August 19, 2016

Health Hazard in Post Emergencies

Access to safe drinking water is very important to prevent the outbreak of infections diseases. Photo: Aye Min Soe
Access to safe drinking water is very important to prevent the outbreak of infections diseases. Photo: Aye Min Soe

In recent years we have been experiencing many disasters around the world. Both natural and man-made disasters have taken front page stories in the world media almost every other day if not daily. Disasters of both categories inevitably leave human suffering in various degrees. Disasters are events that occur when significant numbers of people are exposed to extreme events to which they are vulnerable, with resulting injury and loss of life, often combined with damage to property and livelihoods. Disasters, commonly leading to emergency situations, occur in diverse situations in all parts of the world, in both sparsely populated rural and densely populated urban regions, as well as in situations involving natural and man-made hazards. Disasters are often classified according to their speed of onset (sudden or slow), their cause (natural or man-made), or their scale (major or minor). Various international and national agencies that keep track of disasters employ definitions that involve the minimum number of casualties, the monetary value of property lost, etc. Other definitions are used by countries for legal or diplomatic purposes, e.g. in deciding when to officially declare a region a “disaster area”. The terminology used here is less precise so as to cover a broad range of situations. The forces that bring vulnerable people and natural hazards together are often man-made (conflict, economic crisis, overpopulation, etc.). An example of natural and technological hazards combining in surprising ways was seen in Egypt in 1994. Heavy rain near the town of Dronka weakened railway lines. A train carrying fuel was derailed and leaking fuel was ignited by electrical cables, causing an explosion. Finally, burning fuel was carried by flood waters through the town, killing hundreds of people.

Conflict and Emergencies

Some of the most serious disasters and emergencies are created or further complicated by conflict and the forced movement of large numbers of people. Conflict also imposes the greatest demands on environmental health personnel, equipment, supplies and supporting services, thus calling for the most skilful use of relief resources. The secondary impact of conflict, in terms of the public health problems it creates and the disruption of environmental health services it causes, are of major importance. An emergency is a situation or state characterized by a clear and marked reduction in the abilities of people to sustain their normal living conditions, with resulting damage or risks to health, life and livelihoods. Disasters commonly cause emergency situations, both directly and indirectly. Evacuation or other necessary steps taken to avoid or flee from a disaster, for example, can cause disruption of normal life on a scale calling for emergency action. Sudden, large-scale movements of people within and between countries often produce emergency conditions. Dramatic loss of livelihoods and increased spending needs due to drought or flooding may place people in a very vulnerable situation. A cholera epidemic may overwhelm the capacity of a city’s under-resourced health service, creating an urgent need for support. In such emergency situations, local coping mechanisms are overwhelmed and so collective, specialized and often external action is required. During an emergency, it is common to see primary effects of the disaster followed by secondary effects. For instance, the primary effect of a mudslide might be that many people are injured and need urgent medical attention. A secondary effect might be that blocked sewers and broken water mains lead to an outbreak of water- and sanitation related disease some weeks later, or that the loss of livelihoods through the destruction of vegetable gardens and workshops leads to reduced food intake and a nutrition emergency some months later. Human needs for non-material things, such as security and cultural identity can also be affected, and the psychological and social impacts of a disaster may be felt many years after the event. Emergency situations are often described in public health terms, with the crude mortality rate (CMR) being widely accepted as a global measure of their severity. A CMR which is significantly higher than the rate in the affected population before the disaster, or which is above 1 death per 10 000 population per day indicates an emergency situation (Centers for Disease Control and Prevention, 1992; Sphere Project, 2000). CMRs in the emergency phase following various types of disaster may be many times the background rate for the region or the affected population. Many more deaths may occur during the post-disaster emergency phase than as a direct result of the disaster itself. The term complex emergencies is used to describe situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance and large-scale movements of people, in which any emergency response has to be conducted in a difficult political and security environment. A combination of complex disasters and natural hazards (e.g. military and political problems combined with severe winter weather, coastal storms and flooding, drought and a cholera epidemic) was particularly devastating in the 1990s in such countries as Bosnia and Herzegovina, Iraq, Peru and Somalia.

The effects of disasters on health facilities, services and

One way in which disasters may cause, or worsen, emergency situations is through the damage they do to environmental health facilities and services. Flooding, power failures, broken pipes and blocked roads can all disrupt water, waste and food-handling services. Hospitals could be destroyed and treatment & medication services which are essential will be heavily disrupted or totally out of service. Roads can be cut and bridges washed away making access to the disaster affected area not accessible by external helps and search & rescue team, red cross professionals and volunteers, medical teams, food, medical supplies & drinking water delivery, security forces to help the survivors.

Lack of power may also affect proper functioning of health facilities
There could be a lot of confusions in terms of availability of correct data & information of the affected number of population, list of damaged facilities and infrastructure. Power cuts related to disasters may disrupt water treatment and supply plants, thereby increasing the risk of water-borne diseases. Lack of power may also affect proper functioning of health facilities, including preservation of the cold chain. Deaths associated with natural disasters are overwhelmingly caused by blunt trauma, crush-related injuries or drowning. The sudden presence of large numbers of dead bodies in the disaster-affected area can fuel fears of outbreaks. When death is directly due to the natural disaster, human remains do not pose a risk for outbreaks; the source of infection is more likely to be the survivors than those killed by the natural disaster. Even when death is directly due to communicable diseases, pathogenic organisms do not survive long in the human body following death. Dead bodies pose health risks in a situations requiring specific precautions, such as deaths from cholera or haemorrhagic fevers. The mass management of dead bodies is often based on the false belief that they represent an epidemic hazard if not buried or burned immediately.
•    Burial is preferable to
cremation in mass casualty
•    Every effort should be made     to identify the bodies.
•    Mass burial should be
avoid-ed if at all possible.
•    Families should have the opportunity, and access to materials, to conduct culturally appropriate funerals and burials according to social custom.
•     Ensure use and correct
diposal of gloves
•     Use body bags if
•     Wash hands with soap after handling dead bodies and before eating
•     Disinfect vehicles and equipment
•     Dead bodies do not need disinfection before disposal (except in case of cholera, shigellosis, or haemorrhagic fever)
•    The bottom of any grave must be at least 1.5 m above the water table, with a 0.7 m unsaturated zone.

Prevention of communicable diseases following natural disasters

The following priority measures are critical to reduce the impact of communicable diseases after natural disasters:
•    Ensuring uninterrupted provision of safe drinking-water is the most important preventive measure to be implemented following a natural disaster. Chlorine is widely available, inexpensive, easily used and effective against nearly all waterborne pathogens.
•    Settlement planning must provide for adequate access for water and sanitation needs and meet the minimum space requirements per person, in accordance with international guidelines
•    Access to primary health care is critical to prevention, early diagnosis and treatment of a wide range of diseases, as well as providing an entry point for secondary and tertiary care. The immediate impact of communicable diseases can be mitigated with the following interventions:
•    Ensure early diagnosis and treatment of diarrhoeal diseases and ARI, particularly in those aged <5 years.
•    Ensure early diagnosis and treatment for malaria in endemic areas (within 24 hours of onset of fever, using artemisinin-based combination therapy ACT for falciparummalaria).
•    Ensure availability of drugs included in the interagency emergency health kit, e.g.
oral rehydration salts for management of diarrhoeal diseases, antibiotics for ARI.
•    Distribute health education messages, including:
− encouraging good hygienic practices (eg. 4 clean hygiene awareness);
− promoting safe food preparation techniques;
− ensuring boiling or chlorination of drinking water;
− encouraging early treatment seeking behavior in case of fever;
− encouraging use of insecticide-treated mosquito nets as a personal protection measure in malaria-endemic areas.
•    Vector control interventions adapted to the local context and disease epidemiology Surveillance/early warning system plays a crucial role in rapid detection of cases of epidemic-prone diseases is essential to ensure rapid control. A surveillance/early warning system should be quickly established to detect outbreaks and monitor priority endemic diseases. Priority diseases to be included in the surveillance system should be based on a systematic communicable disease risk assessment. A comprehensive communicable disease risk assessment by the country health authorities and WHO can identify and prioritize these threats.  It is important to ensure sampling and transport materials for investigation, and appropriate stockpiles are readily available for rapid response to outbreaks, e.g. cholera kits, in areas where cholera is considered a risk. Immunization must follow after the surveillance results are established. Mass measles immunization together with vitamin A supplementation are immediate health priorities following natural disasters in areas with inadequate coverage levels. Where baseline coverage rates among those aged <15 years are below 90%, mass measles immunization should be implemented as soon as possible. The priority age groups are 6 months to 5 years, and up to 15 years if resources allow. Typhoid vaccination in conjunction with other preventive measures may be useful to control typhoid outbreaks, depending on local circumstances. The cost of the cholera vaccine, and the logistic difficulties involved with the administration, have prohibited its widespread use. Although helpful in specific circumstances, it should not be viewed as a replacement for the provision of adequate water and sanitation. Prevention of malaria and dengue is very important in post disaster situations. Specific preventive interventions for malaria must be based on an informed assessment of the local situation, including on the prevalent parasite species and the main vectors. An increase in mosquito numbers may be delayed following flooding, allowing time for implementation of preventive measures such as indoor residual spraying of insecticides, or the re-treatment/distribution of insecticide-treated nets preferably long-lasting insecticidal nets (LLIN) in areas where their use is well-known and accepted. Early detection of a possible malaria outbreak can be enhanced by monitoring weekly case numbers must be part of the surveillance/early warning system. Treatment with artemisinin-based combination (ACT) therapy should be provided free of charge to the user in disaster-affected areas with falciparum malaria. For dengue, the main preventive efforts should be directed towards vector control. Social mobilization and health education of the community should emphasize elimination of vector breeding sites as much as possible, specifically by: − continuous covering of all stored water containers; − removal or destruction of solid debris where water can collect (bottles, tyres, tins, cups, coconut shells etc.). Although disaster-related deaths are overwhelmingly caused by the initial traumatic impact of the event, disaster preparedness plans should consider the health needs of the surviving disaster-affected populations. The health impacts associated with the sudden crowding together of large numbers of survivors, often with inadequate access to safe water and sanitation facilities, will require planning for both therapeutic and preventive interventions, such as rehydration materials, antibiotics and measles vaccination materials. Disaster response teams should be aware of and have access to the latest updated guidelines for communicable disease prevention and control, such as the WHO field manual on Communicable disease control in emergencies and the Sphere project’s Humanitarian charter and minimum standards in disaster response. The risk of transmission of endemic communicable diseases, such as ARI and diarrhoeal diseases, is increased in displaced populations due to associated crowding, inadequate water and sanitation and poor access to health care. Improved detection and response to communicable diseases is important in order to monitor the incidence of diseases, to document their impact and to help to better quantify the risk of outbreaks following natural disasters.
1.    Communicable disease control in emergencies-WHO
2.    The Sphere project’s Humanitarian charter and minimum standards in disaster response-2011


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