Operational Achievements

First, the EMT MDS allowed health data to be collected from the onset of the response, with a total of 18,468 consultations recorded from all EMTs. It is very difficult to manage and report data during a disaster response, but this practice must be fostered. The ease of application of the EMT MDS and the robust logistical capacity of the EMTs proved to be key elements that allowed data to be collected even during the acute phase of the disaster.

Second, despite facing challenges that will be mentioned later during the response phase, the EMTCC was able to generate systematic reports on a daily basis. This was possible because the WHO has standardized the daily report form in both paper and csv data formats, facilitating the data analysis. Also, remote support from an off site data management support team played an important role, particularly for data input, since some EMTs submitted their daily reports in the paper form.

Third, the summary provided a better understanding of the evolving situation and enabled the EMTCC to make timely decisions. For example, it was previously reported that women experienced barriers limiting their access to medical care during emergencies due to religious or cultural issues.^{Reference Lee, Behn and Rexrode9} However, the EMT MDS showed that more than one-half of the consultations were for females (Table 1), indicating that female patients had good access to EMT services during this response. Evidence indicating fair access to EMT services is crucial during an operation. As another example of the collected data enabling timely decision making, consultations directly related and not related to the cyclone were found to show an inverse correlation over time, prompting the EMTCC to suggest that the international EMTs prepare their exit strategies as early as April 19 (Figure 3). Furthermore, greater access to data from EMTs and a proper level of analysis enabled and improved coordination with wider stakeholders and prioritization of needs.¹⁰ The willingness and leadership of the government of Mozambique also played an important role in the success of the disaster response and data management, including information sharing.¹¹

Key Findings

Key findings from the EMT MDS data collected during the response to Cyclone Idai are as follows.

Women were more likely than men to visit EMTs. This is consistent with other study results derived from analysis of the 2018 response following heavy rain in West Japan and the 2019 response to an earthquake in Kumamoto and Hokkaido, Japan.^{Reference Kubo, Tomioka, Kondo and Koido12} Outside of statistical gender considerations, this finding could reflect that the majority of men are either working to remediate the disaster or at work during the day whereas women are more likely to stay with family during a disaster and therefore more likely to have a chance to visit EMTs. This finding supports the importance of gender balance within the EMT personnel. This could be especially emphasized when providing care to Muslim countries, since a Muslim female health care provider would be the first choice for a Muslim female patient, followed by a non-Muslim female health care provider.^{Reference Padela and Rodriguez del Pozo13} The current analysis showed that normal vaginal delivery, cesarean section, and other obstetric procedures accounted for 15% of the total procedures performed at EMTs. Ninety-four live births were recorded, and 3.2% of the total consultations provided for women were pregnancy-related. This re-emphasizes the importance of ensuring access to obstetric and gynecologic care as part of the core services provided by EMTs, even during disaster events.³ Pregnant women gave birth at the EMT facilities during the first few weeks of the disaster response, as many health facilities were destroyed or non-functional,^{Reference Calgaro, Borellini and Seni14} whereas no birth was reported at an EMT facility after Week 7 of the response. This shows the EMTs can play an important role as substitute health facilities but do not interfere with the existing referral pathways when the latter are re-established. This is consistent with previous study examining the utilization rate of health facilities versus EMTs by Japanese pregnant women.^{Reference Yamashita, Natsukawa, Kubo, Kondo and Koido15} Minor injuries were more than twice as common in those over the age of five years compared to children under the age of five years. This is consistent with the findings obtained for the response to Typhoon Hayian, which struck the Philippines in 2013, and is thought to suggest that smaller children are more closely protected by their caregivers.^{Reference Salazar, Law, Pesigan and Winkler16} Medical problems such as acute watery diarrhea and ARIs were the most common among children under five years. Acute watery diarrhea decreased steadily after Week 3 of the response, which could reflect the effect of the disease surveillance system established by the MOH of Mozambique to detect and respond to any outbreak of infectious disease, particularly cholera. Overall, it is important to note that the proportion of EMT consultations for non-disaster-related events steadily increased over time (Figure 3). Definitions of relation to disaster on the MDS, including (1) directly related to disaster (patient visit with injury or illness directly caused by a disaster; (2) indirectly related to disaster (patient visit with injury or illness caused or worsened by situational change after a disaster such as ARI, diarrhea, skin disease, injury by debris during clean-up); and (3) not related to disaster (patient visit with health problem not directly/indirectly related to the emergency event such as non-communicable diseases without acute exacerbation or essential medication loss, cancer, or appendicitis), are very practical but allow changes in situation or status to be detected in a timely manner and used to guide the demobilization timing of EMTs. Additionally, a high proportion of consultations were classified as having no relation to the disaster. This shows that during the acute phase of a response, EMTs substitute for regular health facilities experiencing disaster-limited functionality.

Challenges and Opportunities

The challenges and technical gaps identified during the response are as follows.

First, there were some issues related to the completeness and accuracy of data. As this was the first time the EMT MDS was activated for a large international-scale response, the identified gaps might reflect a lack of pre-training. Indeed, only a very brief explanation and minimal guidance were provided to EMTs during a single EMTCC meeting. As an example of an issue with the completeness or accuracy of data, 94 live births were reported in the “Daily Summary” section (Figure 1) while 133 vaginal delivery and cesarean sections were reported in “Procedure” section (Table 2). It was impossible to determine whether the 35 discrepant cases were stillbirths or whether EMTs failed to report a birth from caesarean section as a live birth. This strongly suggests that pre- and real-time training for data collection is critical during a disaster response. The second identified challenge was the need for dedicated human resources with good knowledge of the EMT MDS system for joint management of EMT data collection and EMTCC data management. Third, due to lack of internet access, lack of experience in using the EMT MDS, and/or not perceiving the EMT MDS as a priority, some teams provided daily reports only occasionally. It proved challenging to use the EMT MDS in areas with poor internet connection, but the self-sufficiency of EMTs in their logistic capacity and offline data recording should allow for regular reporting to the coordination body. The time for daily submission was reported to be challenge, given the way each EMT set its daily operational cycle. As a result, during the response, the EMTCC suggested that each EMT should decide their own cut-off time for reporting, as long as the interval was 24 hours and two feedback summary reports were produced, with the second one including data on any delayed submission. Recognizing that the above setup is not ideal, it is proposed that timely data submission and compliance should be pursued through increased awareness of the EMT reporting system and dedicated training.

Points to be considered for further use of the MDS are as follows. First, more than one-half of consultations were reported as “other diseases, not specified” suggesting that some important health events may have not been captured or issues due to the definitions utilized and the way the data were reported. Therefore, regular analysis and discussions with the medical teams should be undertaken to determine additional health problems that should be included in the EMT MDS form as additional line items based on the local context. In the current case, only malaria was recorded as an “Additional” disease, as suggested by the EMTCC. Second, it is noted that many cholera and malaria cases were reported under the “Needs and Risks” section, which overlapped with items already included under the “Health Events and Procedure” section. Additionally, the information provided in the “Needs and Risks” section varied greatly. This suggests that more specific guidance should be provided about the importance and use of this part of the EMT MDS form. Third, given the above, it is believed that a survey should be undertaken among EMTs and other stakeholders who used the EMT MDS during the Cyclone Idai response, including questions about the usefulness and appropriateness of items and challenges encountered while using the EMT MDS form. This could help the current team further improve the MDS form and facilitate adoption during future health emergency responses.

The EMT MDS daily reporting system aims to improve the standardization of health data collection and analysis during emergency medical responses. Although the EMT MDS is currently well-known among classified EMTs, awareness should be increased among wider stakeholders and further training on the system should be undertaken. This will allow the MOH and its counterpart agencies to access the information they need to allocate their resources during the initial phase of an emergency, to ensure continuation of quality care to benefit the health of population affected by the disaster.