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Manag. of health & medical issues in disasters modified14 03-2009

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Manag. of health & medical issues in disasters modified14 03-2009

  1. 1. Management of Health & Medical Issues in Disasters Dr S.J.Gandhi Deputy Director (Epidemic) Commissioerate Of Health Services, Gandhinagar
  2. 2. Seven Fundamental Terms in Risk Management A Logical Framework of Terminology Hazard Any potential threat to public safety and / or public health Risks The potential consequences of hazard interacting with community Emergency Any actual threat to public safety and / or public health Vulnerabilities Factors which determine the type and severity of those consequences Disaster A civil emergency in which the humanitarian needs are beyond local capacity to meet those needs i.e. the response and recovery operation must be managed at the national and/or international level Readiness for Response A determinant of the severity and manageability of those consequences Community is people, property, services, livelihoods and environment i.e. the elements exposed to hazards
  3. 3. Definitions <ul><li>A Hazard is a Human-made or Natural Danger that causes damage to people , property and the environment </li></ul><ul><li>A Risk is the Potential for something to go wrong or for something harmful to occur </li></ul><ul><li>Vulnerability is the potential to be easily hurt or harmed </li></ul><ul><li>Capacity is an ability to cope up with a difficult situation </li></ul>
  4. 4. Hazards <ul><li>There are 4 classes of hazard : </li></ul><ul><ul><li>Natural hazards </li></ul></ul><ul><ul><li>2. Technological hazards </li></ul></ul><ul><ul><li>3. Biological hazards </li></ul></ul><ul><ul><li>4. Societal hazards </li></ul></ul>
  5. 5. A Community Consists of 5 Elements: <ul><li>Their property (infrastructure, possessions and assets; public, private and cultural) </li></ul><ul><li>Their services (government and non-government, commercial and voluntary) </li></ul><ul><li>Their livelihoods (urban and rural, formal and informal) </li></ul><ul><li>The people </li></ul><ul><li>Their environment (air, water and soil; urban and rural, built and natural) </li></ul>
  6. 6. COMMUNITY RISKS <ul><li>COMMUNITY RISKS are proportional to </li></ul><ul><li>HAZARDS </li></ul><ul><li>x </li></ul><ul><li>VULNERABILITIES __________________________ </li></ul><ul><li>READINESS FOR RESPONSE </li></ul><ul><li>WARNING: this is not a mathematical formula! </li></ul>
  7. 7. Vulnerabilities <ul><li>are: </li></ul><ul><li>Factors which determine how much risk </li></ul><ul><li>Higher vulnerability increases the risks arising from a specific hazard in a specific community, or in sub-sections of that community. </li></ul>
  8. 8. Indicators of Vulnerabilities <ul><li>Each element of community can be described in terms of its vulnerabilities: </li></ul><ul><ul><li>people </li></ul></ul><ul><ul><li>property </li></ul></ul><ul><ul><li>services </li></ul></ul><ul><ul><li>livelihoods </li></ul></ul><ul><ul><li>environment </li></ul></ul>
  9. 9. Indicators of Vulnerabilities (for people) <ul><li>Access to health care </li></ul><ul><li>Measles vaccination coverage rate </li></ul><ul><li>Under 5 nutrition rate </li></ul><ul><li>Under 5 mortality rate </li></ul><ul><li>Access to safe water </li></ul><ul><li>Access to sanitation </li></ul><ul><li>Access to adequate housing </li></ul><ul><li>Access to regular source of income </li></ul><ul><li>Female literacy rates </li></ul>
  10. 10. Critical Services – Basic Needs and Lifelines <ul><ul><li>Basic needs for survival: </li></ul></ul><ul><ul><li>water </li></ul></ul><ul><ul><li>food </li></ul></ul><ul><ul><li>shelter (and clothing in cold climates) </li></ul></ul><ul><ul><li>energy (fuel) </li></ul></ul><ul><ul><li>(acute medical care) </li></ul></ul>
  11. 11. Consequences <ul><ul><li>injury (mental and physical) </li></ul></ul><ul><ul><li>disease (mental and physical) </li></ul></ul><ul><ul><li>secondary hazards (fire, disease etc.) </li></ul></ul><ul><ul><li>contamination of the environment </li></ul></ul><ul><ul><li>displacement </li></ul></ul><ul><ul><li>breakdown in security </li></ul></ul><ul><ul><li>damage to infrastructure </li></ul></ul><ul><ul><li>dead and missing </li></ul></ul><ul><ul><li>breakdown in essential services </li></ul></ul><ul><ul><li>loss of property </li></ul></ul><ul><ul><li>loss of income … </li></ul></ul>
  12. 12. Public Health Consequences of Disasters <ul><ul><li>temporary population displacements </li></ul></ul><ul><ul><li>increased numbers of deaths and injuries </li></ul></ul><ul><ul><li>new cases of disease and disability </li></ul></ul><ul><ul><li>exacerbation of and increased numbers of cases of psychological and social behaviour disorders </li></ul></ul><ul><ul><li>food shortages and nutritional deficiencies </li></ul></ul>
  13. 13. Public Health Consequences of Disasters - cont. <ul><ul><li>environmental disruption causing hazards – vectors, waste management, sanitation </li></ul></ul><ul><ul><li>destruction of infrastructure </li></ul></ul><ul><ul><li>disruption to routine health services </li></ul></ul><ul><ul><li>disruption to routine disease surveillance and control services </li></ul></ul><ul><ul><li>diversion of capital investment funds to emergency relief and the rehabilitation or reconstruction of essential infrastructure </li></ul></ul>
  14. 14. Health Services in Emergencies <ul><ul><li>Mass casualty management – first aid, triage, transport, pre-hospital care, in-patient care, post care follow-up </li></ul></ul><ul><ul><li>Management of the dead and missing </li></ul></ul><ul><ul><li>Environmental health (water and sanitation, shelter, health care waste management, environmental pollution) </li></ul></ul><ul><ul><li>Psychosocial services </li></ul></ul><ul><ul><li>Reproductive health </li></ul></ul><ul><ul><li>Communicable disease control measures </li></ul></ul><ul><ul><li>Feeding and nutrition </li></ul></ul><ul><ul><li>Health information and communication </li></ul></ul>
  15. 16. Challenges in Health Emergency Management <ul><ul><li>Lack of legal frameworks, policies, guidelines, protocols </li></ul></ul><ul><ul><li>Lack of evidence base for policy development </li></ul></ul><ul><ul><li>Pressure from the public and media </li></ul></ul><ul><ul><li>Emergency situations are dynamic and in such situations, information is scarce, volatile and often not shared </li></ul></ul><ul><ul><li>Multiple health effects of hazards </li></ul></ul>
  16. 17. Challenges in Health Emergency Management <ul><ul><li>Multiples agencies involved - inter / intra-sectoral, public / private, national / international </li></ul></ul><ul><ul><li>Difficulty in coordination </li></ul></ul><ul><ul><li>Planning is not coordinated within and between sectors </li></ul></ul><ul><ul><li>Plans do not exist or have not been tested </li></ul></ul>
  17. 18. Challenges in Health Emergency Management <ul><ul><li>Lack or mismatch of resources </li></ul></ul><ul><ul><li>Inappropriate donations </li></ul></ul><ul><ul><li>Response and recovery actions are done without needs assessments </li></ul></ul><ul><ul><li>Opportunities for enhancing risk reduction are lost during recovery and reconstruction </li></ul></ul><ul><ul><li>Lessons from disasters are not institutionalised </li></ul></ul><ul><ul><li>Lack of best practices </li></ul></ul>
  18. 19. HEALTH ISSUES <ul><li>WATER & SANITATION </li></ul><ul><li>There was a breakdown of the water and sewerage system. </li></ul><ul><li>HUMAN REFUSE GENERATION </li></ul><ul><li>Relatives of injured people defecated / urinated in the open, in spite of deep trench latrines. </li></ul><ul><li>BIOMEDICAL WASTE DISPOSAL </li></ul><ul><li>Amputated limbs and other biomedical waste was disposed off by burning. </li></ul>
  19. 20. SOCIAL ISSUES <ul><li>DISPOSAL OF DEAD BODIES </li></ul><ul><li>The police was entrusted with the task of identification, photographing and cremation / burial of the dead bodies . </li></ul>
  20. 21. ADMINISTRATIVE PROBLEMS <ul><li>COLLAPSE OF THE CIVIL HEALTH COMMAND AND CONTROL STRUCTURE </li></ul><ul><li>MH Bhuj whose role was to supplement civil resources had to serve as the first responder. </li></ul><ul><li>STRUCTURAL DAMAGE TO HOSPITAL </li></ul><ul><li>Patient care including surgery had to be carried out in the open under tent cover. </li></ul><ul><li>LACK OF COMMUNICATIONS </li></ul><ul><li>No serviceable telephone / satellite phone available at mh bhuj during the first 72 hrs </li></ul><ul><li>NO WATER OR ELECTRICITY SUPPLY INITIALLY </li></ul><ul><li>Generator sets became functional by 3 hrs post impact Water was provided through water- bowsers. </li></ul>
  21. 22. ADMINISTRATIVE PROBLEMS <ul><li>HAPHAZARD INDUCTION OF CIVILIAN HEALTH PERSONNEL INTO THE DISASTER AREA </li></ul><ul><li>Personnel were inducted without adequate planning, briefing and preparation. They were not self contained. </li></ul><ul><li>LOGISTICS MANAGEMENT OF MEDICAL SUPPLIES </li></ul><ul><li>Influx of medical supplies was not necessarily need based. Difficulties were encountered in sorting out necessary items, accounting and storage </li></ul><ul><li>ABSENCE OF LAUNDRY SERVICES INITIALLY </li></ul><ul><li>Laundry services affected due to shortage of water and damage to the washing point. Soiled linen could not be washed, disinfected and reused. </li></ul><ul><li>SHORTAGE OF TENTS </li></ul><ul><li>No tents authorized to MH Bhuj on establishment. Tents had to be procured from the local formation. </li></ul><ul><li>DOCUMENTATION </li></ul><ul><li>Adequate documentation of the massive influx of casualties was not possible with the existing resources. </li></ul>
  22. 23. PATIENT CARE DIFFICULTIES <ul><li>SHORTAGE OF HOSPITAL BEDS AND LINEN </li></ul><ul><li>MH Bhuj is a 99 bed hospital with a 25 bed crisis expansion capability. With the large influx of casualties it ran out of hospital beds, mattresses and linen. Patients had to be treated on the ground. </li></ul><ul><li>SHORTAGE OF OPERATING ROOM EQUIPMENT, INSTRUMENTS, LINEN & DISINFECTANTS </li></ul><ul><li>The capacity of the operating rooms was overwhelmed by the number of the casualties. </li></ul><ul><li>CROWD CONTROL </li></ul><ul><li>Relatives of casualties demanded immediate attention from the limited number of medical / paramedical personnel. They broke cordons and barged into treatment / operating areas, interfering with prioritization and provision of care. </li></ul>
  23. 24. PATIENT CARE DIFFICULTIES <ul><li>CASUALTY EVACUATION TO OTHER HOSPITALS </li></ul><ul><li>Inadequate number of stretchers especially special stretchers for transporting patients with spinal injuries. </li></ul>
  24. 25. INFORMATION MANGEMENT <ul><li>Lack of communications. </li></ul><ul><li>Assessment of the magnitude of the disaster impact was not available. </li></ul><ul><li>Information on health facilities for redistribution / evacuation of patients was not available. </li></ul>
  25. 26. Rapid Assessment- Team composition <ul><li>Public health expert/ Epidemiologist </li></ul><ul><li>Clinician </li></ul><ul><li>Microbiologist </li></ul><ul><li>Environmentalist/entomologist </li></ul>
  26. 27. SPHERE <ul><li>Based on Two Principles: </li></ul><ul><li>(a) Relieve and minimize human suffering arising out of calamity and conflicts </li></ul><ul><li>(b) Affected community has a right to life with dignity and hence a right to receive assistance </li></ul><ul><li>SPHERE initiative was launched in 1997 by a group of Humanitarian NGOs, the Red Cross and Red Crescent movement – </li></ul><ul><li>By framing Humanitarian Charter </li></ul><ul><li>By formulating minimum standards to be applied and achieved in areas affected by all types of Disastrous situations in terms of Five key factors (water supply and sanitation, nutrition, food aid, shelter and health services) </li></ul><ul><li>At present an Expert Group is working on the strategies of applying Sphere standards in Indian context and how best they can be modified to be applicable in current state of affairs </li></ul>
  27. 28. Humanitarian Charter <ul><li>Based on the principles and provisions of International Humanitarian Law, International Human Rights Law, Refugee’s Law & Code of Conduct of International Red Cross etc. during disaster relief </li></ul><ul><li>It asserts the Human rights of people affected by natural or man-made disaster situations like armed conflicts, civil strife and other political emergencies –to have protection, avail assistance to survive and live their life with dignity </li></ul><ul><li>It also pertains to Legal responsibilities of the states and warring parties to provide above services to the people under crisis situation </li></ul><ul><li>If they are unable or unwilling to do so, they are obliged to allow Humanitarian Organizations to provide humanitarian assistance and protection </li></ul>
  28. 29. <ul><li>Sphere standards also relate to the operational framework and accountability aspects of service providers </li></ul><ul><li>In all situations priority would be meeting the urgent survival needs of people affected by disasters </li></ul><ul><li>Ascertain their basic human right to life with dignity </li></ul><ul><li>In all contexts , disaster response should support and/or complement existing government services in terms of structure, design and long term sustainability </li></ul><ul><li>Providing valid information regarding availability and ensuring accessibility to support services by all groups in a non-discriminatory manner as per their specific needs has to be co-coordinated by continuous dialogue with Local Administrative Authorities </li></ul>
  29. 30. <ul><li>Key Vulnerable Groups: </li></ul><ul><li>Women </li></ul><ul><li>Children (age<18 yrs.) </li></ul><ul><li>Older people (age > 60 yrs.) </li></ul><ul><li>People with HIV/AIDS </li></ul><ul><li>Ethnic Minorities </li></ul><ul><li>Cross- cutting Issues: </li></ul><ul><li>Gender groups </li></ul><ul><li>Isolated groups </li></ul><ul><li>Malnourished groups </li></ul><ul><li>Sensitive Issues </li></ul><ul><li>Exploitation </li></ul><ul><li>Abduction </li></ul><ul><li>Recruitment into fighting forces </li></ul><ul><li>Sexual violence </li></ul><ul><li>Lack of opportunity to participate in decision making </li></ul><ul><li>Most harmful effects in such a situation will be felt by Children and young people </li></ul>
  30. 31. <ul><li>Gender Issues will always remain in Focus and priority </li></ul><ul><li>Even the assessment teams should be framed up with equal participation by Female Members </li></ul><ul><li>Protection and Protection Assistance are two separate issues and NGOs can certainly help in providing assistance to Local Authorities </li></ul><ul><li>HIV/AIDS plays it’s role in the way that as the Pandemic matures and more people die , communities would be left with disproportionate number of children, orphans and older people- which require special attention and relief programs may be modified accordingly </li></ul><ul><li>Environmental Issues: </li></ul><ul><li>The physical, chemical and biological environment in which affected people are living in should not be subjected to over-exploitation, pollution and degradations </li></ul><ul><li>NGOs also have to ensure their political clearance, fulfill their visa requirements and should have sufficient financial, human and material resources of their own before they enter into above ventures. </li></ul>
  31. 32. General Principles <ul><li>Affected people’s capacities and available resources should be assessed </li></ul><ul><li>Identify gaps in essential services </li></ul><ul><li>Support inherent skills of local population </li></ul><ul><li>No single sector can be planned and considered in isolation </li></ul><ul><li>Share the findings of assessment with local population </li></ul><ul><li>Allow people to comment upon ongoing relief measures </li></ul><ul><li>Plan outreach services for specific groups identified </li></ul><ul><li>Disaster Response Programs should support and complement existing services and local institutions in terms of structure and design </li></ul><ul><li>Such activities should be sustainable after the external assistance stops and should be framed after due local consultations and approvals </li></ul><ul><li>Host populations extending support to displaced populations should be consulted and where appropriate the developments in disaster relief activities should also lead to a sustainable improvement in the livelihoods of the host population </li></ul>
  32. 33. Hygiene Promotion <ul><li>Much depends upon effective exchange of information between people and service providers- should jointly list out risk factors </li></ul><ul><li>It is in addition to good sanitation and water supplies </li></ul><ul><li>Risk Factors: improper excreta disposal, use and maintenance of toilets, lack of hand-washing with soap, unhygienic storage of water and unhygienic storage and preparation of food </li></ul><ul><li>Form water and sanitation committees made from members from various sections of community and half (50%) should be female members </li></ul><ul><li>Even such committees may be encouraged to manage water points, public toilets and washing areas </li></ul><ul><li>This will ultimately sustain the efforts for a long long time </li></ul>
  33. 34. Water Supply <ul><li>Average water use for drinking, cooking and personal hygiene in any household is at least 15 Liters per person per day </li></ul><ul><li>The maximum distance from any household to the nearest water point is 500 meters </li></ul><ul><li>Queuing time at a water source is no more than 15 minutes </li></ul><ul><li>It takes no more than Three minutes to fill a 20-liter water container </li></ul><ul><li>Water sources and systems are adequately maintained so as to have a consistent and continuous water supply </li></ul><ul><li>Generally ground-water sources are preferred , as they require no treatment </li></ul><ul><li>People living with HIV/AIDS require extra water for drinking and personal hygiene </li></ul><ul><li>Requirements for Livestock and Agriculture crops have to paid attention especially in drought situation </li></ul><ul><li>People affected by emergency situation have increased vulnerability to communicable diseases and their water requirements are more than normal situations </li></ul>
  34. 35. Water Supply…. <ul><li>Excessive Queuing will result in </li></ul><ul><li>(1) reduced per capita water consumption </li></ul><ul><li>(2) increased consumption from unprotected water sources </li></ul><ul><li>(3) resulting in availability of less time for other survival tasks </li></ul><ul><li>In urban areas it may be necessary to supply water into individual buildings to ensure that toilets continue to function </li></ul><ul><li>All users need to be informed when and where water will be available </li></ul><ul><li>Important Quality Indicators: </li></ul><ul><li>(1) There are no faecal colliforms per 100 ml at the point of delivery </li></ul><ul><li>(2) Free Residual Chlorine 0.5 mg per Liter </li></ul><ul><li>(3) Turbidity is below 5 NTU </li></ul>
  35. 36. Water Supply…. <ul><li>Faecal colliforms Bacteria (>99% of which are E. Coli ) are an indicator of the level of human/animal waste contamination in water </li></ul><ul><li>Animal excreta is not as harmful as human excreta </li></ul><ul><li>Disposal of Children Faeces requires more attention as they are more dangerous than those of the adults because- </li></ul><ul><li>(1) In children excreta related infections are on a higher side (2) Children lack antibodies </li></ul><ul><li>People have to be educated for the consumption of Chlorinated water- in terms of health advantages </li></ul><ul><li>If the safe water does not taste good-people will continue to drink from unsafe water sources- thereby putting their health at risk </li></ul>
  36. 37. Water Supply…. <ul><li>Each household should have minimum two containers of 20 Liters capacity to ensure continuous availability </li></ul><ul><li>Water collection and storage containers should have narrow necks </li></ul><ul><li>At least 250 gms. of soap should be available per person per month </li></ul><ul><li>If soap is not available-use alternatives like ash, clean sand , soda or various plants for washing and scrubbing </li></ul><ul><li>At Communal Bathing facilities- sufficient cubicles should be available separately for men and women groups and should be used appropriately and equitably </li></ul><ul><li>At Communal Laundry facilities one washing cubicle is available per 100 persons </li></ul><ul><li>Ensure private laundering facilities for women to wash and dry their undergarments and sanitary cloths </li></ul>
  37. 38. Excreta Disposal <ul><li>Safe disposal of excreta creates the first barrier to excreta related disease, helping to reduce transmission thro’ direct and indirect routes </li></ul><ul><li>People need to provided with adequate no of toilets, sufficiently close their residential premises to allow them rapid, safe and acceptable access at all times of the day and night </li></ul><ul><li>Parameters: </li></ul><ul><li>(1) one toilet per 20 persons </li></ul><ul><li>(2) toilets segregated for men and women </li></ul><ul><li>(3) adequately cleaned and maintained </li></ul><ul><li>(4) not more than 50 meters away from their dwellings </li></ul><ul><li>(5) children Faeces are disposed off immediately </li></ul><ul><li>At times of disasters it may necessary isolating parts of the system, which are still working, re-routing of pipes, installing portable toilets and using septic tanks and containment tanks – which are regularly desludged </li></ul>
  38. 39. Excreta Disposal….. <ul><li>During the initial phase of disaster mark-off an area to be used as defecation field or for trench latrines </li></ul><ul><li>Consult public-educate them on health benefits of using toilets and help them to maintain toilets and keep them clean </li></ul><ul><li>Sufficient no. of women cubicles need to be built up-roughly 3 times of men- </li></ul><ul><li>Wherever possible provide urinals for men </li></ul><ul><li>People with HIV/AIDS frequently suffer with chronic diarrhea and require to use toilets more </li></ul><ul><li>Site selection should be such that all sections of people are able access toilets easily-it should be particularly safe for women and girls throughout the day and night </li></ul><ul><li>Should provide privacy </li></ul><ul><li>Should allow for disposal of women’s sanitary protection </li></ul><ul><li>Should minimize fly and mosquito breeding </li></ul><ul><li>Should have adequate supply of water for anal cleansing an d keep them clean </li></ul>
  39. 40. Excreta Disposal…. <ul><li>Separate water facility should be provided for hand washings and flushing after use of toilets </li></ul><ul><li>Pit latrines and soakaways (for most soils ) should be at least 30 meters from any groundwater source and the bottom of any latrine is at least 1.5 meters above the water table </li></ul><ul><li>Community toilets should be provided with lighting </li></ul><ul><li>Toilet paper may be required in certain settings instead of water </li></ul><ul><li>Women and girls who menstruate should have access to suitable materials for the absorption and disposal of menstrual blood </li></ul><ul><li>Soap-ash may be proided </li></ul><ul><li>Toilets with water-seal, ventilated improved pit latrine design or correct use of a lid on a squat hole may encourage constant use by people </li></ul>
  40. 41. Solid Waste Disposal <ul><li>Organic wastes impose a constant danger of </li></ul><ul><li>(1) Fly and Rodent breeding </li></ul><ul><li>(2) Surface water pollution </li></ul><ul><li>(3) create an ugly and depressive feeling </li></ul><ul><li>(4) Block drainage channels </li></ul><ul><li>Parameters: </li></ul><ul><li>(1) Involve people in designing and management of waste disposal Programme </li></ul><ul><li>(2) Household wastes are put in containers </li></ul><ul><li>(3) Communal Refuse container should be available within 100 meters vicinity </li></ul><ul><li>(4) 100-liter refuse container should be available per 10 families </li></ul>
  41. 42. Solid Waste Management….. <ul><li>Medical wastes should be separated and disposed-off separately </li></ul><ul><li>In disaster situation there is more possibility of infectious sharps and non-sharps e.g. wound-dressings, blood stained clothes ,placentas.. </li></ul><ul><li>Safety boxes need to be provided to HCWs. </li></ul><ul><li>Disposal may be done by on-site burial or incineration </li></ul><ul><li>At public places like markets. slaughter houses Refuse pits, Bins or specified areas should be clearly marked and appropriately fenced </li></ul><ul><li>In case of disposal of waste by Burial method it should covered with a thin layer of soil at least once in a week to prevent it getting attracted by vectors like flies and rodents and becoming a breeding site for them </li></ul><ul><li>Such burial sites should also be fenced </li></ul><ul><li>Prevent any laechate from such sites contaminating ground water </li></ul>
  42. 43. Solid Waste Disposal… <ul><li>At slaughter houses slaughter waste can often be disposed in a large pit with a hole cover next to abattoir </li></ul><ul><li>Blood etc. can be run from the abattoir into the pit through a slab –covered channel (reducing fly access to the pit) </li></ul><ul><li>Water should be made available for cleaning purpose </li></ul><ul><li>Controlled Tipping/Sanitary Land-fill: </li></ul><ul><li>(a) useful for large scale off-site disposal of waste </li></ul><ul><li>(b) Sufficient space and mechanical equipments are required </li></ul><ul><li>(c) Waste that is tipped should be covered by soil at the end of each day to prevent scavenging and vector breeding </li></ul><ul><li>In all settings staff engaged in above work should be provided with protective gloves, boots , masks ,soap and availability of water </li></ul>
  43. 44. Drainage Facilities <ul><li>Surface Water near human settlements may be coming from: </li></ul><ul><li>(1) household and water point Wastewater </li></ul><ul><li>(2) leaking toilets and sewers </li></ul><ul><li>(3) rainwater or rising floodwater </li></ul><ul><li>Health Risks: </li></ul><ul><li>(1) contamination of water supplies and the living environment </li></ul><ul><li>(2) damage to toilets and dwellings </li></ul><ul><li>(3) vector breeding & </li></ul><ul><li>(4) drowning </li></ul><ul><li>Important Considerations: </li></ul><ul><li>(1) areas around water points and dwellings are kept free from standing wastewater </li></ul><ul><li>(2) storm-water drains are kept clear </li></ul><ul><li>(3) Water point drainage from washing and bathing points are well planned and maintained </li></ul><ul><li>(4) drainage water should not pollute existing surface or ground water sources or erode them </li></ul><ul><li>(5) adequate tools ,equipments and human workforce is available for maintainance </li></ul>
  44. 45. Drainage Facilities…. <ul><li>Sullage or Domestic waste water when gets mixed with human excreta= Sewage </li></ul><ul><li>In human settlements during disasters also domestic wastewater should not allowed get mixed with human excreta </li></ul><ul><li>Sewage is more difficult and expensive to treat than domestic wastewater </li></ul><ul><li>At water points and washing and bathing areas encourage to create small gardens to utilize wastewater </li></ul><ul><li>Specially protect toilets and sewers from flooding to avoid structural damage and leakage </li></ul><ul><li>Local community should be involved in providing small scale drainage works as they have good knowledge of the natural flow of drainage water and where channels should be put </li></ul><ul><li>If off site disposal of wastewater is planned channels should be designed to have sufficient flow-velocity for dry-weather sullage and to carry storm water </li></ul><ul><li>Where the slope is more than 5% apply proper engineering methods to prevent excessive erosion </li></ul><ul><li>Drainage of residuals from any water treatment processes should be carefully controlled </li></ul>
  45. 46. Health System in Disasters <ul><li>Accessibility to all without discrimination </li></ul><ul><li>Well trained professionals </li></ul><ul><li>During armed conflicts , medical facilities and civilian hospitals should not be targeted for attack </li></ul><ul><li>Health and medical staff have rights to get protected </li></ul><ul><li>Public Health impacts may be seen in terms of injuries, psychological traumas, increased rates of infectious diseases, malnutrition, complications of chronic disease etc </li></ul><ul><li>Interventions should be planed on evidence based practices- like adequate quantity of safe water, sanitation, nutritional supplements, food aid/ security, shelter and basic clinical care </li></ul><ul><li>Health system beneficiaries are mostly women and children </li></ul><ul><li>Success Indicator of Health services is limitation of crude death rate as well as under-5 mortality rate to Less than twice the Baseline rate documented </li></ul>
  46. 47. Health Systems in Disasters…… <ul><li>The average Base-line CMR for the least developed countries is approximately 0.38 deaths/ 10000 / day </li></ul><ul><li>Health agencies should aim to keep CMR at below 1.0/ 10000/ day </li></ul><ul><li>When the <5 CMR is unknown , Health agencies should aim to maintain this rate below 2.0 / 10000/ day </li></ul><ul><li>No alternate parallel Hospitals / Health facilities should be created by Partners , unless it is clearly indicated by local health authorities </li></ul><ul><li>When the local health authority is not in a position to take a lead in crisis situation, this job can be taken over by United Nations Authority like WHO, UNICEF etc </li></ul><ul><li>After initial Health Assessment , a Health Document should be created which mentions Health sector priorities and objectives-to be shared with all Partners to achieve it </li></ul>
  47. 48. Health Systems in Disasters…. <ul><li>Partner Health Agencies should adhere to the health standards and guidelines of the country including treatment protocols and essential drug lists </li></ul><ul><li>It is advisable to provide resources to existing hospitals so that they can start working again or cope with the extra load </li></ul><ul><li>If at all a Base Hospital is necessary to establish, it should not drain on local resources , but should be able function on it’s own and it must also be cost-effective </li></ul><ul><li>All the Health Agencies need to coordinate with local / nodal health authority for their allocated responsibilities </li></ul><ul><li>A standardized Referral System should be established by Local /Nodal Authority and has to used by identical protocols by all </li></ul><ul><li>Priority Health Messages to be spread to local population have to be developed by consensus and should be consistent for the contents </li></ul>
  48. 49. Health System in Disasters….. <ul><li>Mobile clinics should be well planed for their routes, regularity of comprehensive services and avoid duplications of visits </li></ul><ul><li>Standardized management protocols need to develop and to be adhered by all </li></ul><ul><li>Drug donations are accepted only if they follow internationally recognized guidelines </li></ul><ul><li>While staffing at treatment facility ,ensure to post at least one female health worker and one representative of a minority ethnic group which will increase utilization of health care facility by women and people from minority groups </li></ul><ul><li>In normal circumstance utilization rate would be 0.5-1.0 consultation /person /year </li></ul><ul><li>Among displaced populations: 4.0 consultations/ person /year </li></ul><ul><li>Utilization should be equally represented amongst vulnerable groups like women, children and persons belonging to minority-ethnic groups </li></ul>
  49. 50. Health Services in Disasters…. <ul><li>During disaster situations also patient’s rights to privacy, confidentiality and dignity and informed consent have to enforced </li></ul><ul><li>Drug management to be done on four basic principles i.e. selection, procurement, distribution and use </li></ul><ul><li>Bodies of deceased persons pose dangers from public health point of view only during specific instances of Cholera and Haemorregic fevers </li></ul><ul><li>Health Information system should generate critical data-only essential information is collected </li></ul><ul><li>Data should be analyzed-feed back provided for timely actions </li></ul><ul><li>Surveillance data should be able to provide warning signals </li></ul><ul><li>Data should be shared by all working Partners </li></ul>
  50. 51. Control of Communicable Disease <ul><li>At the time of natural calamities between 60%-90% of deaths are contributed by Four major communicable diseases namely-Measles, Diarrhea, Acute respiratory infections and Malaria </li></ul><ul><li>In no. of cases Acute Malnutrition is noticed as an Associated cause </li></ul><ul><li>In certain disasters there have been increased no. of cases of Meningococcal Meningitis, Yellow Fever, Viral Hepatitis and Typhoid </li></ul><ul><li>As such outbreaks of communicable diseases are far less commonly associated with acute onset natural disasters </li></ul><ul><li>General Preventive measures like water and sanitation, food-aid and food-security, shelter etc. are coordinated by other sectors </li></ul><ul><li>Measles prevention is particularly indicated amongst displaced population or the population affected by conflict </li></ul>
  51. 52. Control of communicable diseases…. <ul><li>First of all an estimation of Measles coverage of children aged between 9 months to 15 years is done </li></ul><ul><li>If above coverage is found to be Less than 90%, a Mass Measles Vaccination campaign for all children in the age group 06 months-15 years is initiated </li></ul><ul><li>Simultaneously Vitamin – A is given to all children between 06-59 months </li></ul><ul><li>Above activities should achieve minimum 95% coverage </li></ul><ul><li>All infants vaccinated between 6-9 months should receive another dose of Measles vaccine upon reaching 09 months </li></ul><ul><li>Routine Programme of EPI is re-established to sustain 95% coverage </li></ul><ul><li>For mobile or displaced populations activities are planned in such a way that at any point of time at least 95% coverage is maintained amongst all newcomers </li></ul><ul><li>Reasons for including children of 06-15 yrs in Measles vaccination: some older children may have escaped both earlier measles vaccination and measles disease also-hence they are vulnerable-and can serve as a source of infection for infants and young children , who are at a higher risk of dying from the disease </li></ul>
  52. 53. Control of Communicable Diseases….. <ul><li>Malaria- Diagnostic facilities are geared up to have lab confirmation in 24 hours in every case </li></ul><ul><li>Anti-malarial drugs are given in prescribed doses for the period specified in the Programme </li></ul><ul><li>Vector control measures and distribution of Insecticide treated mosquito nets are synchronized </li></ul><ul><li>Patients of Tuberculosis are treated as per RNTCP guidelines by DOT therapy </li></ul><ul><li>Single case=outbreak: stands true in diseases like Cholera, Measles, Yellow fever, Shigella and Viral Haemorregic Fevers </li></ul><ul><li>Meningococcal Meningitis: </li></ul><ul><li>(a) for areas with >30,000 population:- 15 cases/100,000/week indicates an outbreak situation </li></ul><ul><li>(b) if no outbreaks of meningitis have occurred in previous +3 years and if vaccination coverage is< 80%- there is High outbreak risk- above thresh-hold would be 10 cases/100,000/week </li></ul><ul><li>(c) for areas with <30,000 population:- incidence of 5 cases in one week or doubling of cases over a three week period confirms an outbreak </li></ul>
  53. 54. What is a Rapid Health Assessment? <ul><li>“ Collection of subjective and objective information in order to measure damage and identify those basic needs of the affected population that require immediate response” </li></ul><ul><li>Rapid Health Assessment protocols for emergencies, WHO, 1999 </li></ul>
  54. 55. Objectives of Rapid Health Assessments <ul><li>Collection objectives. </li></ul><ul><ul><li>identify existing and potential public health needs </li></ul></ul><ul><ul><li>identify gaps and problems in meeting urgent medical needs </li></ul></ul><ul><ul><li>assess existing and potential environmental risk factors </li></ul></ul><ul><ul><li>assess resource and logistics needs </li></ul></ul><ul><ul><li>identify managerial, coordination and organisational gaps, overlaps and problems </li></ul></ul>
  55. 56. Objectives of Rapid Health Assessments <ul><li>Analysis objectives </li></ul><ul><ul><li>set priorities for response / relief </li></ul></ul><ul><ul><li>set priorities for information dissemination and communication </li></ul></ul><ul><ul><li>identify resources needed to meet priorities – external and internal </li></ul></ul><ul><ul><li>identify additional information needs for the response and for planning recovery and reconstruction </li></ul></ul>
  56. 57. Questions Answered by a Rapid Health Assessment <ul><ul><li>Is there an emergency or not? </li></ul></ul><ul><ul><li>What is the existing response capacity? </li></ul></ul><ul><ul><li>What decisions need to be made? </li></ul></ul><ul><ul><li>What information is needed to make these decisions? </li></ul></ul><ul><ul><li>What are the sources of that information? </li></ul></ul>
  57. 58. The Purpose of Health Assessments <ul><li>To give decision makers information that will allow them to make timely and appropriate interventions to: </li></ul><ul><ul><li>save lives </li></ul></ul><ul><ul><li>minimise injury and illness </li></ul></ul><ul><ul><li>prevent escalation of the emergency </li></ul></ul><ul><ul><li>prevent spread </li></ul></ul><ul><ul><li>support recovery planning </li></ul></ul>
  58. 59. Rapid Health Assessment: Common Mistakes <ul><ul><li>No policy or guidelines on assessment </li></ul></ul><ul><ul><li>No standard collection formats </li></ul></ul><ul><ul><li>No training in assessment skills </li></ul></ul><ul><ul><li>Different sectors use different terms and methods </li></ul></ul><ul><ul><li>Data cannot be consolidated </li></ul></ul><ul><ul><li>Too much irrelevant/duplicate data collected </li></ul></ul><ul><ul><li>Too much time taken – accurate is better than precise </li></ul></ul><ul><ul><li>Those collecting the data don’t know how it will be used and don’t have the opportunity to improve the assessment system </li></ul></ul>
  59. 60. Rapid Health Assessment - Common Mistakes <ul><li>The biggest mistake in forms used by the health sector is that they focus too much on collecting (unavailable or unreliable) morbidity and mortality data rather than health sector function information </li></ul>
  60. 61. What is Available in the EHA Webpage?
  61. 62. Recap: the Purpose of Assessments <ul><li>To give decision makers information that will allow them to make timely and appropriate interventions to: </li></ul><ul><ul><li>save lives </li></ul></ul><ul><ul><li>minimise injury and illness </li></ul></ul><ul><ul><li>prevent escalation </li></ul></ul><ul><ul><li>prevent spread </li></ul></ul><ul><ul><li>support recovery planning </li></ul></ul>
  62. 63. Health Needs Assessments (DANA, RHA) Reporting + Surveillance Hospitals cough + fever Clinics and Health Centers diarrhea + fever Laboratories headache + fever PHC Programmes: rash + fever nutrition myalgia + fever IMCI - epi, ari, cdd etc other fever water and sanitation malnutrition <5s vector control trauma, disability MCH, safe motherhood DEP, VBD, VPD, DPHS, PUCD ? workload ? investigation expected needs unexpected needs ? enough supplies ? new supplies ? enough staff ? new staff ? referral system working ? new referral system institution focus disease focus are we meeting the needs? daily daily
  63. 64. RAPID HEALTH ASSESSMENT FORMATS
  64. 79. FINAL REPORT
  65. 84. Rehabilitation Aspects in Disasters-PHEMAP Dr. S. J. Gandhi Deputy Director (Epidemic) Commissioner ate of Health Services Gandhinagar
  66. 85. THANK YOU...

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