Environmental Health Management Natural Disaster No-430 1982

7/29/2019 Environmental Health Management Natural Disaster No-430 1982

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MlCROFlCHEREFERENCELl5MRY

A project of Volunteers in Asia.s--n-after Naturalasters Scientific Publication No. 430

Published by:Pan American Health OrganizationWorld Health Organization525 Twenky-third Street, N.W.: Washington, DC 20037 USA

Available from:Pan American Health OrganizationWorld Health Organization525 Twenty-third Street, N.W.Washington, DC 20037 USAReproduced by permission of the Pan AmericanHealth Organization,;Reproduction of this microfiche document in anyform is subject to the same restrictions as thoseof the original document.

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PAN AMERICAN HEALTH ORGANIZATION 31 na3


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HEALTH FUR ALL BY THE YEAR 2000

In 1977, the World Health Assembtr decided that the main social target of the go~vtntnents and ojWHO should be the attaintnent bp ail peop le crf he world bv the-rear 2000 of a Ier,et of health thatwould permit them to leud a socially anti econotnical~~~ mductioe l+, that is, the goal prpularl~known as headth ar a!1 bv the fear 2000. _

In IO78 the Intcmativnal Conference on Pritaarll Health Ihe (A Ivan-A ta, USSR) de&trd that,as a Cmtral function o/ tiw natifvial fwanltit system avid an integral part II/ tuonorfric~and b xiai htd-optnettt,primary health care tvas tilt+ kuv to itchifuivg that ,qid. St~lh.s~~ tlf~trt~~~,/w ~~f~vt~rtimt~t~t.s-Ottowitted rhr~tm$vusat tiw global level at fhc Ctidd Health A.s.stwb!y, and (it the qird heI (itt~ttdngs oj the PA HO Governing Bodies -to itnplt~mt~t~the resotu ions adopted. ut attaining health

jar all. In the Americas the high point vjthese taai;dates was reachedon 28 September I9Hi when theDirecting Council oj. PA HO app roved the PIan ojAction.jirr implementing the regional strate,gies.forhealth jar ail by the year 2000. These strategies had been apprrned by the Directing Council in 1980(Resolution XX) and todqp constitute the has 9 oj PA HO s poli areas oj the Plan ojAction. PA HOs publication program -including periodicals, scientrjic publications, and of3lciatdocuments-is designed as a means oj promoting the ideas contaitted in the Plan by disseminatingdata on policies, strategies, international cooperation programs, and progress achieued in collaborationwith countries of the Americas in the process ojattaining health for all by the year 2000.


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EnvironmentalHealth anagementafter Natural Disasters

1982 Scientific Publication No. 430PAN AMERICAN HEALTH ORGANIZATIONPan American Sanitary Bureau, Regional Office of theWORLD HEALTH ORGANIZATION525 Twenty-third Street, N.W.Washington, D.C. 20037, U.S.A.


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ISBN 92 75 11430 70 Pan American Health Organization

Publications of the Pan American Health Organization enjoy copyright protection inaccordance with the provisions of Protocol 2 of the Universal Copyright Convention. Forrights of reproduction or translation of PAHO publications, in part or in toto, applicationshould be made to the Office of Publications, Pan American Health Organization,Washington, D.C. The Pan American Health Organization welcomes such applications.The designations employed and the presentation of the material in this publication donot imply the expression of any opinion whatsoever on the part of the Secretariat of thePan American Health Organization concerning the legal status of any country, territory,city, or area of its authorities, or concerning the delimitation of its frontiers orboundaries.The mention of specific companies or of certain manufacturers products does notimply that they are endorsed or recommended by the Pan American Health Organiza-tion in preference to others of a similar nature that are not mentioned.

Published also in Spanish ( 1982) as:Salud ambientalcon posterioridad a Its desastres naturales

The publication of this manual, in English and Spanish, has been made possible byfinancial support of the Canadian International Development Agency (CIDA). theSwedish International Development Authority (SlDA), and the U.S. Office ofForeign Disaster Assistance of the U.S. Agency for International Development(AID/OFDA).


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Contents

Foreword vPreface viiAcknowledgment ix

Part I: The Effects of Disaster on Environmental HealthAn Overview 3Effects of Disasters on Conditions and Services 3

Part II: The Management of Disaster-CreatedEnvironmental Health ConditionsChapter 1: Factors to Consider for Effective Management 9Deciding on Appropriateness of Measures 9The Timing of Emergency Measures 11Chapter 2: Phase One: Predisaster Health Measures 13The Plan for Emergency Environmental Health Operations 13Protective Measures 15Civil Engineering Structural Damage 15

Contamination of Food and Water Supplies 16Power Outage 18Transportation Failure 18Education of Personnel and the Public 20Chapter 3: Phase Two: Measures Taken during Disaster and in theAftermath 23Emergency Warning Period 23Disaster Occurrence Period 24. . .111


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iv Contents

Immediate Postdisaster Emergency Period 24Water Supply 25Environmental Sanitation 28Shelter 28Food Sanitation 30Vector Control 30Personal Hygiene 33General Public Information 33Consolidation Period 34Providing Relief Agencies with Lists of Needs 34Receiving Aid 34Distributing Aid 34Establishing Settlements for Displaced Persons 35Chapter 4: Phase Three: Rehabilitation Measures 37Restoration of Lifeline Services 37Restoration of Essential Environmental Health SurveillanceActivity 38Water Quality 38Food Supplies 39Environmental Sanitation 40Evaluating the Emergency Operations Action (EOA) Plan 40

Part III: Annexes1. Developing an Environmental Health Emergency OperationsPlan 432. Guidelines for the Use of Tablet, Powder, and LiquidDisinfectants in Emergency Situations 473. Technical Guide to Environmental Health Measures Taken inResponse to Natural Disaster 514. Bibliography 57


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ForewordHealth sector representatives repeatedly have expressed their com-mitment to improving the environmental health conditions of thepopulation they serve, as a vital part of the primary care approach thatstresses prevention of disease over cure of avoidable illness. Despitelongstanding recognition of the essential link between the environ-ment in which people live and work and their enjoyment of goodhealth, much progress has yet to be made m this regard. Gastroenteri-tis and diarrheal diseases take a heavy toll in the region of theAmericas, especially on infant life; and water-borne and water-relateddiseases are still major causes of morbidity and early mortality.The importance of environmental health was underscored by anextraordinary session of the United Nations General Assembly, whichin 1980 declared the decade ending in 1990 as the InternationalDrinking Water Supply and Sanitat.ion Decade. Providing healthfulenvironmental conditions, for an expanding, increasingly urbanizedpopuiation is a task that cannot be accomplished by the health sectoralone. It requires the commitment of governments to a broad intersac-toral approach-including education and housing-within the frame-work of economic and social development plans.Yet it falls upon the health sector to provide leadership in determin-ing environmental health needs and planning and executing measuresto meet them. PAHO has developed a comprehensive plan of action for

health strategies in the region of the Americas. High priority is givento the provision of drinking water and basic sanitation services. In thespirit of the International Drinking Water Supply and SanitationDecade, PAHOs Member Governments have set 1990 as the targetdate to provide safe drinking water and adequate sanitation servicesto the greatest possible number of inhabitants. Within the overallstrategy of achieving Health for All by the Year 2000, that year hasbeen set as the date to extend this coverage to all persons.V


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vi Foreword

Natural disasters, to which many countries in the region of theAmericas are prone, can seriously jeopardize progress made in the areaof environmental health. Physical disruption of infrastructure andsp:*vices is aggravated by the displacement of large sectors of thepopulation. The consequent alteration in their daily environment haspotentially hazardous health consequences. Too often, it has beennecessary to spend scarce resources on emergency measures just toreestablish previously existing environmental health services. Prog-ress in such circumstances is severely hampered.The series of manuals on disaster preparedness being issued by thePan American Health Organization is designed to respond to the callfrom member countries to disseminate the appropriate guidelines andmanuals in order to assist health workers in the Americas indeveloping disaster preparedness plans and training the necessaryhuman resources. Given the suddenness of their occurrence and theimportance of speedy measures to prevent potential morbidity andmortality, natural disasters demand that a nation use appropriatetechnology and its own human resources during the immediate emer-gency. Dependence on outside resources can create a time lag that mayhave serious consequences for the health and well-being of the affectedpopulation.

This mani. is intended to provide a framework to assist planners inthe health .d other sectors to incorporate in their action strategiesmeasures ,,+protect the population from the deleterious effects ofnatural d+ ssters. If not taken into account ahead of time, disastersmay wre:ln< unnecessary havoc with environmental health servicesthat were established at tremendous cost where resources are scarce.This will occur even in areas where clean water and adequate sanitaryfacilities have existed for a long enough time to be taken for granted.The manual also addresses measures that should be taken once adisaster strikes to diminish its long-term effects on the health of thepopulation and to speed up the recovery process.If the potential effects of natural disasters are considered andprovided for in advance, serious health ai:wereffects may be averted,costly repairs may be reduced, and progress toward Health for All bythe Year 2000 may be maintained despite adverse natural circum-stances. Hector R. Acuiia, M.D., M.P.H.Director


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Preface

Environmental health is defined as the control of those factors in theenvironment that may have deleterious effects on peoples physical,mental, or social well-being. Because natural disasters expose peopleto danger by disrupting or threatening to disrupt their immediateenvironment, effective management of environmental health after anatural disaster is of primary importance.Natural disasters often increase morbidity and mortality rates.Taking appropriate measures to maintain environmental health helpsto reduce or eliminate the risks of preventable disease and death. Suchmeasures contribute not only to the health of individuals in and neardisaster-stricken areas, but they also contribute to decreasing the highcosts of providing emergency health services in the aftermath ofdisaster.The environmental health measures that must be considered after anatural disaster include the provision of appropriate shelter for indi-viduals or groups of people left homeless; the distribution of safe andaccessible water, first in sufficient quantities for drinking purposesand then for other domestic uses; and the protection and distribution ofsafe fcsd products. Other measures that must be considered for thecontrol of environmental hazards associated with disaster are sanitaryevacuation of excreta, liquid wastes, and refuse; protecting populationsfrom common vectors of disease in stricken areas; and promotinghealthful living-particularly sanitary housing and basic personalhygiene.To effectively manage environmental health during and after adisaster, it is crucial that a state of preparedness was in effect beforethe event actually occurred. During an emergency, success largelydepends on exercising good, rapid judgment about appropriate re-

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viii Preface

sponse measures. High-level decision makers therefore must be famil-iar with sound measures beforehand and should be given an accurateassessment of the disasters specific effects as quickly as possible.This document is intended to serve as a guide for those who may becalled upon to make emergency decisions after natural disasterstrikes. The recommended environmental health measures have beenlisted In the order of priority in which they should be taken during anemergency. However, each natural disaster is unique in the degree ort;rpe of emergency it poses. In response to any given disaster, decisionmakers may find it necessary to change the priority assigned to anyparticular measure.The proper reordering of priorities will be greatly simplified if theprincipal objective of environmental health measures during times ofemergency is kept in mind. The object is to protect the health ofindividuals who live in or near disaster-stricken areas by keeping thedeterioration of environmentai health conditions and services to aminimum. Implied is that the specific objective of emergency measuresis to restore environmental he&h conditions and services to whateverlevels existed before disaster occurred, regardless of judgments aboutpredisaster quality. If predisaster quality was less than desirable, therisk of disease will increase only if environmental health conditionschange for the worse, all other things being equal. Measures toimprove preexisting conditions should be scheduled for the rehabilita-tion phase, not the recovery phase.This document is divided into several parts. The first sectionprimarily addresses the effects of natural disasters on environmentalhealth conditions and services. In the second section, environmentalhealth measures are described that should be undertaken in each ofthree time frames: the predisaster, disaster, and postdisaster periods.


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Acknowledgment

This publication has been made possible by the dedicated work ofMr. Pierre Leger, who drafted the original manuscript. Mr. Leger, acivil engineer who also holds degrees in environmental andsanitary engineering, is Director of International Division ofMedical Care Development, based in Washington. A native ofHaiti, Mr. tiger obtained his graduate degree from New YorkUniversity and did his postgraduate work in the Netherlands.Thanks also are due to Mr. David Donaldson, formerly of the PanAmerican Health Organization, and to the Division of Environ-mental Health Protection of PAHO for their dedicated contributionto the conception and technical content of this manual.

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Part1The Effects of Disaeter onnmental Hedth


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An Overview

The adverse environmental conditions that may accompany naturaldisasters vary according to disaster type. Table 1 presents probableconcomitants to the most common disasters.Table 2 presents the relative severity of the effects of some commondisasters on the environment. These disasters cause considerabledeterioration of environmental conditions. Partial or total disruptionof environmental health services is to be expected, particularly of thelifeline services, such as water systems, food production and distribu-tion, transportation, and power. Increased population density resultsfrom the effects of disaster listed in table 2. This, in turn, disruptsnormal community life by causing health-related conditions to worsenand increasing the need for environmental health services.Effects of Disasters on Conditions and Services

The sudden creation of areas of high population density, such ascamps for displaced persons where there has been no planning for thesanitary accommodation of large numbers of people, is one of the mosttypical ways in which disasters affect environmental health conditionsand services. Because of their generally inadequate facilities andservices, establishing camps can result in secondary health emergen-cies; consequently, even more time and scarce resources will be neededthan are required to address the original emergency situation.Disruptions or overloading of water supply systems, excreta andliquid waste removal systems, and solid waste disposal systems alsoare likely consequences of naturai disasters. When excreta and liquidwaste disposal systems are disrupted, the probability of water-borneand food-borne diseases increases. Other water-related diseases and

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4 Environmental Health Management

Table 1. Consequences by Type of DisasterDisastersstorms(Hurricane, cyclone, tornado)

ConsequencesDestructive windsFloodingHeavy rainsLandslidesPower outages

Earthquakes Destructive vibrationPower outagesFiresVolcanic eruptions EarthquakeTsunamisFiresVolcanic debrisTsunamis (Sea surges! FloodsPower outages

general nuisances are also more likely to affect disaster-strickenpopulations. Whenever access to normal water sources is hampered orcut off, it is critical that authorities make sufficient quantities forhuman consumption available to the populations in need.As sanitation decreases with the disruption of solid waste disposalsystems, the contamination of food and water supplies and the prolif-eration of vectors increase the risk of disease. The bothersome condi-tions that accompany breakdowns in solid waste disposal may contrib-ute to the mental stress that disaster victims undergo. The disruptionof solid waste disposal systems also can create fire hazards in denselypopulated areas.The growth of populations of vectors of diseases such as malaria,yellow fever, tularemia, and typhus is a further common consequenceof natural disasters, particularly in areas where such diseases other-wise are incidental. As was experienced in the aftermath of disaster inHaiti, the interruption of established vector control activities cancause a resurgence of such diseases.1

1. Mason, J., and CavaliB, P. Malaria Epidemic in Haiti Following a Hurricane.American Journal of Tropical Medicine and Hygiene 14(4): l-10 (1965).

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An Overview 5

Table 2. Matrix of Effec ts of Natural Disaster on Environmental Health ServicesService iMost Common Effects onEnvironmental Health- Damage to civil engineeringstructuresBroken mainsPower outages

Water supply Contamination (biological orand waste chemical )water disposal Transportation failurePersonnel shortagesSystem overloading (due toshifts in population)Equipment, parts, & supplyshortages.~_,--^ ,I* _,, yI.~_,-i-l.l.- ,i,,-_ .^ ^,~ _Damage to civil engineeringstructuresSolid waste Transportation failureshandling Equipment shortagesPersonnel shortagesWater, soil, and air pollution

Damage to food preparationfacilitiesTransportation failureFood handling Power outagesFlooding of facilitiesContamination/degradation ofrelief supplies

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Earth- Hurricane/ Flood Tsuna-quake Tornado mis

II__-- - ---.-Proliferation of vector breedingsites lVector control Increase in human-vectorcontacts 0Disruption of vector-bornedisease control programs l

Destruction or damage tostructures 0Contamination of water andHome sanitation food QDisruption of power. heat fuel.water supply waste disposal:services 0Overcrowding 0

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90l Severe possible effectQ Less severe possible effect0 Least or no possible effect


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II


Finally, decreased standards of general housing sanitation andpersonal hygiene are among the most common effects of disaster uponenvironmental health conditions and services. When displaced personsmove into areas in which physical structures have been damaged bythe disaster, overcrowding often causes housing sanitation to decline.The lack of proper clothing, water, soap, detergent and basic cleaningand washing facilities makes it difficult to maintain usual standards ofpersonal hygiene; as a result, there are increases in diarrhea1 disease,vector-borne diseases like typhus, and conditions like scabies in areaswhere they were already prevalent before the disaster.


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Part IIThe Management of Disaster-Created EnvironmentalHeaElth Conditions


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Chapter 1Factors to Consider forEffective ManagementDeciding on Appropriateness of Measures

To alleviate conditions in disaster-stricken areas, appropriate mea-sures must be taken to halt the deterioration of predisaster levels ofenvironmental conditions and the disruption of environmental healthservices and normal community life. Environmental health controlmeasures must be undertaken before and in the aftermath of disasterand, whenever possible, during the disaster itself. In determiningcourses of action at these various stages, a given measure should bejudged not only according to its technical feasibility and the availabil-ity of resources,but also according to the extent to which the measureis directed at returning environmental conditions to predisaster levels.Factors to consider in making decisions about actions include areasof priority of intervention, the priority of needs for the various-environmental health services, and the availability of manpower. Themajor factor that determines the priority of areas for intervention isthe ,presenceor absenceof disease-related risks in the areas in whichdisaster victims reside. The relative risk of disease merits particularattention in the peripheries of urban centers and in camps and othertemporary settiements.The highest priority should be accorded to environmental healthservices that are essential to the protection of the well-being ofindividuals in high-risk areas. The cooperation of persons n high-riskareas should be sought, and they should be actively involved in theprqvision of services. The minimum levels of necessary services thatmust be provided are the following:

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1.2.3.4.5.

adequate shelter for displaced personssticient quantities of accessible drinking waterfacilities for excreta and liquid waste disposalprotection of food supplies against contaminationthe protection of individuals in affected populations againstvector-borne diseases through vector control activities andthrough chemoprophylactic methods.Unavailability of appropriate environmental health manpower canbe a limiting factor in emergency intervention after a disaster. The use

of locally available experts therefore should be given first consider-ation. Because they are familiar with the predisaster and socioeconom-ic conditions in affected areas, and-even more important-becausethey have experience in working under conditions similar to those ofdisaster-stricken areas, these individuals are usually best equipped to

J. Vizcarra BrennerlPAHOWomen collecting water from a common pump in rural Bolivia. Guaranteeing sufficient wateris a health priority after natural disasters.


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Factors in Effective Management 11

handle the emergency contingencies caused by natural disaster. Incontrast, outside experts often are unfamiliar with both predisasterconditions and the particular environmental health standards of agiven disaster-stricken area. Their lack of knowledge may in facthinder the success of relief activities, so caution should be exercisedwhen foreign experts are recruited.The Timing of Emergency Measures

Environmental health problems created by natural disaster shouldbe managed in three major phases. These are presented with recom-mendations about the appropriate timing for initiating the measures;the duration of the phases, however, will vary according to the natureof the problems created by each actual disaster.PhaseOne consists of measures undertaken before a disaster strikesin order to develop and maintain a state of preparedness. Preparednessplanning focuses on areas of known high risk of natural disaster-areas with a history of occurrences,or areas that have been designatedas sites of potential natural disaster.Phase Two begins when the disaster strikes. The emergency-relatedactivities of Phase Two are taken during the event, if possible, and inthe aftermath of the disaster. Usually, the environmental healthcontrol measures of this phase take place within the first seven daysfollowing the disaster. They are, however, divided into subphases:immediate measures, taken within the first three days after thenatural disaster strikes; and consolidation measures, initiated once theimmediate measuresof the emergency phase have been put into effect.Phase Three involves the rehabilitation of the environment. Consid-eration of appropriate rehabilitation measures should actually beginas soon as the emergency-related measures of Phase Two have beeninitiated. Like Phase Two measures, those of Phase Three also takeplace in two subphases:short-term measures, to return environmentalconditions and services to predisaster levels; and long-term measuresof reconstruction, consisting of all the steps taken to improve environ-mental conditions and services that require long periods of time toaccomplish.It is recommended that all postdisaster measures except for long-term reconstruction activities be carried out within three weeks of theoccurrence of the disaster. Table 3 presents a guideline for the timing


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Table 3. Anticipated Schedule of Measures for Emergencies Created by NaturalDisasters-~~.-__. ; ..---~~redisaster . Postdisaster -

Phase Measure 0 mm---~1 _~ ~~___ --.~ .~~Days12 4 6 8 10 I2 14 16 18 20 2Q 21 26.--_--.-.-----.-~--.1 Predisaster I -~------~-.-~ - -~---~--I_~ ..-. -~ __.__.. -~ ~. _ .~~ .~~2 Emergency I-Immediate -h-Consolidation- _ --.__-~~3 Rehabilitation

; c!!! Yr!-Short-term-Long-term

1 c-e-I I-Anticipated duration of measure- - -Possible extension of measure

of the adoption and completion of all postdisaster measures.The specific environmental health measures that should be takenduring each of these phases are elaborated in the following chapters.Although exhaustive discussion of long-term measures for rehabilita-tion is beyond the scope of this document, some basic recommendationsare offered.

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:,:.-,(~,?(a:-:b,s,.; Chapter 2;n~. Phase One:Predisaster Health Measures

Most natural disasters are sudden, and the warning period in whichprotective action can be taken is usually very short or nonexistent.With current technology we can at best predict some disasters only afew days before they strike. Often the warning is available onlymoments ahead of when the disaster hits. The only effective method ofresponding to a disaster, therefore, is to develop a state of preparednessin high-risk areas.The principal objective of predisaster environmental health mea-sures is to eliminate or reduce the hazards to environmental health inaffected areas once disaster has actually hit. The way to achieve this isto develop a plan for environmental health control activity during theemergency, to adopt routine measures to protect environmentalhealth, and to develop an emergency education and informationprogram aimed at both public health personnel and the generalpopulation.The Plan for Emergency Environmental Health Operations

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Effective response to disaster depends heavily on planning theemergency environmental health operations. Once plans are drawnup, they should be revised every five to ten years, generally speaking.Actual experience with a disaster most likely will necessitate revisionsimmediately thereafter.An emergency plan is not the intention to make a plan; rather, it is awell-developed but simply and clearly defined prescription for the who,when, and what of activities, using existent local resources, oncedisaster strikes. Guidelines and priorities for action should be stated in

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the plan, but lengthy descriptions of the functions and duties ofparticular persons should be avoided. This is not to say that thefunctions and responsibilities of individuals within organizations areunimportant, but such descriptions usually emerge after it is deter-mined how existing resources can best be used under the uniquecircumstances of each natural disaster.The overall operations plan primarily entails a guide for coordinat-ing all the activities that will be undertaken, after prediction (oroccurrence) of the disaster, by personnel of the various types ofenvironmental health and related services. Separat,e subplans shouldbe de+eloped for water supply service, solid waste service, and so forth.Detailed steps for the development of emergency plans by environmen-tal health and related services are presented in Annex 1. The integra-tion of these subplans forms the basis for finalizing the overallpredisaster preparedness plan.An overall plan contains seven basic components. The first is astatement of the extent of damage that is likely to result from the typeof disaster to which the area is subject. The next three componentsconsist of demonstrating how to estimate the resources that wouldremain af%era disaster strikes; indicating how to calculate the needs ofaffected communities; and, finally, stating how these requirement.3will be matched with the resources. An assessment of vulnerabilityand of the inventories of supplies, equipment, and personnel yields thebasic data for determining which emergency steps should be takenduring the warning period (if there is one), the time immediately afterimpact, and the postdisaster period.The last three componentsof the emergency plan are carried outafter the disaster has taken place. These steps jointly make up theEmergency Operations Action (EOA) Plan. The EOA Plan shouldspecify the schedule for addressing specific community needs (forexample, providing food or shelter or water or sanitation before takingmeasures to ensure personal hygiene); indicate the best program forusing existing resources; and assign specific tasks to environmentalhealth control personnel assumed to survive the disaster. It must bestressed that the EOA Plan should be drawn up only after assessingexistent measures.At this point, it may be worthwhile to repeat the priority measureslisted previously: to provide adequate shelter from inclement weatherand ensure that the shelters do not burden environmental health


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Bredisaster Health Measures 15

conditions and services; to provide at least the minimum quantity ofsafe drinking water; to remove human excreta and liquid and solidwastes from the immediate surroundings to nonharmful disposal sites;to bring the control of vectors to a level at which they will not transmitdisease or affect the supplies of available food; and to ensure that foodsanitation practices do not contribute to the spread of disease.Finally, the emergency plan should be explicit about the way todisseminate information during the emergency period and aboutproviding protection and accommodation for relief personnel. All reliefworkers should receive appropriate vaccinations. Personal protectionin the form of clothing and washing facilities should also be ensured.StafF members should be instructed about the proper handling ofequipment and supplies.Protective Measures

Taking protective measures involves a wide spectrum of activitiesthat range from considering appropriate design to putting decisionsinto effect before, during, and after a disaster. The most effectiveapproach to planning such a variety of measures is to first review theeffects of disaster, to then think about which protective measuresmitigate the effects most common to all types of disasters, and finallyto consider those measures that are related to specific disaster types orthat are applicable to unique local conditions.In reviewing the known effects of disasters on environmental health,it is evident that damage to civil engineering structures, the contami-nation of food and water supplies, power outages, and transportationfailure all are of high probability and often are critical elements of astate of emergency. Appropriate measures to counteract each of theseeffects will be discussed.

Civil Engineering Structural DamageAny natural disaster can destroy or severely damage civil engineer-ing structures: buildings; water structures (such as pipelines, pumpingstations, intake structures, and dams); retaining walls; electricalpoles; roads; and platforms. Damage of these structures can causecasualties to nearby individuals, and it may lead to either partial ortotal disruption of lifeline services to the communities they serve.


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Making advance preparations for the possibility of destruction andmodifying existing facilities are major ways in which the damage canbe reduced or eliminated. Structures can be reinforced to withstand theimpact of a disaster. Likewise, the anchorage and support of machin-ery, equipment, and storage tanks can be improved. Bypass facilitiescan be provided; for example, in preparation for the possibility that awater plant, its equipment, or processes may fail, the plant can bebypassed to a point where raw water can be chlorinated. Finally, theadoption of standard operating rules and procedures will maximizereadiness for any disaster.Another way to reduce the impact of disaster on civil engineeringstructures is to improve the planning of the data base and of designstandards. Conducting meteorological, topographical, hydrological,geological, and soil engineering studies in newly chosen sites willenable planners to avoid vulnerable locations. Vital structures can belocated in areas known to be protected from the impact of disasters.Specific design methods can be prepared, used, and updated to protectstructures, equipment, and supplies from disaster. For example, waterdistribution reservoirs can be sized with a storage factor of 1 l/2 to 2times their normal capacity in order to guarantee emergency supplies.

Contamination of Food and Water SuppliesContamination of food or water is one of the major public healthhazards associated with the occurrence of disaster. Contamination cantake place at the source of the supply, during transport, at thetreatment or processing plant, during storage, or at various timesduring distribution. The primary cause of contamination after adisaster is damage to civil engineering structures.Unless there are good reasons to suspect that chemical contaminantshave found their way into food or water supplies, microbiological

contamination should be the first concern of the decision maker inemergency cases. It is recommended that means to identify andmonitor microbiological (and, whenever possible, chemical) character-istics of food and drinking supplies be found in emergency periods.Food analysis, however, is feasible only if the requisite laboratoryservices were available prior to disaster. Highly technical resourcerequirements make analysis of food products more difficult than that of


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-1. \~Z(TIFFCI WFC~~I UCF PA HOA water caretaker in Saint Lucia diverts surface water to a reservoir for disinftvtion.

Preparedness includes ilssessing the ru!nerahility of water treatment plants and rtwrvoirs.


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water. Inspection techniques and field test kits can be used for a quickassessment of food contamination.Other measures to avert the effects of contamination are to identifyalternative sources of safe food and water if regular supplies areunusable, and to identify standby or portable water processing ortreatment units for use if the system fails. When economically feasible,means should be provided to drain or reduce water supply levels asquickly as possible and to use large dilution capacities to reduce thestrength of contaminants. Actions to take against contaminants in thevicinity of source supplies need to be devised.

Power OutagePower outage--mostly due to damaged transmission lines, damagedcivil engineering structures, and equipment failures-is a commonoccurrence both while a disaster is in progress and in its aftermath.Outages tend to exacerbate problems with delivering lifeline services.They cause the disruption of operations in pumping and treatmentplants in water systems and in pumping fuel. They also interfere withthe refrigeration essential for safe food storage, and they limit theability of hospitals to provide their services.Measures to overcome the effects of power outages include providingnonelectrical means of maintaining limited power distribution (bytaking advantage of gravity flow in providing water supply, forexample) and supplying alternative electrical and auxiliary powersystems to such critical facilities as pumping stations, processing andtreatment plants, and hospitals. It is better to use portable generatorsthan standby generators. Fuel for auxiliary power must be stored insticient quantities for three to five days of operation. Finally, powersystems should be designed to allow the bypassing of plants andequipment, thus preventing total disruption of service when power

fails.Transportation Failure

Transportation is critical to the success of disaster relief efforts. Itsfailure can cripple the provision of lifeline services, particularly waterand food supply distribution and solid waste disposal.


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Predisaster Health Measures 19

J. Vizcarra BrennedPAHOAll means for transportation of water during an emergency should be identified.


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The effects of transportation failure can be reduced by constructingalternate secondary roads to vital locations of the water supply system.All other means of transportation that can be used during theemergency also should be identified. Rough terrain vehicles, such asthose with four-wheel drive, and animal-traction vehicles are particu-larly useful after disaster. They are excellent for transporting bothpeople and goods over short distances. In addition to taking thesemeasures, a list should be prepared outlining the priority means oftransportation to be available in the aftermath of disaster.Basic materials, such as chemicals and spare parts, should bestockpiled against the possibility of transportation failure. It is recom-mended that arrangements be made with local distriblltors of chemi-cals, fuel, spare parts, and food to stock a small percentageof essentialitems that can become available during an emergency. In Barbados,for example, an agreement has been reached with local distributors offood to keep enough of certain items in stock to last five days. This notonly guarantees the availability of essential foodsafter disaster, it alsoeliminates the costs of maintaining food stocks for long periods by thenational relief organization.Education of Personnel and the Public

A primary consideration in developing a state of preparedness n adisaster-prone area is the proper education of both personnel and thepublic. Each environmental health service, public and private, mustdevelop training programs for emergency operations. Such trainingprograms may offer an orientation course to all personnel aboutemergency measures for natural disasters. The course should be of ageneral nature, providing information regarding what may happen,what can be done by whom, and how to do it. It should be repeated atleast once a year as a means to instruct new personnel. The courseshould be complemented by a more detailed one prepared for essentialemergency personnel-employees selected for training to performcertain tasks in emergency situations.A program for preparedness also should include training exercises.Periodic drills are important for personnel to practice emergencyoperational measures. The training program can be reinforced byspecial courses about emergency situations or by conferences, semi-nars, and printed material about natural disasters.


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Predisaster Health Measures 21

Public education is of utmost importance in emergency situations.The aim of a public education program should be to win the acceptanceof disaster preparedness in disaster-prone areas. Awareness of theemergency measures that may be necessary and of what may beexpected of the public is a major step toward the reduction of operation-al problems.


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Chapter 3Phase Two:Measures Taken during Disasterand in the Aftermath

The emergency environmental health control measures of PhaseTwo are divided into three time frames, and these immediate emergen-cy periods are followed by a period of consolidation. The first of theemergencyperiods, the warning period, is a few hours or a few days induration. The second, the disaster occurrence period, lasts from anumber of secondsor, when the onset is slow, a number of days. Thethird, the postdisaster immediate emergency period, lasts three to fourdays after the disaster. The consolidation period may also last three tofour days. There are a number of measures o be taken in each of thesespans of time.Emergency Warning Period

Emergency environmental health control measures should be putinto effect as soon as warning is received that a disaster is imminent(this obviously applies only in such caseswhere warning is available).The goals of environmental health management in threatened areasare to protect the population and to ensure a state of preparednessandthe avaiiability of water, food, shelter, and clothing.Specific measures o be taken in the warning period include inform-ing and mobilizing personnel of all environmental health services.Inventories should be obtained of the available recommended healthpersonnel, equipment and supplies needed to address anticipatedcontingencies. Key elements of water and food supply and humanwaste systems should be protected against impact. The threatened

23


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24 Environmental Hearth Management

population should be informed about appropriate measures to take forself-protection. They should be requested to store ample quantities ofwater in clean containers, such as bathtubs.If the onset of disaster will be relatively slow, as in the case of somefloods or hurricanes, the criteria for a number of measures should bereviewed and disseminated. Among these criteria are those for theestablishment of emergency shelters in camps or buildings, the useand development of re~x~ces~ and proper procedures for issuingrequests for aid.

Disaster Occurrence &GodThe rescue and accommodation of displaced persons are the objec-tives of measures taken during this period. During rescue operations,special attention must be given to the establishment of camps fordisplaced persons. Environmental health technicians should be includ-ed as members of the teams that determine the criteria for choice ofcampsites and design of camp layouts. This step is particularly impor-tant because once people are settled in particular locations, it is difficultto ask them to moue again. Areas proposed for accommodating dis-

placed persons must be surveyed in order to determine whether basicenvironmental health services can be provided and whether use of thesites might upset the environmental health services of the area or ofsurrounding areas.If the natural disaster persists, the impact of its progression shouldbe monitored. Damage should be evaluated at this time and personnelshould draw up lists of priority measures to resolve the problemsidentified.

Immediate Postdisaster Emergency PeriodThere are five major concerns to address as soon as the full impact ofthe disaster begins to diminish and the relief effort can be initiated:making basic quantities of safe drinking water available to the generalpopulations and essential users; providing safe, adequate shelter tostricken populations; protecting water and food from contamination byhuman waste; ensuring that victims follow the principles of basic


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Measures during and after Disaster 25

personal hygiene; and protecting the affected populations againstvector-borne diseases that are prevalent in the disaster-stricken area.Addressing these concerns effectively will depend on evaluating thedisasters impact on environmental health conditions and services.Thus, an initial survey is required of the availability of health andother related services in the stricken areas. Particular focus should beplaced on public supplies of water and food, human and solid wastedisposal, housing, and power systems. An inventory is necessary ofavailable resources, essential personnel, equipment, supplies, and?.-gistics that can be used to meet immediate needs.To determine which areas merit greater attention because of multi-ple risk factors for disease and other hazards of high populationdensity, information should be gathered about population movementswithin or near stricken sites. For example, t,he presence of partially ortotally evacuated areas and of settlement sites for displaced personsand relief workers needs to be known.The specific environmental health concerns that must be addressedin the immediate postdisaster emergency period are described in detailbelow.

Water SupplyDrinking water, the most essential item provided to disaster-strick-en populations, is both indispensable to the support of life and a majormedium of disease transmission. Thus, although provision of adequateamounts of water for drinking purposes is of utmost importance afterdisaster, it is simultaneously necessary to ensure the potability of thewater used for drinking in asected sites.Adequate drinking water should first be made accessible to victims

and relief workers and in essential locations, such as hospitals andtreatment centers. Water can then be made available in peripheralareas of urban centers and in densely settled rural areas and scatteredrural s ites. After drinking water is secured within stricken areas,making water available for domestic uses (such as cleaning andwashing) should be considered.Drinking water should be obtained from operational water distribu-tion systems. However, it also should be sought from undamaged,


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private sources (such as power plants, breweries, and other similarestablishments); from undamaged springs, wells, or rainwater cis-terns; and from newly constructed water structures, such as bore-holedwells. All water supplies must be carefully evaluated in order toeliminate the risk of water-borne infection and poisoning. The adviceof an environmental health specialist (e.g., a sanitary engineer orsanitarian) should be sought when auxiliary water supplies arechosen.Water suspected of contamination by human or chemical wasteshould not be used until it has undergone laboratory analysis. Sourceslocated in the vicinity of sewage outfalls, chemical plants, solid wastedisposal fields, abandoned mines, and other hazardous places should beconsidered suspect until such time that an environmental healthspecialist familiar with local conditions recommends otherwise.Water delivered to disaster-stricken populations must be kept safeuntil consumed. This is ensured by disinfecting all supplies, particu-larly from surface sources and flood structures (such as wells, reser-voirs, and rainwater cisterns), within stricken areas. The systematicdisinfection of unaffected supplies is not necessary, however; thiswould be wasteful of the already scarce human and material resources.Proper health education should suffice to reduce the use of unsafewater supplies.Ensuring the safety of drinking water is a function of a large numberof measures. First, water should be tested for the presence of Esche-richia coli and unsafe concentrations of nitrate as soon as possible.Detection of E. coti indicates contamination by human waste andtherefore requires immediate protective and corrective measures.High concentrations of nitrate are extremely dangerous for infants, sothis age group must be protected.The residual concentration of chlorine in the distribution systemshould be increased after disaster. This reduces contaminants that canenter the system because of inadequate water treatment and allowsdetection of any water already contaminated that penetrates thedistribution system. The dangers posed by water collected and storedin a nonhygienic fashion also will be diminished.From previous experience we know that great care must, however,be taken to avoid overchlorination of drinking water. It is important toascertain that supplies, especially of public water, are free of chlorineresidual. Before chlorination begins, whether through the distribution


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of tablets or the issuing of instructions for the use of household bleach,it is recommended that the chlorination program be supervised by anenvironmental health specialist.The monitoring of water quality should be restored or initiatedimmediately. During this phase of emergency measures, daiiy deter-mination of the chlorine residual in public water supplies is sufficient.Increasing water pressure compensates for pressure loss due to thebreaks of mains and helps to control contamination. It is imperative toconsider the importance of water pressure in multistory housing.If water supplies in the disaster area are not being chlorinatedbecause chlorination systems within the distribution networks are notfunctioning, water must be disinfected in small quantities. This can beaccomplished by boiling the water or by adding agents in the form ofpills, powder, or solution. Methods for disinfecting small amounts ofwater that the Pan American Health Organization recommends areenumerated in Annex 2.It is usually worthwhile to use mobile water purification plantsduring natural disaster emergencies if they are available locally.However, they produce limited quantities of water. In most casesmobile units are not essential and are of low priority in requests foraid. For the relatively minimal benefits they bestow, they are expen-sive; also, when shipped they occupy valuable space that is better usedfor drugs, medical supplies, food, and clothing.Large volumes of water that will be hauled to camps or othersettlements and to consumers in affected areas also should be disinfect-ed. This can be accomplished with a chlorine compound (e.g., calciumor sodium hypochlorite) in the dosages and at the contact timesrecommended.Tanks used for transporting and storing drinking water must be freeof and protected against contamination. Mosquitoes should not bepermitted to use such tanks as breeding sites. Tanks available locallyfrorn~commercial water companies, dairies, breweries and so forth canserve to transport water if they are cleaned and disinfected before use.The general rule is to avoid placing drinking water in adaptedgasoline, chemical, or sewage trucks and containers.The final measure for protecting the safety of water is to repair andrestore all public supplies. This should be undertaken immediately.All repaired mains, reservoirs, wells, cisterns, and similar units shouldbe cleaned and disinfected.


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Environmental SanitationEnvironmental sanitation measures are necessary for protecting theenvironment from the human wastes normally responsible for thecontamination of food and water. Such measures also counteract thedevelopment of breeding sites of disease vectors and pests. Excretadisposal should receive primary consideration. Improper disposal notonly leads to the contamination of water and food supplies; it alsoattracts flies and other disease-carrying pests. Other measures that.should be taken are providing a sanitary solid waste system, includingreceptacles, means of transportation, and incineration and burialfacilities at camps; providing a disposal system for liquid wastes; andrestoring municipal disposal services.For appropriate excreta disposal, trench latrines should be dug atcamps and relief worker settlements. When this is not feasible, toiletfacilities such as portable units should be provided. The trench latrinesshould be made accessible in densely populated areas if excretadisposal facilities have been destroyed. Tools and other materialsshould be given to the population, who should be instructed aboutconstructing such facilities under the supervision of an environmentalhealth specialist. Moreover, a health education program in latrineusage is essential to the sanitary upkeep of latrines.As soon as excreta disposal systems have been provided, attentionshould be turned to public sewage systems. First, sewer lines andmanholes that cause flooding in the streets and basements of denselypopulated areas should be unclogged. The next step is to repair sewerlines, manholes, sewer outfalls, and treatment units. Sewage tanktrucks can be used to empty the overflow from septic tanks in publicbuildings used to accommodate displaced persons, casualties, andrelief workers.

ShelterAs soon as rescue work has started, accommodating displacedpersons under conditions that will not lead to the deterioration ofpublic health and the environment should be considered. Immediatelyfollowing a natural disaster, displaced persons usually seek accommo-dation with families or friends. In some cases, public shelter has to beprovided temporarily until more permanent locations can be planned.


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Existing public buildings--schools, meeting halls, churches, and ho-tels-often are chosen as temporary shelters because they can beconverted easily into dormitories. They are also likely to have sourcesof water supply and waste disposal and bathing and washing facilities.Some even have cooking and mass feeding facilities.It is important to underscore the fact that once individuals havebeen located and established on a site, it is difficult to ask them tomove again. This point should be considered carefully especially in theestablishment of camp settlements.After the first two or three days following a disaster, more perma-nent shelters may become necessary. At this time, accommodatingdisplaced persons should receive priority. To reduce the number ofdisplaced persons who require shelter, they should be encouraged andassisted o stay with family or friends. As soon as pussible, they shouldbe helped to return to their own homes. If adequate resourcesexist toprovide them with materials for constructing temporary shelter ontheir own property, this step should be taken. Wherever they locate,however, they must have access o water and food and a sanitarymeans of waste disposal.

J. Vizcarra BrennedPAHOThe crowding and lack of sanitary facilities characteristic of temporary settlements createhealth hazards. Displaced persons should be helped to return to their own homes.


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30 Environmentai Health Management

Accommodating displaced persons in tent camps should be consid-ered only as a measure of last resort. The use of uncompleted publichousing projects instead has, for example, proven a very elective wayto provide temporary shelter.Food Sanitation

Locally available food products can become degraded or contaminat-ed as a result of a natural disaster. Food usually becomes contaminat-ed by polluted flood waters and, in some cases, by disease vectors andby unsanitary handling, especially in mass feeding facilities. Degrada-tion results from long periods of power outages that disrupt refrigera-tion and from contact with water, fradulent adulteration, and the useof old stocks of food products.Since consumption of contaminated and degraded food leads topoisoning or infection, it has serious health implications. These conse-quences are best dealt with by locating available food supplies andinvestigating their fitness. Priority should be given to the consumptionof uncontaminated, perishable food, particularly if the food supplyoriginates in areas where there has been a power outage. ALZ food,however, needs to be inspected. The analysis of food products should beof low priority, because it often is too complex an undertaking toinitiate in areas affected by the disaster. Adequate inspection never-theless can be made with simple kits for testing food, such asphosphate determination kits.A qualified environmental health specialist should inspect all dam-aged places of food production and distribution before operations arecarried out. The activities at mass feeding facilities also should besupervised by a specialist.To avert health problems related to food degradation and contamina-tion, the public should be informed about measures that can be takento guarantee the safety of domestic supplies. The public should knowwhich foods are safe to consume and the best methods of preparingthem.Vector Contd

The impoundment of rain or flood water in empty receptacles or onthe soil and other places creates unsanitary conditions because debris


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Measures during and a/-?erDisaster 31

and solid wastes accunu&&e, and it allows insects and rodents toproliferate. Certain diseases-malaria, yellow fever, typhus, tulare-mia, and &m&al infections-are transmitted in this way; foodsupplies can be reduced; and other nuisances are created.The god of emergency activities is to control vector-borne diseases,especially where they are known to be prevalent. Environmentalhealth control meas-aes should be reinfbrced by other health measures(for example, chemoprophylactic efforts to control malaria).Hou&hes and rodents are nearly impossible to control in theaftermath of&aster. Environmental sanitation and personal hygienemeasures are the only ef$ec$iveways to combat the problems theycreate. Food and water &otiId., be stored in areas where flies androdents cannot get to them, and all debris and solid wastes should becleaned up and disposed of as soon as Possible-Many steps can be t&en to ensure effective control of vectors duringdisaster-created emergencies.2 AlI operations should be supervised bya qualified specialist in vector control, preferably one with experiencein disaster-stricken areas.Both the threatened population and specialists must work to elimi-nate breeding sites. me population should be informed about mea-sures to eliminate such sites and about other means of protecting

themselves hm vector-borne diseases. Authorities should take per-manent measures-drainage, filling, overturning receptacles, and soforth-to eliminate breeding sites. Locally obtainable larvicidesshould be utilized in large-scale water impoundments, since the directelimination of such ho&es of water requires excessive time, effort, andresources.Potential breeding sites of mosquitoes should be identified bysurveying campsites a& other densely populated areas. These surveysshould focus on specific diseases transmitted by the mosquitoes ratherthan on general mosquito control* Wherever malaria is prevalent, forexample, the purpose of the survey should be to identify the breedingsites of the speciesof mosquitoes which carries malaria (the Anophe-led.These measures till greatly reduce the need to spray insecticides,2. For detailed measures against specific ector&We mergency Vector Control afterIVatu& D&a&r, Pan American Health Organization, scientific Publication No.419 (Washington, DC., 1982).


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Marcel0 MontecinolPAHOTrash collection in Havana, Cuba, during the 1981 dengue fever epidemic. The sanitary disposalof trash and garbage is essential in vector control.


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Il:1,4)If.


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the emergency, reduce confusion, and improve the effectiveness ofemergency environmental health activities.Environmental health measures applicable to emergencies createdby natural disasters are summarized in Annex 3. These should be ofva!ue to decision makers in formulating and publicizing policiesduring emergencies.Consolidation Period

A few days into the emergency period, those environmental healthmeasures that have been taken should undergo consolidation. Themeasures to be accomplished in this period of consolidation includepreparing lists of needed assistance and submitting them to rti>liefagencies, receiving and distributing the aid, and establishing camps.Providing Relief Agencies with Lists of Needs

By comparing current needs to the results of earlier surveys, one orseveral lists should be made of technical manpower, equipment, andsupplies needed. Lists should be prepared for representatives of nation-al and international agencies, giving priority to aid obtainable fromlocal rather than foreign resources.Receiving Aid

All aid received must be checked against the lists of aid requested inorder to ensure that needed items actually have been provided. Thesuitability of equipment and supplies also needs to be checked; thismay require assistance from a local expert, such as a chemist or anengineer. To avoid damage and waste of incoming aid, all equipmentand supplies should be handled properly.Distributing Aid

A list should be made of priority areas to receive aid. Distribution ofgoods should be guided by good judgment of actual needs so that localcapabilities are not overwhelmed. When aid is distributed improperly,valuable supplies may be wasted.


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Establishing Settlements for Displaced PersonsSafe water, food supplies, and basic sanitation facilities must beavailable in all camps for displaced persons. Sanitation teams, whichwill provide services and educate camp dwellers, should be designatedfor each campsite. Teams can be composed of volunteers, but theyshould be supervised by an environmental health technician. Theyshould develop sanitation regulations for the sites and make theresidents aware of them.Finally, settlement dwellers must be encouraged o return to theirhomesas soon as they can do so safely. They should return to the sitesof their homes even if they need to be given construction materials forerecting temporary shelters on their property.


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Chapter4Phase Three:Rehabilitation Measures

Although rehabilitation implies the reconstruction of services topredisaster levels and therefore involves long-term postemergencyactivity, some rehabilitation measures have to be taken during boththe emergency and immediate postemergency periods. Environmentalhealth rehabilitation measures should be initiated as soon as possiblein the emergency phase. The specific rehabilitation measures to beundertaken during the emergency phase are to restore lifeline servicesimmediately, to return environmental health surveillance back to itsnormal state, and to evaluate the emergency operations plan once ithas been implemented.Restoration of Lifeline Services

All of the lifeline services-water supply, sewage and solid wastedisposal, electricity, transportation, communication, and, in someinstances, heating fuel-should be given primary consideration. Thefirst short-term measure to address breakdowns in lifeline services isto create a national committee of representatives of all local andgovernment service agencies and at least one environmental healthspecialist. The committee should assume responsibility for planning,monitoring, and coordinating all reconstruction activities. If neces-sary, a subcommittee for health and environment may be formed tooversee responses to specific public health problems.Technical surveys for evaluating and planning the restoration oflifeline services should be conducted by specialists familiar with theaffected areas and their predisaster conditions. They should gatherinformation about specific equipment and supplies needed, in addition37


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to information concerning general reconstruction needs. The surveyshould enable officials to establish the order in which measures mustbe taken to achieve both the short-term and the long-term restorationof services.Once the emergency period has passed, replacements for partiallyand totally destroyed su.pplies and parts will have to be purchased. Thelist of items to be ordered should be drawn up during the technicalsurveys. Purchase orders for these should be completed at the earliestpossible time, since procurement frequently is delayed.Supplies and parts should be ordered from abroad only if they cannotbe purchased locally. In the same vein, expertise and manpowerresources to carry out repairs and the construction of environmentalservices should be contracted locally whenever possible. The cost ofmanpower and material resources usually increases substantially inemergency situations; thus, employment of members of the strickenpopulation is socially and economically beneficial.Plans for restoring lifeline services should be designed to strengthenenvironmental health services in stricken areas. This may call forimproving upon the human, material, and financial resources andoperating methods of the predisaster services.Restoration of Essential Environmental Health SurveillanceActivity

Essential environmental health surveillance activities should beinitiated or restored as soon as environmental health services are inoperation. The purposes of surveying environmental health servicesprimarily are to ensure that no increased risk of disease exists and tomeasure the progress of the activities conducted during both theemergency and rehabilitation phases. Only essential surveillanceactivities should be considered; it may be judged necessary, however,to develop special environmental health surveillance programs oneither a short-term or a long-term basis. The essential activitiesdiscussed below are presented in order of importance.Water Quality

Routine testing of chlorine residual in the water should beginimmediately after tne disaster occurs. Routine determination of levels


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Reh.abilitation Measures 39

of Escherichia coli and nitrates should be initiated thereafter. Oncemunicipal water distribution systems have been restored, routinetesting should begin for chlorides, sulfates, magnesium, total dissolvedsolids, and pH level. If the concentration of chloride changes dramati-cally, it may indicate contamination of the water by human waste. Thepresence of high levels of sulfates, magnesium, and totally dissolvedsolid concentrations needs to be checked, because these can have alaxative effect.Food Supplies

Utmost in importance is surveillance of the sources and quality ofthe water supply used in food preparation, the cleanliness of thepremises where food is handled and prepared, washing facilities,sanitary storage of food supplies (including refrigeration), and facili-ties for sanitary excreta disposal. Testing of milk quality to determine

J. Vizcarra BrennerlPAHOAn open marke t, South America. It is important to monitor the cleanliness of areas in whichfood is handled and prepared.


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if water has been added may be done routinely if phosphatasc determi-nation kits are available.

During this phase, surveillance of latrine construction projects, solidwaste handling, and general sanitation in high-risk places (such assettlements for displaced persons, hospit.als, and schools) should berestored or initiated.

Evaluating GIP Emergency Operations Action (EOA) IhUpon consolidating the emergency and postcmergcncy mcasurc!s, itis necessary to evaluate comprehensively all ottho activit,ios that havetaken place. Both the strengths and weaknesses of the predisastor,emergency, and immediate postemergency measures should be under-scored. This information can be used to itnprove the entire emergencyplan handling postdisaster problems. It also reinforces policy decisionsabout rehabilitation, such as those concerning changes in the designand construction of civil engineering structures and replacing equip-ment and supplies.The questions to be posed during the evaluation arc the foliowing:1. What happened during the disaster?2. What did not happen? Why?3, Who was or was not there?4. What should be done to improve the entire EOA Plan?5. What laws or regulations need to be changed to improve the EOAPlan?6. What material should be stocked for etnergency use in the future?The report of this final evaluation shoulcl be o&red to the localgovernmental and nongovernmentat agencies of concern and to inter-national relief organizations. An evaluation of this kind will alsoensure proper coordination of routine activities, essential for improv-ing preparedness for the future occurrence of disaster.


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Part IIIAnnexes


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Annex 1Developing an EnvironmentalHealth Emergency Operations PlanStep 1: Identifying Organizational Resources

The first step in developing an environmental health emergencyoperations plan is to make an inventory of the organizations that willparticipate in the emergency activities and to assign members of theseorganizations to particular staffs and teams. Professionals, each work-ing with an advisory committee, should be responsible for developingthe plan and training the individuals who will participate in the reliefeffort. clontact should be made with civil defense, military, and othergroups to learn about local contingency plans, to ask for help inplanning for disaster, and to establish channels of liaison. The respon-sibilities of organizational stall members and teams and channels ofcommand should be specified. In assigning individuals to the groups,alternates also should be designated. A list of names, addresses, andphone numbers should be made, including both regular and alternatemembers.Step 2: Vulnerability Analysis

Assessing vulnerability is the second step in developing the plan. Toassess he vulnerability of areas that may be stricken by disaster, it isnecessary first to identify and describe the components of entireenvironmental health service systems and then to chart the character-istics of those natural disasters that might occur (floods, earthquakes,windstorms, and so forth). The effects of each type of disaster on eachcomponent of services can then be estimated. (If 50 percent of the watertreatment plants serving a particular area might be damaged whendisaster strikes, for example, the result might be that safe water can be43


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provided to only 15 percent of the affected population.) After theseestimates have been obtained, the service requirements and thecapacities of services to meet these requirements should be estimated.This estimation reveals the balance between the capacity of a serviceaffected by disaster and the minimum estimated need for it in thepopulation. If the capacity exceeds the estimated need, there is amargin of safety, and priority placed on that service can be relaxed.But if requirements exceed the estimated capacity of the service, thisindicates a need to improve the service. Finally, the critical compo-nents of services should be identified.Step 3: Allocating Resources

The third step is to specify priorities and establish the best programfor using resources. Baseline environmental health levels should bedetermined. Needs and their priorities can then bs established byallocating services under assumed postdisaster conditions, preparingguidelines for service allowances, rationing and deciding upon thetiming of estimated needs, and selecting procedures for dealing withthe conditions caused by disasters.Step 4: Protecting Personnel

The fourth step is to make provisions for protecting personnel. Aplan should be developed to test personnel with exercises to familiarizethem with emergency procedures. The program for providing sheltershould guarantee shelter to essential personnel.Step 5: Inventory of Supplies and Equipment

In the fifth step, the equipment, supplies, and other materialsnecessary for the emergency are assessed. It is necessary to makeinventories of those needs that will be essential for recovery, to plan todispense them as necessary, and to provide security for them. Multiplecopies should be made of the following records that will facilitaterecovery:1. maps and engineering plans2. lists of regular and auxiliary personnel


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-

Annex 1 45

3. lists of emergency supplies, including description of their avail-ability and how to use them4. inventories of items in stock5. descriptions of emergency methods of operation ar,d procedureThese records must be readily accessible to persons employed at alllevels of environmental health services. Plans must be made forupdating them and for keeping mutual aid parties informed of theircontents and location.

Step 6: Coordination AgreementsIn the sixth step, mutual aid agreements and other cooperativearrangements are initiated. Agreements with related services andcivil defense agencies encompass the exchange or assignment ofpersonnel, equipment, and supplies of the various cooperating groups.The coordination of reconnaissance and assessment, taking inven-tories, standardizing, training, and so forth also are covered in theagreements. Responsibilities should be defined and assigned, and legallimitations of cooperation should be considered.

Step 7: Specifying Emergency MeasuresOnce mutual aid agreements have been established, the seventhstep follows: determining the actions to be taken during the emergencyphase. The longer the period of warning, the greater the number ofdisaster readiness measures that can be accomplished. Disaster readi-ness measures include the following:1. alerting and assigning personnel2. undertaking abbreviated training3. disseminating information to the public4. increasing the protection of personnel5. increasing the protection of structures and equipment6. receiving emergency plans and proceduresThe concerns of the warning period are personnel, plants andequipment, community action liaison, and public information. Con-


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46 bnvironmental Health Management

terns of the period of impact are public information and, as limited byconditions, operations.Step 8: Specifying Recovery Measures

The eighth step is to plan the postdisaster recovery. First, commandmust be assumed, and these actions must be taken:1. activation of the disaster organization2. mobilization of regular and auxiliary disaster relief staff mem-

bers3. the implementation of procedures for protecting personnelFollowing this, the plan for maintaining or initiating liaison withmembers of relief services and mutual aid agencies should be devel-oped. Procedures must be provided in time phases for the following:1. reconnaissance2. assessment of damage3. determination of priorities4. cleaning and decontaminating5. initiating the operation of surviving facilitiesThe least of these measures consists of conserving water and food;isolating and repairing damaged facilities; monitoring environmentalhealth factors, such as water supply; and advising the public.

Step 9: Improving CapabilitiesThe final step is to improve the capabilities of services if deficiencies

are indicated. This is accomplished by increasing stocks of materialsand supplies, developing auxiliary power sources and providing sup-plies offuel, acquiring additional repair equipment, and recruiting andtraining personnel-volunteers, retired individuals, and other similarworkers. The emergency plan must be improved and updated as aresult of new additions. Finally, private benefactors who can augmentlocal capabilities during emergencies should be identified, and a list oflocal consultants who can be called upon in emergencies should becompiled. All of these measures should be repeated at least once a year.


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i

In general, these disinfectants should be considered during anemergency for disinfecting small quantities of drinking water inlimited and controlled populations, on an individual basis, and only forthe limited time period of one to two weeks. Every effort should bemade to restore normal chlorination facilities and to guarantee thatwater sources are protected.Whenever disinfection is considered during an emergency, carefulattention must be given to the initial condition of the water. Turbidityand color should be reduced as much as possible by allowing the water

Annex2Guidelines for the Use of Tablet,Powder, and Liquid Disinfectantsin Emergency Situations

Providing tablet, powder, or liquid disinfectants to individual usersshould be considered only when distribution can be coupled with:1. a strong health education campaign in which people are instruct-ed about how to use them2. the distribution of containers for water storage3. the assistance of public health or auxiliary personnel in providing

the follow-up needed to ensure proper and continued use of thetablets4. a network for distribution of additional supplies needed through-out the emergency phase and into the rehabilitation phase

Adapted from The Pan American Health Organization Interoffice Memorandum:Provisional Guidelines on the Use of Water Disinfection Tablets following NaturalDisasters (Washington, D.C., 1979).

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to settle or by straining it through layers of cloth. Once disinfected, thewater should be stored in clear, covered, and noncorrodible containers.Before any form of disinfectant is provided to individual users foremergency treatment, public health personnel must be sure that theavailable sources of water to be used are not and have not beenchlorinated. The chlorine residual should be determined before anydisinfectant is distributed to individual users.The most common agents that can be used to disinfect smallquantities of drinking water under emergency conditions are chlorine,iodine, and potassium permanganate. Detailed discussion of eachfollows.Chlorine CompoandsTablets

The most common chlorine compound in use is known as Halazonetablets. Instructions for use of Halazone tablets are usually present onthe bottle. If not, one tablet (4mg) should be used in each liter(approximately 1 quart) of water. If the water is turbid or highlycolored the dosage should be doubled. The water should be stirred andlef% o stand for ten minutes before it is consumed. bHalazone tablets lose strength quickly once the wax seal on thebottle is broken. They should, therefore, be used as soon as possible,and the bottle should be capped between uses.Higher strength tablets (160mg) are available in larger tablet size.Halazone (160mg) can be used to disinfect 40 liters of clear water or 20liters of turbid or highly colored water. Care must be taken to notutilize Ha&one (160mg) in the same tablet-to-water ratio as thatprescribed for Halazone (4mg) tablets. Personnel involved in distribu-tion should be aware of this precaution and should educate users.Granular Calcium Hypochlorite

This dry powder, called HTH or Perchloron, contains 60 to 70percent available chlorine. It remains quite stable when stored intightly sealed containers in dark, dry, cool places. Once the containerhas been opened, it loses 5 percent of its initial available chlorine inforty days.


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Annex 2 49

care must be taken not to contaminate the powder with oil orcombustible organic materials when it is mixed, because to do SO mayCau~ fire. To use HTH, add and dissolve one heaping teaspoon(approximately l/4 ounce or 7 grams) per 2 gallons (8 liters) of water,thus producing a stock solution of 500 milligrams/liter. Add the stocksolution to the water to be disinfected in the proportion of 1 partsolution to 100 parts water. Let this stand for thirty minutes. If thetaste of chlorine is too strong, allow it to aerate by standing anotherfew hours or by pouring it several times from one clean container toanother. The stock solution should be used within two weeks after it isprepared.Sodium Hgptwhlorite Bleach or &we1 Water

c@mmonhousehold bleach contains a compound that can, in emer-gencies, be used to disinfect water. The content of available chlorine(dually 3 to 10 percent) should be determined. It should be added tothe Water according to the following table:Availablechlorine

1%4-6s7-10s

Drops/liter of Drops/liter of turbidclear water or colored water--.--__ -~.-._- .__. __ __ . _^... _~ ~~ ..10 202 41 2

If the strength of available chlorine in the bleach is unknown, tendrops of bleach should be added. After mixing the treated water, allowit to stand for thirty minutes. There should be a slight odor of chlorine.If not, repeat the dosage and allow the water to stand for fifteenminutes.IodineTablets

The most convenient and reliable iodine tablet forms are those thatcontain approximately 20 milligrams of tetraglycine hydroperiodine,90 milligrams of disodium &hydrogen pyrophosphate, and 5 milli-grams of talc. These tablets will dissolve in less than one minute at


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about 20C, iberating 8 milligrams of elemental iodine per tablet. Thisamount will be adequate to treat 1 liter of most natural waters withinten minutes.

Common household tincture of iodine from a medicine chest or firstaid kit (2 percent tincture of iodine) can be used to disinfect water. Fivedrops of tincture of iodine will be suflicient to disinfsf. 1 liter of clearwater. For turbid water, however, add ten drops. Let the water standfor at least thirty minutes.

Potassium Permanganate (KMnOJPotassium permanganate is seldom used becauseof its long contacttime. It is usually considered as a disinfectant for large quantities ofwater in wells, springs, or storage tanks. Potassium permanganate isof doubtful efficacy against pathogenic organisms, with the possibleexception of Vibrio choleme.To use the chemical, prepare a solution by dissolving 40 milligramsof KMnOd in 1 liter of warm water. The solution will disinfectapproximately 1 cubic meter of water after twenty-four hours ofcontact time.,


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Annex 3Technical Guide to EnvironunenHealth Measures Taken inResponse to Natural Disaster

This annex consists of a summary of recommendations. These are tobe carried out during evacuation and relief operations.Evacuation

During evacuation, water from suspicious sourcesmust be boiled forone minute before it is cooled or it must be disinfected with chlorine,iodine, or potassium permanganate in either tablet, crystal, powder, orliquid form. The minimum amounts of water to be provided are:3 liters/person/day in cold and temperate climates;6 liters/person/day in hot climates.Food must be nonperishable and should not require cooking.Waste disposal should be in a shallow, all-purpose trench of thefollowing dimensions:10 centimeters deep x 45 centimeters wide x 3 meters long/l000

p=SOIlS.

: Relief Operations: Tent CampsDuring relief operations, sites for tent campsshould be chosenwherethe slope of the land and the nature of the soil favor easy drainage andwhere there is protection from adverse weather. Sites must be awayfern mosquito breeding places, refuse dumps, and commercial andindustrial zones. The layout of the site should meet the followingspecifications:

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1. 3-4 hectares of land/l000 persons2. roads of 10 meters width3. minimum distance between edge of roads and tents of 2 meters4. minimum distance between tents of 8 meters5. minimum floor area/tent of 3 square metersWater distribution in campsites should consist of:1. minimum capacjty of tanks of 200 liters2. minimum capacity/capita of 15 liters/day3. maximum distance of tanks from farthest tent of 100 metersSolid waste disposal containers in tent camps should be waterproof,insect-proof, and rodent-proof; the waste should be covered ightly witha plastic or metallic lid. The final disposa l should be by incineration orby burial. The capacities of solid waste units should be:1 liter&8 tents; or50-100 liters/2550 persons.Excreta and liquid waste should be disposed n bore-holed or deeptrench latrines in tent camps. Specifications for these a

Documents

Environmental Health Management Natural Disaster No-430 1982