the risk of malaria and dengue as well as other less commonly reported illnesses such as Japanese encephalitis, plague, hantavirus, chikungunya and filariasis.

4. Malnutrition and communicable diseases. The combination of malnutrition and communicable diseases creates the potential for a significant public health problem particularly in infants and children. Malnutrition compromises natural immunity, leading to more frequent, severe and prolonged episodes of infections. Severe malnutrition often masks symptoms and signs of communicable diseases, making prompt clinical diagnosis and early treatment more difficult.

5. Poor access to health services is of immediate concern. The damage caused by the cyclone to the health infrastructure is preventing access to usual services, as well as to emergency medical and surgical services being put in place in response to this emergency.

6. Flooding may initially flush out mosquito breeding, which can restart when the waters recede. The lag time is usually around 6-8 weeks before the onset of increased malaria or dengue transmission.