pocket emergency tool 2005

8/8/2019 Pocket Emergency Tool 2005

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CONTENTS

Acknowledgements ....................................................................iiiIntroduction .................................................................................1

Abbreviations .............................................................................2Roles and Responsibilities .........................................................

Coordinating with Other Agencies ............................................11Drafting the Health Disaster Management Plan .......................15

Rapid Health Assessment ........................................................19Critical Incident Management ...................................................22Pre-Hospital Activities ...............................................................23Hospital Activities .....................................................................25Prevention and Control of Communicable Diseases ................29

Nutrition Concerns ...................................................................Environmental Health ...............................................................Water Supply ...........................................................................Sanitation and Waste Management .........................................43Vector and Vermin Control .......................................................49Epidemiology and Surveillance ................................................52Psychosocial Care and Mental Health .....................................56

Management of Dead Bodies ..................................................63Forensic Science Concerns in Mass Fatalities .........................65Resource Management ............................................................71Risk Communication ................................................................73

Emergency Manager Deployment Checklist ............................78Rapid Health Assessment Forms ............................................79Reference Values for Rapid Health Assessment and

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PREPARING FOR EMERGENCIES ..........................................5

RESPONDING TO EMERGENCIES .......................................16

APPENDICES ..........................................................................77

POCKET EMERGENCYTOOL

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ii

CO

NTENTS

Contingency Planning .........................................................85Radio Procedures .....................................................................98

ConversionTable ......................................................................99Websites ................................................................................101References .............................................................................103Emergency Call Number Directory .........................................105


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This pocket tool is a project of the Department of Health-Health Emergency Management Staff (DOH-HEMS), with

support from the World Health Organization-Regional Office forthe Western Pacific Region (WHO-WPRO).

The review and revision for this second edition was donethrough the efforts of Dr. Emmanuel S. Prudente, under thetechnical supervision of Dr. Arturo M. Pesigan of Emergency andHumanitarian Action (EHA) of the WHO-WPRO.

Acknowledgement is also given to Dr. Carmencita A. Banatin,Dr. Marilyn V. Go, Dr. Teodoro J. Herbosa, Dr. Josephine H.Hipolito, Ms. Florinda V. Panlilio, Dr. Arnel Z. Rivera, Dr. EdgardoSarmiento and Dr. Xiangdong Wang, who reviewed the text andprovided valuable comments. Lay-out and cover design wasdone by Mr. Zando Escultura.

The first edition was through the efforts of the followingindividuals: Engr. Russell Abrams; Dr. Shigeki Asahi ;Dr. Carmencita A. Banatin ; Dr. Agnes B. Beegas ; Mr. MiguelC. Enriquez ; Mrs. Guia P. Flores ; Dr. Raquel dR. Fortun ;Dr. Camilla A. Habacon ; Dr. Lourdes L. Ignacio ; Mrs. ElizabethM. Joven; Dr. Susan P. Mercado; Dr. Daniel T. Morales; Dr. Jean-

Marc Oliv; Dr. Hitoshi Oshitani; Dr. Arturo M. Pesigan;Dr. Manuel F. Quirino; Dr. Lilia M. Reyes; Dr. Arnel Z. Rivera;Dr. Edgardo Sarmiento; Dr. Enrique A. Tayag; Dr. YoshihiroTakashima; Dr. Xiangdong Wang; Mrs. Zen Delica Willison;Mr. Robin Willison; and Dr. Ladislao N. Yuchongco, Jr.

ACKNO

WLEDGEMENTS

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Human survival and health are the common objectives andmeasures of success of all humanitarian endeavors.

The goal of the Department of Health (DOH) through theHealth Emergency Management Staff (HEMS) is to prevent orminimize the loss of lives during emergencies and disasters incollaboration with government, business and civil society groups.The main purpose of this pocket tool is to help guide andprepare health sector professionals in the field in the event that

an emergency occurs. A compendium of recent DOH, WHO andother international agencies' guidelines, checklists andstandards, this booklet provides essential pointers on how tocarry out rapid health assessment, networking and coordination,planning, and other necessary tools especially in times oftragedies and adversities.

This pocket tool, however, neither provides nor claims to bethe definite and only guideline to follow in emergencies. Thus,references to complementary documents and websites, wheremore detail can be found, are provided at the end of the booklet.Also, because every disaster is unique, some of the suggestedprocedures may need to be tailored to local conditions.

ndFurthermore, this pocket tool is an evolving text; this 2

edition was conceived from the lessons learned from the recentdisasters that affected the country and the Western PacificRegion. Indeed, the success of this guide depends largely on thedynamics of its use and the tireless efforts of its users to improve

it.

INTROD

UCTION


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CDC Centers for Disease Control and Prevention (USA)CHD Center for Health DevelopmentCMR Crude Mortality RateCSR Communicable disease Surveillance and ResponseDND Department of National DefenseDOH-HEMS Department of Health-Health Emergency

Management StaffDOTC Department of Transportation and CommunicationDPWH Department of Public Works and HighwaysDSWD Department of Social Welfare and Development

EHA Emergency and Humanitarian UnitEMS Emergency Medical ServicesEOC Emergency Operations Center EPI Expanded Program of ImmunizationER Emergency RoomIEC Information, Education and CommunicationHEICS Hospital Emergency Incident Command System

LGU Local Government UnitMUAC Mid-Upper Arm CircumferenceNBI National Bureau of InvestigationNDCC National Disaster Coordinating CouncilNEC National Epidemiology Center NEHK New Emergency Health KitNGO Nongovernmental organization

NNC National Nutrition CouncilNPDEP Nutrition Preparedness in Disasters andEmergencies Plan

OpCen Operation Center PHC Primary Health CarePNRC Philippine National Red CrossRDCC Regional Disaster Coordinating CouncilSARS Severe Acute Respiratory Syndrome

WHO-WPRO World Health Organization-Office for the WesternPacific Region

WMD Weapons of Mass Destruction

ABBREVIATIONS


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T.R.A.I.T. of a Health EmergencyManager/Coordinator

T ake the lead within the community in:! health coordination and networking! rapid health assessment! disease control and prevention! epidemiologic and nutrition surveillance! epidemic preparedness! essential medicines management! physical and psychosocial rehabilitation! health risk communication! forensic concerns and management of mass casualties

R ecord and re-evaluate lessons learned to improvepreparedness in the future

A ssess and monitor health and nutrition needs so that theyare immediately dealt with

I mprove health sector reform and capacity building bynetworking

T end and protect the practice of humanitarian access,neutrality and protection of health systems in emergencysituations

ROLESANDRESPONS

IBILITIES


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Roles of Hospitals in Health EmergencyManagement

1. Observe all requirements and standards (hospital emergencyplan, HEICS, Code Alert System, etc.) needed to respond toemergencies and disasters.

2. Ensure enhancement of their facilities to respond to the

needs of the communities especially during emergencies.

3. Network with other hospitals in the area to optimize resourcesand coordinate transferring of victims to the appropriatefacility.

4. Report all health emergencies to the Operation Center, and

document all incidents responded.

ROLESANDRESPONSIBILITIES


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PREPARINGFOR EMERGENCIES


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PREPAR

INGFOREMERGENCIES


Steps in Preparing for Emergencies

1. Policy Formulation and Development! policy statement/implementing rules! guidelines, protocols, procedures! organizational structure! roles and functions! resource mobilization

2. Capability Building! training needs assessment! human resource development! training of trainers! database of experts! tabletop drills and exercises

3. Facilities Development! standardization/mprovement/upgrading of ER, ambulance,

Operation Center, hospitals! procurement of supplies, communications and equipment

4. Networking! organization of the health sector! coordination and planning! memorandum of agreement with stakeholders! networking activities

5. Disaster Planning

! vulnerability and hazard assessment! all-hazards emergency operations plan! specialized planning for uncommon incidents (e.g. SARS,

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PREPARINGFOREMER

GENCIES


WMD)! communication plans

! hospital preparedness and response plans

6. Public Information and Mass Media! advocacy activities! development of IEC's

7. Post-disaster Response Evaluation! monitoring and evaluation activities! postmortem evaluation

8. Systems Development! Logistics Management System! Management Information System!

Communication System

9. Establishment of Emergency Operation Centers! Infrastructure, manpower, technology

10. Documentation and Research! publications

! databanking! accomplishment reports! research studies! lessons learned

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Roles of Centers for Health Development inEmergency Management

1. Serve as the DOH Coordinating Body in their region

2. Manintain updated hazard and vulnerability assessment oftheir catchment areas

3. Observe all requirements and standards needed to respondto emergencies (Regional Emergency Plan)

4. Organize health sector in the region and provide mechanismfor coordination and collaboration. Provide advice to theRDCC for health emergency concerns

5. Maintain operation center as regional repository of vents forthe health sector. Identify an official spokesperson to answerconcerns by the public and the media

6. Provide technical assistance and empower all LGUs in thearea on health emergency management

7. Report to the Central DOH (HEMS) for all emergencies anddisasters and any incident with the potential of becoming anemergency

8. Document all health emergency events and conductresearches to support policies and program development.

(Based on DOH Administrative Order 168, s.2004)

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At the Center for Health Development (CHD) level

The following should be readily availablefor reference and may be compiled in collaboration with otherpartners (government and non-government units). Theseinformation must be updated regularly:

Disaster profile of the regionPopulation size and distribution

Topography and maps showing communication linesEpidemiologic profile of the regionLocation of health facilities and the services they provideLocation of potential evacuation areasLocation of stocks of food, medicine, health and watertreatment and other sanitation supplies in governmentstores, commercial warehouses and international

agencies and major NGOsKey people and organizations who would be responsiblefor/active in relief (contact phone numbers ANDaddresses)Individuals with special competencies and experience whomay be mobilized on secondment from their institutions oras consultants in case of need (contact phone numbersAND addresses)A roster of regular resource persons ready to translatetechnical information materials into local dialect (i.e.,traditional healers, indigenous health workers, barangaycaptain, etc.)

information

!

!

!

!

!

!

!

!

!

!

PREPARINGFOREMER

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The following should be readily available for

use AT ALL TIMES:

1. Vehicles2. Communications equipment3. Back-up power supplies4. Computers, printers, facsimiles and photocopyingmachines5. Water testing sets6. Food supplements7. Temporary shelter capacities8. Funding requirements9. Personal protective equipment

resourcesPREPAR

INGFOREMERGENCIES


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Prepare internal arrangements within the DOH and with otherpublic health related government entities, UN agencies, NGOs,

and other institutions in the country whose expertise and/orservices may be called upon during emergencies (DND, NDCC,DSWD, DPWH, DOTC, PNRC, etc.)

Stepsin Establishing Good WorkingRelationships with Other Groups or Entities

1. Have a common goal.2. Designate a good and strong facilitator.3. Define the parameters of the project. Reach a consensus

on objectives, strategies and plans.4. Discuss needs and lines of action.5. Have operating guidelines.

6. Encourage memberparticipation.7. Build trust among members. Fix issues early on.8. Maintain regularcommunication and correspondence

among members.9. Give priority to the whole group. Each agency is vital.10. Develop clear and attainable mission statements from the

beginning of the project.11. Enlist and maintain the support of top-level-management.12. Educate all members about the range ofservices each

agency can provide.13. Make partners aware ofpolicies and protocols.14. Adopt responsibilities in the context of what was agreed

upon

15. Adjust to changes. Be flexible and be open to possibilities,unforeseen events and new opportunities.

COORDIN

ATINGWITHOTHERA

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16. For members to attend, allow adequate incentive.17. Have a product or concrete result showing the team's effort

and share among members so that there is a sense ofaccomplishment. Celebrate.

Ps of Facilitation:

1. PURPOSE explains the overall aim of the session.

! Have ground rules, a clear agenda, and desiredoutcomes.

2. PRODUCT describes the session's deliverables in specificoutputs.! Discuss needs and lines of action.! Reach a consensus on objectives, strategies, and plans.

3. PARTICIPANTS push the issues. Know their perspectivesand concerns. A designated and experienced chairpersonshould practice facilitative behavior: listening, encouragingparticipation, not being defensive, asking open-endedquestions, and optimistic but realistic

4. PROBABLE ISSUES give an idea of the potential

5

Health coordination must start as soon aspossible, it should be regular and frequent. Atthe start of a crisis, changes are fast and many.

To coordinate is to facilitate.

COORD

INATINGWITHOTHER

AGENCIES


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Disaster Reaction Sequence:

! Surprise: Is it true? Has it really happened?! Lack of information: What is happening?! Events escalate: It's getting worse but I don't know! the details?! Lack of control: I don't know therefore I cannot do.! Siege mentality: Why is this happening to us?! Panic: Will we ever recover from this?! Short term reaction: Get everyone away from me

Common Communication Concerns:

! I don't have the correct facts.!

I might upset other people with what I'll say.! There might be a better spokesperson.! There may be legal implications to what I say.! I might risk my reputation.! I might be asked something I cannot answer.! I might sound stupid.

If you do not tell, information will be gatheredelsewhere, leading to misinformation,

misunderstanding, and their consequences

COORD

INATINGWITHOTHER

AGENCIES


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You may follow the outline provided below; however, it is notmeant to replace alternative outlines that you may deem more

appropriate and useful.

I. BackgroundPresent the following:! geographic description! disasters that have occurred! gaps in response! hazard maps! vulnerabilities and risks

II. Goals and Objectives

III. Potential Problems Analysis

IV. Resource Analysis

V. Management Structurea. Explain the organization (an accompanying diagram is

essential)b. Specify command, control, lead organization and

coordination

VI. Roles and Responsibilities

VII. Strategies

VIII. Annexes (i.e., glossary, abbreviations, directory of contactpersons)

DRAFTINGTHEDISASTERHEALTHMANAGEME

NTPLAN


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RESPONDINGTO EMERGENCIES


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Steps in Responding to Emergencies

Immediate Response:1. Assess the situation2. Contact key health personnel3. Develop initial health response objectives and establish an

action plan4. Establish communication and maintain close coordination

with the EOC5. Ensure that the site safety and health plan is established,

reviewed, and followed6. Establish communication with other key health and medical

organizations.

7. Assign and deploy resources and assets to achieveestablished initial health response objectives

8. Address health-related requests for assistance and informa-tion from other agencies, organizations and the public

9. Initiate risk communications activities10.Document all response activities

Intermediate Response:1. Verify that health surveillance systems are operational2. Ensure that laboratories likely to be used during the response

are operational and verify their analytical capacity3. Ensure that the needs of special populations (e.g., children,

disabled persons, elderly, etc.) are being addressed4. Manage health-related volunteers and donations

Hours 0-2

Hours 2-12

R

ESPONDINGTOEMER

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5. Update emergency risk communication messages6. Collect and analyze data that are becoming available through

health surveillance and laboratory systems7. Periodically assess health resource needs and acquire as

necessary

Extended Response:

1. Address psychosocial and mental health concerns2. Prepare for transition to extended operations or response

disengagement3. Address risks related to the environment4. Continue health surveillance/epidemiologic services5. Ensure that local health systems are preserved and access to

health care, including essential drugs and vaccines, isguaranteed

(Adapted from CDC's Public Health Emergency Response Guide.)

Hours 12-24

RESPON

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RAPIDHEALTHASSE

SSMENT


The following

should be made available for reference

from the event.

Basically, the following key questions need to be answered:! Is there an emergency or not? (If so, indicate type, date,

time and place of emergency, magnitude and size ofaffected area and population)

! What is the main health problem?! What health facilities or services have been or may be

affected?! What is the existing response capacity? (actions taken by

the local authorities, by DOH-HEMS)! What decisions need to be made?! What information is needed to make these decisions?

Situation Report Outline:

1. Executive Summary2. Main Issue

a. Nature of the emergency (causative and additionalhazards, projected evolution)

b. Affected area (administrative division, access)c. Affected health facilitiesd. Affected population (sex/age breakdown)

3. Health Impacta. Direct impact: reasons for alert (3 main causes of

morbidity/mortality, CMR, under-5 mortality rate, acute

malnutrition rate)b. Other reasons for concern (e.g., trauma, reports/rumors ofoutbreak)

critical information required

within 24 hours

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c. Indirect health impact (e.g., damage to criticalinfrastructures/lifelines)

d. Pre-emergency baseline morbidity and mortality (whenavailable)

e. Projected evolution of health situation: main causes ofconcern if the emergency will be protracted

4. Vital Needs: current situationa. Waterb. Waste disposal

c. Foodd. Shelter and environment on sitee. Fuel, electricity, and communicationf. Other vital needs (e.g., clothing and blankets)

5. Critical Constraintsa. Security: coordinate with the safety officer to identify

hazards or unsafe conditions associated with the incidentb. Transport and logisticsc. Social/political and geographical limitsd. Other constraints

6. Response Capacity: functioning resourcesa. Activities already underwayb. National protocols, contingency plans

c. Operational support (command post, regional unit andreferral system, external assistance, state ofcommunications)

d. Operational coordination (lead agencies, mechanisms,flow of information)

e. Strategic coordination (local/international relationships)

7. Conclusionsa. Are the current levels of mortality and morbidity above-average for this area and this time of the year?

RAPIDHEALTHASSESSMENT


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b. Are the current levels of morbidity, mortality, nutrition,water, sanitation, shelter and health care acceptable by

international standards?c. Is a further increase in mortality expected in the next 2

weeks?8. Recommendations for Immediate Action

a. What must be put in place as soon as possible to reduceavoidable mortality and morbidity?

b. Which activities must be implemented for this to happen?

c. What are the risks to be monitored?d. How can they be monitored?e. Which inputs are needed to implement all these?f. Who will be doing what?

9. Emergency Contacts: local donor representatives, DOH

counterparts and neighboring regional directors.10.Annexes: include all detailed information that are relevant

*See appendix for sample of rapid health assessment form.

Be honest in the conclusions and practical in

the recommendations. Recommendations thatcannot be put into practice quickly are useless.Prioritize the health problems (in terms of

magnitude and severity and of feasibility ofresponse interventions).

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CRITICA

LINCIDENTMANAGEMENT


Steps as First Responders

a. Assume command (until a more senior personnel arrives)b. Assess the situation and advise the appropriate authorities

and agenciesc. Set perimeters

! Identify and set perimeter (hot zone, warm zone, coldzone)

! Implement safety and security measures! Identify access and egress routes

d. Establish the initial medical command poste. Establish Safety Officerf. Establish Staging Officerg. Establish liaison with other services on siteh. Determine priorities and time constraints

i. Develop an incident plan in conjunction with members of theIncident Management Team

j. Task response agencies and supporting servicesk. Coordinate resources and supportl. Monitor events and respond to changing circumstancesm. Report actions and activities to the appropriate agencies and

authorities

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PRE-HOSPITALACTIVITIES


Triaging

Objective:To quickly identify victims needing immediate stabilization or

transport and the level of care needed by these victims byassessing airway, breathing, and circulation (ABC's).

Color Tagging

Ideally, the following information should be contained in thepatient's color tag:

a. patient's sequence numberb. name of patientc. injuries identifiedd. previous interventions given at the scene

1st priority: Life-threatening - needs to be treated within1-3 hoursa. obstruction/damage to airwayb. breathing disturbance (RR =30/min or RR


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YELLOW TAG

GREEN TAG

BLACK TAG

2nd priority: Urgent - needs to be treated within 4-6 hoursa. major burns: involving hands, feet or face (excluding

respiratory tract); complicated by major soft tissue traumab. spinal injuries; long bone or pelvic fracturesc. environmental injuries (heat/cold exposure)

3rd priority: Requires no treatment or can be delayeda. minor injuries not threatened by ABC instabilityb. minor fractures/soft tissue injuries/burnsc. injuries so severe that survival cannot be expected even

under the most ideal conditions; obviously mortal wounds

where death is certain (such as head injuries or massiveburns)

Last priority:

a. death or moribund state

In emergency situations the most practicalmeans of tagging may only be by color ribbons

or even pentel pens

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HOSPITALACTIVITIES


Color-Coded Alert Systems

The hospital alert status shall be declared either by theSecretary of Health, the HEMS Director, the Chief of Hospital orthe HEMS Coordinator. The alert status shall continue to be ineffect until cancelled by the Chief of Hospital or the HEMSCoordinator.

CODE WHITE

Alert Mode is called with any of the following conditions:! a strong possibility of a military operation (e.g., coup

attempt)! any planned mass action or demonstration within the area! forecasted typhoons, the path of which may affect the area

! national or local elections or plebiscites! national holidays or celebrations (e.g., New Year's Eve,

Holy Week, etc.)! other conditions which may be declared as disasters by

the Chief of Hospital or other appropriate authority

There should be necessary preparations of the necessary

equipment and even personnel. Aside from those who are onregular duty for the day, the following should be on-call anytimeduring his/her duty days:1. surgeons2. orthopedic surgeons3. anesthesiologists

4. internists5. O.R. nurses6. ophthalmologists

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7. otorhinolaryngologistsnd

8. 2 response team should be on call

9. EMS, nursing personnel and administrative personnelresiding at the hospital dormitory shall be placed on on-callstatus for immediate mobilization

Partial/Selective Activation is proclaimed when 20-50casualties (red tags) are expected. This may require theactivation of the hospital network or at the judgment of the

director or the HEMS coordinator, may only involve the hospitalnearest the emergency site.

The following should respond once CODE BLUE is on:1. on-scene response team2. medical officer in charge of the emergency room

3. ALL orthopedic residents4. medical officer in charge of the operating room5. surgical team on duty for the day

CODE BLUE

HOSPITALACTIVITIES


The composition of the back-up and on-callteams would depend on the type and level ofthe hospital. The suggestions here are based

on a general tertiary hospital. Each hospitalcan come up with its own team members. Insome places like Metro Manila, there can also

be designated support hospitals (usuallyspecialty hospitals). These specialty hospitalsact as support to a receiving hospital (e.g., SanLazaro and Fabella Hospital supporting Jose

Reyes Memorial Medical Center).

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6. officer in charge of supplies at the CSR7. surgical team on duty the previous day

8. ALL anesthesiology residents9. nursing supervisor on duty10.operating nurses living within or in the vicinity of the hospital11.ENTIRE security workforce12.ALL third and fourth year residents13.ALL O.R. nurses14.institutional workers on duty

Full Activation is put into effect when more than 50 (red tag)casualties are momentarily anticipated, expected or suddenly

brought to the hospital. The situation may require more than onehospital to respond by sending an on-scene team.

The following should respond once Code Red is on:1. ALL persons enumerated under Code Blue2. ALL institutional workers3. ALL nursing attendants

4. ALL nurses5. ALL medical interns and clinical clerks

CODE RED

HOSPITALACTIVITIES


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If there is a strong possibility that there wouldbe a need to change the alert status from code

white to blue to red, the Chief of Hospital isauthorized to:1. Cancel all leaves of personnel and for them

to report to the hospital.2. Put back-up teams on standby within the

hospital for rapid deployment.3. Take other steps necessary to respond to

the emergency situation (e.g. cancelelective surgeries, etc.).

HOSPITALACTIVITIES


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Steps in Ensuring CommunicableDisease Control in Emergencies

1. Conduct rapid health assessment (see previous section)2. Provide general prevention measures in coordination with

other sectors, including:! Food security, nutrition and food aid! Water and sanitation! Shelter

3. Provide community health education messages includinginformation on how to prevent common communicablediseases and how to access relevant services! Encourage people to seek early care for fever, cough,

diarrhea, etc., (especially children, pregnant women andolder people)

! Promote good hygienic practice! Ensure safe food preparation techniques! Ensure boiling or chlorination of water

4. Implement as indicated, specific prevention measures, suchas mass measles vaccination campaign, Expanded Programon Immunization, and vector control.

5. Provide essential clinical services

6. Provide basic laboratory facilities7. Set-up surveillance/early warning systems

a. Detect outbreaks earlyb. Report diseases of epidemic potential immediatelyc. Monitor disease trends

8. Control outbreaks

a. Preparationb. Detectionc. Confirmation

PREVENTIONANDCONTROL

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d. Investigatione. Control measures

f. Evaluation

Notes on Immunization

! A single suspected measles case is sufficient to prompt animmediate immunization response. Life-saving measlesvaccine should be made available immediately targeting allinfants and children 6-59 months of age. The suggestedtarget age group may be expanded up to 15 years, if feasible,in areas where there is substantial crowding.

! Each visit to health care facilities should be seen as anopportunity to vaccinate for routine EPI regardless of the

reason for the visit. Vaccination program activities should beincluded as part of basic emergency health care services.

! Mass vaccination against cholera and typhoid fever is notrecommended. The most practical and effective strategy toprevent cholera and typhoid is to provide clean water inadequate quantities and adequate sanitation. Sufficient soap

and hygiene education will further prevent the transmission ofboth diseases.

! Mass tetanus vaccination programs are not indicated.However, tetanus boosters may be indicated for previouslyvaccinated people who sustain open wounds or for other

injured people depending on their tetanus immunization history.

! Mass vaccination for Hepatitis A is not recommended.

PREVEN

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Nutrition Preparedness

1. Planning: Every effort should be done to formulate an inter-sectoral and comprehensive plan (i.e., NNC's NutritionPreparedness in Disasters and Emergencies Plan or NPDEP).

2. Nutritional Management: Is an institutional and multi-sectoral concern. It is equally the responsibility of the nationalgovernment, local government and even non-governmentunits. Disaster Coordinating Teams implement the NPDEPwhile involving the Municipal Nutrition Action Officer in thecreation of Disaster Response Teams.

3. Adequate Nutrition: During emergencies, infants (


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6. Cultural and Indigenous Habits: Customs should be takeninto consideration in food management.

7. Gate Keepers: Identification of local/tribal leaders are critical fornutrition education, supplementation, and resettlement feeding.

NUTRIT

IONCONCERNS


! Following a major sudden disaster, somepeople may have no access to food and/or beunable to prepare food for a few days at

least.! In slow-onset crisis or in situations where

the livelihood of the community is greatlyundermined, particularly in areas wherenutritional status was already poor, it will beimportant to monitor nutritional status andhouseholds' access to food, and to initiateremedial action (e.g. through supplementaryfeeding) if nutritional status is at risk.

! In extreme cases, nutritional rehabilitationthrough intensive, supervised therapeuticfeeding (TF) may be required.

! Because the number of caregivers is

reduced during emergencies and their abilityto cope is diminished by physical and mentalstress, strengthening caregiving capacity isan essential part of promoting good feedingpractices for infants and young children.

! Healthy workers are essential. Aside fromlooking after the basic health and nutritional

needs of the displaced population, healthworkers have to be debriefed to look after theirpersonal health as well.

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NUTRITIONCO

NCERNS


Energy Requirements

For initial planning purposes:! Average daily energy requirement : 2,100 kcal/person/

day! When the data are available, the planning figure should be

adjusted according to:! Physical activity level add 140 kcal for moderate activity,

350 kcal for heavy activity (e.g., during construction or landpreparation works)

! Age/sex distribution when adult males make up more than50% of the population, requirements are increased; when thepopulation is exclusively women and children, requirementsare reduced.

! Special needs of pregnant and lactating women

a. Pregnant women? Need an additional 300 kcal/day? If malnourished, need another500 kcal/day? Should receive iron and folate supplements

b. Lactating women? Need an additional 500 kcal/day? If malnourished, need another500 kcal/day? Should receive sufficient fluids, taking into account

activity

Other nutritional requirements:! Protein: 10 to 12% of diet (i.e. 52 to 64 g)! Fat/oil: = 17% of diet (i.e. 50 g)

! Micronutrients: a range of micronutrients (vitamins andminerals) are required for survival and good health

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Ideal Foods for Disaster! Carbohydrate sources rice, root crops, bread, noodles

! Protein sources eggs, canned meat and fish, fresh meat andfish, dried meat and fish, milk

! Fat sources cooking oil, margarine! Vitamin and mineral sources fruits and vegetables! Others coffee and other beverages

* see appendix for examples of rations.

Nutritional Assessment

The most widely accepted practice is to assess malnutritionlevels in children aged 6-59 months as a proxy for the populationas a whole. Reports should always describe the probable causes of

malnutrition, and nutritional edema should be reported separately.

NUTRIT

IONCONCERNS


Two-stage cluster sampling is normally used:30 clusters are selected, then 30 children

within each cluster.

Edema of both feet

Weight-for-Height*

MUACBody Mass Index

Mild Malnutrition

No

80-90%

(-1 to -2 SD)

12.5 to 13.5 cm17 to


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Age

6-11 months

1-5 years

Dose

100,000 IU

200,000 IU

*see appendix for length-for-weight/height-for-weight referencevalues

**see appendix for decision framework for implementing

feeding programs.

Feeding Recommendations

! Up to 6 months of age: Encourage mothers to exclusivelybreastfeed as often as the child wants, day and night, at least

8 times in 24 hours. Do not give any other fluid or food.

! 6 months to 12 months: Breastfeed as often as the childwants. In addition, give adequate servings of locally availablecomplementary foods at least 3 times a day.

! 12 months to 2 years: Breastfeed as often as the child wants.Give adequate serving of locally available complementaryfood at least 5 times a day.

Give vitamin A if a child has severemalnutrition. Give one dose in your presence

and give one dose to the mother to give it tothe child at home the next day.

There should be a continual search formalnourished children so that their condition

can be identified and treated before it becomessevere.

NUTRITIONCO

NCERNS


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! 2 years and older: Give three meals of family food per day.Also, give nutritious snacks, twice daily.

Notes on Breastfeeding

! Breastfeeding's multiple advantages are especially importantduring emergencies (i.e., protection from infection and itsconsequences, contraceptive effect, privileged nurturingmoment important for both mother and child). Every effortshould be made to identify ways to breastfeed infants whosemothers are absent or incapacitated. Every effort should bemade to create and sustain an environment that encouragesfrequent breastfeeding for children under two years of age.

! A nutritionally adequate breast-milk substitute, fed by cup,

should be available for infants who do not have access tobreast milk. The use of infant-feeding bottles and artificialteats in emergency settings should be actively discouraged.

! Emergencies do not justify routine distribution of breast-milksubstitutes. Formula feeding may increase the considerablerisk of child morbidity and mortality.

! The nutritional status of breastfeeding women should beprotected as an end in itself, and as a means of maintainingthe adequate growth and development of their children.

NUTRIT

IONCONCERNS


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ENVIRONMENTALHEALTH


Minimum level of necessary services to be provided:1. Adequate shelter for displaced persons

! Evacuees should be protected from the elements! Secure against violence! Provide allocations for privacy! Avoid overcrowding.! Floor area per person: 3.5 square meters! Fresh air ventilation per person per hour: 20-30 cubic

meters! Lighting: adequate (minimum is a 5-foot candle)! Ventilation: adequate (combined openings at least 10% of

floor area)2. Sufficient quantities of accessible drinking water3. Facilities for excreta and liquid waste disposal4. Protection of food supplies against contamination

5. Protection of individuals in affected population against vector-borne diseases through vector control activities and throughchemoprophylactic methods.

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WATER

SUPPLY


Assessment

1. Assess water resources for human consumption to ascertainthe availability of water (quantity and quality) in relation to thedemand.

2. Estimate the demand, identify possible sources and assess

the possibility of developing these resources.3. Consult local people in the identification of water sources tobe developed.

4. Tap the expertise of the local Sanitary Engineer in theassessment of the water resources and the conduct ofsanitary survey.

5. Always consider seasonal factors in the assessment.

Organization1. Organize water allocations between the host community and

the evacuees to prevent overstraining water resources.2. Evaluate the technology used in the water supply system to

ensure that continuous and long-term operational needs are

within reach of the community and the evacuees.3. From the start, involve the evacuees in the maintenance andoperation.

Provision of adequate amounts of drinkingwater is of utmost importance after disaster. It

should first be made accessible to victims andrelief workers and in essential locations, suchas hospitals and treatment centers. After

drinking water is secured within stricken areas,making water available for domestic uses (such

as cleaning and washing) should beconsidered.

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4. Train evacuees without prior experience.5. Combine water control and treatment with improved personal

hygiene and environmental health practices.6. The design and construction of the water supply system must

be closely coordinated with evacuation camp planning andlayout as supported by health promotion and sanitation.

7. Consider using pumps and other mechanical equipmentattainable in the area where fuel and spare parts areavailable, and maintenance is not a complicated aspect.

Technical breakdown should be quickly repaired.8. Monitor both the organizational and technical aspects of the

complete water supply system.

Immediate Action after a Disaster

1. Estimate water requirements and assess water supplypossibilities.

2. Make an inventory of water sources and assess all sources interms of their quality and yield.

3. Protect water sources from pollution. Provide water in goodquantities and reasonable quality.

4. Improve access to supplies by developing water sources and

a storage and distribution system to deliver sufficientamounts of safe water, including reserve.

5. Conduct regular sample collection and testing of waterquality.

6. If possible, use water sources that do not need treatment. Ifthere is a large number of evacuees, decontamination of

water is necessary. Treat water according to thecharacteristics of the raw water.7. Set up schedules for operation and maintenance.

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8. Maintain and update information on water resources obtainedduring needs assessment, planning, construction, operation

and maintenance.

Intermediate Response

1. If the minimum amount of water cannot be made availablefrom local sources, recommend transfer to anotherevacuation camp.

2. If storing the water in tanks is employed, the storage shouldbe tested periodically.

3. Domestic hygiene and environmental health measuresshould be observed in order to protect the water betweencollection and use.

Organize a distribution system that prevents pollution of the

source and ensures equity if water is insufficient.

Water Need

1. Minimum Demand (per person per day); calculate thefollowing:a. 2 liters for drinkingb. 10 liters for food preparation and cookingc. 15 liters for bathingd. 15 liters for laundrye. 10 liters for sanitation and hygiene

2. Quality: To preserve public health, a large amount ofreasonably safe water is preferred over a small amount of

purified water.3. Control: Bacteriological, biological, chemical, physical and

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radiological quality of water must be deemed safe.! There are no fecal coliforms per 100 ml at the point of

delivery.! People drink water from a protected or treated source in

preference to other readily available water sources,! Steps are taken to minimize post-delivery contamination.! No negative health effect is detected due to short-term use

of water contaminated by chemical (including carry-over oftreatment chemicals) or radiological sources, and

assessment shows no significant probability of such aneffect.

4. Other Needs:a. Hospital and Clinics:

! Out-Patient: 5 liters per patient per day! In-Patient: 40-60 liters per patient per day

b. Mass Feeding Centers: 20-30 liters per person per dayAnimals! Cow/Carabao: 30 liters per day! Pig: 1.5 liters per day! Goat: 1.5 liters per day! Poultry: 2 liters per day

5. Water Decontamination/Disinfectants:

! Water Purifier: 2 tablets per person per day! HTH (high-test hypochlorite) Stock Solution: 1 liter/20

families/5 days! Shock Disinfection: 50-100 parts per million (ppm) of 60-

70% of available chlorine! Environmental Cleaner-Sanitizer

6. Drinking Water Container: one container of 10 liters per family7. Communal Water Storage Tank: 10 liters per person per day.

Volume of tank good for 2 days demand; half full in the

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evening; with free residual chlorine of 0.7 ppm.8. Shallow Well: for toilet flushing and cleaning

9. Water Points:! Distance between Water Point and Users: 150 m (max.)! Minimum Number of Water Points: 1 tap per 250 users! Queuing time at a water source is no more than 15

minutes.! It takes no more than three minutes to fill a 20-liter

container.

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SANITATIO

NANDWASTEMANA

GEMENT


Assessment

Excreta Disposal1. What is the current defecation practice (including anal

cleansing)? If it is open defecation, is there a designatedarea?

2. Is the current defecation practice a threat to water supplies(surface or ground water) or living areas?

3. Are there any existing facilities? If so, are they used, are theysufficient and are they operating successfully? Can they beextended or adapted?

4. What is the ratio of domestic facilities to population?5. What is the maximum one-way walking distance for users?6. Are people prepared to use pit latrines, defecation fields,

trenches, etc.?

7. What is the level of the groundwater table?8. Are soil conditions suitable for on-site excreta disposal?9. Do current excreta disposal arrangements encourage

vectors?10. Are there materials or water available for anal cleansing?

How do people normally dispose of these materials?11.How do women manage issues related to menstruation? Are

there appropriate materials available for this?

Drainage1. Is there a drainage problem (e.g. flooding of dwellings or

toilets, vector breeding sites, polluted water contaminatingliving areas or water supplies)?

2. Is the soil prone to water logging?3. Do people have the means to protect their dwellings andtoilets from local flooding?

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SANITATIONANDWASTEMAN

AGEMENT


Solid Waste Management1. Is solid waste a problem?

2. How do people dispose of their waste? What type of howmuch solid waste is produced?

3. Can solid wastes be disposed of on-site, or does it need to becollected and disposed of off-site?

4. Are there health facilities and activities producing waste?How are wastes being disposed of? Who is responsible?

Immediate Action

1. Localize defecation and prevent contamination of watersupply.

2. Collect baseline data of the site and locate zones for sanitaryfacilities.

3. Develop appropriate systems for the disposal of excreta,refuse and wastewater.4. Plan the number and location of sanitary facilities and

services to be established and provided.5. Establish sanitation teams for the construction and mainte-

nance of facilities.6. Set up services for vector and vermin control.

7. Set up services for management of dead bodies8. Establish a monitoring and reporting system.9. Include environmental health as an integral part of health

promotion.

Excreta Facilities

1. Communal Trench Latrine: for 50 persons, 1.2 m x 0.3 m x0.6 m. Use only soil for cover.2. Pit Latrine: 1 seat for 20 persons, 1.2 m x 0.6 m x 0.6 m

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3. Ventilated Improved Pit:1 seat for 20 persons, 0.8 m x 0.7 m x 3.0 m

4. Pour-Flush Water-Sealed Toilet: 1 seat for 20 persons.5. Others: Antipolo, Aqua Privy, Deep Pit Latrine, Reed Odorless

Earth Closet (ROEC), Chemical Toilet: 1 seat for 20 persons.6. Urinals: Urine Soakage, Four-Funnel Urinal7. Children's Feces: should be disposed of immediately and

hygienically8. Distance of Latrines:

! From users: 250 m (max.)! From shelters: 30 m (min.)! From any water source: 25 m radial distance

Liquid Waste Facilities

1. Infiltration Trench, Grease Trap and Soakage Pit, Baffle

Grease Trap, and Cold Water Grease Trap.2. Locate not less than 25 meters radial distance from any

source of water supply.3. Protect from vermin harborage and breeding.4. There should be no standing wastewater around water points

or elsewhere in the settlement.

5. Drainage: Run-in and run-off water management.6. Shelters, paths, water and sanitation facilities should not beflooded or eroded by water.

Bottom of any latrine should be at least 1.5meters above the water table. Drainage or

spillage from defecation systems must not runtowards any surface water source or shallow

groundwater source

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Solid Waste Facilities

1. Storage:! 100-liters capacity per 10 families! Distance from users: 15 m (max.)! Bulk storage bin: centralized bin for temporary storage

before collection! No contaminated or dangerous health waste in living or

public spaces

2. Collection: organize a camp refuse collection team3. Disposal:

! Burial: Communal Open Pit, 1.2 m x 1.2 m x 1.8 m! Cross Fire Trench Incinerator: for 20 families (2.4 m x 0.3

m x 0.3 m)! Barrel and Trench Incinerator, Bailleul Incinerator, Inclined

Plane Incinerator, Open Corrugated Iron Incinerator, RockPit Incinerator, Drying Pan Incinerator and Open TurfIncinerator: for 10 families

! Final disposal does not create health or environmentalproblems

Health-care Wastes

1. Be aware of the public health and occupational risks fromhealth-care waste

a. Vaccination, notably for Hepatitis B should therefore beprovided to waste handlers.b. All waste handlers should wear protective clothing.

c. Hand-washing and disinfection are a must.2. Minimize health-care waste3. Segregate:

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! To be done at point of generation using dedicated, coloredand/or marked containers

! Separate wastes into three main categories:i. infectious sharps (collect sharps in puncture proof

containers with a lid that can be closed, mark withbiohazard symbol)

ii. non-sharp infectious wastesiii. non-infectious wastes

! If no separation of wastes takes place, the whole mixed

volume of health care waste needs to be considered asbeing infectious.

1. Dispose properly. Wastes to be buried and should not beincinerated:

a. used infectious plastic syringes and needlesb. other infectious PVC plastics such as tubing, catheters, IV setsc. anatomical wastes

All these should be buried in a sharps waste burial pit.

Dig a pit 1 to 2 meters wide and 2 to 5 meters deep. Line thebottom of the pit with clay or low permeable material. Constructan earth mound around the mouth to prevent to prevent water

SANITATIO

NANDWASTEMANA

GEMENT


Non-infectious waste 80%

Pathological waste and infectious waste 15%

Sharps waste 1%Chemical or pharmaceutical waste 3%

Pressurized cylinders, broken Less than 1%thermometers

Approximate percentage of waste typesper total waste in PHC centers

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V

ECTORANDVERMINC

ONTROL


Assessment

1. What are the vector-borne disease risks and how serious arethese risks?

2. If vector-borne disease risks are high, do people at risk haveaccess to individual protection?

3. Is it possible to make changes to the local environment (bydrainage, excreta disposal, refuse disposal, etc.) to discour-age vector breeding?

4. Is it necessary to control vectors by chemical means?5. What information and safety precautions need to be provided

to households?

Preventive Measures

a. Conduct vermin population density survey.b. Vulnerable populations are settled outside of the malar-

ial/dengue zone.In areas of known malaria risk:! spraying of shelters with residual insecticide and/or

retreatment/distribution of insecticide-treated mosquito

nets in areas where their use is well-known.In areas endemic of dengue:! water storage containers should be covered to prevent

them from becoming mosquito-breeding sites. Attemptsshould be made to eliminate pooled water which may begathering amongst the debris.

c. Vector breeding or resting sites modified.

d. Screening of living quarters.e. Rats, flies and other mechanical nuisance pests kept within

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VECTOR

ANDVERMINCONTROL


acceptable levels.f. Intensive fly control is carried out in high-density settlements

when there is risk or presence of diarrhea outbreak.g. Removal of breeding and harborage places of vectors and

maintenance of sanitation. Garbage must be collected andappropriately disposed to discourage rodent vector breeding.

h. Larvi-trapping

Chemical Control

a. 1 sprayer for every 50 familiesb. 1 misting machine for every 50 familiesc. 1 fogging machine for every 500 familiesd. Fumigation for the camp, if needed (with proper precautions);

done under the supervision of an emergency Sanitary

Engineere. Adulticides: for crawling and flying insectsf. Rodenticide: for rats and mice (under some conditions)g. Larviciding: introduction of local bioremediation microbes

Estimation of Vector Population

Mosquitoes:1. Select several shelters in the camp.2. In the shelter, close all openings, windows, holes, etc.3. Spread a white sheet on the floor of the rooms.4. Spray the insecticide and wait 20 minutes until the insecticide

has killed the mosquitoes.

5. Count the number of killed adult mosquitoes and record.6. The following can be determined:

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! The number of killed adult mosquitoes divided by thenumber of inspected shelters will give the average

mosquito density per shelter.! The number of killed adult mosquitoes divided by the

number of persons occupying each shelter will give theaverage number of mosquitoes per person.

! The number of mosquitoes found with blood in theabdomen (red or black) divided by the number of personliving in the shelter will give the average number of bites

per person.

7. Send the collected mosquitoes to a laboratory for identifica-tion.

Flies:

1. Count the average number of flies that land on a grill placedwhere flies congregate during three 30-second periods.

(from: Lacarin, CJ and Reed RA (1999) Emergency Vector Control UsingChemicals, Water, Engineering and Development Center (WEDC),Loughborough.)

V

ECTORANDVERMINC

ONTROL


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EPIDEM

IOLOGYANDSURVEILLANCE


Epidemiologic Methodsof Emergency Management

Objectives:! Assess the urgent needs of human populations! Match available resources to needs! Prevent further adverse health effects! Monitor and evaluate program effectiveness!

Improve contingency planning! Optimize each component of emergency management

Application:! Hazard mapping! Analysis of vulnerability! Assessment of the flexibility of the existing local system for

emergency! Assessment of needs and damages! Monitoring health problems! Implementation of disease-control strategies! Assessment of the use and distribution of health services! Etiological research on the cause of mortality and morbidity! Follow-up long-term impacts of health, etc.

Steps in Developing a SurveillanceSystem After a Disaster

1. Establish objectives! Detect epidemics! Monitor changes in the population

? Numbers

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EPIDE

MIOLOGYANDSURVE

ILLANCE


? Health status including nutritional conditions? Security

? Access to food? Access to water? Shelter and sanitation? Access to health services

! Facilitate the management of relief

2. Develop Case Definitions (Request NEC)! Standard case definitions of health conditions simplify

reporting and analysis

3. Choose the Indicators! Indicators must:

? Illustrate the status of the population?

(e.g., death rates)? Measure the effectiveness of relief? (e.g., immunization coverage)

4. Determine Data Sources! Data can come from health-care facilities (passive

surveillance) and from surveys in the community (activesurveillance)

! Involve those who provide health care! Health surveillance in an emergency requires input from

all sectors

Case definitions and Indicators need to beagreed upon by all those involved in the relief

operations.

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5. Develop Data Collection Tools and Flows! Use pre-existing local formats and/or international

standards! Use formats that facilitate data entry (EpiInfo):! Utilize existing process flows

6. Field-Test and Conduct Training! Can these data produce the information required?! Training field workers will improve data facility and local

analysis

7. Develop and Test the Strategy of Data Analysis! Data analysis should cover:

? Hazards and impact on the population's health? Quality and quantity of services provided?

Impact of services on population's health? Relation between services provided to different groups

(evacuees and hosts)? Deployment and utilization of resources

! Major operations may require a central epidemiologicalunit

8: Develop Mechanisms for Disseminating Information (RiskCommunication)

! Who will receive the information?! For the information to be useful, it must be disseminated

widely and in a timely fashion:? Feedback will sustain data collection and the

performance of field workers? Health information is important for the activities of other

sectors

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! Sharing information is good coordination

9: Monitor and Assess Usefulness of the System! Is everybody reporting on time? Which data are missing?! Lack of information in areas or programs that have

problems! Is the system useful?! Is the information generated by the system being used for

decision making?! If not, readjust the system

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PSYCHO

SOCIALCAREANDMENTALHEALTH


Steps in Promoting Psychosocial

and Mental Health1. Assess psychosocial and mental health concerns. Schedule

consultative meetings with the provincial and municipal healthworkers in the affected area to:! Estimate the psychosocial problems experienced by the

people, guided by the classification of people at high risk

! Estimate available resources for mental health/socialservices

* see appendix for Summary Table on Projecting Mental Health Assistance

2. Brief field officers in the areas of health and social welfareregarding issues of fear, grief, disorientation and need for

active participation. Mobilize informal human resources in thecommunity (e.g., Red Cross volunteers, religious and politicalleaders).

3. Conduct mostly social interventions that do not interfere withacute needs such as the organization of food, shelter,

clothing, PHC services, and, if applicable, the control ofcommunicable diseases.

The impact of a traumatic event is likely to begreatest in persons who had a pre-existing

mental health problem, a history of priortrauma, greater exposure to the disaster and itsaftermath, and those who lack family and peer

support.

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PSYCHOSOCIALCAREANDMENTALHEALTH


4.Establish contact with PHC.! Develop the availability of mental health care for a broad

range of problems through general health care and

community-based mental health services.! Manage urgent psychiatric complaints (i.e., dangerous-

ness to self or others, psychoses, severe depression,mania, epilepsy) within PHC.

! Ensure availability of essential psychotropic medications atthe PHC level. Many persons with urgent psychiatric

complaints will have pre-existing psychiatric disorders andsudden discontinuation of medication needs to be avoided.

5. Start planning medium- and long-term development ofcommunity-based mental health services and socialinterventions needed during recovery and rehabilitation. Thisis vital since it is during this phase that survivors will be

rebuilding their lives amidst the grief from the loss of lovedones, property, and livelihood.

6. If the acute phase is protracted, start training and supervisingPHC workers and community workers (e.g., provision ofappropriate psychotropic medication, 'psychological first aid',supportive counselling, working with families, suicideprevention, management of medically unexplained somaticcomplaints, substance use issues and referral).

As far as possible, manage acute distresswithout medication. It is also not advisable to

organize single session psychological debriefingto the general population as an early interven-

tion after exposure to trauma.

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7. Educate other humanitarian aid workers as well as communityleaders (e.g., village heads, teachers, etc.) in core psychological

care skills (e.g., 'psychological first aid', emotional support,providing information, sympathetic reassurance, recognition ofcore mental health problems) to raise awareness and commu-nity support and to refer persons to PHC when necessary.

8. Carefully educate the public on the difference betweenpsychopathology and normal psychological distress, avoiding

suggestions of wide-scale presence of psychopathology andavoiding jargon and idioms that carry stigma.

9. Facilitate creation of community-based self-help supportgroups. The focus of such self-help groups is typicallyproblem sharing, brainstorming for solutions or more effective

ways of coping (including traditional ways), generation ofmutual emotional support and sometimes generation ofcommunity level initiatives.

10.Provide support to caregivers who, because of the exhaustionand enormity of the job, may experience "burn-out."

Interventions for Children Affectedby Emergencies

1. Encourage parents, teachers, and other caregivers tounderstand and monitor child emotional reactions. Rememberthat children's reactions vary with age.

2. Help reduce effects by offering emotional support andsecurity to the child.

PSYCHO



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3. Facilitate recovery by modelling healthy coping strategies.

* See Mental health and psychosocial care of children in disasters (WHO,2005) for further guidance.

Valuable social interventions include:

! Ensuring ongoing access to credible information on theemergency, on the availability of assistance, and on thelocation of relatives to enhance family reunion

! Establishing access to communication with absent relatives, iffeasible

! Organizing family tracing for unaccompanied minors, theelderly and other vulnerable groups.

! Giving 'psychological first aid':? basic, non-intrusive pragmatic care with a focus on

listening but not forcing talk? assessing needs and ensuring basic physical needs are

met? providing or mobilizing company (preferably family or

significant others)? encouraging but not forcing social support? protecting from further harm

! Widely disseminating uncomplicated, empathic informationon normal stress reactions and culturally appropriaterelaxation techniques to the community at large

! Public education should focus primarily on normal reactions,because widespread suggestion of physical and mentaldisease may potentially lead to unintentional harm.

! The information should emphasize an expectation of hope,resilience and natural recovery.! Promote community self-help activities- conceived and



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managed by communities themselves.! Discouraging unceremonious disposal of corpses. Facilitate

conditions for maintaining or re-establishing appropriatecultural practices, including grieving and burial rituals byrelevant practitioners.

! Assuming the activity is safe:1. Encouraging activities that facilitate the inclusion of the

bereaved, orphans, widows, widowers, or those withouttheir families into social networks

2. Encouraging the organization of normal recreationalactivities for children and encouraging starting schoolingfor children, even partially

3. Involving adults and adolescents in concrete, purposeful,common interest activities (e.g., assist in caring for the illespecially if people are cared for at home, construct-

ing/organizing shelter)

! Strengthening the community's and the family's ability to takecare of children and other vulnerable persons.

Specific Concerns for Victims of AttacksInvolving Biochemical Weapons

Attacks involving biochemical weapons may inducesignificant mental and social effects.1. Exposure to any stressor is a risk factor for a range of long-

term social and mental problems (including anxiety andmood disorders as well as non-pathological trauma and grief

reactions)2. Physical exposure to agents may induce organic mentaldisorders

PSYCHO



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3. Attacks are associated with experience of intense social andpsychological distress, especially fear

4. Fear of biochemical attacks may be associated withepidemics of medically unexplained illness

5. Social problems may emerge after exposure to agents (e.g.,population displacement; breakdown of community supportsystems; and social stigma associated with contagion orcontamination)

! In case of quarantine or evacuation, enhance access tocommunication with absent relatives and friends.

! If appropriate and feasible, set-up telephone support systemsto reduce isolation of people who are isolating themselves toreduce the chance of infection.

! Manage medically unexplained symptoms immediately to

prevent potential chronicity of such symptoms.! Public education campaigns may need to be organized to

reduce social stigma and related social isolation of ex-patients and health workers who may be shunned because ofundue public fear of contagion or contamination.

Psychosocial Concerns for Disaster Workers

Burnout or Disaster Fatigue:! state of extreme exhaustion or depletion, physically,

emotionally, mentally and socially! person feels worn-out and depleted of energy but feels that

he/she has not done enough

Signs of Burnout:! Low energy and exhaustion



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! Detachment and separation from one's self; increasingfeeling of non-feeling, deadness, indifference and even

skepticism! Aloneness, feeling unappreciated and mistreated! Impatience, heightened irritability! Increasing anger, suspiciousness! Confusion, agitation, limiting ability to focus mind and

behavior! Depression, psychosomatic complaints! Denial that anything is wrong; I don't care

Management of Burnout! Rotation of work assignments to allow time away from the

daily routine of disaster work for those in the field! Rest and recreation program for those in active duty!

CISD sessions should be done regularly for those in the field! Superiors and the agency itself should provide for situations

to give credit, express appreciation and recognition of theirdisaster workers at regular intervals

! Provision of appropriate assistance for those who mightrequire counseling and/or specialist psychiatric attention

PSYCHO



Historical research on group behavior hasshown that contrary to common expectations,

public panic is uncommon. Disasters mayleave some communities with increased socialcoherence. Community members often showgreat altruism and cooperation, and people

may experience great satisfaction from helping

each other.

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M

ANAGEMENTOFDEAD

BODIES


Health Considerations in Casesof Mass Fatalities

Emphasize that, in general, the presence of exposed corpses posesno threat of epidemics. The corpse has a lower risk for contagionthan an infected living person. The key to preventing disease is toimprove sanitary conditions and to educate the public.If death resulted from trauma, bodies are quite unlikely to causeoutbreaks of diseases.They may, however, transmit gastroenteritis or food poisoningsyndrome to survivors if they contaminate streams, wells, or other

water sources. Thus, any bodies (or dead animals) lying in watersources should be removed as soon as possible.

!

!

!

! The National Disaster Plan/EmergencyOperations Committee should specify the

institution that willcoordinate all processesrelated to the management of dead bodies.

! The health sector should take the leadingrole in:1. Addressing concerns about the

supposed epidemiological risksposed by dead bodies

2. Providing medical assistance tofamily members of the victims.! The work of handling, identifying, and

disposing of dead bodies is based onforensic sciences and requires amultidisciplinary team. However, in theabsence of medico-legal experts, the healthofficer may need to carry out these tasks to

the best of his or her abilities.

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MANAG

EMENTOFDEADBOD

IES


!

!

The risk posed by bodies buried by a landslide or mudslide isnonexistent.It should be noted that in areas where certain diseases are endemic,the disposal of bodies may become a priority. However, even in suchcases the presence of dead bodies should not be considered animportant public health risk.

Principal diseases that should be avoided by those responsible formanaging corpses in order to prevent possible contagion:

1. streptococcal infection

2. gastrointestinal infection (e.g., cholera, salmonellosis)3. Hepatitis B and C4. HIV

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FORENSICSCIENCEC

ONCERNSINMASSFA

TALITIES


Practical Approach to a MultipleFatality Incident

1. Initial Concerns! Type of incident (natural hazards, e.g., flood, landslide,

earthquake, epidemics; human-generated, e.g., fire,land/sea/air transport crash, accidental or deliberate useof biochemical/radionuclear agents)

!

Probable condition of remains (e.g. burnt, with severetrauma, decomposed, contaminated)! Estimated number of fatalities! Location of incident! Local authority in-charge! Budget

2. Personnel! Tap medico-legal officers from the NBI or PNP and local

government doctors.! Mobilize volunteers like medical and dental students or

specialists from the area.

Ideally a list of the people involved and their contact numbersshould have been prepared beforehand.

3. Handling of the Bodies at the Scene! As much as possible document the location and position

of each body at the scene prior to removal.! Mark bodies/body parts to preserve their relationship to

one another.! Sketch and photograph for documentation.

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FORENSICSCIENCECONCERN

SINMASSFATALITIES


! Every effort must be taken to identify the bodies at the sitewhere they are found. Tags should be attached to the

bodies that provide the name (if known), approximate age,sex, and location of the body.

4. Evidence and Property! All items of property that are on the body should remain on it.! Other items associated with a body should be collected as

property and tagged with the body.! The location of loose items (e.g., proximity to which body)

should be documented prior to collection.

5. Removal and Transport of Remains! Before removing any body, body part or property, there

should be adequate documentation.! Care must be taken not to lose, contaminate or switch

such body, body parts or property to be removed andtransported.

! Properly labeled separate bags must be used.! Be particularly careful of potential loss of teeth if they are

loose (e.g., badly burned or crushed remains); put a bagaround the head.

! When adapting vehicles to transport dead bodies, it isadvisable to use trucks or vans, preferably closed, withfloors that are either waterproof or covered with plastic

!

Using health service vehiclesspecifically, ambu-lancesto transfer human remains from the site of thedisaster is ill-advised.

Before anything else, observe and record first.

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6. Temporary Mortuary Facility! Identify a place that can be converted into a makeshift

morgue (e.g., empty warehouse, covered basketballcourt).

! Basic requirements:? Security? Adequate lighting, ventilation, water supply? Examining tables? Instruments for examining the remains and documenta-

tion! Ideally, should consist of a reception, a viewing room, a

storage chamber for bodies not suitable for viewing and aroom to store personal possessions and records.

7. Examination of Remains!

Objectives of the postmortem examination:? Identification of the remains? Cause of death determination? Manner of death determination? Collection of forensic evidence

! In emergency situations, usually the critical need is toidentify the victims.

! Identification through visual identification by the next-of-kinshould be limited to bodies that are suitable for viewing(i.e., not decomposed, burnt or mangled) and should besubject to verification by other means.

! A more reliable system of identification entails anobjective comparison of antemortem and postmortem

information.! Because of limited resources, not all bodies can undergo afull autopsy; priority may be given to certain remains (such


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as those of transport operators driver, pilot/ship captainand crew).

! A detailed examination of the external body is done; markssuch as tattoos, scars, moles and deformities aresearched.

! Fingerprints are obtained and dental charting is done.! Blood and other tissue/fluid samples are collected for

possible tests (e.g., histopathology, DNA analysis,toxicology).

! Property collected from each body (e.g., clothes, jewelry,wallets, IDs) must be described and inventoried.

8. Preservation of the Body! Remains are best stored refrigerated (e.g., in rented

refrigerated storage trucks) while awaiting examination.!

After the postmortem examination, embalming can bedone.

9. Dealing with Claimants! Notify family members of the death or disappearance of

victims in a clear, orderly, and individualized manner.! Organize a separate area where the next-of-kin can be

systematically interviewed for data.! Useful antemortem information to get:

Name, age, sex, height, buildAppearance when last seenDistinguishing features (tattoos, scars, moles, deformities,etc.)

Significant medical history! Ask the next-of-kin to submit the following:Medical records including x-ray films


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Dental recordsClear photograph with teeth bared

Fingerprints on file! Note that personal items that a person believed to be

among the victims could have used (e.g., toothbrush,hairbrush, other items), could potentially contain referencefingerprints or DNA samples.

10.Death Certification and Release of Bodies! Properly identified victims shall be issued death certifi-

cates and the bodies released to the next-of-kin.! Maintain a record of how the bodies are disposed of

including information regarding the claimants' names,addresses and contact numbers.

! Bodies could remain unidentified in case of insufficient

antemortem and postmortem data; these remains shouldbe buried separately (not cremated!) and their postmortemrecords stored for future evaluation.

! Court proceedings could be initiated according toPhilippine laws that would legally declare dead theunidentified and missing victims.

11.Disposal of Dead! Respond to the wishes of the family and provide all

possible assistance in final disposition of the body.! Burial is the preferred method of body disposal in

emergency situations unless there are cultural andreligious observances that prohibit it.?

The location of graveyards should be agreed upon bythe community and attention should be given to groundconditions, proximity to groundwater drinking sources


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(which should be at least 50 m) and to the nearesthabitat (500 m).

? Burial depth should be at least 1.5 m above thegroundwater table, with at least 1 m of soil cover.

? If coffins are not available, corpses should be wrappedin plastic sheets to keep the remains separate from thesoil.

? Burials in common graves and mass cremations arerarely warranted and should be avoided.

! Reject unceremonious and mass disposal of unidentifiedcorpses. As a last resort, unidentified bodies should beplaced in individual niches or trenches, which is a basichuman right of the surviving family members.

12.Other concernsEnsure that there is a plan for the psychological andphysical care for the relief workers. Handling a large numberof corpses can have an enormous impact on the health of theworking team.

Give priority to the living over the dead: Thepriority is to treat survivors and re-establish the

health care system as soon as possible!


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The arrival of inappropriate relief donations cancause major logistic chaos.

RESOURCEMANA

GEMENT


Supply Management General Guidelines:

! Only a single government official should be made responsi-ble for channeling requests to avoid duplication andconfusion.

! Donors should be asked to provide large amounts of a fewitems to simplify and expedite transfers.

! Requests should indicate clearly the order of priority,amounts, and formulations (compatible with the size of theaffected population).

! Do not request perishable products and vaccines unless

refrigeration and special handling facilities are available.

Guidelines for Drug Donations

! Based on expressed needs of the affected population.! Sent only with prior consent of recipient.! Based on the list of essential drugs.! Obtained from a quality source with quality standards.! Formulation and efficacy of foreign donations should be

similar to those commonly used in the country.! Label should at least contain generic name, dosage forms,

strength, quantity in container, and expiry date.! After the arrival of foreign drug donations, the medicines must

have a remaining shelf life of at least 1 year.

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RESOURCEMANAGEMENT


Donation Labeling and Donation Marking

foodstuff

clothing and household items

medical supplies/equipment

1. Labeling:!

Consignments of medicines branded green shouldindicate expiry date and temperature controls.! English should be used on all labels.

2. Size and weight! Goods should be in a 25-50 kg container, manageable by

a single person.

3. Contents! Relief supplies must be packed by type in separate

containers.! Value of relief goods is lost if there is no color-coding.! Give advance notice to the health relief coordinator and

supply information about the package (e.g., name andcontact number of donor, date, method of transport, detailsof contents, and other special requirements for handling).

RED

BLUE

GREEN

Upon arrival of the donations/ consignments,acknowledge their receipt. Call or write the

senders and thank them.

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RISKCOMMUN

ICATION


Communication Objectives:

! Acknowledge the event with empathy.! Establish spokesperson credibility! Explain and inform the public, in simplest terms, about the

risk! Provide emergency courses of action (including how/where

to get more information)! Commit to partners and public to continued

communication.! Listen to feedback and correct misinformation.! Empower risk/benefit decision-making.

Steps in Communicating Risks

1. Verify situation! Get the facts.! Obtain information from additional sources to put the

event in perspective.! Review and critically judge all information. Determine

credibility.! Clarify information through subject matter experts.! Begin to identify staffing and resource needs to meet the

expected media and public interest.! Determine who should be notified of this potential

emergency.

2. Conduct notifications

3. Activate Crisis Plan! Ensure direct and frequent contact with the EOC

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RISKCO

MMUNICATION


! Determine what your organization is doing in response tothe event.

! Determine what other agencies/organizations are doing.! Determine who is being affected by this crisis. What are

their perceptions? What do they want and need toknow?

! Determine what the public should be doing.! Determine what's being said about the event. Is the

information accurate?

4. Organize assignments! Identify the spokesperson for this event.! Determine if subject matter experts are needed as

additional spokespersons.! Determine if the organization should continue to be a

source of information to the media about this emergency,or would some issues be more appropriately addressed byother government entities?

5. Prepare information and obtain approvals

6. Release information to media, public and partners

through arranged channels! Provide only information that has been approved by the

appropriate managers. Don't speculate! Repeat the facts about the event! Describe the data collection and investigation process! Describe what your organization is doing about the

emergency.! Describe what other organizations are doing.! Explain what the public should be doing

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! Describe how to obtain more information about thesituation

7. Obtain feedback and conduct communication evaluation

8. Conduct public education

9. Monitor events

(Adapted from CDC (2002).

pocket emergency tool 2005

Documents