Pocket Emergency Tool 2005

C O N TE N TS Acknowledgements ...iii Introduction ...1 Abbreviations ...2

Roles and Responsibilities ... Coordinating with Other Agencies ...11

Drafting the Health Disaster Management Plan ...15

Rapid Health Assessment ...19

Critical Incident Management ...22

Pre-Hospital Activities ...23

Hospital Activities ...25

Prevention and Control of Communicable Diseases ...29

Nutrition Concerns ... Environmental Health ... Water Supply ... Sanitation and Waste Management ...43

Vector and Vermin Control ...49

Epidemiology and Surveillance ...52

Psychosocial Care and Mental Health ...56

Management of Dead Bodies ...63

Forensic Science Concerns in Mass Fatalities ...65

Resource Management ...71

Risk Communication ...73

Emergency Manager Deployment Checklist ...78

Rapid Health Assessment Forms ...79

Reference Values for Rapid Health Assessment and 3 31 37 38 PREPARING FOR EMERGENCIES ...5

RESPONDING TO EMERGENCIES ...16

C O N TE N TS _{Contingency Planning ...85} Radio Procedures ...98 ConversionTable ...99 Websites ...101 References ...103

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 for the Western Pacific Region (WHO-WPRO).

The review and revision for this second edition was done through the efforts of Dr. Emmanuel S. Prudente, under the technical supervision of Dr. Arturo M. Pesigan of Emergency and Humanitarian 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. Edgardo Sarmiento and Dr. Xiangdong Wang, who reviewed the text and provided valuable comments. Lay-out and cover design was done by Mr. Zando Escultura.

The first edition was through the efforts of the following individuals: Engr. Russell Abrams; Dr. Shigeki Asahi ;

Dr. Carmencita A. Banatin ; Dr. Agnes B. Beñegas ; Mr. Miguel C. Enriquez ; Mrs. Guia P. Flores ; Dr. Raquel dR. Fortun ; Dr. Camilla A. Habacon ; Dr. Lourdes L. Ignacio ; Mrs. Elizabeth M. Joven; Dr. Susan P. Mercado; Dr. Daniel T. Morales; Dr. Jean-Marc Olivé; 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. Yoshihiro Takashima; Dr. Xiangdong Wang; Mrs. Zen Delica Willison; Mr. Robin Willison; and Dr. Ladislao N. Yuchongco, Jr.

A C K N O W LE D G EM EN TS

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

The goal of the Department of Health (DOH) through the Health Emergency Management Staff (HEMS) is to prevent or minimize the loss of lives during emergencies and disasters in collaboration with government, business and civil society groups. The main purpose of this pocket tool is to help guide and prepare health sector professionals in the field in the event that an emergency occurs. A compendium of recent DOH, WHO and other international agencies' guidelines, checklists and

standards, this booklet provides essential pointers on how to carry out rapid health assessment, networking and coordination, planning, and other necessary tools especially in times of tragedies and adversities.

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

nd

Furthermore, this pocket tool is an evolving text; this 2 edition was conceived from the lessons learned from the recent disasters that affected the country and the Western Pacific Region. Indeed, the success of this guide depends largely on the dynamics of its use and the tireless efforts of its users to improve it. IN TR O D U C TI O N

CDC Centers for Disease Control and Prevention (USA) CHD Center for Health Development

CMR Crude Mortality Rate

CSR Communicable disease Surveillance and Response DND Department of National Defense

DOH-HEMS Department of Health-Health Emergency Management Staff

DOTC Department of Transportation and Communication DPWH Department of Public Works and Highways DSWD Department of Social Welfare and Development EHA Emergency and Humanitarian Unit

EMS Emergency Medical Services EOC Emergency Operations Center EPI Expanded Program of Immunization ER Emergency Room

IEC Information, Education and Communication HEICS Hospital Emergency Incident Command System LGU Local Government Unit

MUAC Mid-Upper Arm Circumference NBI National Bureau of Investigation NDCC National Disaster Coordinating Council NEC National Epidemiology Center NEHK New Emergency Health Kit NGO Nongovernmental organization NNC National Nutrition Council

NPDEP Nutrition Preparedness in Disasters and Emergencies Plan

OpCen Operation Center PHC Primary Health Care PNRC Philippine National Red Cross RDCC Regional Disaster Coordinating Council SARS Severe Acute Respiratory Syndrome

WHO-WPRO World Health Organization-Office for the Western Pacific Region

WMD Weapons of Mass Destruction

A B B R EV IA TIO N S

T.R.A.I.T. of a Health Emergency

Manager/Coordinator

T

! 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

preparedness in the future

A

are immediately dealt with

I

networking

T

neutrality and protection of health systems in emergency situations R O LE S A N D R ES PO N SI B IL IT IE S

Roles of Hospitals in Health Emergency

Management

1. Observe all requirements and standards (hospital emergency plan, HEICS, Code Alert System, etc.) needed to respond to emergencies 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 resources

and coordinate transferring of victims to the appropriate facility.

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

R O LE S A N D R ES PO N SIB IL IT IE S

PREPARING

PR EP A R IN G F O R E M ER G EN C IE S

Steps in Preparing for Emergencies

! 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

PR EP A R IN G F O R E M ER G EN C IE S 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

Roles of Centers for Health Development in

Emergency Management

1. Serve as the DOH Coordinating Body in their region 2. Manintain updated hazard and vulnerability assessment of

their catchment areas

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

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

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

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

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

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

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

PR EP A R IN G F O R E M ER G EN C IE S

At the Center for Health Development (CHD) level…

The following should be readily available

for reference and may be compiled in collaboration with other partners (government and non-government units). These information must be updated regularly:

Disaster profile of the region Population size and distribution

Topography and maps showing communication lines Epidemiologic profile of the region

Location of health facilities and the services they provide Location of potential evacuation areas

Location of stocks of food, medicine, health and water treatment and other sanitation supplies in government stores, commercial warehouses and international agencies and major NGOs

Key people and organizations who would be responsible for/active in relief (contact phone numbers AND addresses)

Individuals with special competencies and experience who may be mobilized on secondment from their institutions or as consultants in case of need (contact phone numbers AND addresses)

A roster of regular resource persons ready to translate technical information materials into local dialect (i.e., traditional healers, indigenous health workers, barangay captain, etc.) information ! ! ! ! ! ! ! ! ! ! PR EP A R IN G F O R E M ER G EN C IE S

The following should be readily available for

use AT ALL TIMES:

1. Vehicles

2. Communications equipment 3. Back-up power supplies

4. Computers, printers, facsimiles and photocopying machines

5. Water testing sets 6. Food supplements

7. Temporary shelter capacities 8. Funding requirements 9. Personal protective equipment

resources PREP_A R IN G F O R E M ER G EN C IE S

Prepare internal arrangements within the DOH and with other public health related government entities, UN agencies, NGOs, and other institutions in the country whose expertise and/or services may be called upon during emergencies (DND, NDCC, DSWD, DPWH, DOTC, PNRC, etc.)

Steps in Establishing Good Working

Relationships 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 member participation.

7. Build trust among members. Fix issues early on. 8. Maintain regular communication 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 of services each

agency can provide.

13. Make partners aware of policies 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.

C O O R D IN A TI N G W IT H O TH ER A G EN C IE S

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 of accomplishment. Celebrate.

P

1. PURPOSE explains the overall aim of the session. ! Have ground rules, a clear agenda, and desired

outcomes.

2. PRODUCT describes the session's deliverables in specific outputs.

! Discuss needs and lines of action.

! Reach a consensus on objectives, strategies, and plans.

3. PARTICIPANTS push the issues. Know their perspectives

and concerns. A designated and experienced chairperson should practice facilitative behavior: listening, encouraging participation, not being defensive, asking open-ended questions, and optimistic but realistic

4. PROBABLE ISSUES give an idea of the potential

5

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

To coordinate is to facilitate. C O O R D IN A TIN G W IT H O TH ER A G EN C IE S

roadblocks.

! Sort issues by categories and types.

! Approve the agenda before starting the meeting. 5. PROCESS is the detailed set of steps that will be taken to

create the product.

! Circulate information among partners.

! Preliminary word clarification and definition, brainstorming, rank order of issues according to importance to the group. ! Have group memory by using flip charts or handouts.

Coordination is sharing information with other

persons or organizations so they can work together in harmony without friction or overlapping - based on regular communication

of relevant data.

The resulting consensus should be that everyone feels that he has been heard and that

everyone agrees and is willing to support the decision. C O O R D IN A TI N G W IT H O TH ER A G EN C IE S

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 gathered elsewhere, leading to misinformation, misunderstanding, and their consequences…

C O O R D IN A TIN G W IT H O TH ER A G EN C IE S

You may follow the outline provided below; however, it is not meant to replace alternative outlines that you may deem more appropriate and useful.

I. Background Present 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 Structure

a. 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 contact persons) D R A FT IN G T H E D IS A ST ER H EA LT H M A N A G EM EN T PL A N

RESPONDING

Steps in Responding to Emergencies

Immediate Response: 1. Assess the situation 2. Contact key health personnel

3. Develop initial health response objectives and establish an action plan

4. Establish communication and maintain close coordination with the EOC

5. Ensure that the site safety and health plan is established, reviewed, and followed

6. Establish communication with other key health and medical organizations.

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

8. Address health-related requests for assistance and informa-tion from other agencies, organizainforma-tions and the public 9. Initiate risk communications activities

10.Document all response activities

Intermediate Response:

1. Verify that health surveillance systems are operational 2. Ensure that laboratories likely to be used during the response

are operational and verify their analytical capacity

3. Ensure that the needs of special populations (e.g., children, disabled persons, elderly, etc.) are being addressed 4. Manage health-related volunteers and donations

Hours 0-2

Hours 2-12

5. Update emergency risk communication messages

6. Collect and analyze data that are becoming available through health surveillance and laboratory systems

7. Periodically assess health resource needs and acquire as necessary

Extended Response:

1. Address psychosocial and mental health concerns 2. Prepare for transition to extended operations or response

disengagement

3. Address risks related to the environment

4. Continue health surveillance/epidemiologic services

5. Ensure that local health systems are preserved and access to health care, including essential drugs and vaccines, is guaranteed

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

Hours 12-24

R A PI D H EA LT H A SS ES SM EN T 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 of affected 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 Summary

2. Main Issue

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

b. Affected area (administrative division, access) c. Affected health facilities

d. Affected population (sex/age breakdown) 3. Health Impact

a. 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 of outbreak)

critical information required within 24 hours

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

d. Pre-emergency baseline morbidity and mortality (when available)

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

4. Vital Needs: current situation a. Water

b. Waste disposal c. Food

d. Shelter and environment on site e. Fuel, electricity, and communication

f. Other vital needs (e.g., clothing and blankets) 5. Critical Constraints

a. Security: coordinate with the safety officer to identify hazards or unsafe conditions associated with the incident b. Transport and logistics

c. Social/political and geographical limits d. Other constraints

6. Response Capacity: functioning resources

a. Activities already underway

b. National protocols, contingency plans

c. Operational support (command post, regional unit and referral system, external assistance, state of

communications)

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

e. Strategic coordination (local/international relationships)

7. Conclusions

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

R A PID H EA LT H A SS ES SM EN T

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 reduce avoidable 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 that cannot be put into practice quickly are useless. Prioritize the health problems (in terms of magnitude and severity and of feasibility of

response interventions). R A PI D H EA LT H A SS ES SM EN T

C R IT IC A L I N C ID EN T M A N A G EM EN T

Steps as First Responders

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

and agencies c. Set perimeters

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

! Implement safety and security measures ! Identify access and egress routes d. Establish the initial medical command post e. Establish Safety Officer

f. Establish Staging Officer

g. Establish liaison with other services on site h. Determine priorities and time constraints

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

j. Task response agencies and supporting services k. Coordinate resources and support

l. Monitor events and respond to changing circumstances m. Report actions and activities to the appropriate agencies and

PR E-H O SP IT A L A C TI V IT IE S

Triaging

To quickly identify victims needing immediate stabilization or transport and the level of care needed by these victims by assessing airway, breathing, and circulation (ABC's).

Color Tagging

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

a. patient's sequence number b. name of patient

c. injuries identified

d. previous interventions given at the scene

1st priority: Life-threatening - needs to be treated within 1-3 hours a. obstruction/damage to airway

b. breathing disturbance (RR =30/min or RR <10/min) c. circulation disturbance (HR =100/min or weak pulses) d. altered level of consciousness

e. external bleeding with CVS collapse

RED TAG

Triaging is done if there are more victims than health responders. Reverse triaging is done during the Search and Rescue stage where the

priority is to get as much people out of danger with the least effort.

YELLOW TAG

GREEN TAG

BLACK TAG

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

respiratory tract); complicated by major soft tissue trauma b. spinal injuries; long bone or pelvic fractures

c. environmental injuries (heat/cold exposure)

3rd priority: Requires no treatment or can be delayed a. minor injuries not threatened by ABC instability b. minor fractures/soft tissue injuries/burns

c. 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 massive burns)

Last priority:

a. death or moribund state

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

or even pentel pens

PR E-H O SP IT A L A C TIV IT IE S

H O SP IT A L A C TI V IT IE S

Color-Coded Alert Systems

The hospital alert status shall be declared either by the Secretary of Health, the HEMS Director, the Chief of Hospital or the HEMS Coordinator. The alert status shall continue to be in effect until cancelled by the Chief of Hospital or the HEMS Coordinator.

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 on regular duty for the day, the following should be on-call anytime during his/her duty days:

1. surgeons 2. orthopedic surgeons 3. anesthesiologists 4. internists 5. O.R. nurses 6. ophthalmologists

7. otorhinolaryngologists

nd

8. 2 response team should be on call

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

Partial/Selective Activation is proclaimed when 20-50 casualties (red tags) are expected. This may require the activation of the hospital network or at the judgment of the director or the HEMS coordinator, may only involve the hospital nearest the emergency site.

The following should respond once CODE BLUE is on: 1. on-scene response team

2. medical officer in charge of the emergency room 3. ALL orthopedic residents

4. medical officer in charge of the operating room 5. surgical team on duty for the day

CODE BLUE H O SP IT A L A C TIV IT IE S

The composition of the back-up and on-call teams would depend on the type and level of the hospital. The suggestions here are based on a general tertiary hospital. Each hospital can come up with its own team members. In some places like Metro Manila, there can also

be designated support hospitals (usually specialty hospitals). These specialty hospitals act as support to a receiving hospital (e.g., San

Lazaro and Fabella Hospital supporting Jose Reyes Memorial Medical Center).

6. officer in charge of supplies at the CSR 7. surgical team on duty the previous day 8. ALL anesthesiology residents 9. nursing supervisor on duty

10.operating nurses living within or in the vicinity of the hospital 11.ENTIRE security workforce

12.ALL third and fourth year residents 13.ALL O.R. nurses

14.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 one hospital to respond by sending an on-scene team.

The following should respond once Code Red is on: 1. ALL persons enumerated under Code Blue 2. ALL institutional workers

3. ALL nursing attendants 4. ALL nurses

5. ALL medical interns and clinical clerks

CODE RED H O SP IT A L A C TI V IT IE S

If there is a strong possibility that there would be a need to change the alert status from code white to blue to red, the Chief of Hospital is authorized 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. cancel elective surgeries, etc.).

H O SP IT A L A C TIV IT IE S

Steps in Ensuring Communicable

Disease 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 including information on how to prevent common communicable diseases and how to access relevant services

! Encourage people to seek early care for fever, cough, diarrhea, etc., (especially children, pregnant women and older people)

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

4. Implement as indicated, specific prevention measures, such as mass measles vaccination campaign, Expanded Program on Immunization, and vector control.

5. Provide essential clinical services 6. Provide basic laboratory facilities 7. Set-up surveillance/early warning systems

a. Detect outbreaks early

b. Report diseases of epidemic potential immediately c. Monitor disease trends

8. Control outbreaks a. Preparation b. Detection c. Confirmation PR EV EN TI O N A N D C O N TR O L O F C O M M U N IC A B LE D IS EA SE S

d. Investigation e. Control measures f. Evaluation

Notes on Immunization

! A single suspected measles case is sufficient to prompt an immediate immunization response. Life-saving measles vaccine should be made available immediately targeting all infants and children 6-59 months of age. The suggested target 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 an opportunity to vaccinate for routine EPI regardless of the reason for the visit. Vaccination program activities should be included as part of basic emergency health care services. ! Mass vaccination against cholera and typhoid fever is not recommended. The most practical and effective strategy to prevent cholera and typhoid is to provide clean water in adequate quantities and adequate sanitation. Sufficient soap and hygiene education will further prevent the transmission of both diseases.

! Mass tetanus vaccination programs are not indicated. However, tetanus boosters may be indicated for previously vaccinated people who sustain open wounds or for other injured people depending on their tetanus immunization history. ! Mass vaccination for Hepatitis A is not recommended.

PR EV EN TIO N A N D C O N TR O L O F C O M M U N IC A B LE D IS EA SE S

Nutrition Preparedness

1. Planning: Every effort should be done to formulate an inter-sectoral and comprehensive plan (i.e., NNC's Nutrition Preparedness in Disasters and Emergencies Plan or NPDEP). 2. Nutritional Management: Is an institutional and

multi-sectoral concern. It is equally the responsibility of the national government, local government and even non-government units. Disaster Coordinating Teams implement the NPDEP while involving the Municipal Nutrition Action Officer in the creation of Disaster Response Teams.

3. Adequate Nutrition: During emergencies, infants (<1y/o) and children (<5y/o) are the most vulnerable group. Interrupted breastfeeding and inappropriate complementary feeding will heighten the risk for malnutrition, illness and mortality.

4. Resource Generation and Mobilization: Maintain a

stockpile of culturally acceptable food items that can be stored for a long period of time such as rice, canned goods, noodles, dried fish and canned/powdered milk. Intensify campaign on creating vegetable gardens in schools and backyards. Identify and coordinate with donor agencies and companies that can donate food during disasters.

5. Public Education: Promote the acceptability and utilization of donated foods ideal for disasters (i.e. compact food). Support the innovation of nutritionally dense ready-to-eat foods. N U TR IT IO N C O N C ER N S

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

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

N U TR IT IO N C O N C ER N S

! Following a major sudden disaster, some

people may have no access to food and/or be unable to prepare food for a few days at least.

! In slow-onset crisis or in situations where

the livelihood of the community is greatly undermined, particularly in areas where nutritional status was already poor, it will be important to monitor nutritional status and households' access to food, and to initiate remedial action (e.g. through supplementary feeding) if nutritional status is at risk.

! In extreme cases, nutritional rehabilitation

through intensive, supervised therapeutic feeding (TF) may be required.

! Because the number of caregivers is

reduced during emergencies and their ability to cope is diminished by physical and mental stress, strengthening caregiving capacity is an essential part of promoting good feeding practices for infants and young children.

! Healthy workers are essential. Aside from

looking after the basic health and nutritional needs of the displaced population, health workers have to be debriefed to look after their personal health as well.

N U TR IT IO N C O N C ER N S

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 land preparation works)

! Age/sex distribution when adult males make up more than 50% of the population, requirements are increased; when the population is exclusively women and children, requirements are reduced.

! Special needs of pregnant and lactating women a. Pregnant women

?

?

?

b. Lactating women

?

?

?

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 and minerals) are required for survival and good health

Ideal Foods for Disaster

! Carbohydrate sources rice, root crops, bread, noodles ! Protein sources eggs, canned meat and fish, fresh meat and

fish, 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 malnutrition levels in children aged 6-59 months as a proxy for the population as a whole. Reports should always describe the probable causes of malnutrition, and nutritional edema should be reported separately.

N U TR IT IO N C O N C ER N S

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

within each cluster.

Edema of both feet Weight-for-Height* MUAC

Body Mass Index

Mild Malnutrition No 80-90% (-1 to -2 SD) 12.5 to 13.5 cm 17 to <18.5 Moderate Malnutrition No 70-79% (<-2 to -3 SD) 12.0 to 12.5 cm 16 to <17 Severe Malnutrition Yes < 70% (<-3 SD) <12 cm <16

Age 6-11 months 1-5 years Dose 100,000 IU 200,000 IU

*see appendix for length-for-weight/height-for-weight reference values

**see appendix for decision framework for implementing feeding programs.

Feeding Recommendations

! Up to 6 months of age: Encourage mothers to exclusively breastfeed 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 child

wants. In addition, give adequate servings of locally available complementary 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 complementary food at least 5 times a day.

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

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

There should be a continual search for malnourished children so that their condition can be identified and treated before it becomes

severe. N U TR IT IO N C O N C ER N S

! 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 important during emergencies (i.e., protection from infection and its consequences, contraceptive effect, privileged nurturing moment important for both mother and child). Every effort should be made to identify ways to breastfeed infants whose mothers are absent or incapacitated. Every effort should be made to create and sustain an environment that encourages frequent 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 to breast milk. The use of infant-feeding bottles and artificial teats in emergency settings should be actively discouraged. ! Emergencies do not justify routine distribution of breast-milk

substitutes. Formula feeding may increase the considerable risk of child morbidity and mortality.

! The nutritional status of breastfeeding women should be protected as an end in itself, and as a means of maintaining the adequate growth and development of their children.

N U TR IT IO N C O N C ER N S

EN V IR O N M EN TA L H EA LT

H _{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 water 3. Facilities for excreta and liquid waste disposal 4. Protection of food supplies against contamination

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

W A TE R S U PP LY

Assessment

1. Assess water resources for human consumption to ascertain the availability of water (quantity and quality) in relation to the demand.

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 to be developed.

4. Tap the expertise of the local Sanitary Engineer in the assessment of the water resources and the conduct of sanitary survey.

5. Always consider seasonal factors in the assessment. Organization

1. 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 and operation.

Provision of adequate amounts of drinking water is of utmost importance after disaster. It should first be made accessible to victims and relief workers and in essential locations, such

as hospitals and treatment centers. After drinking water is secured within stricken areas, making water available for domestic uses (such

as cleaning and washing) should be considered.

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 and layout as supported by health promotion and sanitation. 7. Consider using pumps and other mechanical equipment

attainable in the area where fuel and spare parts are available, 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 supply possibilities.

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

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

4. Improve access to supplies by developing water sources and a storage and distribution system to deliver sufficient amounts of safe water, including reserve.

5. Conduct regular sample collection and testing of water quality.

6. If possible, use water sources that do not need treatment. If there is a large number of evacuees, decontamination of water is necessary. Treat water according to the characteristics of the raw water.

7. Set up schedules for operation and maintenance.

W A TE R S U PP LY

8. Maintain and update information on water resources obtained during needs assessment, planning, construction, operation and maintenance.

Intermediate Response

1. If the minimum amount of water cannot be made available from local sources, recommend transfer to another evacuation camp.

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

3. Domestic hygiene and environmental health measures should be observed in order to protect the water between collection 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 the following:

a. 2 liters for drinking

b. 10 liters for food preparation and cooking c. 15 liters for bathing

d. 15 liters for laundry

e. 10 liters for sanitation and hygiene

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

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

W A TE R S U PP LY

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 of treatment chemicals) or radiological sources, and assessment shows no significant probability of such an effect.

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 day Animals

! 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 family 7. Communal Water Storage Tank: 10 liters per person per day.

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

W A TE R S U PP LY

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. W A TE R S U PP LY

SA N IT A TI O N A N D W A ST E M A N A G EM EN T

Assessment

1. What is the current defecation practice (including anal cleansing)? If it is open defecation, is there a designated area?

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 they sufficient and are they operating successfully? Can they be extended 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? Drainage

1. Is there a drainage problem (e.g. flooding of dwellings or toilets, vector breeding sites, polluted water contaminating living areas or water supplies)?

2. Is the soil prone to water logging?

3. Do people have the means to protect their dwellings and toilets from local flooding?

SA N IT A TIO N A N D W A ST E M A N A G EM EN T

Solid Waste Management 1. Is solid waste a problem?

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

3. Can solid wastes be disposed of on-site, or does it need to be collected 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 water supply.

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

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 bodies 8. 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 x 0.6 m. Use only soil for cover.

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 Urinal

7. Children's Feces: should be disposed of immediately and hygienically

8. 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 be flooded or eroded by water.

Bottom of any latrine should be at least 1.5 meters above the water table. Drainage or spillage from defecation systems must not run

towards any surface water source or shallow groundwater source SA N IT A TI O N A N D W A ST E M A N A G EM EN T

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 team 3. 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, Rock Pit Incinerator, Drying Pan Incinerator and Open Turf Incinerator: for 10 families

! Final disposal does not create health or environmental problems

Health-care Wastes

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

a. Vaccination, notably for Hepatitis B should therefore be provided to waste handlers.

b. All waste handlers should wear protective clothing. c. Hand-washing and disinfection are a must. 2. Minimize health-care waste

3. Segregate: SA N IT A TIO N A N D W A ST E M A N A G EM EN T

! To be done at point of generation using dedicated, colored and/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 with biohazard symbol)

ii. non-sharp infectious wastes iii. non-infectious wastes

! If no separation of wastes takes place, the whole mixed volume of health care waste needs to be considered as being infectious.

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

a. used infectious plastic syringes and needles

b. other infectious PVC plastics such as tubing, catheters, IV sets c. 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 the bottom of the pit with clay or low permeable material. Construct an earth mound around the mouth to prevent to prevent water

SA N IT A TI O N A N D W A ST E M A N A G EM EN T 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 types per total waste in PHC centers

from entering. Construct a fence around to prevent unauthorized entry. Alternately place layers of waste and 10 cm of lime and soil inside. When the pit is within about 50 cm of the ground surface, cover the waste with soil and permanently seal it with cement or embedded wire mesh.

Another method involves placing the sharps waste in hard containers such as metal drums and adding an immobilizing material such as bituminous sand, clay or cement mortar. The container or drum can be sealed and buried in a trench or transported to a local landfill.

(For other strategies, please see WHO (2004). Management of solid health-care waste at primary health-care centres: A decision-making guide. Geneva: World Health Organization.) Security fence 50cm of soil cover Cement or embedded wire mesh Earth mound to prevent surface water from flowing

into the pit

2 to 5m 1 to 2m Soil or soil-lime layer Bio-medical waste Bottom clay layer SA N IT A TIO N A N D W A ST E M A N A G EM EN T

V EC TO R A N D V ER M IN C O N TR O L

Assessment

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

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

3. Is it possible to make changes to the local environment (by drainage, 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. Attempts should be made to eliminate pooled water which may be gathering amongst the debris.

c. Vector breeding or resting sites modified. d. Screening of living quarters.

V EC TO R A N D V ER M IN C O N TR O L 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 and appropriately disposed to discourage rodent vector breeding. h. Larvi-trapping

Chemical Control

a. 1 sprayer for every 50 families b. 1 misting machine for every 50 families c. 1 fogging machine for every 500 families

d. Fumigation for the camp, if needed (with proper precautions); done under the supervision of an emergency Sanitary Engineer

e. Adulticides: for crawling and flying insects

f. 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:

! The number of killed adult mosquitoes divided by the number 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 the average number of mosquitoes per person.

! The number of mosquitoes found with blood in the abdomen (red or black) divided by the number of person living 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 placed where flies congregate during three 30-second periods. (from: Lacarin, CJ and Reed RA (1999) Emergency Vector Control Using Chemicals, Water, Engineering and Development Center (WEDC), Loughborough.) V EC TO R A N D V ER M IN C O N TR O L

EP ID EM IO LO G Y A N D S U R V EIL LA N C E

Epidemiologic Methods

of Emergency Management

! 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 Surveillance

System After a Disaster

1. Establish objectives ! Detect epidemics

! Monitor changes in the population ? Numbers

EP ID EM IO LO G Y A N D S U R V EI LL A N C E

? 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 (“active surveillance”)

! Involve those who provide health care

! Health surveillance in an emergency requires input from all sectors

“Case definitions” and “Indicators” need to be agreed upon by all those involved in the relief

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 epidemiological unit

8: Develop Mechanisms for Disseminating Information (Risk Communication)

! 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 EP ID EM IO LO G Y A N D S U R V EIL LA N C E

! 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

EP ID EM IO LO G Y A N D S U R V EI LL A N C E

PS Y C H O SO C IA L C A R E A N D M EN TA L H EA LT H

Steps in Promoting Psychosocial

and Mental Health

1. Assess psychosocial and mental health concerns. Schedule consultative meetings with the provincial and municipal health workers 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/social

services

* see appendix for Summary Table on Projecting Mental Health Assistance

2. Brief field officers in the areas of health and social welfare regarding issues of fear, grief, disorientation and need for active participation. Mobilize informal human resources in the community (e.g., Red Cross volunteers, religious and political leaders).

3. Conduct mostly social interventions that do not interfere with acute needs such as the organization of food, shelter, clothing, PHC services, and, if applicable, the control of communicable diseases.

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

mental health problem, a history of prior trauma, greater exposure to the disaster and its

aftermath, and those who lack family and peer support.

PS Y C H O SO C IA L C A R E A N D M EN TA L H EA LT H

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 at the PHC level. Many persons with urgent psychiatric complaints will have pre-existing psychiatric disorders and sudden discontinuation of medication needs to be avoided. 5. Start planning medium- and long-term development of

community-based mental health services and social interventions needed during recovery and rehabilitation. This is vital since it is during this phase that survivors will be rebuilding their lives amidst the grief from the loss of loved ones, property, and livelihood.

6. If the acute phase is protracted, start training and supervising PHC workers and community workers (e.g., provision of appropriate psychotropic medication, 'psychological first aid', supportive counselling, working with families, suicide prevention, management of medically unexplained somatic complaints, substance use issues and referral).

As far as possible, manage acute distress without medication. It is also not advisable to organize single session psychological debriefing

to the general population as an early interven-tion after exposure to trauma.

7. Educate other humanitarian aid workers as well as community leaders (e.g., village heads, teachers, etc.) in core psychological care skills (e.g., 'psychological first aid', emotional support, providing information, sympathetic reassurance, recognition of core 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 between

psychopathology and normal psychological distress, avoiding suggestions of wide-scale presence of psychopathology and avoiding jargon and idioms that carry stigma.

9. Facilitate creation of community-based self-help support groups. The focus of such self-help groups is typically problem sharing, brainstorming for solutions or more effective ways of coping (including traditional ways), generation of mutual emotional support and sometimes generation of community level initiatives.

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

Interventions for Children Affected

by Emergencies

1. Encourage parents, teachers, and other caregivers to understand and monitor child emotional reactions. Remember that children's reactions vary with age.

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

PS Y C H O SO C IA L C A R E A N D M EN TA L H EA LT H

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 the emergency, on the availability of assistance, and on the location of relatives to enhance family reunion

! Establishing access to communication with absent relatives, if feasible

! Organizing family tracing for unaccompanied minors, the elderly 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 information on normal stress reactions and culturally appropriate relaxation techniques to the community at large

! Public education should focus primarily on normal reactions, because widespread suggestion of physical and mental disease 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

PS Y C H O SO C IA L C A R E A N D M EN TA L H EA LT H

managed by communities themselves.

! Discouraging unceremonious disposal of corpses. Facilitate conditions for maintaining or re-establishing appropriate cultural practices, including grieving and burial rituals by relevant practitioners.

! Assuming the activity is safe:

1. Encouraging activities that facilitate the inclusion of the bereaved, orphans, widows, widowers, or those without their families into social networks

2. Encouraging the organization of normal recreational activities for children and encouraging starting schooling for children, even partially

3. Involving adults and adolescents in concrete, purposeful, common interest activities (e.g., assist in caring for the ill especially if people are cared for at home, construct-ing/organizing shelter)

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

Specific Concerns for Victims of Attacks

Involving Biochemical Weapons

Attacks involving biochemical weapons may induce significant 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 and mood disorders as well as non-pathological trauma and grief reactions)

2. Physical exposure to agents may induce organic mental disorders PS Y C H O SO C IA L C A R E A N D M EN TA L H EA LT H