Event Type: Cyclone
Event onset date: March 15, 2019
Location of Event: City of Beira; Sofala Province; Mozambique
Geographic Coordinates: -19.79852823441601, 34.901979096369544
Date of observations reported: April 1-30, 2019
Response type: Medical Relief (PT Emergency Medical Team)
Introduction
The tropical cyclone Idai hit Mozambique in the city of Beira (Sofala Province) on March 15, 2019 with torrential rain and strong winds, severely affecting the provinces of Manica, Sofala, Tete, and Zambézia.Reference Devi1 According to the World Health Organization (WHO; Geneva, Switzerland)2 and the International Committee of Red Cross (ICRC; Geneva, Switzerland)3 reports, this resulted in 603 deaths and 1,641 injuries that were directly related to the disaster. The devastation and destruction caused approximately 1.85 million people in need of humanitarian aid and led to the opportunity for the emergence of outbreaks, like cholera.
Portuguese Emergency Medical Team (PT EMT) Type 1 Fixed
The WHO’s Emergency Medical Team (EMT) Initiative has standards defining the key elements to be followed by EMTs, as well as the critical points to assure before and during deployment of a field hospital.Reference Albina, Archer and Boivin4,5
The Portuguese National Institute of Medical Emergency (INEM; Lisboa, Portugal), a government agency under the umbrella of the Minister of Health (Lisbon, Portugal), had its final certification visit on the same day of Cyclone Idai. Once certified by the WHO, the PT EMT deployed immediately an assessment team of three members who worked with the local emergency management authority to evaluate necessities. These elements helped to establish the first EMT Coordination Cell (EMT CC), optimizing the communication by taking advantage of speaking Portuguese. The EMT infrastructure deployed on Mozambican soil with the mission of helping a local health center in collaboration with the local authorities. The goal was to work in integration and not in overlap.
The PT EMT used the skills and expertise of its members, namely doctors of different specialties (ie, intensive care, internal medicine, pediatrics, surgery, obstetrics, and infectious diseases); specialized nurses in critically ill patients, or emergency and disaster; prehospital technicians; psychologists; x-ray technicians; pharmaceuticals; and logistical elements. The PT EMT infrastructure has several care areas, namely an emergency room, ambulatory, minor surgery/orthopedics, pediatrics, pharmacy, and x-ray. This mission lasted for 30 days with a two-team rotation (28 elements each), always in self-sufficiency, and without any record of health problems within the team members.
Data Sources
Data analyzed were collected during the period of the deployment of the PT EMT in Mozambique. The patients admitted to PT EMT were registered with the age, gender, and final diagnosis using the PT EMT Clinical Record that responds also to the Minimum Data Set defined by the WHO. Data used for this report did not include patient personal identifiers or confidential information.
Observations
From the 1,662 patients admitted to PT EMT during the 30-day mission, the majority (98%) had health problems not related to the cyclone and only two percent were directly or indirectly related to the disaster. First admissions accounted for 92.2% of the cases (n = 1,532) and 7.8% were follow-ups (n = 130).
The average age was 33 years, 48% were men, and 52% were women (one percent pregnant women). Regarding the pathology of the admitted situations, according to the framework defined by the Minimum Data Set, 88.87% classified as non-trauma and 11.13% as trauma. The five most prevalent diagnoses were: 61.49% “other unspecified diagnoses” (code 29), 9.15% of cases referred to skin disease, 8.90% to minor injuries, 6.74% to acute respiratory infection, and 3.19% were obstetric/genecology complications.
Considering the high prevalence of “other unspecified diagnoses” with a wide diagnostic diversity, the detail of cases were coded as 29. According to clinical records, the most prevalent of diagnosis were low back pain (11.47%), headache (6.37%), and gastritis (5.86%).
The PT EMT differs from most EMT Level 1 as it has a portable x-ray. This complementary diagnosis capacity proved to be very important. It was used in 276 cases (16.6%), namely in limb trauma (27.5%) and medical situations (72.5% %) such as pulmonary tuberculosis and respiratory infection.
The analysis of the drugs consumed highlighted pain management, with analgesic drugs being the most consumed (48.2%). Antibiotics had a reduced consumption (16.1%).
Regarding discharge, 88.61% were discharged permanently, 7.83% were identified for follow-up (n = 130), and 3.31% (n = 55) were transferred to the Spanish EMT-2 installed nearby or to the regional hospital in the city of Beira.
The last days of the mission, the PT EMT worked directly with local health professionals in the facilities of the Primary Health Centre of Mafambisse; also, training sessions were promoted with local staff. These activities were not included in the results but impacted very positively on the handover.
Analysis
The clinical analysis revealed that the PT EMT care targeted a young population, with minor non-trauma health issues that were not directly related to the cyclone, possibly due to the fact of the time of arrival on the ground.
Throughout the deployment, difficulties were identified that needed to be addressed, namely the patient transfer process and the Minimal Data Set register.
The EMT philosophy defines a pathway from EMT-1 to EMT-2, EMT-3, or local facilities. Despite wanting to proceed accordingly, the field experience proved that it was not possible to support those transfers on local prehospital Emergency Medical Services and a transportation cell must be in the equation when a deployment is considered. The WHO and the EMT initiative should consider creating this capacity.
Regarding the clinical activity, the coded diagnoses defined by the Minimum Data Set, namely the “code 29,” is insufficient to allow an adequate analysis of EMT clinical activity. This clinical and pharmacologic analysis is of utmost importance as it contributes to a better adjustment of the EMT’s pharmacological load to be included in a future deployment. Also, it can influence the training and selection of the medical team (doctors and nurses) according to the typology of reported diseases, improving the quality of care to patients affected by disasters in the future.
Recommendations
The EMTs are a major improvement in the international humanitarian response after a disaster. The Mozambique deployment after Cyclone Idai was the first mission of a recently certified EMT Type 1 fixed - PT EMT.
The benefit of the deployment was not only in the direct care to the affected Mozambican population, but also through the support and partnership work with local health authorities and Mozambican health professionals.
Nevertheless, improvements to future missions must take into consideration the field acquired experience. This team identified the need of addressing the inter-EMT transport as an important issue, even considering the deploying of a specialized cell, enabling a true network between EMTs and local health care structures. On the other hand, the analysis of data referring to EMT’s clinical activity after a deployment is of extreme importance to support a better future clinical practice.
To promote a common clinical language between international EMTs, the Minimum Data Set should consider a more precise identification of non-communicable diseases, as this can be the main activity in some deployments.
Acknowledgments
The success of this mission is closely related to a strong and cohesive team, with a high level of competence and a great altruistic spirit. For them, a very special thanks:
Alexandre David Rosa Frutuoso, Ana Cristina Seabra Martins, Ana Luisa Da Costa Carvalho De Abreu, Ana Moreira, Andreia Amaral Matos, António Jorge Duarte Ferreira, António Rui Ruão Machado Barbosa, Bruno Borges, Bruno Filipe Rodrigues Rito, Catarina Pais Rodrigues De Oliveira Paulo, Claudia Fernanda Catarino Ferreira Da Silva Monteiro, Cláudio Ascensão, Edmundo Daniel Martins Dias, Elsa Benvinda Rodrigues Da Rocha, Fernando José Somarinho Ferreira Ruas, Filipa Maria Carmo De Barros, Filipe André Da Luz Gonçalves, Francisco Manuel Mendinhos, Gustavo Manuel Da Silva Lages Oliveira E Carmo Oliveira, Helder Fernando Dos Santos Peres Ribeiro, Isabel Jesus Cunha Costa, Ivo Manuel Traquina Belo Cardoso, Joana Campos, João Jose Santos Lourenço, João Miguel Nascimento Monteiro, João Silva, Jorge Manuel Da Silva Joaquim, José Carlos Raposo Alves, Jose Carlos Rego, José Magalhães, Leonel Belarmino Faria Alves, Lia Alexandrina Fernandes Limão Gata, Liliana Andreia Fernandes Da Costa, Luis Manuel Patrício Ladeira, Luis Pinto, Maria Da Luz Carvalho Rodrigues, Mario Jorge Ferreira Ventura, Miguel Amaro, Nuno Fernando Ferreira Marques, Nuno Miguel Oliveira Ribeiro, Olga Maria Amaral Gomes, Paula Cristina Marques Correia Neto, Pedro Miguel Afonso Mateus, Pedro Miguel Sebastião Cavaco, Raquel Ramos, Ricardo André Costa Toga Moreira Rocha, Roberto José Da Silva Santos, Rui Manuel Pedro Rocha, Sara Da Conceição Do Carmo Rosado Basto, Tiago Oliveira Almeida Augusto, Vasco Miguel Soares Craveiro Alves Monteiro, and Vitor Manuel Soares Almeida.
Conflicts of interest
All the authors work at INEM. There are no conflicts of interest.
