JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 1
JOURNAL OF HEALTH MANAGEMENTSPECIAL EDITION VOL II: DECEMBER 2015
2 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
ADVISOR
Dr. Shahnaz Binti Murad Deputy Director General of Health (Research and Technical Support)
EDITOR IN-CHIEF
Dr. Nor Izzah Binti Hj Ahmad Shauki Director, Institute of Health Management MD (USM), MCommHealth (H&HM) (UKM)
EDITORIAL BOARD
Dr. Nor Filzatun Binti Borhan MD (USM), MPH (UM) Datin Dr. Noriah Bidin MBBS (DOW), MPH (UM) Dr. Nor Haniza binti Zakaria MD (AIR LANGGA UNIVERSITY)
MANAGING EDITOR
Dr. Pangie anak Bakit Dr. Munirah Ismail Minson Majimbun Siti Zubaidah Ahmad Mohd Idris Omar Nooreyzan Manangin
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 3
Table of Content
Rapid Assessment Of Floods In Kelantan: Information For Action 5
Saraswathi BR1, Fadzilah K2, Rosemawati A21Penang State Health Department2Office of Deputy Director General of Health (Public Health)
Post Flood Delivery Of Humanitarian Assistance To 13The Orang Asli Settlements In Gua Musang, Kelantan
Alzamani Mi, Siti MY, Mohd Khairi AL, Hani HH, Syed Hazran SM, Abu HAA Emergency Department, Hospital Kuala Lumpur
Bugs In The Water: A Review Of Effects Of Floods 20 Among Rescue Workers, Healthcare Workers And Flood Victims
Eswaran KClinical Research Center, Hospital Duchess of Kent
Institute For Health Management - Transit Center For 38Flood Disaster 2015; Psychosocial Impact On Volunteers
Munirah I, Norhidayah MDInstitute For Health Management
Lessons From The Remediation Of A Flood-Damaged Health Clinic 49
Alzamani MI, Malathy R, Hafiz SM, Abu HAA Emergency Department, Hospital Kuala Lumpur
Post Deployment Activities And Challenges In Crisis 62Preparedness Response Center Institute For Health Management M Fairuz AR, Pangie B, Krishan O, Noriah B, N Filzatun B, N Izzah ARInstitute For Health Management
Managing Child Flood Victim by Psychological 75Engagement: A Pilot Project
Alzamani MI, Mona KG, Nurul LR, Hafiz SM, Ahmad IKB, Abu HAAEmergency Department, Hospital Kuala Lumpur
Public Health Challenges During Flood Disaster: Managing 86Food Poisoning Outbreak In Pusat Pemindahan MRSM Pasir Salak Perak Tengah District January 2015
Nor Samsiah AR, Ariza ARPerak State Health Department
4 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 20151
JOURNAL OF HEALTH MANAGEMENT SPECIAL EDITION VOL II: DECEMBER 2015
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 5
Rapid Assessment of Floods in Kelantan: Information for Action
Saraswathi BR1, Fadzilah K2, Rosemawati A21Penang State Health Department
2Office of Deputy Director General of Health (Public Health)
AbstractIn December 2014, Kelantan faced unprecedented flooding which damaged infrastructure, disrupted services
and caused mass destruction. The response mechanisms in place for such an event failed. The epidemiology
intelligence team was called in to carry out an assessment to determine functionality of the health centres,
identify potential threats and take immediate measures where possible. We assembled in teams at the
office of the Director General of Health and targeted eight affected districts affected. After collection of
information on functioning routes to the areas, we arrived at the field where we appraised the evidence
through direct observation, focus group discussion, key informant interviews and street interviews. We took
steps where possible to mitigate the risks identified on site. All evidence and information gathered form our
teams were channelled back to the National Coordination committee through social media application in
real time. This information was then transformed into action by the relevant departments and committees.
The basis for any action taken in times of disaster must be a good assessment of the situation on the field.
This is to target the response according to the need.
Key words: floods, information, disaster
IntroductionKelantan, located on the north-east coast of peninsula
Malaysia has a tropical climate and experiences
intermittent rain throughout the year. The North-
East monsoon that prevails from November to
January brings heavy rain to this region annually.
Often, during this period low-lying regions get
flooded. But climate change, can result in extremes
that may present in the form of floods, landslides and
flash floods. In December, 2014, an unprecedented
amount of rainfall caused massive flooding in the
state of Kelantan. The areas affected first were
those in the coastal, riverine and low-lying areas.
But with the concomitant high tides larger areas
were affected and the destruction that followed
came about in two waves. The first wave occurred
on the 17th December 2014 followed by another
wave on 25th December 2014.
Response mechanisms are in place for the annual
flooding that occurs during this period; however
the magnitude of this year’s flooding caused these
systems to fail, resulting in a displaced population
without emergency relief such as food, clean
clothing, clean water and access to medical aid.
Many parts of the interior of the state and clinics were
cut off, communication lines were down, and roads
were submerged and inaccessible. Information was
sketchy. The State Crisis Preparedness and Response
centre (CPRC) was in operation but to escape the
floods that affected the State Health Department,
they had to move their operation centre several
times. Health staff throughout the state was limited
as they dealt with their own situations: many were
affected by the floods with their homes submerged
or destroyed. Some were unable to get to work,
and there was no information from the state of
some staff.
6 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
On 29th December, the Deputy Director General
of Public Health Malaysia issued a directive to the
Epidemiology Intelligence Malaysia (EIP Malaysia)
teams to deploy to the affected areas to carry out
an assessment of health infrastructure and services.
The objectives were to determine operational
capacity of the health services, identify potential
threats, take immediate measures where possible to
avert further risk and to recommend interventions
that may alter the course and influence the outcome
of potential health threats.
MethodologyA very quick risk assessment was carried out as we
were given four days on the field including travel
time. There were several stages in the process of
carrying out the risk assessment.
1. Stage of Preparation: teams were identified
and assembled. We were equipped to be
self-sufficient, with a four-wheeled drive
and stocked with sufficient dry rations and
water for our personal use. In anticipation
of what may be needed, we stocked up on
disinfection, spray can for disinfection, as
well as with sufficient petrol.
2. Collection of event information and
literature search: we learnt through the
media and websites the current local
situation specifically about accessibility.
The CPRC Ministry of Health data updated
us with a list of affected district health
clinics and with maps of the area.
3. Extraction and appraisal of the evidence:
This was done on site by the various teams.
We used qualitative methods that are
survey information and direct observation.
We collected data identified from:
a. Key information interviews – this was
carried out by interviewing health
personnel from the clinics, operations
room staff at the district CPRC,
staff from other department at the
evacuation centres and the evacuees
b. Focus groups – we met with CPRC
staff and the evacuees to identify
problems and to better understand
their needs
c. Rapid assessment surveys using
street interviews
d. Direct observation; we observed the
procedures going on at the CPRC, at
the health centres, at the evacuation
centres and also on the street where
possible, to assist us in the rapid
assessment of the situation
In each of the stages, there was transparency and
sharing of information. We informed the stakeholders
of all our findings daily. We were in contact with
all the other teams carrying out risk assessment in
the state through the social application ‘telegram’
where we uploaded photographs and provided daily
feedback to the EIP Director and the Deputy DG
of Health in real time. They then channelled the
relevant information to the flood central coordinating
committee at CPRC, Ministry of Health.
Satellite phones were used to communicate in
areas where the telephone lines were down. The
phones were also used for us to log in every day
to the office of the DG of Health to confirm our
whereabouts and safety.
ResultsWe started travel on the 30th December, 2014 after
deciding on our modus operandi. We left for the
field on the afternoon of the same day. On 2nd
January, all the teams headed back to the Office of
the Deputy DG of Health to consolidate and present
the findings to the National Coordination Committee
(NCC) on the 4th January, 2015.
Preparation and collection of information
The fully equipped teams met at the office of the
Director of the Epidemiology Intelligence Programme
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 7
Malaysia to determine which districts to go to, the
most appropriate routes based on the current road
situation and the data required from each of the
teams. We started a group on social media using
the ‘telegram’ application to communicate with each
other. We were also provided with satellite phones.
Our orders were to report daily on our findings: this
was also to ensure our safety.
There are 10 districts in Kelantan and we targeted
8 that were affected by the flooding.
Evidence appraisal
From the 8 districts we assessed the extent of
damage. The findings are summarised as in Table
1 and Table 2. All information was relayed to the
EIP Director who then relayed it to the National
Coordination Committee for action. All our findings
were accompanied by photographs.
Table 1: Summary of Health facility and evacuation centres visited
District Health facility visited Evacuation centre (EC) Date of and communities visited assessment
Kota Baru 1. Kota Baru Health Office 2. Flood district operations centre 3. KK Badang - 31.12.14 4. KK Kijang 01.01.15 5. K1M Seri Cemerlang
Tumpat 1. Tumpat Health Office 1. SK Pasir Pekan 31.12.14 2. KD Pasir Pekan 2. Mukim Sungai Pinang 01.01.15
Jeli 1. Jeli Health Office 1. SK Kuala Balah 2. KK Kuala Balah 2. SK Bukit Jering 31.12.14 3. KK Kubor Datu 3. SK Lubok Bongor 4. KK Lubok Bongor
Tanah 1. Tanah Merah District Merah Health Office 1. Kusial Baru EC 2. KKIA Tanah Merah 2. EC Gobek 01.01.15 3. KK Gual Ipoh 4. KD Kulim
Gua Musang 1. Gua Musang Health Office 1. SMK Tengku Indra Putra 1 (TIP 1) 2. CPRC Gua Musang district 2. SMK Tengku Indra Putra 2 (TIP 2) 31.12.14 3. KK Bandar Gua Musang 3. Bertam Baru 01.01.15 4. KK Aring 4. Community at Kesedar region 5. KK Bertam Baru 5. Community at Gua Musang 6. KK Chiku
Kuala Krai 1. KK Dabong 2. KK Laloh 3. KK Manik Urai 31.12.14 4. KD Keroh 5. KD Kuala Nal 6. KD Kemubu
Pasir Mas 1. Rantau Panjang Health Clinic 2. KK Tendong 1. Gelang Mas EC 31.12.14 3. KD Lati 01.01.15 4. KK Bandar Pasir Mas
Machang 1. KD Kerilla 01.01.15
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Table 2: Summary of findings, recommendations and actions taken
Scope Summary of Findings Our recommendation Action taken bycentral committee
CPRC management and disease surveillance
1. In some districts the CPRC was affected and they had to move to safer ground as well. Since lines were down and some clinics totally cut off information was sketchy.
2. The districts were just organising their disease surveillance. In some areas there were no maps.
1. CPRC to be located preferably within the state health department. However where this was also flooded, we recommended a location where the staff can easily access it.
2. Water and electricity needs to be available so gen sets to be provided to CPRC to function effectively.
3. Assistance in running the CPRC especially in districts where the staff were already overwhelmed.
1. Sourcing of gen sets by the National Coordinating Committee
2. Deployment of staff from other states to CPRC to decide where they would be most needed and sent there.
Communication There was no alternative communication line in areas where there was no power nor telephone line.
Satellite phones to be kept centrally and to be used in disasters.
This issue is being considered for long term planning.
Transport Most of the vehicles were saved during the floods. However there was a desperate need for more vehicles as they were needed to transport staff to and fro from affected areas. The vehicles were also used to go into villages carrying medical supplies for the affected community.
Deploy more vehicles to the area.
When staff from others districts were deployed to the State, they were asked to come with their own transport and driver. This was coordinated at the Institute for Health Management.Transport was also sourced and sent to the districts for their own use.
Electricity Power supply affected in all districts and many clinics and health facilities without power.
To supply gen sets to clinics.
The National coordinating committee sourced for gen sets and had them sent to affected areas.
Water Most water supplies cut as pipe lines were either destroyed or submerged. Many parts of Kelantan also depends on gravity feed system (GFS).
To carry out chlorination of all tube wells and GFS source of water supply.
The engineering division was given the task to ensure that extensive comprehensive chlorination was carried out according to the specification as set by Ministry of Health guidelines to prevent disease.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 9
Scope Summary of Findings Our recommendation Action taken bycentral committee
Human Resource
Many health facilities with insufficient staff and those who were there were tired. Some were working continuously in spite of their own homes being affected.
1. Deploy more staff from other states.
2. The health officer of some badly affected districts to be replaced temporarily so that they may rest.
1. Staff were deployed from other states and there was continuous replacement of staff when the batch returned to original state
2. Three Public Health Physicians were immediately sent to serve 2 weeks each at the districts of Gua Musang, Pasir Mas and Tumpat respectively.
Medical supplies and stockpiles
1. Disinfection was done using very small spray cans which was labour intensive.
2. A lot of drugs and medical supplies were destroyed in the floods as not all were saved.
1. Suggest providing bigger spray cans.
2. Send in more supplies of medicines
1. The medical supplies were totally coordinated by the central committee through the pharmaceutical services and this was continuously sent.
2. Hospitals from other states also sent medical supplies when their staff went down to the region.
Personal Protective Equipment
1. There were insufficient masks for staff working in the flood areas.
2. Staff were not wearing boots in spite of risk of leptospirosis and other infection.
To supply PPE and boots to the staff in the field.
1. Masks and boots were mobilised to the state immediately.
2. All volunteers and staff working in flood prone area ordered to bring their rubber boots and to wear them.
Affected clinics Some were a total loss while others were a partial loss. Partial loss meant that the clinic would be able to function after cleaning.
1. Total loss clinics to be replaced or to find alternate sites where the staff can function with setting up of temporary tents.
2. Partial loss clinics to start with available equipment after cleaning.
3. Assistance in cleaning
1. Engineering divisions sent to follow up on the findings and reassess the clinics to make sure that they are able to function as soon as they are found to be safe.
2. Identify areas where tents could be placed and used as temporary clinics.
3. Central committee coordinate with the Ministry of Education to assist in cleaning the affected health facility.
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Scope Summary of Findings Our recommendation Action taken bycentral committee
Flood Management Plan
SOP and flood plans do not take into account severe flooding which would not only affect infrastructure, but would affect staffing and communication.
To review the flood management plan to take into account major disasters.
Simulation exercises are being considered.
Evacuation centres
1. In addition to the gazetted evacuation centres, there are many non-gazetted centres, some located on hillsides and some even in vehicles by the roadside.
2. Toilets in most of the EC are clogged due to very high usage and insufficient water.
We requested for hygiene kits for the evacuees at the EC that has none or limited water supply.
All needs were channelled to the respective departments and units. The kits as requested were prepared and distributed.
There were some measures taken by the team
when they visited the districts. Disinfection was
carried out at evacuation centres that we visited.
We focused on the toilets and the drains as water
was needed to mix the disinfectant and water was
in short supply. We also distributed hand sanitizers
to the clinic staff. In addition, health promotion
materials were handed out: these covered food
and water borne disease, leptospirosis and general
cleanliness and precautions necessary to prevent
disease during floods. In some areas, where the
clinics were totally gone, we were able to advice
where temporary static clinics could be set up after
discussion with the local staff.
DiscussionNatural disasters are a more common occurrence
in tandem with global climatic change. The Annual
Global Climate and Catastrophe Report published
by Impact categorizes each event by economic loss
and insured loss and it is stated there that eight
of the most damaging natural disasters occurred in
Asia in 2014. In the same year about 35 percent of
all global economic losses were the result of flooding
- the highest rate since 2010i. The top three perils
were floods, tropical cyclones and severe weather
and these contributed for 72% of all economic
losses. Floods were overall the costliest peril.
The Kelantan floods in December 2014 also affected
other states in the county and continued into 2015.
It hit Malaysia from 15th December 2014 to 3rd
January, 2015. Johore, Kedah, Negeri Sembilan,
Pahang, Perak, Perlis, Sabah, Sarawak, Selangor and
Terengganu were also affected. By 20th December
2014, most of the rivers in Kelantan Pahang, Perak
and Terengganu had reached dangerous levels.
Twenty one people died in the floods. The state
of Kelantan had the most number of evacuees –
20,468. As the heavy rains continued, the situation
worsened and most of the roads in Kelantan were
inaccessible.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 11
Our task covered the health centres and we found
that the health centres were affected – these
included the Klinik Desa. Hospitals were more
resilient as they were a bigger institution and they
have gen sets of their own but this is not true in
health centres. Many of the health centres were
located close to the riverine areas and near the
banks. This may be chosen to facilitate river travel
in predominantly rural Kelantan but this came with
its associated risk. The Ministry of Health should
consider relocating such health facilities to higher
ground. With the current change in climate, seasonal
flooding is eminent. Hospitals were therefore able
to provide the public with immediate medical
treatment. Health centres that were affected used
mobile vans and temporary shelters to provide
immediate basic medical care.
The success of our actions is the speed with which
we return to the non-emergency system. This is
a challenging task taking into consideration the
level of destruction that occurred here. We aimed
to prevent excessive mortality and morbidity and
strengthen overall capacity to manage with limited
resources. This is seen in the data from the Ministry
of Health where in tangent with our efforts there
were no outbreaks of typhoid, leptospirosis,
melioidosis or any other outbreaks associated with
the floods, recorded.
Every need that we presented from our findings was
discussed at the central committee and action was
taken to meet the needs after assessing feasibility.
Three Public Health Physicians were sent to critical
districts to assist and replace tired staff for between
4 to 6 weeks. This enabled the district health officers
to have much needed rest and tend to their own
families who were affected by the floods. It also
helped to boost the morale of the doctors involved
as we worked together in this disaster as a team.
The disease surveillance and response system
was improved to prevent disease outbreaks and
to ensure prompt response to any disease threat.
Immediately following the floods and in anticipation
of outbreaks of leptospirosis and melioidosis, a
directive was sent out to the whole country for
states to report daily, cases of melioidosis as this
was not a disease listed that carried mandatory
notificationii. Leptospirosis and other food and
water borne diseases were monitored daily though
the ‘e-notifikasi’ system of the Ministry of Health
where all diseases are registered on line.
ConclusionThe unprecedented floods that took place in
Kelantan caught the Health services off guard. In
spite of lack of information, the EIP team played a
major role in the early period to assess the extent of
the damage and disruption of services and provide
feedback to the National Coordination Committee.
Their early information assisted in formulating the
action taken by the central coordinating committee
to help mitigate the effects on health.
RecommendationsThe floods in Kelantan at the end of 2014 and
early 2015 were unprecedented and a severe
test of our services. To be better prepared in the
future we recommend that the state develop an
info blast system to alert the districts of potential
disasters and also to update them so that they
can prepare accordingly. Evacuation facilities need
to be identified in advance and supplied with
the necessary items such as blankets and other
necessities. Medical supply should also be kept on
standby especially towards the end of the year as
the floods are a recurrent event. On a long term
basis, we suggest that future health facilities be
built away from riverine and low-lying areas.
Disaster management is the way forward for us.
To achieve this we recommend that disaster
12 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
epidemiology and disaster management to be
included in the training of young doctors especially
in the Masters of Public Health courses. Simulation
exercises to encompass this would also assist in
preparing our staff to handle such events.
Our public health response team that carried out
this assessment faced challenges in getting into the
area and carrying out our own assessment: in the
long term we suggest developing a mobile public
health response team with a vehicle such as a bus
or a truck suitably equipped so that we can function
out of that vehicle.
LimitationsAs time was essential, we relied in part on expert
knowledge from key informants, who were usually
the medical and health staff from the state or
community leaders. At the EC we held focus group
discussions with the evacuees and community
leaders. Where possible we attempted to concur
with our observations. Some clinics were still
inaccessible at the time of our visit.
AcknowledgmentWe would like to acknowledge the Director General
of Health, Malaysia for permission to publish the
article.
References1. Aon Benfield (2014). Annual Global Climate
and Catastrophe Report, Impact Forecasting.
(cited : 19 May 2015). Available from:
http://thoughtleadership.aonbenfield.com/
Documents/20150113_ab_i
f_annual_climate_catastrophe_report.pdf.
2. Law of Malaysia (2013). Act 342. Prevention
and Control of Infectious Disease Act 1988.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 13
Post-Flood Delivery of Humanitarian Assistance to the Orang Asli Settlements in Gua Musang, Kelantan
Alzamani MI, Siti MY, Mohd Khairi AL, Hani HH, Syed Hazran SM, Abu HAAEmergency Department, Hospital Kuala Lumpur
Abstract Introduction: Major floods affected Kelantan towards the end of December 2014. Among the worst hit
areas were Kuala Krai and Gua Musang. There were a number of aboriginal settlements there that were
hard hit and almost ‘forgotten’.
Materials & Methods: To assist the aborigines who were badly affected by the floods, we collaborated
with the Society for the Orang Asli, the Department of Orang Asli Affairs (JHEOA) and the National Welfare
Foundation (YKN). We provided a mobile medical team comprising two Emergency Physicians, one medical
officer, three housemen, a health attendant and a driver. We worked with YKN and they provide water
filtration units, wellness kits and bedding worth RM126,000.
Results: The team used four-wheel drive vehicles to gain access to the aboriginal settlement areas. The
team set up mobile clinics at Kampung Pasir Linggi in Kuala Krai and Pos Tohoi in Kuala Betis. We observed
that the victims at these villages lost nearly all their belongings. They did not have access to medical servi
ces due to their location and lack transport to the nearest health center. We served a total of 476 aborigines.
The common illnesses included upper respiratory tract infections, acute gastroenteritis and dyspepsia.
Conclusion: A natural disaster caused a breakdown in basic amenities. Aborigines located deep in the
jungle should not be neglected. Resources need to be deployed to the victims’ location. Mobile clinics were
the best way to provide the required medical care in this situation. Collaboration between multiple agencies
ensured good logistical support in the provision of medical care for the aborigines.
Introduction
Massive floods affected the Malaysian east coast
from 15th December 2014- 3rd January 2015.
One of the worst hit areas affecting the aborigines
was the inland area of Gua Musang. There were
a number of aboriginal settlements there and they
were hard hit and almost ‘forgotten’. Some 42,000
indigenous people from 261 villages throughout
the country were reportedly affected in these
catastrophic floods. The worst affected was the
indigenous community in Kelantan involving a total
of 7,995 people from 67 villages, especially those
in Gua Musang. The Orang Asli Affairs Department
(JAKOA) had spent more than RM2 million on food
and basic necessities for the indigenous communities
affected by the floods. We describe our relief work
in the Gua Musang Orang Asli settlements.
14 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Photo1: Team members in convoy for the humanitarian assistance
Main Objectives
The main aims of this mission were to provide medical
services and to supply basic needs, including items
for personal hygiene, household items, cleaning
supplies and school supplies, water purifiers, beds,
bedding and blankets to the villagers who had lost
nearly all their belongings in the floods.
Materials and Methods
The project was carried out from 30th-31st January
2015 at Kampung Kuala Linggi in Kuala Betis and
Pos Tohoi in the district of Gua Musang. It was a
collaboration between the Emergency Department
of Hospital Kuala Lumpur, the National Welfare
Foundation and the Department of Orang Asli Affairs
and the Pahang Association for Orang Asli Concerns
(POAPP). The mobile medical team from the
Emergency Department of Hospital Kuala Lumpur
(HKL) comprising two Emergency Physicians, one
medical officer, three housemen, a health attendant
and a driver was formed. The team was joined by
another 37 volunteers in a convoy of 12 four-wheel
drive vehicles and a lorry and supplied water filters,
bedding and wellness kits worth RM126,000 to the
indigenous community in Gua Musang, Kelantan.
The mission took 2 days from 30th-31st January
2015 and involved mainly Kampung Pasir Linggi in
Kuala Betis and Pos Tohoi in Gua Musang, Kelantan.
Results
The journey A convoy of 12 four-wheel drives and
a truck made their way by the East Coast Highway
to Gua Musang, Kelantan. From Gua Musang, the
convoy made its way to Kampung Pasir Linggi
at Kuala Betis. The obstacles encountered were
minimal as the flood had subsided considerably.
The village was damaged and furniture could be
seen hanging from trees and clothes were found on
electrical cables, marking the level of floods.
Photo 2: On the way to Kuala Betis via off-road access
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 15
Mobile Medical Service Operations at
Kampung Pasir Linggi, Kuala Betis
Kuala Betis has two settlements. Upon arrival, we
observed that the houses had been damaged and
furniture could be seen hanging from trees. The
villagers had minimal clothing and the children
walked barefooted. A mobile clinic was set up under
a tent. A triageur performed both registration and
triaging. 4 doctors provided medical examination
simultaneously while a fifth doctor and a health
assistant assisted with drugs dispensing. A total
number of 94 patients were treated there. After
serving this community, the team moved uphill to
another settlement (about 5 minutes’ drive away)
and set up a clinic behind the four-wheeled drive
vehicles and treated another 80 patients. The main
illnesses include upper respiratory tract infections,
acute gastroenteritis and dyspepsia. In total we
treated 174 patients in Kuala Betis. The distribution
of illnesses is illustrated in Figure 1.
Photo 3: Medical Team operating under a tentFigure 1: The distribution of illnesses for the
patients treated at Kuala Betis
The total population here was about 300 people. The distribution of cases included Upper Respiratory Tract
Infection (URTI) 83.9 % (146), Acute Dyspepsia 2.9% (5), Acute Gastroenteritis (AGE) 2.9 % (5), Fungal
Infection 2.9% (5) and Herpes Zoster 0.5% (1). The distribution of donated items worth RM 78,000 was
done by the National Welfare Foundation at Kuala Betis. This included 10 water purification units of 20 litres
capacity, bedding and family wellness kits.
Figure 2: The distribution of illnesses for the patients treated at Pos Tohoi
16 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
302 patients treated at Pos Tohoi. The distribution of cases included 63.2% (191)
Upper Respiratory Tract Infection (URTI) 78.8% (238), Acute Dyspepsia 8.3% (25)
, Acute Gastroenteritis (AGE) 6.6% (20) , Fungal 6.0% (18) and Goitre 0.03% (1).
Table 1: Distribution of Cases Managed at both Kuala Betis and Tohoi
Location URTI Acute AGE Herpes Fungal Goitre Total Dyspepsia Zoster
Kuala Betis 148 5 5 1 5 0 174 (85.1%) (2.9%) (2.9%) (0.5%) (2.9%) (0.0%)
Tohoi 238 25 20 0 18 1 302 (78.8%) (8.3%) (6.6%) (0.0%) (6.0%) (0.03%)
Total 476
Discussion
During the major floods, the access to the Orang
Asli areas was cut off completely. For two days,
they stayed on a hill and had limited food. In
the future, areas isolated by the floods should be
referred to the military or similar agencies with the
vehicles appropriate for such emergencies. Gupta
et al (2012) described the damage and dysfunction
of a civil hospital of Leh in the Ladakh region of
North India following flash floods. In this disaster,
search and rescue operations were launched by the
Indian Army immediately after the disaster. Mass
casualty management was handled by the army
doctors while relief work was mounted by the army
and civil administration. The authors found that
disaster preparedness was critical, particularly in
natural disasters. The Army’s immediate search,
rescue, and relief operations and mass casualty
management effectively and efficiently mitigated
the impact of the flash floods, and restored normal
life rapidly.
Post-flood volunteer work must be community
based with field orientation. More often than not,
access to health centres may not be possible.
Existing health centres too, may not be functional.
This is more so for the Orang Asli community as
they stay far inland and shy away from developed
areas. Buajaroen (2013) described volunteer work
by nurses to care for those affected and assist in
re-establishing a functioning health care system
following a flood in 2010. The author found that
the concept and principle of health care services
management were community based and involved
home care and field hospital services. A community-
based approach such as the mobile teams placed
within the community as we had done proved to be
beneficial for the Orang Asli.
The Orang Asli community, like any other aboriginal
community are a passive lot and only require
basic needs for their livelihood. They rarely seek
help in most situations and will do all they can
to survive. Nevertheless, the National Orang Asli
Affairs Department (JAKOA) - the authority in-
charge of this community checks on them and
organizes help. Despite having experienced
mulitiple disaster events in the past, they do not
display the attitude of seeking help and could
easily be forgotten. In reality, they could be in dire
circumstances. Stimpson et al (2008) described
how the frequency of exposure to a flood was
associated with the probability of seeking help from
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 17
agencies that provide disaster-related services. The
authors discovered that the probability of seeking
disaster relief services increased with the number
of flood experiences. Racial/ethnic minorities, rural
residents, economically challenged individuals, and
people with low levels of perceived social support
may be more likely than people without these
characteristics to seek services. Nevertheless, this
was not the case in the Orang Asli community.
The level and pattern of community development
affect its capacity to respond to flooding. The Orang
Asli community obviously has a limited resilience in
the face of flood disaster. They are also situated
too far from relief centers that can be counted for
assistance. Buckland and Rahman (1999) examined
the relationship between community preparedness
and response to natural disaster and their level and
pattern of community development by investigating
preparation and response to the 1997 Red River
Flood by three rural communities in Manitoba,
Canada. The hypothesis was supported in that
the level and pattern of community development
affect community capacity to respond to flooding.
Communities characterised by higher levels of
physical, human and social capital were better
prepared and more effective responders to the
flood. The Orang Asli who remain unsophisticated
had a low capacity to respond and thus needed
assistance.
The recovery of the Orang Asli needs to be facilitated.
They were under-resourced and rather backward
being aborigines. Rowlands (2013) described
Australia’s broad disaster recovery planning and
management approach, adopting a social and
community recovery perspective. Strengths-based,
solution-focused approaches to intervention, and a
sound understanding of community development
principles, were essential to facilitating community
recovery. He illustrated the full spectrum of planning,
immediate psychosocial response, and longer term
community and individual recovery. Such planning
would be of great effectiveness if employed among
the Orang Asli community.
Network centrality is essential for faster recovery
of all Orang Asli settlements. The Orang Asli Affairs
Department do have the date of populations at
settlements. Nevertheless, the establishment of
an operations center would facilitate all assistance
to all affected areas. Moore et al (2003) described
the Mozambique floods in 2000. Mozambique then
suffered its worst flooding in almost 50 years.
Coordination of disaster assistance was critical for
effective humanitarian aid operations, but limited
attention had been directed toward evaluating
the system-wide structure of inter-organisational
coordination during humanitarian operations. In
our experience, we noted there were other groups
participating in humanitarian assistance as well.
One group was stranded when their vehicles could
not exit the area they had served. Therefore, a
central information network to ensure no overlap
occurs would be good for this situation.
‘Structural factors’ also affect residential location or
relocation. The relocation of Orang Asli was limited
to nearby hilly areas during floods. Patients mobility
was also limited being located in the jungle.
Chan (1995) described the strong influence of
‘structural’ factors in people’s persistent occupation
of floodplains. Thus, despite a high level of flood
hazard awareness, a high level of pessimism and
a high level of expectation of future floods, poorer
individuals seldom attempt to leave for more
advantageous locations but remain instead trapped
in their present locations by structural factors
such as poverty, low residential and occupational
mobility, low educational attainment, traditional
land inheritance, government aid, and government
disaster preparedness, relief and rehabilitation
programmes. These forces exerted a strong
influence upon individuals and largely control
18 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
their choice of residential location in response to
flood hazards, thereby reinforcing the persistent
occupation of floodplains. On the other hand,
structural factors such as landlessness, rural-urban
migration, floodplain encroachment and squatting
were highly influential in leading people to move.
However, even for those who moved, structural
factors largely confined their choice of residential
location to urban floodplains. The same was noted
among the Orang Asli community in that they
stayed put at their settlement areas and would not
move to relief centres.
Soliman et al (1998) designed a survey to elicit
workers’ perceptions of providing crisis outreach
services to survivors of the 1993 flood in Illinois.
Their findings highlighted the benefits of recruiting
local workers in disaster relief work. The positive
outcomes of the experience included both personal
and professional growth. The benefit of recruiting
local workers in disaster relief work was seen as
Orang Asli could be recruited in the recovery phase
to rebuild homes and provide transport in this
disaster. This should be considered in all recovery
efforts such as rebuilding their homes and others
in the future.
Conclusion
Co-operation between governmental and non-
governmental organizations facilitated the
efficient delivery of humanitarian assistance to the
aborigines. Local authority involvement ensured
safe journey through the interior and acceptance by
affected aborigines. The main illnesses in the Orang
Asli victims were upper respiratory tract infection,
acute gastroenteritis and dyspepsia in post-
flood phase. We recommend a multi-organization
approach in the delivery of humanitarian assistance
to the Orang Asli community in the future.
Acknowledgment
We would like to acknowledge the Director General
of Health, Malaysia for permission to publish the
article. We also would like to thank the National
Welfare Foundation (YKN), the Pahang Association
for Orang Asli Concerns (POAPP) and the Orang Asli
Affairs Department (JAKOA) for their contributions.
References
1. Stimpson, J.P., Wilson, F.A., Jeffries, S.K.
(2008). Seeking help for disaster services after
a flood. Disaster Med Public Health Prep, 2(3),
139-141.
2. Buckland, J., Rahman, M. (1999). Community-
based disaster management during the 1997
Red River Flood in Canada. Disasters, 23(2),
174-191.
3. Rowlands, A. (2013). Disaster recovery
management in Australia and the contribution
of social work. J Soc Work Disabil Rehabil,
12(1-2), 19-38.
4. Gupta, P., Khanna, A., Majumdar S. (2012).
Disaster management in flash floods in leh
(ladakh): a case study. Indian J Community
Med, 37(3), 185-190.
5. Buajaroen, H. (2013). Management of health
care services for flood victims: the case of the
shelter at Nakhon Pathom Rajabhat University
Central Thailand. Australas Emerg Nurs J,
16(3), 116-122.
6. Moore, S., Eng, E., Daniel, M. (2003).
International NGOs and the role of network
centrality in humanitarian aid operations: a
case study of coordination during the 2000
Mozambique floods. Disasters, 27(4), 305-
318.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 19
7. Soliman, H.H., Lingle, S.E., Raymond, A.
(1998). Perceptions of indigenous workers
following participation in a disaster relief
project. Community Ment Health J, 34(6), 557-
568.
8. Chan, N.W. (1995). Choice and constraints
in floodplain occupation: the influence of
structural factors on residential location in
Peninsular Malaysia. Disasters, 19(4), 287-
307.
9. Kendall, E., Del, Fabbro, L., Ehrlich, C., Rixon, K.
(2011). Rebuilding community: considerations
for policy makers in the wake of the 2011
Queensland floods. Aust Health Rev, 35(4),
520-522.
10. Blum, N., Fee, E. (2008). The Sungari River
flood and the Jewish community in Harbin,
China. Am J Public Health, 98(5), 823.
20 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Bugs in the water: A review of effects of floods among Rescue Workers, Healthcare Workers and Flood Victims
Eswaran K
Clinical Research Center, Duchess of Kent Hospital
Abstract Introduction: Several Malaysian states were inundated due to floods which occurred in December 2014. This
review article focuses on the bioecological characteristics of several waterborne or water-related pathogens
and the susceptibility of humans which may be associated with communicable disease transmission among
Rescue Workers (RWs) and Healthcare Workers (HCWs) who are mobilised during disaster management.
Methodology: Research articles pertaining to common waterborne diseases due to extreme water events
were searched electronically and profiled according to latitude. Diseases which are more endemic in tropics
and subtropics were evaluated.
Results: Ecological, climatic factors and human activities cause pathogens to proliferate before floods and
disseminate during and after floods. The increased concentration of these pathogens in the environment
and animal reservoir around human habitation are risk factors for disease outbreaks. Improving RWs
and HCWs competencies to take immediate and appropriate measures after floods will reduce the risk of
waterborne disease outbreaks.
Conclusion: The bioecological properties of pathogens in Malaysia may need to be studied further to
understand the interactions between these factors. The applicability of appropriate frameworks such as
cross-cutting competencies and surveillance systems utilized in other countries can be adapted to suit the
needs of the Malaysian population.
Keywords: pathogen, bioecological, waterborne, flood, worker
Introduction Communicable disease outbreaks following the
wake of natural disasters have a deleterious effect
on disaster victims. Rescue Workers (RWs) and
Healthcare Workers (HCWs) involved in disaster
management are not exempt from the health
hazards of these diseases1-3. RWs respond to
remove victims from the dangers of a disaster and
comprise military, police, fire, rescue services and
emergency medical services personnel4. Healthcare
Workers (HCWs) are mobilised to areas which
are affected by disaster to provide medical and
psychological aid to disaster victims.
During extreme water events such as floods,
outbreaks due to waterborne diseases and vector-
borne diseases are common. This article will focus
on waterborne diseases and water-related diseases
which occur during and after extreme water events
such as storms and floods. Diseases and disease
outbreaks are evaluated in terms of bio-ecological
aspects of pathogens and susceptibility factors
of populations. Characteristics of pathogens and
ecological aspects of environment drivers during
floods which could adversely affect RWs and HCWs
are also analysed.
The main objective of this review article is to
describe common waterborne and water-related
pathogens which affect RWs and HCWs. The
secondary objective is to illustrate the correlation
between bioecological factors, susceptibility factors
and measures that need to be taken to reduce
disease outbreaks during and after floods.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 21
Methodology
A literature search for this article was carried out
using the following using search terms: (floods
OR natural disasters) AND (waterborne diseases
OR water-related diseases OR infectious diseases
OR bacteria OR protozoa OR virus OR fungus OR
pathogen OR cholera OR gastroenteritis OR typhoid
OR melioidosis OR leptospirosis OR cryptosporidiosis
OR giardiasis OR Hepatitis E OR aspergillosis) AND
(healthcare workers OR rescue workers).
The following databases were searched: PubMed
Central, (http://www.ncbi.nlm.nih.gov/pmc/), Bio
Med Central (http://www.biomedcentral.com/),
Emerging Infectious Disease (http://wwwnc.cdc.
gov/eid/), Morbidity and Mortality Weekly Report
(http://www.cdc.gov/mmwr/), Centres for Disease
Control and Prevention (http://www.cdc.gov/) and
WHO website (http://www.who.int/en/).
Information from relevant research articles were
analysed an correlated. Common waterborne
diseases and water relateddiseases which are
related to outbreaks following floods and storms
from countries that are situated in tropical and
subtropical latitudes were gathered. Pathogen
bioecological characteristics including environmental
factors, zoonotic hosts, mode of transmission,
clinical features and complications resulting from
infection were collated. These bio-ecological factors
were correlated with several outbreak mitigation
measures, surveillance frameworks and surveillance
systems which are currently applied or undergoing
evaluation in countries such as United States,
Canada, Thailand, Pacific Island Countries (PICs)
and Australia.
Results Bacteria constitute the most common causal
pathogens associated with disease outbreaks
reported. 46.7% of the causal pathogens for
waterborne outbreaks due to extreme water events
are bacteria. The second most common pathogen
reported is virus (27.6%) while the third most
common is protozoa (25.1%). Fungal outbreaks
are least frequently reported (0.6%) (5). The
hosts, mode of transmission and clinical features
of the diseases are summarised in Table 1. Figure 1
illustrates the pathogens profiled in Malaysia while
Figure 2 illustrates the pathogens profiled at the
tropics and subtropics.
Bacterial
1. Cholera
Vibrio cholera is a small, curve-shaped gram
negative rod bacilli with a single polar flagellum5.
It is a facultative anaerobe which possesses
fermentative and respiratory metabolism5. To date,
three strains of Vibrio cholera namely classical, E1
Tor and O139 have been identified5-6. The first six
cholera pandemics were caused by classical strains.
V. cholera O1 E1 Tor coexisted with O139 strain
during the 7th cholera pandemic. Both E1 Tor and
O139 strains have been implicated in extensive
outbreaks in the Indian subcontinent. E1Tor strains
were also responsible for the 2000 and 2009
outbreak in Kelantan, Malaysia7.
Cholera is severe in people who have not previously
been vaccinated or infected. People who consume
antacids or are of the O blood group are more
susceptible to this infection5. Ingestion of minimum
amount of V. cholera cells is adequate to produce
symptoms. The disease is more severe among
patients who ingest high number of organisms5.
The mortality rate of this infection is 50%
without the institution of treatment5. Depending
on the level of dehydration, orally administered
rehydration salt will suffice for mild dehydration
while moderate to severe level of dehydration
requires vigorous administration of intravenous
fluid5. The administration of antibiotics serves as
an adjunct and reduces the duration of diarrhoea7.
The indiscriminate prescription of antibiotics causes
22 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
cholera strains to develop resistance to antibiotics7.
The proliferation of V. cholera in brackish water
is associated with seasonal variation and micro-
level environmental factors such as temperature,
salinity, aquatic reservoirs and the presence of
vibriophage6. The suitable salinity ranges from
0.25 to 3.0 % while temperatures higher than
5°C assist in maintaining the pathogen in the
environment6. Heavy blooms of aquatic reservoirs
such as zooplankton and phytoplankton which act
as vectors for this pathogen enhances the risks of
cholera epidemics. Zooplankton and phytoplankton
blooms occur as the temperature of water and
precipitation increase5-7. When the environmental
conditions are not suitable for bacterial proliferation,
the bacteria enters a dormant stage for an extended
period of time. The rise in sea surface temperature
enhances zooplankton bloom. This results in an
explosion of the zooplankton population during
dry seasons6. As the sea surface height increases
during the monsoonal season, the bacteria
harboured by the zooplankton are washed from
coastal waters into inland waters6.In addition, it
has been hypothesised that low concentrations of
vibriophages after monsoonal seasons play a role
in increasing the risk of cholera epidemics6. Hence,
the risk of cholera epidemic increases as a result of
increased availability of aquatic reservoir in coastal
water during extreme water events such as floods.
2. Salmonellosis
Salmonellosis is caused by a facultative gram
negative bacterium5,8. Salmonella enterica serovar
Typhi ( S. typhi ) causes enteric or typhoid fever
while S.paratyphi causes paratyphoid fever8. Both
S. typhi and S. paratyphi are pathogenic to humans.
Diseases such as melioidosis and scrub typhus can
mimic the symptoms of enteric fever8. The organism
can be isolated in cultures of blood, stool, urine,
sputum, bone marrow and identified via serology8.
The case-fatality rate (CFR) due to complications
ranges between 10 and 15%8. Patients who have
been treated with antibiotics have been known to
have a higher incidence of relapse as compared to
patients who have not been treated with antibiotics8.
Pregnant women constitute a particularly vulnerable
group in that 70% may suffer miscarriage if
complications are not treated8. In addition,
individuals with low educational level are more
vulnerable to the disease9. Sharing food with people
suffering from salmonellosis, poor hand washing
and consumption of raw vegetables are among the
risk factors for contracting salmonellosis9. A Fijian
study suggested that sharing Kava, a local beverage
could have contributed to typhoid outbreaks among
indigenous Fijians during the months following
Cyclone Tomas which affected all four divisions of
the republic in March 201010.
Salmonellae is also known to survive for weeks if the
humidity, temperature and pH of the soil or water is
favourable5. Sewage, agricultural waste and storm
runoff contribute to the increased concentration of
this pathogen5. Untreated sewage effluent which
flows into coastal areas will contaminate shellfish
which concentrate this bacteria in their water
filtration process5.
4. Melioidosis
This disease is caused by Burkholderia pseudomallei,
a gram negative bacillus which is a free living
soil saprophyte3,8. The incidence rate (IR) varies
between states in Malaysia and is between 6.1 and
16.35 per 100 000 population per year in Pahang
and Kedah respectively.
Treatment of melioidosis consists of intravenous
administration of ceftazidime, meropenam or
imipenam for a period of two weeks followed by
sulfamethoxole / trimethroprim and doxycycline
for three months8. Treatment compliance may be
affected by the long course of treatment. There
is a possibility that this pathogen establishes
its virulence by developing in vivo resistance to
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 23
recommended standard antibiotics11.
The case fatality rate (CFR) among patients in
Kedah according to a hospital-based Melioidosis
Registry set up in 2005 was 33.811. A significantly
higher CFR (70%) due to melioidosis was observed
among RWs and rescuers from the village who
assisted in a rescue operation in Lubuk Yu, Pahang3.
The possible reasons for this were due to delayed
identification of the outbreak and co-infection with
Leptospirosis3.
Vulnerable occupational groups comprise farmers,
fishermen and people who work in the forest3,11.
Diabetes mellitus is a major risk factor which
increases the mortality and morbidity of patients11.
Alcoholism, as observed in Northern Territory,
Australia is another risk factor11. The environmental
drivers for the proliferation of this pathogen are
precipitation, periods of high rainfall and soil
erosion containing B. pseudomallei into water
banks3,12. Aerosolization of dust particles containing
the pathogen has also been linked to disease
outbreaks12.
5. Leptospirosis
Leptospirosis is caused by a pathogenic spiral
bacteria that belongs to the genus Leptospira
3. The prevalence of this infection in Malaysia is
12.6%3. Approximately half of Leptospirosis cases
are attributed to occupational exposure. The
vulnerable occupational groups are agricultural
workers, poultry farmers, sewage workers and
military personal3. Young and male patients are
also more vulnerable to the disease while being old
increases the chances of mortality3,13. Recreational
activities such as water sports in contaminated
water increases the chances of contracting the
disease3.
Humans are the incidental host of this pathogen via
contact with rodent urinecontaminated water3. Fatal
leptospirosis due to Weil’s disease is characterised
by signs and symptoms of jaundice, anuria and
haemoptysis13. The CFR can be as high as 47%
when haemoptysis occur13. Prompt diagnosis of the
disease reduces the risk associated with morbidity
and mortality. Rapid-test kits such as the Leptospira
Serology Kit (Bio-Rad Marnes-la Coquette) and the
PanBio IGM ELISA were used during a leptospirosis
outbreak in the Philippines after the floods13. The
availability of these kits in a nearby hospital resulted
in timely management of patients13. Climatic factors
such as torrential rain and increased precipitation
prior to torrential rain have been strongly associated
with outbreaks12.
Hence a heavy downpour in the beginning of search
and rescue operations in Lubuk Yu could have
caused seepage of the bacteria from surrounding
soil into the river3. Increased human activity such
as littering during and before the operation and
dilapidated stalls may have attracted rodents3.
Protozoal
1. Cryptosporidiosis
Cryptos poridium parvum is a zoonotic waterborne
protozoan parasite5,8. This pathogen has a low
infectious dose16.
Chlorination does not eliminate the oocyst
completely. The oocyst can be eliminated in
drinking-water by boiling it12.
2. Giardiasis
The disease caused by this flagellate enteric
protozoa is the most commonly reported intestinal
parasitic infestation in the world14. The main reason
for its high global endemicity is due to the highly
infectious nature of the Giardia cyst and its ability to
remain infectious for many months regardless of the
favourability of the environment14. The prevalence
of giardiasis in Malaysia is 11.6 %14. The infection
rate is higher in Peninsular Malaysia (13.6%) than
in Sabah (5.8%) and Sarawak (2%)14. The Dusun
tribe was found to have experienced significantly
higher prevalence rates of this enteric protozoa
than the Murut and Bajau tribes14.
24 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
It is interesting to note that the indigenous people
of Sabah who consumed piped water have a higher
prevalence of giardiasis than people who drank
water from streams14. This was in contrast with the
indigenous population in East Malaysia where the
prevalence of giardiasis was lower in populations
that consumed piped water14. Treated water from
water plants showed no contamination with these
protozoa and the contamination process was
postulated to occur after the treatment process.
One reason pointed out was the contamination of
uncovered water tanks which are commonly used
by the natives in Sabah to store piped water14.
Vulnerable populations were identified as those
with a low level of education, those who stayed in
houses without latrines and those whose lifestyles
included unhygienic practices such as not boiling
water, not washing hands after playing with animals,
indiscriminate garbage disposal, barefootedness
and indiscriminate defecation14. IgA deficiency and
malnutrition are predisposing factors that underlie
chronic infection8.
Environmental factors related to Cryptosporidiosis
and Giardiasis outbreak As environmental factors
of both cryptosporidiosis and giardiasis are
usually associated together in most studies, these
pathogens will be discussed under the same context
in this article.
In Malaysia, water beds which contain high
concentration of C. parvum are recreational lakes
and rivers15. High C. parvum concentration in
these water beds have also been observed in other
countries. A study in California, USA compared
microbial concentration in three types of wetlands16:
1) Tidal wetland that receives water runoffs from
urban and agricultural areas and drains into a
nearby bay.
2) A diary wetland which receives runoffs from
cattle farms
3) A constructed wetland which was built as a field
research site.
The tidal wetland was initially an estuary. Landscape
conversion from estuary to accommodate agricultural
and livestock operations caused degradation of the
wetlands. Subsequently, water salinity in these
areas become brackish or hypersaline. Other than
salinity, changes in water quality parameters such
as dissolved oxygen, total dissolved solids and
water temperature are significantly associated
with changes in both protozoal concentrations16.
The prevalence of the Cryptosporidium oocyst and
Giardi a cyst in the dairy wetland was significantly
higher than in the other two wetlands. Sampling
revealed that the prevalence of both protozoa was
highest at sites nearest to the dairy farm and lowest
further downstream16. Concentrations of both
protozoa were significantly higher after rainfall16.
The probability of detecting Crytosporidium
oocyst and Giardia cysts was 45 and 1510 times,
respectively, more likely during wet season than
during dry season16.
A Malaysian-Thailand study, on the other hand,
theorised that heavy rain washed away the protozoa
and contamination of rivers by these protozoa was
low as a result of dilution15. High precipitation has
also been identified as a cause of cryptosporidiosis
and giardiasis outbreaks14,16.
Virus
1. Hepatitis E
Hepatitis E virus (HEV) is a single stranded RNA,
caliciviradae8. The spectrum of the disease ranges
between subclinical, acute, chronic and fulminant
hepatitis17.
Fulminant hepatitis is characterised by a sudden
onset of symptoms of liver failure18. Treatment for
acute infection is by providing supportive care8.
Individuals with high susceptibility to infection
include women who are on oral contraceptives,
haemodialysis patients and patients with pre-
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 25
existing liver cirrhosis8. The death rate due to
fulminant hepatitis in pregnant women can exceed
20%8.
The 4 genotypes of this virus are G1, G2, G3 and G4,
all of which have been known to affect humans19.
Genotypes G1 and G2 were only identified from
humans19. G3 and G4 have displayed zoonotic
transmission19. The animal reservoir for genotypes
3 and 4 include swine, deer, mongoose, rabbits
and cattle19. Porcine related infections have been
linked to the consumption of raw porcine meat19.
The overflow of sewage into the drinking water
supply during the 1955-1956 floods in Delhi, India
lead to the first confirmed outbreak of Hepatitis
E18. Another outbreak that occurred in the 2005
Pakistan earthquake was linked to poor sanitary
and hygienic conditions due to unavailability of a
clean water supply after the earthquake20.
Fungal
Fungal infection has become an increasingly
common disease among evacuees and rescue
workers in the recent years due to global hydro-
meteorological changes1. The resulting clinical
outcome of fungal infection could range from an
uncomplicated infection by Tenia corporis 2 to a
life threatening condition such as aspergillosis1.
The major factor linked to infection during flooding
is environmental disruption of fungal spores. The
warmer average global temperature has caused
expansion of some species of fungus to countries
with different latitude1.
1. Aspergillosis
Aspergillus fumigatus accounts for the most number
of filamentous fungi that cause infection1. There are
fungal species such as Neosartorya hiratsukae that
are closely related to A. fumigatus which have been
known to cause localised and invasive infections21.
The mode of entry of this pathogenic fungus is via
aspiration of debris-laden water or contaminated
water due to drowning or near-drowning incidents1.
Aspiration pneumonia caused by fungi, bacteria
or both pathogen have been commonly known as
‘Tsunami Lung’1. Immuno-competence does not
eliminate the mortality risk, as previously healthy
individuals who have nearly drowned in tsunami
related incident have succumbed to pneumonia
secondary to A. fumigatus and multi organ
disseminated aspergillosis1.
A high propensity for misdiagnosis leads to cases
where fungal infection are misdiagnosed as upper
respiratory tract infections (URTI)1. This could
lead to administration of medications which may
not cure the disease. For example, an outbreak
of fungal infection was missed during a fungal
outbreak which occurred following an earthquake in
California in 19941. Another reason for the delayed
diagnosis of aspergillosis in the aftermath of the
2011 earthquake and tsunami in Japan was due to
delayed transportation of patients who would have
required treatment in secondary or tertiary health
facilities. In addition, investigative samples could
not be transported to nearby medical laboratories
because public roads were inundated by flood water
after the catastrophe1.
26 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Table 1: The host, mode of transmission, clinical features and complications associated with waterborne
and water-related disease transmission after extreme water events. The references for the pathogens are
stated for each pathogen.
Pathogen Hosts Mode of transmission Clinical features and complication
1 Vibrio cholera5 1. Zooplan 1. Shellfish consumption 1. Acute and intense diarrhoea kton 2. Hypovolemic symptoms 2. Phytopla 2. Contact with 3. Circulatory collapse nkton contaminated water 3. Contaminated surface water usage or consumption
2 S. typhi and Various 1. Oro-faecal 1. Myalgia S. paratyphi 5,8,9 species of 2. Contaminated food and 2. Diaphoresis reptiles and water 3. Headache birds 3. Contaminated shellfish 4. Anorexia consumption 5. Vertigo
3 Burkholderia 1. Sheep 1. Entry via breaks in skin 1. Soft tissue abscess Pseudomallei 8,1 1 2. Horse 2. Aerosolization of 2. Osteomyelitis 4. Swine contaminated dust particles 3. Septic arthritis 5. Rodent 3. Goat 4. Liver and splenic abscess 6. Monkey 5. Brain abscess 7. Marsupial 6. Subacute pneumonia 7. Fulminant pneumonia
4 Leptospira Rodent 1. Break in skin and mucous 1. Fever, myalgia, tea coloured spp. 3.13 membrane urine, jaundice 2. Contact with contaminated 2. Weil’s disease water 3. Disseminated Intravascular Coagulation symptoms 4. Haemolytic Uremic Syndrome symptoms 5. Thrombotic Thrombocyto penic Purpura symptoms 6. Vasculitis
5 Cryptosporidium 1. Cattle 1. Contaminated water 1. Diarrhoea parvum 5,8 2. Oyster consumption 2. Nausea 2. Oro-faecal 3. Vomiting 4. Abdominal cramps 5. Dehydration 6. Mild fever
6 Giardia Cattle 1. Contaminated water or 1. Fever with chills spp. 5,14,16 food consumption 2. Nausea 2. Oro-faecal 3. Vomiting 3. Oro-anal 4. Abdominal pain 4. Contact with infected animals 5. Weight loss
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 27
Pathogen Hosts Mode of transmission Clinical features and complication
7 Hepatitis E 17-19 1. Swine 1. Oro-faecal 1. Flu-like symptoms 2. Deer 2. Contact with infected rodents 2. Chills 3. Mongoose 3. Fatigue 4. Rabbits 4. Nausea 5. Cattle 5. Vomiting 6. Rodent 6. Right hypochondria pain 7. Jaundice 8. Dark urine
8 Aspergillus Aspiration of debris- laden water 1. Pneumonia fumigatus1 2. Multi-organ dissemination symptoms 3. Meningitis
Figure 1: Pathogens profiled in Malaysia: Vibrio cholera (1), Burkholderia pseudomallei (2), Leptospira spp. (3), Cryptosporidium parvum (4), Giardia spp. (5)
28 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
37
Figu
re 2
: Pat
hoge
ns p
rofil
ed a
t the
trop
ics a
nd s
ubtro
pics
: Vib
rio c
holer
a (1
), S.
typh
i and
S. p
arat
yphi
(2),
Burk
hode
ria p
seud
omall
ei (3
), Le
ptos
pira
spp.
(4),
Cryp
tosp
orid
ium
par
vum
(5),
Giar
dia
spp.
(6),
Hepa
titis
E (7
), As
perg
illus f
umig
atus
(8).
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 29
Measures To Reduce Disease OutbreaksDisaster management affects the physical and mental health of RWs and HCWs. Mitigation in this review,
has been divided into 2 phases, pre-disaster and post-disaster phases. These measures are outlined in Table
2.
Table 2: Measures to reduce disease outbreaks following extreme water events such as floods. The
references for mitigation for both phases are stated next to each measure.
Mitigation During Pre- Details Disaster Phase
Develop conceptual
frameworks and cross-
cutting competencies22
l Develop frameworks to identify potential hazards and take
rapid measures to avoid disease outbreaks.
l Emphasis on multidisciplinary approach.
1
Mitigation During Pre- Details Disaster Phase
2 Identification of
determinants including
healthcare capacity to
respond to disaster23
l Identify determinants such as healthcare capacity.
l Training of RWs to initiate response effectively and efficiently.
l Improve coordination between NGOs, civil society, military
services, HCWs and RWs.
l Training HCWs who are often mobilised to disaster areas on
specific diseases which frequently occur after floods.
3 Evaluation of risk factors
which obstruct prevention
and control program20
l Evaluation of socioeconomic changes, dysfunctional public
health system, clean water supply disruption, sewage
disposal during and after floods during policy-making for
disaster management.
l Reducing vulnerability of RWs and HCWs to communicable
diseases.
4 Pre-positioning and
distributing Emergency
Kits24
l Emergency Kits containing suitable medications and rapid
tests according to factors including population characteristics
produced and distributed to shelters.
30 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Mitigation During Post- Details Disaster Phase
Suitable shelter
establishment by utilising
GIS mapping25
l Identify geographical areas with clean water supply, sanita-
tion facilities and transport.
l Innovation and use of portable clean water devices to clean
and utilise natural water sources.
1
2 Vaccination campaigns25 l Immediate tetanus vaccination for RWs, HCWs and victims
injured during disaster.
l Consider vaccinating populations where certain waterborne
diseases are endemic.
3 Improvement in transport
of investigational samples
and medications13,25
l Device systems to transport investigational samples to
nearby functioning healthcare facilities and laboratories.
l Improve transport of medications from healthcare facilities to
shelters.
4 Use of appropriate Faecal
Indicator Bacteria (FIB)
and faecal coliform5,16
l Utilise parameters from FIBs and faecal coliforms to predict
risk of disease outbreaks
DiscussionHydro-meteorological events such as floods
have increased in frequency due to climate
changes, changing patterns of precipitation
and an increase in the sea level1. Global
warming and the El-Nino effect has enhanced
proliferation of hosts that harbour pathogens.
It has also contributed to emerging and re-
emerging infections that are affected by
climatic changes6.
The strength of this article is that examples of
various pathogen including bacteria, protozoa,
virus and fungi were assessed in terms of
environmental factors, host, vulnerable
population and mode of transmission. Several
measures which could be taken before and
after disasters were also discussed. This study
has several limitations. Outbreaks due to
flooding caused by vector-borne diseases were
not emphasized. This review article focused
on waterborne and water-related diseases.
Moreover some evidence from this study may
not represent the entire Malaysian population
because studies regarding diseases such as
giardiasis were gathered from indigenous
Malaysian communities.
There are similarities and differences with
regards to environmental factors, vulnerable
populations and hosts which affect transmission
of disease to humans. For example, increased
precipitation before periods of heavy rainfall
is a common environmental factor associated
with leptospirosis, melioidosis, cholera and
cryptosporidiosis outbreaks.
The experimental infection of R. norvegicus
rats by HEV human strain isolated from humans
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 31
resulted in replication of HEV human strain
in the R. norvegicus rats17. This replicated
strain was detected in the faeces and serum
of the infected rodent suggesting possibility
of transmission of this replicated virus among
humans17. In addition, rodents such as the
Asian Musk shrew which originally inhabited
the Indian subcontinent have been recently
found in South East Asia19.
Hence, there remains a high possibility that
pathogens may be harboured by pests such
as rodents which live within close proximity
of human dwellings17,19. Epidemics following
changes in the environmental factors such
as flooding can potentially cause HEV
epidemics because rodents harbouring HEV
may contaminate water and food with their
excretions.
With regards to melioidosis, the prevalence
of alcoholism in Malaysia is lower than
Australia. However, there may be regional
differences of alcoholism in Malaysia. Suffice
to say, alcoholism is more prominent in several
states in Malaysia. Alcohol consumption is
highest in Kuala Lumpur (20.3%) followed
by Sarawak (19.7%) and Sabah(18.4%)26. In
addition, traditional alcohol beverages such as
‘montoku’ and ‘tapai’ is commonly consumed
by the indigenous communities in Sabah and
Sarawak26.
The high rate of fatality among RWs in Lubuk
Yu, Pahang was caused by a co-infection
of leptospirosis and melioidiosis. This co-
infection is possible because both organism
thrive in similar environments and are driven
to proliferate under similar conditions3.
Although individual susceptibility varies,
immunosuppressed individuals are more
susceptible to leptospirosis, meliodiosis and
HEV infection.
In the pre-disaster phase, measures to
develop the competencies of HCWs and RWs
are imperative. Contrary to the popular belief,
handling human corpses does not pose a
high risk of disease transmission among RWs.
However, PPE is still recommended as stated in
fact sheets which were developed for disaster
victim identification (DVI) teams, to reduce
disease transmission through contact with
liquid waste from dead bodies27. PPE including
disposable gowns, latex gloves, respirators and
surgical masks were supplied to disaster victim
identification
(DVI) teams in Thailand after the 2004
Tsunami catastrophe27. NISOH certified N-95
(N95) masks were recommended to public
health officials and the victims of the 2005 New
Orleans hurricane28. A qualitative review of
participants who were involved in mould clean-
up activities revealed the respirator was worn
upside down by 22% of the respondents while
21% of the respondents used only one strap28.
The limited protection offered by a poorly
placed mask enhances disease transmission
because unfiltered air is introduced through the
gaps in the respirators28. Training in wearing
PPE usage must be done before disasters. The
morbidity and mortality due to leptospirosis
and melioidosis outbreaks among RWs can
be reduced by training HCWs to identify these
infections22.
With regards to protozoa, chemical parameters
such as ammonia, nitrate and nitrite are
associated with changes in Giardia cyst and
32 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Cryptosporidium oocyst concentration29. A high
concentration of ammonia could be linked to
the usage of fertilizers in agricultural activities29.
Hence, chemical and water quality parameters
are factors associated with the level of
contamination of Cryptosporidium oocyst and
Giardia cyst in rivers15,16,29. In addition, recent
rainfall plays a significant role in altering the
concentration of both protozoa in rivers16,29. This
shows that changes in the above mentioned
factors could be related to Cryptosporidium and
Giardia outbreaks following continuous rainfall
which may result in floods. Further research
is required to assess the relationship between
these factors.
Suitable Faecal Indicator Bacteria (FIB) and
faecal coliform can be used to assess the
probability of disease outbreaks5. FIB levels
could be monitored to predict protozoa levels
in wetlands. FIB also offers an easier and
cheaper method to predict the concentration
of pathogens in rivers and streams16. The
public health importance of this finding is
that it would be essential to predict the
chances of an outbreak among RWs, HCWs
and disaster victims after a recent downpour
or a prolonged period of rain which may
cause floods by utilising parameters derived
from FIB and faecal coliform. Co-morbidity
and social determinants of health such as
educational level, socioeconomic status and
the living conditions are factors which affects
a population’s susceptibility to diseases14. For
example, a group of indigenous people in
Peninsular Malaysia prefer to drink unboiled
water rather than boiled water because they
say it tastes better30. As a result, 28.6% of the
studied population utilized untreated water
from wells, rain and rivers30.
Lastly, it would be relevant to ascertain the
incubation period (IP) of various pathogens as
this may inform surveillance for diseases which
may require measures such as Syndromic
Surveillance (SS)31. As such, a multidisciplinary
approach should not only be emphasized
among HCWs and RWs but a collaborative
initiative between professionals from
various departments should be encouraged.
Collaboration between professionals from the
Environmental Health Department, The Bureau
of Meteorology and tertiary education facilities
would benefit prevention of disease outbreaks
immensely. Disease outbreak frameworks or
models can be developed with the collaborative
effort of various relevant departments. An
example of a disease outbreak model is
illustrated in Figure 3.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 33
42
Lastly, it would be relevant to ascertain the incubation period (IP) of various pathogens as this may inform surveillance for diseases which may require measures such as Syndromic Surveillance (SS)31. As such, a multidisciplinary approach should not only be emphasized among HCWs and RWs but a collaborative initiative between professionals from various departments should be encouraged. Collaboration
between professionals from the Environmental Health Department, The Bureau of Meteorology and tertiary education facilities would benefit prevention of disease outbreaks immensely. Disease outbreak frameworks or models can be developed with the collaborative effort of various relevant departments. An example of a disease outbreak model is illustrated in Figure 3.
Figure 3: Example of framework or model of a water-related or waterborne disease illustrating the interplay between bio-ecological factors, vulnerability factors and measures to reduce an outbreak.
Figure 3: Example of framework or model of a water-related or waterborne disease illustrating the inter-
play between bio-ecological factors, vulnerability factors and measures to reduce an outbreak.
ConclusionThe results of this study show that a close
relationship exists between pathogens, the
susceptibility of the human host, animal reservoir
and environmental factors when extreme water
events such as floods occur. Hence, measures
or frameworks can be designed taking these
factors into consideration. The identification of
‘silent carrier’ or chronic carrier of pathogens
and vulnerable groups among HCWs or
RWs can potentially reduce transmission of
diseases during floods. In addition, identifying
vulnerable populations among disaster victims
would also reduce the risk of disease outbreaks
and transmissions.
Poor planning of flood mitigation strategy and
an unstructured surveillance system could
undermine the ability of RWs and HCWs to
recognise and take preventive measures
to reduce the risk of disease transmission.
The coexistence of pathogens in a similar
environment will pose an additional challenge
and should be taken into consideration. This
could be done by identifying animal reservoirs,
analysing agricultural activities, recent
deforestation and environmental changes which
occur before extreme water events. Disaster
management strategies are complicated by
pathogens which have mutated. These ‘new’
pathogens identified by their serotypes are
resistant to conventional drugs. New animal
reservoirs of these mutated serotypes are being
identified. Outbreaks secondary to emerging
and remerging diseases will be common in
future.
Evidence pertaining to the competencies of
RWs and HCWs which have been collated show
34 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
that improvements can be made to reduce the
morbidity and mortality among RWs and HCWs
due to disease outbreaks. There is a need to
study the vulnerability factors of the Malaysian
population as the applicability of frameworks and
surveillance systems has to suit environmental,
climatic and serotypes of pathogens which are
commonly found in Malaysia and surrounding
regions. In future, climatic changes due to El-
Nino and unscrupulous human activities will
increase the frequency and intensity of extreme
water events such as tropical cyclones, storms
and floods.
Competing interestsThe author declares that he does not have any
competing interest.
AcknowledgementI would like to acknowledge the Director
General of Health, Malaysia for permission
to publish this article. I also would like to
thank the Director of Hospital Duchess of
Kent, Sandakan, Sabah for supporting the
publication and presentation of this article. A
special thanks to my parents and friends for
their encouragement.
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38 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 201548
Institute For Health Management - Transit Center For Flood Disaster 2015; Psychosocial Impact On Volunteers
Munirah I, Norhidayah MD Institute for Health Management
Abstract The Institute for Health Management (IHM) was appointed as a transit center for health worker volunteers handling logistics, lodging, Psycholosocial First Aid (PFA) and post-deployment debriefing. The first group of volunteers was deployed on 28th December 2014 and after 19 days in operation, 224 volunteers returned to IHM. Returnees were given a debriefing session with counsellors, psychosocial assessment and a clinical examination. Psychosocial assessment of the volunteers was measured by the Depression, Anxiety and Stress Scale (DASS). The majority of volunteers were aged between 20-30 years (n=141, 62.9%) and worked as nurses (n=144, 64.3%). More than half the volunteers were female (n=144, 64.3%) and 80 (35.7%) were male. Most volunteers (197) were deployed to Kelantan in view of the severity of the flood over there. 135 volunteers spent 11-15 days in the disaster affected area, 78 volunteers spent 6-10 days and the rest spent less than 5 days. From the psychosocial assessment (DASS), 12 volunteers were identified with abnormal emotional states in at least two of the emotional states. Among these, there were 8 nurses, 2 assistant medical officers, 1 assistant engineer and 1 IT officer. Most of them had spent 10 or more days as volunteers. Volunteers are exposed to traumatic events in the disaster setting and these may act as stressors. If left unrecognized or untreated this may lead to mental health disease such as Post Traumatic Stress Disorder (PTSD). Awareness of volunteers’ wellbeing and their psychosocial state should be included in the preparedness for handling disasters. Keyword: volunteers, psychosocial impact, post-deployment, DASS Introduction The northeast monsoon brought heavy rains especially to the east coast of Malaysia causing its worst flood in decades. Floods in Kedah, Perak, Selangor, Pahang, Johor, Terengganu and Kelantan saw displaced victims within a day and the continuous rise in the number of evacuees
thereafter. The scale and severity of the flood impacted many aspects of life, such as health, education, security, social issues and economy. The Ministry of Health (MOH) has assigned its Crisis Preparedness Response Centre (CPRC) as the main coordinating agency for
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 3949
flood updates, flood related disease outbreak information, medical relief team deployment, machinery/power supply support as well as other disaster public health related issues. The flood caused major damage to MOH infrastructure and would have disrupted healthcare services. Apart from rescue and relief missions, MOH focused on ensuring sustainability of health services to affected patients and flood victims. The Institute for Health Management (IHM) was appointed as a transit center for MOH volunteers tasked with managing the logistics, lodging, PFA and also post-deployment debriefing of these volunteers. Our centre (IHM), deployed the first group of MOH volunteers on 28th December 2014. Over 19 days (28th December 2014 to 16th January 2015), 494 of volunteers departed for flood areas with 224 volunteers returning to IHM while the rest (270) returned directly to their respective state or center Upon return, all the volunteers were given a debriefing by counsellors and a clinical examination in IHM. This was conducted to screen for acute clinical illness and psychosocial red flags resulting from their stay in the flood affected area.
Methodology The Crisis Preparedness Centre Response IHM was activated on the 28th December 2014 as the transit centre for MOH and non-MOH volunteers. IHM handled the logistic arrangements ie. transport and accommodation, as well as psychosocial first aid prior to departure and upon return from the flood affected site. Samples were taken from the volunteer registry, where 224 MOH volunteers who had returned from flood-affected areas such as Kuala Krai, Gua Musang, Kota Bahru, Tanah Merah, Bentong, Jerantut, Kuantan and Temerloh. Upon their return to IHM, the volunteers were debriefed by counsellors and subjected to psychosocial assessment and clinical examination. The tool used for psychosocial assessment of the volunteers was the Depression, Anxiety and Stress Scale (DASS). DASS functions to assess the severity of the core symptoms of Depression, Anxiety and Stress. High DASS scores alert the clinician to explore the psychosocial status of the subject further. The scale should meet the need of both researchers and clinicians to measure the current psychosocial state and its change over time (Agency for Clinical Innovation, 2010).
40 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 201550
DASS has a shorter (21 items) and a longer version. Use of the shorter version requires that the final score for each emotional state (Depression, Anxiety and Stress) be multiplied by 2 (x2) (Agency for Clinical Innovation, 2010).
Table 1: DASS Severity Ratings
Severity Depression Anxiety Stress Normal 0-9 0-7 0-14 Mild 10-13 8-9 15-18 Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely Severe 28⁺ 20⁺ 34⁺
Source: Agency for Clinical Innovation, (2010). A Guide to the Depression, Anxiety and Stress Scale (DASS) (http://www2.psy.unsw.edu.au/groups/dass/ accessed on 6 February 2015) Results The majority of volunteers were aged between 20-30 years and were therefore junior in service. 52 volunteers were aged between 31 to 40 years and 23 volunteers were in their forties. Staff aged between 51 to 60 years old comprised the smallest number participating as volunteers (Figure 1).
Figure 1: Age group of volunteers
224 volunteers completed the post-deployment assessment at the IHM transit center. Most volunteers were female, 144, 64.3%, and the rest were male 80, 35.7%. Majority of the volunteers were nurses i.e. 144 or 64.2%, 17 were medical officers and 4 specialists. There were 8 psychologists to provide psychological support. 10 of the volunteers were drivers employed to provide transportation in the disaster area (Table 2).
141
52
23
7
0
20
40
60
80
100
120
140
160
20-30 31-40 41-50 51-60
Num
ber o
f Vol
unte
ers
(n)
Age Group (years)
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Table 2: Numbers of volunteers for each professions
No Profession No. Of Volunteers 1 Nurse 144 2 Medical Officer 17 3 Driver 10 4 Assisstant Medical Officer (AMO) 10 5 Pembantu Perawatan Kesihatan (PPK) 6 6 Pembantu Pegawai Kesihatan Persekitaran (PPKP) 6 7 Engineer 7 8 Psychologist 8 9 Pharmacist 4 10 It Officer 2 11 Pembantu Kesihatan Awam (PKA) 4 12 Pembantu Rendah Awam (PRA) 1 13 Medical Specialist 2 14 Social Worker 1 15 Public Health Specialist 2
Total 224
Most volunteers were deployed to Kelantan, given the severity of the flood there. 197 volunteers were placed in affected areas such as Kuala Krai, Manek Urai, Gua Musang, Tanah Merah, HUSM and other remote areas of Kelantan. 27 volunteers were deployed to Pahang to assist the flood victims and the staff of the District Health Office, Bentong (Figure 2).
Figure 2: Volunteers deployment location
When the CPRC was activated, MOH appealed to its staff for volunteers to assist MOH facilities and mobile health services units in affected areas. Most of the volunteers deployed to the flood affected areas within the first 24 hours of the disaster spent between 11 to 15 days as volunteers. In the early stages of the MOH response to the flood disaster, volunteers were
197, 88%
27, 12%
Kelantan Pahang
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given a two-week deployment in the assigned flooded area. However, in the second week of the operation and from volunteer feedback, the duration was shortened to one week taking into consideration their physical and mental exhaustion. 78 of volunteers spent 6 to 10 days in the affected area and 11 volunteers spent less than 5 days (Figure 3).
Figure 3: Number of days spent at disaster affected area All returning volunteers underwent basic medical screening and DASS assessment to screen for any medical condition or psychosocial disturbance. Of the 224 volunteers, 12 volunteers showed abnormal ratings in at least two of the emotional states. Respondents with at least two abnormal emotional states would be followed-up by counsellors. If a volunteer
demonstrated symptoms of severe emotional disturbance, he or she was referred to a psychiatrist. There were eight nurses, two assistant medical officers, one assistant engineer and one IT officer who showed mild to extremely severe emotional states after returning from the flood affected area. Most of them had spent 10 or more days as volunteers (Table 3).
11
78
135
0
20
40
60
80
100
120
140
160
0 to 5 Days 6 to 10 Days 11 to 15 Days
Num
ber o
f Vol
unte
ers
(n)
Days Spent Volunteering
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Table 3: Volunteers (case) with at least two abnormal scores on DASS assessment
No Occupation No Of Days
Spent In The Flood
Affected Area
Flood Affected
Area
DASS
Stress Anxiety Depression
1. Nurse 15 Kelantan Mild Mild Normal 2. Nurse 15 Kelantan Mild Mild Normal 3. Nurse 15 Kelantan Moderate Severe Severe 4. Assistant
Medical Officer 15 Kelantan Extremely
Severe Extremely
Severe Moderate
5. Information Technology Officer
15 Kelantan Severe Moderate Moderate
6. Nurse 14 Kelantan Mild Moderate Normal 7. Nurse 14 Kelantan Mild Moderate Mild 8. Nurse 14 Kelantan Moderate Severe Severe 9. Nurse 10 Kelantan Mild Moderate Normal 10. Nurse 10 Pahang Normal Moderate Mild 11. Assistant
Medical Officer 10 Pahang Normal Moderate Mild
12. Assistant Engineer
4 Kelantan Normal Moderate Mild
Discussion Malaysia experienced several traumatic events in 2014 from air crashes to the worst floods. Whilst air crashes may be rare in Malaysia, floods are a recurring event due to the North-East Monsoon that brings a heavy rain especially to the east coast states. That the recent floods were the worst experienced for sometime may be due to other exacerbating factors such as the loss of the water reservoir because of increasing deforestation and the swallowing of rivers because or sedimentation and rubbish accumulation. Malaysia needs to strengthen its response to major disasters such as the recent floods to enable a prompt and smooth delivery of rescue, evacuation, service continuity and
recovery. With regard to the Ministry of Health, establishing a Crisis Preparedness Response Centre was very important in coordinating the management of a crisis or disaster especially from a public health perspective. Often, when a disaster strikes, the main focus is centered on the victims’ welfare and the efforts made to ease their recovery process. Until recently, very little emphasis was placed on the wellbeing of the volunteers. Few studies have been conducted to examine this aspect of the situation even though volunteers play a crucial role in any disaster response. Individuals exposed to stressful events in a disaster setting may develop an adverse
53
Table 3: Volunteers (case) with at least two abnormal scores on DASS assessment
No Occupation No Of Days
Spent In The Flood
Affected Area
Flood Affected
Area
DASS
Stress Anxiety Depression
1. Nurse 15 Kelantan Mild Mild Normal 2. Nurse 15 Kelantan Mild Mild Normal 3. Nurse 15 Kelantan Moderate Severe Severe 4. Assistant
Medical Officer 15 Kelantan Extremely
Severe Extremely
Severe Moderate
5. Information Technology Officer
15 Kelantan Severe Moderate Moderate
6. Nurse 14 Kelantan Mild Moderate Normal 7. Nurse 14 Kelantan Mild Moderate Mild 8. Nurse 14 Kelantan Moderate Severe Severe 9. Nurse 10 Kelantan Mild Moderate Normal 10. Nurse 10 Pahang Normal Moderate Mild 11. Assistant
Medical Officer 10 Pahang Normal Moderate Mild
12. Assistant Engineer
4 Kelantan Normal Moderate Mild
Discussion Malaysia experienced several traumatic events in 2014 from air crashes to the worst floods. Whilst air crashes may be rare in Malaysia, floods are a recurring event due to the North-East Monsoon that brings a heavy rain especially to the east coast states. That the recent floods were the worst experienced for sometime may be due to other exacerbating factors such as the loss of the water reservoir because of increasing deforestation and the swallowing of rivers because or sedimentation and rubbish accumulation. Malaysia needs to strengthen its response to major disasters such as the recent floods to enable a prompt and smooth delivery of rescue, evacuation, service continuity and
recovery. With regard to the Ministry of Health, establishing a Crisis Preparedness Response Centre was very important in coordinating the management of a crisis or disaster especially from a public health perspective. Often, when a disaster strikes, the main focus is centered on the victims’ welfare and the efforts made to ease their recovery process. Until recently, very little emphasis was placed on the wellbeing of the volunteers. Few studies have been conducted to examine this aspect of the situation even though volunteers play a crucial role in any disaster response. Individuals exposed to stressful events in a disaster setting may develop an adverse
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54
psychological state after dealing with difficult and stressful conditions that predispose them to clinical disorders such as panic disorder, major depression and substance addiction (Polusny & Follette, 1995; Duncan et al., 1996; Green et al., 2000). The volunteers deployed to a disaster-affected area undertake gruelling tasks to assist victims. The MOH volunteers also come from various professional backgrounds in that they include medical officers, clinical specialists, nurses, assistant medical officers, counsellors, drivers, engineers, social workers as well as IT officers. While the volunteers with a medical background, may be used to handling victims with illnesses, running the mobile health service and MOH facilities, some volunteers may not have any worked in a disaster setting previously. Armagan et al. (2006) studied the contribution of factors such as gender, age, professional experience and/or prior experience of traumatic events to the prevalence of PTSD among the Aceh tsunami volunteers. The study found no differences between most factors but identified that the PTSD symptoms were more serious in volunteers with less experience. Perrin et al. (2007) reported volunteers from professions that are not usually prepared for disaster were more likely to develop PTSD. PTSD is a traumatic psychological event following the
experience of or witnessing a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents, or sexual assault (U.S Department of Veterans Affairs). The severity and duration of traumatic events or exposure are important risk factors in developing PTSD (The National Alliance on Mental Illness). In the feedback received from the volunteers, most of them reported being unclear on their task when they reached the flood area. Most nurses assumed they were relieving a colleague who had been on from duty for more than 48 hours rather than to help with the cleaning the hospitals or health clinics. The miscommunication between and mistaken expectations of the volunteers contributed to the confusion with regard to their tasks and being unprepared also may act as a of the stressor (Paton, 1994). In his study, Paton (1994) also described role that confusion was more prominent in professionals than in volunteers. However, Dyregrov (1996) reported that role confusion or uncertainty was more common among volunteers. The majority of volunteers scored normal in DASS and only 12 individuals required some follow up with regard to their psychosocial states. Studies on this topic however did not mention timing of subsequent assessment/screening, but the
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practice in MOH is that re-assessment is done 2 weeks post deployment. The authors recommend further studies to follow up the volunteers and assess their psychosocial status especially at the time PTSD is likely to peak. Andrews et al. (2007) emphasized that PTSD may develop years after the traumatic event and that some will show the symptoms earlier and be affected for years. Kato et al. (2012) agreed that the mental health of an individual who experiences disaster/trauma may be affected immediately and may persist for about a week. However, many studies
showed persistence of symptoms up to 1 year. It is natural after a dangerous event to have some of these symptoms. Some serious symptoms such as Acute Stress Disorder (ASD) may go away after a few weeks. PTSD usually appears within 3 months of the trauma and its symptoms persist for more than few weeks, (U.S Department of Veterans Affairs). A longitudinal study also explored the effect of social support availability, personal or work related that may contribute to PTSD development (Renck et al., 2002) (Table 4).
Table 4: Category of Post Traumatic Stress Disorder (PTSD) symptoms
No Category Examples 1 Avoiding reminders of the
trauma Staying away from places, events, or objects
that are reminders of the experience. Isolating from other people. Feeling emotionally numb. Strong guilt, depression, or worry.
2 Re-experiencing the traumatic event
Recurrent nightmares or flashbacks, Recurrent images or memories of the event, Intense distress at reminders of trauma.
Frightening thoughts.
3 Increased arousal Difficulty falling asleep or staying asleep. Feeling on guard, irritable. Startling easily.
Source: The National Alliance on Mental Illness
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When CPRC MOH deployed its first group of volunteers, they were given assignment for duration of two weeks. During the second week of duty, some of the volunteers were already physically and mentally exhausted. A study by Long et al. (2007), the duration of exposure only weakly correlated to symptoms of PTSD. Mitchell et al. (2004) also reported the association between trauma severity or length of exposure and PTSD and found significant relationship. Volunteers should be given a break from the disaster setting before being re-deployed to the affected area again. Volunteers should be offered psychological support especially who had experienced stress and psychological disturbance following prolonged or several deployments (Adams, 2007). Recommendations
1. Training programs and sharing of best practices in disaster response such as effective orientation to the disaster operation at all levels – emergency planner, coordinating officers, front liners and volunteers.
2. To monitor and establish intelligence during the disaster response to ensure effective communication and monitoring of service provided.
3. To identify the appropriate length of exposure at disaster area to
prevent mental and physical exhaustion.
4. To establish social support networks for both victims and volunteers and appropriate referral to counselors or clinical psychiatrist.
Conclusion
In a large scale disaster, the role of volunteers are vital in helping the authority in the evacuation and rescue operation, continuing of service such as in health services, and recovery process. Like the victims, volunteers also are exposed to the harmful and traumatic events during the disaster setting and these can be the stressor. If left unrecognized or treated it can lead to mental health disease such as PTSD. Awareness of volunteers’ wellbeing and their psychosocial state should be highlighted and included as part of preparedness in handling disaster.
Acknowledgement
The authors wish to thank the Director General of Health for permission to publish this report and special thanks to all who were involved in CPRC Institute for Health Management.
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References
1. Adams, L. (2007). Mental Health Needs of Disaster Volunteers: A Plea for Awareness. Perspective in Psychiatric Care, 43, 1.
2. Agency for Clinical Innovation. A Guide to the Depression, Anxiety and Stress Scale (DASS) (2010). (cited : 6 February 2015). Available from http://www2.psy.unsw.edu.au/groups/dass/.
3. Armagan, E., Engindeniz, Z., Devay, A.O., Erdur, B. & Ozcakir A. (2006). Frequency of Post-traumatic Stress Disorder Among Relief Force Workers After the Tsunami in Asia: Do Rescuers Become Victims?. Prehosp Disaster Med, 21, 168-172.
4. Andrews, B., Brewin, C.R., Philpott, R.
& Stewart, L. (2007). Delayed-onset Post traumatic Stress Disorder: A Systematic Review of The Evidence. Am J Psychiatry , 164, 1319 -1326.
5. Duncan, R.D., Saunders B.E., Kilpatrick,
D.G., Hanson, R. & Resnick, H.S. (1996). Childhood Physical Assault As a Risk Factor for PTSD, Depression and Substance Abuse: Findings From a National Survey. Am J Orthopsychiatry, 66, 437-448.
6. Dyregrov, A., Kristoffersen, J.I. & Gjestad, R. (1996). Voluntary and Professional Disaster-workers: Similarities and Differences in Reactions. J Trauma Stress, 9, 541-555.
7. Green, B.L., Goodman, L.A., Krupnick J.L., Corcoran, C.B., Petty, R.M., Stockton, P. & Stern, N.M. (2000). Outcomes of Single Versus Multiple Trauma Exposure In a Screening Sample. J Trauma Stress, 13, 271-286.
8. Hagh-Shenas, H., Goodarzi, M.A.,
Dehbozorgi, G. & Farashbandi, H. (2005). Psychological Consequences of The Bam Earthquake on Professional and Non-professional Helpers. J Trauma Stress, 18, 477-483.
9. Kato, Y., Uchida, H. & Mimura M.
(2012) Mental Health and Psychosocial Support After the Great East Japan Earthquake. Keio J Med, 61(1), 15-22.
10. Long, M.E., Meyer, D.L. & Jacobs, G.A.
(2007). Psychological Distress Among American Red Cross Disaster Workers Responding to The Terrorist Attack of September 11, 2001. Psychiatry Res, 149, 303-308.
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11. Mitchell, T.L., Griffin, K., Stewart, S.H. & Loba, P. (2004). We will never ever forget: The Swissair flight 111 Disaster and Its Impact on Volunteers and Community’s. J Health Psychol, 9, 245-262.
12. Paton, D. (1994). Disaster Relief Work: An Assessment of Training Effectiveness. J Trauma Stress, 7, 275-288.
13. Perrin, M.A., DiGrande, L., Wheeler, K.,
Thorpe, L. & Farfel, M., Brackbill, R. (2007). Differences in PTSD Prevalence and Associated Risk Factors Among World Trade Center Disaster Rescue and Recovery Workers. Am J Psychiatry, 164, 1385-1394.
14. Polusny, M.A. & Follette, V.M. (1995).
Long Term Correlates of Child Sexual Abuse: Theory and Review of The Empirical Literature. ApplPrev Psychol, 4143-4166.
15. Renck, B., Weisaeth, L. & Skarbo, S.
(2002). Stress Reactions in Police Officers After a Disaster Rescue Operation. Nord J Psychiatry, 56, 7-14.
16. The National Alliance on Mental Illness.
Posttraumatic Stress Disorder FACT SHEET (1979). (cited : 11 April 2015).
Available from: www.nami.org/factsheets/ptsd_factsheet.pdf.
17. Thormar, S.B. , Gersons, B.P.R., Juen,
B., Marschang, A., Djakababa ,M.N. & Olff, M. (2010). The Mental Health Impact Of Volunteering in a Disaster Setting. The Journal of Nervous and Mental Disease, 198(8), 529-538.
18. U.S Department of Veterans Affairs.
The National Centre of Post-Traumatic Stress Disorder (1920). (cited : 11 April 2015). Available from: http://www.ptsd.va.gov/public/pages/what-is-ptsd.asp.
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Lessons from the Remediation of a Flood-damaged Health Clinic Alzamani MI, Malathy R, Hafiz SM, Abu HAA Emergency Department, Hospital Kuala Lumpur
Abstract Introduction: Following a flood, health facilities may be damaged. The Kuala Krau Health Clinic in Temerloh, Pahang was badly affected by the floods that occurred at the end of 2014.Following the floods, the Health Clinic was non-functional and the entire clinic and equipment was filled with mud and badly damaged. We describe our experiences in planning the remediation and restoration activities of this clinic till it became functional again. Materials & Methods: The ‘cleaning project’ was strategically planned. A total of 44 volunteers from various departments at Hospital Kuala Lumpur (HKL) was assembled. We worked with the National Welfare Foundation to provide us with cleaning equipment. The HKL team was joined by members of the Tzu Chi organization and students from Jerantut Nursing College in the planned remediation process. After ‘macro-cleaning’, usable and valuable items were returned to the clinic. This was followed by ‘Micro-cleaning’ phase which entailed cleaning the equipment on day 2. Results: All activities in the remediation were performed by all the volunteers. On the third day, the clinic was functional again. Conclusion: From this experience, co-ordination between stakeholders, volunteers and partners is essential in facilitating an efficient cleaning exercise. Cleaning equipment, water and water jets and power generator for electricity are essential to ensure effective cleaning. Keyword:remediation, cleaning, macro-cleaning, micro-cleaning Introduction
The flood that occurred between 15th December 2014 and 3rd January 2015 in the east coast of West Malaysia, damaged many health facilities. By 29th December 2014, 102 health facilities were affected.
We report our experience in remediation of the Kuala Krau Health Clinic in Temerloh, Pahang following the flood. Based on our analysis team which was despatched on 2nd January 2015, the Health Clinic was non-functional and the entire clinic and equipment were filled with mud.
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Materials & Methods We describe our approach and experience in cleaning up the Kuala Krau Health Clinic in Temerloh, Pahang in the east coast of Malaysia. A fact-finding visit was made to the operations room of the Temerloh Health Clinic. At the briefing, the District Health Officer informed us that the clinic was inundated with mud. A visit was made to the clinic for assessment of damage. A strategy to get the clinic up and running again was agreed upon.Results
I. Damage Assessment
Photo 1: Damage at the Kuala Krau Health Clinic The assessment team included a senior consultant in Emergency Medicine, two Emergency Physicians, a Matron, three staff nurses, one Assistant Medical Officer and four officers from the National Welfare Foundation. The clinic was completely submerged in muddy flood water during the major east coast flood of 2014/2015. The river near the clinic rose and the water submerged the clinic up to the ceiling. The clinic’s sewerage system had overflowed and contaminated the whole clinic. Furniture,
equipment and drugs were damaged with mostly beyond repair and use. The clinic was rendered non-functional. The smell of mud was very strong. The dried mud would also lengthened the cleaning process long and made it more challenging. Water-logged equipment included the ultrasound machine, laboratory equipment, refrigerators and a television set. None of the drugs at the clinic were usable. The clinic interior was dark as there was no electricity. Tap water was not available.
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II. Strategy for ‘Mega Cleaning’ Project
Following a co-ordination meeting at HKL, permission was obtained from the hospital director to send assistance. A total of 44 volunteers from various departments at Hospital Kuala Lumpur were assembled. They ranged from clinical specialist, staff nurses, assistant medical officers, dietitians and hospital attendants. Preparation of food and drink was made for volunteers. A list of cleaning equipment was prepared to ensure all needs would be met for the cleaning exercise. Funds were needed to purchase the cleaning equipment. We worked with the National Welfare Foundation to acquire shovels, spades, mops, wheel-barrows, water jet pumps, electric generators, water-resistant boots, aprons, masks, gloves and rubbish bags. The foundation also assisted with logistics in the form of rented four-wheel drive vehicles as well as food for volunteers. A ‘cleaning project’ was strategically planned. A plan was laid out via a special meeting at HKL. Contact was established with the Family Physician in-charge of the Kuala Krau Clinic to arrange the time and date for our team to carry out the cleaning exercise. The district Fire & Rescue Department was contacted to provide water for the remediation exercise. They would also assist in opening the clinic doors to ensure there were no dangerous animals such as snakes inside the clinic.
III. Pre-Deployment Instruction
On the cleaning day, the other volunteers joined the HKL team; one group was from the Tzu Chi organization and another group of about 50 people were from nursing colleges and other hospitals. A briefing was held for all volunteers. Safety precautions were advised. All volunteers were advised to wear personal protective equipment (PPE), hats, sports attire, water-resistant boots and to bring extra clothes and towels. Spades, shovels, wheel-barrows, water jets and power generators were made available by the National Welfare Foundation. They were also briefed on the ‘ethics’ of disaster assistance. Volunteers were divided into various areas of the clinic. Food and drinks were prepared by the cleaning team so as not to burden the host. The cleaning process started at 8.30 am. The fire and rescue services came upon our request and assisted not only in provision of water but also in ensuring volunteer safety before entering the clinic. There were no dangerous animals such as snakes found inside the clinic.
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In this cleaning exercise, all volunteers were reminded of the ethics of assistance. We made sure that the host was not inconvenienced by our presence. Volunteers worked as a team and wherever possible, publicity was avoided. Finally, when all processes were completed, the premises were left in order. The flood victims were encouraged and respected at all times. IV. Cleaning Process Macro-cleaning: Removal of damaged furniture and rubbish
Photo 2: Damaged furniture and equipment at the Kuala Krau Health Clinic
Volunteers began by removing all furniture and rubbish. The pervasive mud made this a labour intensive exercise. Spades and wheel-barrows proved very useful. The Wellington boots provided safety and comfort as volunteers waded through the mud inside the clinic. The masks were necessary as the stench was unbearable. All rubbish was collected in garbage disposal bags for final removal by the municipal garbage trucks. The removal of furniture, equipment and rubbish took time.
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Micro-cleaning: cleaning of small items In this process, salvaged equipment were cleaned and then replaced in the clinic.
Photo 3: ‘Micro-cleaning’ team: cleaning salvaged equipment
Removal of mud with water
Photo 4: Cleaning with water from water tanker & water jet required to remove thick mud
stain
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The water for the clean-up was provided by the Fire and Rescue Department tanker. The floors were scrubbed. Later, one of the taps was found to be working. Two water jets and power generators donated by the National Welfare Foundation had to be used to remove the mud stains in the clinic. ‘Scavenger Teams’: Salvaging Valuable Equipment and Material
After the removal of damaged furniture, ‘scavenger’ teams were sent in to salvage precious material and equipment. These equipment were then returned into the clinic and locked for safekeeping. After the cleaning was completed on Day 1, it was observed that more cleaning was needed to make the clinic functional. For example, cleaning the stains with water jets took time. Hence, the team returned for a second day to continue cleaning until all items had been cleaned and the state of the clinic became functional.
Photo 5: Some of the equipment salvaged by ‘scavenger’ team
V. THE RESUMPTION OF HEALTH CLINIC The cleaning activities began on 4th January 2015. The clinic was functional again on 7th January 2015. It was the first clinic to be functional of all Ministry of Health clinics damaged by the floods.
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Discussions Cleaning a health clinic following a flood is a challenge. The number of volunteers needed is often underestimated, and there can never be an oversupply of volunteers. This undertaking also requires the right equipment. Water supply is a challenge and teams must make this a priority in order to make the cleaning process effective. Cleaning teams should expect immense damage during such activity. Our experience showed that rubbish and damaged equipment filled the whole clinic compound. Post-flood needs had to be determined so that they could be addressed. In this case, the clinic required assistance for a major cleaning exercise. There was no water or electricity, both of which are essential for a speedy cleaning process. Wisitwong and McMillan (2010) focused on the process of managing a flood situation and the experiences of flood victims at Chainat Province, central Thailand, so as to develop expertise in the handling of such disasters. There was a lack of sanitation and clean drinking water, people were sick, and stressed. The government assisted by supplying the needs that had been damaged or cut-off by the floods such as electricity, food and clean water, sanitation and health services and water drainage. Having a functioning health centre is an
essential part of community’s recovery after a flood. In the cleaning process, we asked for the assistance from the Fire and Rescue Department for provision of water and their help enabled our mission to be completed. Adams et al (2015) asserted that primary care hospitals are a decisive part in the chain of medical supply and are confronted with great challenges, which demand detailed emergency plans and also repeated exercises. In planning and exercises, special attention should be given to the cooperation with the fire and rescue department and other medical services. Having a network of help which includes the department would be handy as evident in our experience of cleaning up the clinic.
The recovery of a health centre takes time. Water takes time to recede and therefore access is a challenge as well. During this event, the water level stayed level with the clinic’s roof for almost two weeks. The longer furniture and equipment were submerged, the more damage is sustained. After the water receded, more time was needed for the clinic to dry up. In addition, the sewerage from the toilets had risen and contaminated the whole clinic. Evans (2012) found that more than a month after superstorm Sandy, five hospitals were still scrambling to restore inpatient services in New York, while hospitals were assessing the changes they would need to make to
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withstand future storms that may be worse. In order to reduce the public health risk posed by flooded buildings that have been restored, it is important to understand their drying behaviour. In our experience, we observed that drying mud was heavy and needed shovelling. The smell was very bad as the sewerage had contaminated the already muddy water. According to Taylor et al (2011), floods can bring pathogens indoors and cause lingering damp and microbial growth in buildings, with the level of growth and persistence dependent on the volume, chemical and biological content of the flood water, the properties of the contaminating microbes, and the surrounding environmental conditions, including the restoration time and methods, the heat and moisture transport properties of the building design, and the ability of the construction material to sustain the microbial growth. The public health risk will depend on the interaction of these complex processes and the vulnerability and susceptibility of occupants in the affected areas. This was illustrated after the 2007 floods in the UK, when the Pitt review noted that there was a lack of relevant scientific evidence and consistency with regard to the management and treatment of flooded homes, which not only put the local population at risk but also
caused unnecessary delays in the restoration effort. Given that community seeks treatment at health clinics, they should not be a source of infection. Proper post-flood remediation lowers illnesses. Hoppe et al (2012) found, following the Cedar River flooding that proper post-flood remediation led to improved air quality and lower exposure among residents living in homes that had been flooded. Proper remediation of flood-damaged homes can reduce bio-aerosols to acceptable levels but exposure is significantly increased while remediation is in-progress leading to an increased burden of allergy and allergic rhinitis. An increase in illnesses was found in households living in flooded homes. It is feared that a clinic affected by floods would harbour infections. A thorough cleaning is required. Waringet et al (2002) described assessment of household needs during Tropical Storm Allison, which hit landfall near Galveston, Texas, in 2001 and caused the most severe flood-related damage ever recorded in the Houston metropolitan area. They found a 4-fold increase in illness among persons living in flooded homes compared with those living in non-flooded homes. These findings suggest a need for rapid resolution of flood-related damage and the recommendation that residents should seek temporary housing during clean-up and repair. The findings
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withstand future storms that may be worse. In order to reduce the public health risk posed by flooded buildings that have been restored, it is important to understand their drying behaviour. In our experience, we observed that drying mud was heavy and needed shovelling. The smell was very bad as the sewerage had contaminated the already muddy water. According to Taylor et al (2011), floods can bring pathogens indoors and cause lingering damp and microbial growth in buildings, with the level of growth and persistence dependent on the volume, chemical and biological content of the flood water, the properties of the contaminating microbes, and the surrounding environmental conditions, including the restoration time and methods, the heat and moisture transport properties of the building design, and the ability of the construction material to sustain the microbial growth. The public health risk will depend on the interaction of these complex processes and the vulnerability and susceptibility of occupants in the affected areas. This was illustrated after the 2007 floods in the UK, when the Pitt review noted that there was a lack of relevant scientific evidence and consistency with regard to the management and treatment of flooded homes, which not only put the local population at risk but also
caused unnecessary delays in the restoration effort. Given that community seeks treatment at health clinics, they should not be a source of infection. Proper post-flood remediation lowers illnesses. Hoppe et al (2012) found, following the Cedar River flooding that proper post-flood remediation led to improved air quality and lower exposure among residents living in homes that had been flooded. Proper remediation of flood-damaged homes can reduce bio-aerosols to acceptable levels but exposure is significantly increased while remediation is in-progress leading to an increased burden of allergy and allergic rhinitis. An increase in illnesses was found in households living in flooded homes. It is feared that a clinic affected by floods would harbour infections. A thorough cleaning is required. Waringet et al (2002) described assessment of household needs during Tropical Storm Allison, which hit landfall near Galveston, Texas, in 2001 and caused the most severe flood-related damage ever recorded in the Houston metropolitan area. They found a 4-fold increase in illness among persons living in flooded homes compared with those living in non-flooded homes. These findings suggest a need for rapid resolution of flood-related damage and the recommendation that residents should seek temporary housing during clean-up and repair. The findings
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underscore the usefulness of a rapid-needs assessment as a tool to identify actual health threats and to facilitate delivery of resources to those with the greatest and most immediate need.
In this disaster, laboratory equipment were damaged from submersion in water. The water supply following the floods may also be contaminated and may damage them as well. Yamada et al (2011) described the damage of analytical devices following flood inundating Okazaki City Hospital in Aichi, Japan in 2008. Hospital functioning did not stop, but some devices were damaged by the water. There was no direct damage to the clinical laboratory area, but an abnormality in the measurement of Troponin-I occurred after the downpour. It was suggested that this measurement abnormality was caused by the pollution of the water supply to the analyzer. For our health clinic, all the laboratory equipment were damaged in this event.
The recovery phase after disaster represents an opportunity to improve services. The Kuala Krau clinic needs to acquire new equipment and materials. Following the cleaning exercise, it was able to function again after three days with very few equipment salvageable. The management however, would need to obtain a budget allocation to acquire new equipment and to repair and renovate the
clinic. A disaster plan for the clinic could also take into account measures for early detection and early response for future floods.
Phalkey et al (2012) asserted that early warning of an impending flood and the availability of counter measures to deal with it can significantly reduce its health impact. In developing countries, public primary health care facilities are the frontline organizations that deal with disasters particularly in rural settings. To develop robust counter reacting systems, evaluating preparedness capacity within existing systems becomes necessary. The authors showed that the healthcare facilities were ill prepared to handle the flood despite being faced by them annually. Basic utilities like power generators and essential medical supplies were lacking during floods. Lack of human resources along with missing standard operating procedures, pre-identified communication and incident command systems, effective leadership and weak financial structure were the main impending factors in mounting an adequate response to the floods. Simple steps like developing facility specific preparedness plans which detail standard operating procedures during floods and identify clear lines of command will go a long way in strengthening the response to future floods. Each facility should maintain contingency funds for an
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 5968
emergency response along with local vendor agreements to ensure stock supplies during floods. The facilities should ensure that baseline public health standards for health care delivery identified
by the Government are met in non-flood periods in order to improve the response during floods. Building strong public primary health care systems is a development challenge.
Recommendation Guidelines on Remediation and Restoration of a flood-damaged Health Clinic The experience of cleaning the Kuala Krau Health Clinic gave us a clear idea of how to conduct an efficient and successful cleaning exercise. This experience enabled us to establish a basic guideline for cleaning a health clinic following floods. The followings are included in the guideline:
1. Determine date for cleaning up with the District Health Officer 2. Gather volunteers at your place for the determined date 3. Give advisory to volunteers: hat/head cover, rubber gloves, Wellington boots, plastic
apron, face mask, clean clothes and towel for change and shower after cleaning up exercise
4. Get tools (may team up with donors): spade, shovels, wheelbarrows, brushes, water containers, water jets, generators, rubbish bags and torch lights
5. Get information of availability of clean piped water. If not, “dry cleaning” can be done i.e removal of furniture and equipment out of clinic. Co-ordination with Fire & Rescue or local municipal authorities can be made to bring water tankers
6. Brief volunteers on ethics of volunteerism: not to trouble the victims, bring the right assistance, bring own food and ‘complement gaps’ when joining work if other group already started the work
7. Get briefing with clinic stakeholders. Divide groups to tackle areas to clean. Work in teams
8. Start by taking out all furniture and equipment outside 9. Use shovel and spade to scoop muds. Expect bad stench as equipment, papers, files
and wood are soaked for days 10. Take care of safety: beware of broken glasses, needles and even poisonous animals
which might have gotten lost in the premises 11. Use rubbish bags and place all disposables into them. This shall enable municipal
lorries to clear the rubbish later on
60 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 201569
12. If clean water is available, water jets can be used by connecting them to generators 13. Salvaging of useable and valuable items should be performed. These items should be
placed back in the clinic and locked 14. Micro cleaning can be performed in teams to clean up each dirtied equipment 15. If time is enough, arrange for a second phase cleaning 16. Have fun, exchange positive vibes among volunteers. Have a sincere heart 17. Leave the premise in orderly manner. Give words of encouragement and respect to
the victim
Conclusion Co-ordination between stakeholders, volunteers and assisting partners is essential for the efficient and effective remediation and restoration of a health clinic. Cleaning equipment, water supply and water jets and power generators were essential in ensuring an effective cleaning exercise. Volunteers must observe the ethics of assistance in disaster and work in a true spirit of volunteerism. The guideline, established from our experience, may be used as a reference for future cleaning exercise. Acknowledgement We would like to acknowledge the Director General of Health, Malaysia for permission to publish this article. We also would like to thank to all who directly and indirectly involved in this activity.
References
1. Wisitwong, A., McMillan M. Management of flood victims: Chainat Province, Central Thailand.
2. Adams, H.A., Flemming. A., Lange,
C., Koppert, W., Krettek, C. (2015). Care concepts in mass casualty incidents and disasters. Concept for primary care clinic. Med Klin Intensivmed Notfmed, 110(1), 27-36.
3. Evans, M. (2012). Recovery mode.
Mod Healthc, 42(50), 6-7, 16, 1.
4. Taylor, J., Lai, K.M., Davies, M., Clifton, D., Ridley, I., Biddulph, P. (2011). Flood management: prediction of microbial contamination in large-scale floods in urban environments. Environ Int, 37(5), 1019-1029.
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5. Yamada, O., Ishii, M., Hayashi, K. (2011). Hospital flooding caused by torrential rain--what happened to analytical devices?. Rinsho Byori, 59(2), 146-151.
6. Phalkey, R., Dash, S.R.,
Mukhopadhyay, A., Runge-
Ranzinger, S., Marx, M. (2012). Prepared to react? Assessing the functional capacity of the primary health care system in rural Orissa, India to respond to the devastating flood of September 2008. Glob Health Action, 5.
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Post-Deployment Activities and Challenges at the Crisis Preparedness Response Center Institute for Health Management (CPRC IHM)
M Fairuz AR, Pangie B, Krishan O, Noriah B, N Filzatun B, N Izzah AS Institute for Health Management
Abstract Introduction: Volunteerism is the heart of disaster management. A disaster spurs people from walks of life into volunteering to provide economical, physical or emotional support to disaster victims. Consequently, the management of volunteers is crucial. Among other things that the effort is effective and efficient, it does not burden the local authority and volunteers are not compromised in any way. Objective: Managing volunteers in time of a disaster is crucial especially during return of the volunteers from disaster sites. This article examines the processes and workflow practised by CPRC IHM in its role as a transit centre for healthcare volunteers, with particular focus on the management of the post-deployment activities phase. Results and Discussions: Healthcare volunteer management in CPRC IHM transit centre was phased into pre and post-deployment activities. Pre-deployment activities focused primarily on the mental and physical status of the volunteers before they deploy to the assigned area. Meanwhile, post-deployment team responsible for post- deployment activities such as registration, medical screening, mental health assessment, accommodation and logistics. For the 20 operating days, IHM received 272 post-deployment volunteers at CPRC IHM transit centre. 84.4% (n=224) post-deployment volunteers completed mental and physical assessment at CPRC IHM. 17.6% (n=48) of post-deployment volunteers decided to have their medical and psychological assessment at their respective state health office. Among the challenges experienced by IHM were inconsistencies on content and timing information relayed and inadequacy of post- deployment debriefing due to the preference of returning for briefing at their own centres. Conclusion and Recommendation: The experience of IHM as post-deployment centre for the Ministry of Health volunteers was value added to the institution. As this is the first mandate and experienced by IHM, there are challenges in volunteer management. The IHM needs to develop Standard Operating Procedures for the management of disaster volunteers at transit centre. This would help other MOH transit centre in future. Keyword: Post-deployment, volunteer, flood, human management
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Introduction Volunteerism is the heart of disaster management. A disaster spurs people from walks of life into volunteering to provide economical, physical or emotional support to disaster victims. Consequently, the management of volunteers is crucial. Among other things that the effort is effective and efficient, it does not burden the affected local authority and volunteers are not compromised in any way. The flood disaster which occurred in the East Coast of Malaysia had opened many eyes. The flood damage was estimated at about RM1 billion and affected public schools, roads, homes, agriculture loss and causing landslides (The Malay Mail Online, 2015). A major issue following a flood disaster is the spread of communicable diseases. This not only affects the victims, the volunteers at the disaster sites as well. Largely, the communicable diseases can be classified into two broad categories, water borne and vector borne diseases. Flooding causes risk escalation in the spreading of water borne diseases such as cholera, typhoid, leptospirosis and hepatitis A (WHO). Leptospirosis, a zoonotic bacterial infection is known to be locally endemic at the affected sites. Flash flood releases bacteria which mainly resides
deep in soils and raises the likelihood of volunteers being exposed to this organism. The process of cleaning disaster sites using air-jets also increases the risk of infection, as the exposure is over a prolonged time period. Without proper guidelines and awareness training from the management
regarding the risks, these enthusiastic volunteers are at risk of being infected. In this regard, Vollaard AM (2004) reported flooding as a significant risk factor for diarrheal disease caused by Salmonella enterica serotype Paratyphi A (paratyphoid fever) in a large study carried out in Indonesia from 1992 to 1993. In a separate study, Katsumata T (2004) evaluated the risk posed by Cryptosporidium parvum in Indonesia between 2001 and 2003 to be four times because of floods. Vector borne diseases were a concern too, as Malaysia is endemic for dengue infection, a viral disease transmitted by the mosquito. Floods would make stagnant water available for the vector and cause spreading of the disease. Thus increasing risk of dengue in the affected population and volunteers. Multiple factors such as overcrowding and stagnant water will exacerbate the outbreak. It is crucial for to obtain information regarding disaster sites as outlined by Watson JT (2007) that is the 1) endemic and epidemic diseases that are common in
64 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 201572
Introduction Volunteerism is the heart of disaster management. A disaster spurs people from walks of life into volunteering to provide economical, physical or emotional support to disaster victims. Consequently, the management of volunteers is crucial. Among other things that the effort is effective and efficient, it does not burden the affected local authority and volunteers are not compromised in any way. The flood disaster which occurred in the East Coast of Malaysia had opened many eyes. The flood damage was estimated at about RM1 billion and affected public schools, roads, homes, agriculture loss and causing landslides (The Malay Mail Online, 2015). A major issue following a flood disaster is the spread of communicable diseases. This not only affects the victims, the volunteers at the disaster sites as well. Largely, the communicable diseases can be classified into two broad categories, water borne and vector borne diseases. Flooding causes risk escalation in the spreading of water borne diseases such as cholera, typhoid, leptospirosis and hepatitis A (WHO). Leptospirosis, a zoonotic bacterial infection is known to be locally endemic at the affected sites. Flash flood releases bacteria which mainly resides
deep in soils and raises the likelihood of volunteers being exposed to this organism. The process of cleaning disaster sites using air-jets also increases the risk of infection, as the exposure is over a prolonged time period. Without proper guidelines and awareness training from the management regarding the risks, these enthusiastic volunteers are at risk of being infected. In this regard, Vollaard AM (2004) reported flooding as a significant risk factor for diarrheal disease caused by Salmonella enterica serotype Paratyphi A (paratyphoid fever) in a large study carried out in Indonesia from 1992 to 1993. In a separate study, Katsumata T (2004) evaluated the risk posed by Cryptosporidium parvum in Indonesia between 2001 and 2003 to be four times because of floods. Vector borne diseases were a concern too, as Malaysia is endemic for dengue infection, a viral disease transmitted by the mosquito. Floods would make stagnant water available for the vector and cause spreading of the disease. Thus increasing risk of dengue in the affected population and volunteers. Multiple factors such as overcrowding and stagnant water will exacerbate the outbreak. It is crucial for to obtain information regarding disaster sites as outlined by Watson JT (2007) that is the 1) endemic and epidemic diseases that are common in
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 6573
the affected area; 2) living conditions of the affected population, including number, size, location, and density of settlements; 3) availability of safe water and adequate sanitation facilities; 4) nutritional status and immunization coverage of the population; and 5) degree of access to healthcare and to effective case management. CPRC IHM Post-Deployment Team Healthcare volunteer management in CPRC IHM transit centre was phased into pre and post deployment activities. Pre-deployment activities focused primarily on the mental and physical status of the volunteers before they deploy to the assigned area. While, post-deployment activities, assessed the physical and mental status of the
healthcare volunteers after their stint at the affected sites. This article examines the processes and workflow practised by CPRC IHM in its role as a transit centre for healthcare volunteers, with particular focus on the management of the post deployment activities phase. For 20 days of operation, we received 272 post-deployment volunteers at its CPRC IHM transit centre. 84.4% (n=224) volunteers were completed post-deployment mental and physical assessment at CPRC IHM while 17.6% (n=48) volunteers were decided to have their post-deployment medical and psychological assessment at their respective state health offices.
Table 1: Job Description of Post-Deployment Volunteers Who Transit at CPRC IHM
No Job Description Total Volunteer Percentage (%) 1. Specialist 3 1 2. Medical Officer 17 6 3. Nurse 172 63 4. Assistant Medical Officer 11 4 5. Pharmacist/ Pharmacist Assistant 17 6 6. Counsellor 10 4 7. Engineer 7 3
8. Penolong Pegawai Kesihatan Persekitaran 8 3
9. Social Worker 3 1 10. Pembantu Kesihatan Awam 2 1 11. Driver 11 4 12. Pembantu Perawatan Kesihatan 9 3 13. Pembantu Rendah Awam 2 1
Grand total 272 100
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The Head of CPRC IHM was the Director of Institute for Health Management. The post deployment team was responsible for management of volunteers who had returned from disaster sites. The several tasks assigned to the post-deployment team are depicted in Figure 1. The team was also required to ensure the orderliness of post deployment activities at CPRC IHM transit centre by following the established workflow. Finally, the wrap-up session at the end of each operating day was a forum for the team to share their issues and discuss solutions to improve the post-deployment activities or management of volunteers.
Figure 1: The CPRC IHM Post-deployment team workflows
Post-Deployment Activities at CPRC IHM Transit Centre Post-deployment activities involved several processes that were executed by the CPRC IHM. These processes were based on the Pre and Post-Deployment Healthcare Volunteers Guideline by CPRC MOH issued on 7th January 2015. The guideline states that the MOH healthcare volunteers who returned and transit at CPRC IHM were required to attend the in- house PFA
74
The Head of CPRC IHM was the Director of Institute for Health Management. The post deployment team was responsible for management of volunteers who had returned from disaster sites. The several tasks assigned to the post-deployment team are depicted in Figure 1. The team was also required to ensure the orderliness of post deployment activities at CPRC IHM transit centre by following the established workflow. Finally, the wrap-up session at the end of each operating day was a forum for the team to share their issues and discuss solutions to improve the post-deployment activities or management of volunteers.
Figure 1: The CPRC IHM Post-deployment team workflows
Post-Deployment Activities at CPRC IHM Transit Centre Post-deployment activities involved several processes that were executed by the CPRC IHM. These processes were based on the Pre and Post-Deployment Healthcare Volunteers Guideline by CPRC MOH issued on 7th January 2015. The guideline states that the MOH healthcare volunteers who returned and transit at CPRC IHM were required to attend the in- house PFA
74
The Head of CPRC IHM was the Director of Institute for Health Management. The post deployment team was responsible for management of volunteers who had returned from disaster sites. The several tasks assigned to the post-deployment team are depicted in Figure 1. The team was also required to ensure the orderliness of post deployment activities at CPRC IHM transit centre by following the established workflow. Finally, the wrap-up session at the end of each operating day was a forum for the team to share their issues and discuss solutions to improve the post-deployment activities or management of volunteers.
Figure 1: The CPRC IHM Post-deployment team workflows
Post-Deployment Activities at CPRC IHM Transit Centre Post-deployment activities involved several processes that were executed by the CPRC IHM. These processes were based on the Pre and Post-Deployment Healthcare Volunteers Guideline by CPRC MOH issued on 7th January 2015. The guideline states that the MOH healthcare volunteers who returned and transit at CPRC IHM were required to attend the in- house PFA
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 6775
briefing, undergo Depression, Anxiety, Stress Scale (DASS) assessment and physical examination. The post-deployment activities for the volunteers included (Figure 2):
i. Registration of the post-deployment volunteers ii. Medical/physical screening iii. Post-Deployment PFA briefing and DASS screening iv. Accommodation and Catering facilities v. Logistics
Figure 2: The Post-Deployment Process for Volunteers in CPRC IHM
1.0 Registration of Post-deployment Volunteers Upon arrival at CPRC IHM, post-deployment volunteers needed to register at the counter located at the IHM lobby. They were requested to complete the daily volunteer attendance form. The completed forms were collected by the post-deployment registration team and despatched to the CPRC IHM operation room. The operation room secretariat used the information to update the daily census and to prepare the report for CPRC MOH.
68 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 201576
Photo 1: Post-deployment volunteers being registered at IHM lobby before PFA briefing and
medical screening 2.0 Medical/Physical Screening Medical or physical screening of post-deployment volunteers was conducted in collaboration with other NIH Institutes. Medical officers from the Clinical Research Center, Institute for Health System Research and Institute for Health Management examined and advised the volunteers about water borne related diseases. In the event that a post-deployment volunteer had a medical issue or problem, they would be referred to the nearest health clinic or hospital for further diagnostic assessment and prompt treatment. The signs and symptoms of flood related communicable diseases were also highlighted to the post-deployment volunteers. The information on water borne diseases especially meloidosis, leptospirosis, cholera and typhoid was displayed at the IHM lobby to increase awareness among volunteers. Table 2: Medical problems detected in post-deployment medical screening of volunteers in
transit at CPRC IHM
No Medical problem No of Volunteers Affected 1. Upper Respiratory Tract Infection 4 2. Hypertension 4 3. To Rule Out (TRO) Dengue Fever 3 4. Acute Gastroenteritis (AGE) 2 5. Tachycardia for investigation 2 6. Fever for investigation 1 7. Anal fissure 1 8. Hyperthyroidism 1
Grand Total 18
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As shown in Table 2, no volunteer was diagnosed with these communicable diseases at CPRC IHM. However, the volunteers were reminded to seek medical attention immediately if they showed any sign or symptom of infection.
Photo 2: Medical Officers examining post-deployment volunteers at the Kristal Room 3.0 Post-deployment PFA Briefing and DASS assessment The mental assessment was carried according to the National Guidelines for Mental Health and Psychosocial Response to Disaster developed by the Ministry of Health. Post traumatic stress disorder (PTSD) among the post-deployment volunteers was the main concern. In view of this, mental assessment was crucial for
this group. As instructed by CPRC MOH, DASS was the tool used for mental assessment at CPRC IHM. 224 post-deployment underwent DASS assessment and 5.3% (n=12) of them had at least two abnormal scores on the scales (Table 3). Volunteers who showed moderate to severe DASS scores were counselled by a PFA trained counsellor. They were followed up two weeks later at a hospital.
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Table 3: Distribution of Abnormal DASS Findings at Psychosocial Screening (Munirah I, Norhidayah MD, Institute for Health Management - Transit Center for Flood Disaster Jan 2015; Psychosocial Impact on Volunteers.)
No Occupation No Of Days
Spent In The Flood
Affected Area
Flood Affected
Area
DASS
Stress Anxiety Depression
1. Nurse 15 Kelantan Mild Mild Normal 2. Nurse 15 Kelantan Mild Mild Normal 3. Nurse 15 Kelantan Moderate Severe Severe 4. Assistant
Medical Officer 15 Kelantan Extremely
Severe Extremely
Severe Moderate
5. Information Technology Officer
15 Kelantan Severe Moderate Moderate
6. Nurse 14 Kelantan Mild Moderate Normal 7. Nurse 14 Kelantan Mild Moderate Mild 8. Nurse 14 Kelantan Moderate Severe Severe 9. Nurse 10 Kelantan Mild Moderate Normal 10. Nurse 10 Pahang Normal Moderate Mild 11. Assistant
Medical Officer 10 Pahang Normal Moderate Mild
12. Assistant Engineer
4 Kelantan Normal Moderate Mild
Photo 3: Post-deployment volunteers undergoing DASS assessment before the PFA.
78
Table 3: Distribution of Abnormal DASS Findings at Psychosocial Screening (Munirah I, Norhidayah MD, Institute for Health Management - Transit Center for Flood Disaster Jan 2015; Psychosocial Impact on Volunteers.)
No Occupation No Of Days
Spent In The Flood
Affected Area
Flood Affected
Area
DASS
Stress Anxiety Depression
1. Nurse 15 Kelantan Mild Mild Normal 2. Nurse 15 Kelantan Mild Mild Normal 3. Nurse 15 Kelantan Moderate Severe Severe 4. Assistant
Medical Officer 15 Kelantan Extremely
Severe Extremely
Severe Moderate
5. Information Technology Officer
15 Kelantan Severe Moderate Moderate
6. Nurse 14 Kelantan Mild Moderate Normal 7. Nurse 14 Kelantan Mild Moderate Mild 8. Nurse 14 Kelantan Moderate Severe Severe 9. Nurse 10 Kelantan Mild Moderate Normal 10. Nurse 10 Pahang Normal Moderate Mild 11. Assistant
Medical Officer 10 Pahang Normal Moderate Mild
12. Assistant Engineer
4 Kelantan Normal Moderate Mild
Photo 3: Post-deployment volunteers undergoing DASS assessment before the PFA.
78
Table 3: Distribution of Abnormal DASS Findings at Psychosocial Screening (Munirah I, Norhidayah MD, Institute for Health Management - Transit Center for Flood Disaster Jan 2015; Psychosocial Impact on Volunteers.)
No Occupation No Of Days
Spent In The Flood
Affected Area
Flood Affected
Area
DASS
Stress Anxiety Depression
1. Nurse 15 Kelantan Mild Mild Normal 2. Nurse 15 Kelantan Mild Mild Normal 3. Nurse 15 Kelantan Moderate Severe Severe 4. Assistant
Medical Officer 15 Kelantan Extremely
Severe Extremely
Severe Moderate
5. Information Technology Officer
15 Kelantan Severe Moderate Moderate
6. Nurse 14 Kelantan Mild Moderate Normal 7. Nurse 14 Kelantan Mild Moderate Mild 8. Nurse 14 Kelantan Moderate Severe Severe 9. Nurse 10 Kelantan Mild Moderate Normal 10. Nurse 10 Pahang Normal Moderate Mild 11. Assistant
Medical Officer 10 Pahang Normal Moderate Mild
12. Assistant Engineer
4 Kelantan Normal Moderate Mild
Photo 3: Post-deployment volunteers undergoing DASS assessment before the PFA.
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Photo 4: Counsellor giving PFA to the post-deployment volunteers 4.0 Accommodation and Catering Facilities The volunteers who decided to lodge at IHM were given access to the hostel room by the hotel supervisor upon registration. Only 5 post-deployment volunteers from Johor lodged for two days at CPRC IHM. The majority (98.2%, n=267) of post-deployment volunteers returned to their state on the same day using their health departmental transportation. These volunteers were healthcare staff from
Wilayah Persekutuan Kuala Lumpur, Putrajaya, Selangor, Perak and Melaka. A catering team was in charge of ordering and providing food for the volunteers. Food and beverage were prepared by the in-house caterer according to the number of volunteers to transit at CPRC IHM for that particular day. The volunteers had their meals at the IHM cafeteria.
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Photo 5: The volunteers who lodged at IHM registering with Hostel Supervisors 5.0 Logistics The transport from the airport to IHM for post-deployment volunteers was arranged and coordinated by the logistics team. The logistics officers arranged airport transfer according to the returnee and their flight schedule information supplied by CPRC MOH. CPRC IHM also worked with CPRC Institute of Public Health (IPH) on the assignment of drivers and vehicles for this purpose. Transport for volunteers to return to their state was arranged and provided by their respective departments. Challenges and Recommendation Post-Deployment Information One of the challenges in managing post-deployment volunteers was the information relayed by CPRC MOH. There were inconsistencies in and timing information relayed. It is important to get clear and correct information from CPRC MOH and in-
time as logistic matters need to be sorted prior to the arrival of volunteers. CPRC IHM needed prior notification to arrange accommodation, food and most importantly, transportation to fetch volunteers from the airport. Due to the inconsistencies of information, resources were wasted in that the buses came back with few or no passengers at all. The main reason for this was that volunteers made their own transport arrangements. Consequently, most of the volunteers did undergo the required medical and mental health screening.
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Post-Deployment Briefing Feedback from the volunteers included that, certain states had organised post deployment briefing for volunteers at the respective affected sites. During transit in IHM, volunteers reported that the briefing was more of an appreciation and recognition of their assistance. There was no medical or psychological screening carried out by the medical and certified Psychosocial First Aid (PFA) team. Recommendation In a time of crisis, a large number of volunteers is needed to ensure that aid is given to the affected areas. Volunteerism has reduced the cost of rebuilding and recovery of affected areas. However, management of a large number of volunteers can be challenging as the fundamental principle of volunteerism is to provide aid and not to burden the local authority. Furthermore, efficient and thorough post deployment management of volunteers is vital to screen and prepare the volunteers to resume work. In any crisis control room, intra-organisation and inter-organisation communication determines the effectiveness and proficiency of volunteer management. In this case, effective communication between these three organisations, that is CPRC MOH, CPRC IHM and CPRC IPH is vital. As for post-
deployment volunteer management, CPRC IHM has contacts CPRC MOH to ascertain each volunteer team’s transport needs for the return to their respective health facilities. With clear information, CPRC IHM will make the necessary arrangements for these volunteers. These arrangements would include catering, transport and lodging. Due to the lacking of cohesion in providing appropriate post deployment briefing, the task of giving psychosocial and medical screening is left to the State Office. It is the responsibility of the State Offices to screen returning physically and mentally before releasing them for work. This ensures that any volunteer found ill is referred to experts for treatment and only healthy and able volunteers are allowed to resume work. Conclusion The experience of IHM as post deployment centre for the Ministry of Health volunteers was value added to the institution. As this is the first mandate and experienced by IHM, there are challenges in volunteer management. The IHM needs to develop Standard Operating Procedures for the management of disaster volunteers at transit centre. This would help other MOH transit centre in future.
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Acknowledgment We would like to acknowledge the Director General of Health, Malaysia for permission to publish this article. Special thanks also to all those involvedand support the operation of the CPRC IHM. Reference
1. Volunteers of America (2008). Disaster Related Volunteerism: Best Practices Manual Based on Lessons Learned from Hurricanes Katrina and Rita. Greater New Orleans.
2. Faye S. (2003). Managing Spontaneous Disaster Volunteers, North Carolina Commission on Volunteerism and Community Service. Washington, USA.
3. Katsumata, T., Hosea D., Wasito, E.B., Kohno, S., Hara ,K., Soeparto, P., et al. (1999). Cryptosporidiosis in Indonesia: a hospital-based study and a community-based survey. Am J Trop Med Hyg, 59, 628–632.
4. Points of Light Foundation & Volunteer Center National Network (2004). Managing Spontaneous Volunteers in Times of Disaster:The Synergy of Structure and Good Intentions. USA.
5. The Jamsetji Tata Centre for Disaster Management (2010).
Training Volunteers in Disaster Response. Japan.
6. Vollaard, A.M., Ali S., Van, Asten, H.A., Widjaja, S., Visser, L.G., Surjadi, C., et al. (2004) Risk factors for typhoid and paratyphoid fever in Jakarta, Indonesia. JAMA, 291, 2607–2615.
7. WHO: Flooding and communicable diseases fact sheet. (Cited: 20 August 2015). Available from: http://www.who.int/hac/techguidance/ems/flood_cds/en/.
8. Watson, J.T., Gayer, M., Connolly, M.A. (2007). Epidemics after natural disasters. Emerg Infect., Jan. Available from http://www.cdc.gov/ncidod/EID/13/1/1.htm
9. The Malay Mail. Flood damage estimate tops RM1b (2015). (cited : 20 August 2015). Available from http://www.themalaymailonline.com/malaysia/article/flood-damage-tops-rm1b.
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Managing Child Flood Victims by Psychological Engagement: A Pilot Project
Alzamani MI, Mona KG, Nurul LR, Hafiz SM, Ahmad IKB, Abu HAA
Emergency Department, Hospital Kuala Lumpur
Abstract
Introduction: After a disaster, the focus of assistance for victims is usually on basic survival needs
such as shelter, food and water. The psychological needs of the children are often neglected. This
study reports the intervention used to meet the children’s psychological needs during the major
flood that occurred in Temerloh, Pahang from 3 December 2014 to 3 January 2015.
Material & Methods: We describe the employment of psychological intervention in children via
play and art therapy. A team of 15 personnel including 1 Emergency Physician, 4 Medical Officers,
3 Staff Nurses, 2 Assistant Medical Officer from Kuala Lumpur Hospital’s Emergency Department,
established an Emergency Medical Services and Observation Ward at the Temerloh Relief Center
in Pahang which housed about 3,000 victims. In addition, a team of 3 psychologists was recruited
to provide psychological intervention. The team stayed at the center for 1 week to provide medical
services. The play therapy and art therapy was specifically targeted at the children. This was a
pilot project to provide mental support for children. A ‘walkabout’ team consisting of an emergency
physician, a medical officer and a psychologist screened children for change of behavioural. 10
children who had noticeable behavioral changes were recruited for this study on voluntary basis.
Results: Subjects were able to express their state of mind via play and art therapy. Psychologists
provided mental therapy to affected victims. The ‘walkabout’ team was able to screen for children
who had a troubled mental state. Early detection and therapy could mitigate symptoms and
prevent progress to more serious problems such as anxiety disorder or post-traumatic stress
disorder.
Conclusion: Play and art therapy are useful modes of mental therapy for children affected by
disaster. Psychological engagement should not be forgotten as disaster victim are often mentally
troubled. Without close observation, this aspect may be missed. Psychologists can play effective
roles by engaging the victims in activities that help them express themselves, and therapeutic
measures such as play and art therapy.
Keyword: Child, flood victims, psychological engagement, play and art therapy
76 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
IntroductionAfter a disaster, the focus of assistance is usu-
ally on basic survival needs such as shelter, food
and water. The victims’ psychological needs are
often neglected. Children, who are at a critical
age in development, can suffer tremendous-
ly when their experiences are not given any
form of expression. Since children’s preferred
form of expression is action and play, using
language-based therapy is akin to providing
therapy for an adult in a foreign language (La
Motte, 2011). The purpose of this crisis inter-
vention is to restore the victim’s functioning to
pre-disaster levels. It is crucial for children to
make sense of the events so that they regain a
sense of control. This report describes the art
and play intervention used to address the chil-
dren’s psychological needs following the major
flood that occurred in Temerloh, Pahang from
3 December 2014 to 3 January 2015.
Material & MethodsWe describe the employment of psychological
intervention in 10 children as a pilot project.
A group of 3 psychologists were recruited to
work alongside a medical services unit at the
Temerloh relief center located at a school. A
team of 15 personnel including 1 Emergency
Physician, 4 Medical Officers, 3 Staff Nurses, 2
Assistant Medical Officers from Kuala Lumpur
Hospital’s Emergency Department established
an Emergency Medical Services and Observa-
tion Ward at the Temerloh Relief Center in Pa-
hang. This center housed about 3,000 victims.
In additional, a team of 3 psychologists was
recruited to provide psychological intervention.
The team stayed at the center for 1 week. The
intervention applied for children was play and
art therapy. Art and play therapy were adapt-
ed psychological using the medium of play as
the means of communicating with the child
(McKinney Clark, 2015). Proactive screening
via medical walkabout was done to identify
children who needed ‘psychological first aid’
or critical incident stress management. This
screening was based on parental communica-
tion of behavioral changes they had observed
in their children following the disaster. From
this screening, 10 children were identified and
asked to voluntarily participate in our study.
Art TherapyMaterials provided for art therapy were drawing
paper and coloring pens. Subjects were asked
to draw anything they pleased, whether it was
related to the flood or not. Subjects would then
describe the finished drawings. Interpretation
of emotions was done by psychologists based
on objects drawn and the choice of color. For
example red represents aggression, danger,
excitement and yellow represents happiness,
joy and fear.
Play TherapyNine different stuffed animals of various shapes
were provided. Each toy represented a certain
character or emotion. Play Therapy comprised
patient selecting one or more stuffed animals
given to them. The subjects were asked the
following questions:
“Which of these stuffed animals makes you
feel happy?”
“Which of these stuffed animals do you like
the most?”
‘Which of these stuffed animals represents
you?”
“Why did you choose it?”
All results were then interpreted by the psy-
chologists.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 77
ResultsPart 1: Art therapy
Child 1: A 10 year old girl drew her dream house; a wooden house on stilts on the beach side,
surrounded by animals (cats, dogs, fish). There was a swimming pool and next to it there were
two palm trees with a hammock suspended between them. (Figure 1)
Figure 1: Drawing of Child 1
Interpretation: The drawing filled up the entire page and this represents a range of normalcy.
The birds represent freedom and her need to be free. The animals that she has around her house
show that they keep her company when she is alone. The two palm trees represent mother
figures; her mother & her aunt that she has close relationships with. The position of the house
near the beach shows that what she built may not be permanent and may be destroyed in the
long run. This reflects her current view of the situation of her home at the time of therapy session.
Child 2: A 6 year old boy drew his family; parents, him and his sister. There was a cat that sat
on the roof (Figure 2)
Figure 2: Drawing of child 2
78 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Interpretation: The color red (mud brought by the flood) may represent courage, danger and
determination. The drawings done in thick lines shows trauma or aggression. What he experienced
was very traumatizing for him.
Child 3: An 8 year-old girl who was trapped with her family in the flood and who was looking for
ways to stay safe indoors while the water level was rising. She drew houses that were submerged
with the roof visible; two men floating in the water.
Interpretation: This child described the two men afloat whom she saw as corpses. The stick
figures that represented her family represent the feeling of being insecure or depressed. The thick
lines used to draw the roof and corpses represent trauma or aggression.
Child 4: A 9 year old boy drew his favorite toy; a robot in blue and red. It has a huge head and
large metal hands holding a weapon.
Interpretation: The large head represents fantasy thinking and this represents an egoistic person.
Large hands show that he may be aggressive or hostile. The red color represents aggression or
excitement in him. The color blue represents authority, depression and confidence.
Child 5: An 8 year old girl drew a rainbow in red, yellow, blue and green with the rain still falling.
There was a stick figure of herself under the rainbow smiling.
Interpretation: The color red represents compassion, courage, emotions; blue represents
balance, calmness, confidence; yellow represents energy, expression, happiness; green represents
adventure, calmness and faith. Stick figure represent the feeling of being insecure or depressed.
The roof of the houses, and the corpses that she saw were drawn in thick lines and they represent
trauma or aggression.
Note: Actual drawing pictures for child 3, 4 & 5 were not available as they were not captured
during the activity.
Our observation of children experiencing the ‘Art Therapy’:
1. The children were able to convey traumatizing experiences that may not have come
through if done using the conventional therapy.
2. The children enjoyed themselves and the therapy served as a distraction while living in a
shelter.
3. They were happier after completion of therapy.
4. The ‘art therapy’ promoted communication skills between children when they interacted
between to explain their drawings.
5. Some of the children sought therapy repeatedly because it made them feel good about
themselves.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 79
Part 2: Play Therapy
Children were asked to choose from an array of stuffed animals. Stuffed animals were used as
play and communication medium between the child and the counsellor (Figure 3). Explanation
was given to the patients that the interpretation of their selection would usually unraveled deep
seated issues. Those issues were not easily obtained by typical verbal therapy (Figure 4). Children
often found relief in being able to share their experience and emotions that were extremely trau-
matic. Children who participated in the Art or Play Therapy were rewarded with candy (Figure 5).
Figure 3: The stuffed animals used as play and communication medium between child and the counselor
Figure 4: The stuffed animals used in play therapy
Figure 5: Candy offered to participating children
80 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Child 1: A 12 year old boy was asked which one of the stuffed animals that he liked the most and
why. He picked up a grey koala because it reminded him of his silly brother.
Interpretation: A koala is a wild animal, thus it represents power and strength that he may see
in his brother.
Child 2: A 10 year old girl was asked which of the stuffed animals made her happy and why?
She chose the cat that had big eyes and head because she loved cats and they always made her
smile. She had a cat at home and was not sure where it was after her family was evacuated from
their home during the flood. She also said that thinking of her cat made her worry.
Interpretation: The girl was not only able to identify the animal that made her happy but she
managed to convey a very traumatic event that she experienced during the flood; she had lost her
cat and it worried her that the cat may have drowned. On the other hand, the cat is a domestic
animal that represents family and vulnerability. The child may be feeling vulnerable from losing
the cat, which is also a part of her family.
Child 3: A 5 year old boy was asked to choose the animal that represents him and why?
He chose the tiger with the long, large tail because the tiger is a fierce animal like him and he
loves the large tail because it looked funny.
Interpretation: The tiger is a wild animal that represents aggression, anger and survival. The
child went through a traumatic experience with the flood but was coping with it well.
Child 4: A 4 year old boy was asked to choose an animal that he loved the most.
He chose a black cat with large teeth but did not give any reasons for it.
Interpretation: The cat represents dependency; relations or family and the large teeth may
represent anger or aggression. The child may have an issue of anger with one of his family
members or relations.
Child 5: A 9 year old girl was asked to choose a toy that she liked the most and why.
She chose the panda because it was very cute and cuddly.
Interpretation: The panda is a wild animal thus it represents power and strength. She needed
someone friendly whom she would feel safe with and count on. She loves to hug which indicates
the presence of a loving character and very likely an experienced caring caretaker(s) in her life.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 81
Our observation of children experiencing the ‘Play Therapy’:
1. Encouraged the children to talk about the traumatizing circumstances events that they had
experienced in their lives especially during the flood devastation.
2. The children became more playful and enjoyed the time they spent with their peers and
the counsellors in therapy.
3. They became comfortable in expressing their anxieties or problems to the counsellors
because they trusted them.
4. Encouraged creativity in role-playing with the toys.
5. The children enjoyed themselves and the therapy served as a distraction and a form of
activity for them to enjoy while in shelter.
Discussion
Psychological engagement should not be
forgotten as disaster victims are often mentally
troubled. Without close observation, this
aspect may be missed. Counsellors can play
effective roles by engaging victims in activities
such as play and art therapy which can help
them express themselves.
Through ‘Art Therapy’, the children were able
to convey their traumatizing experience that
may not have emerged with conventional
therapy. They enjoyed themselves and
the therapy served as a distraction and an
enjoyable activity while housed in a temporary
shelter. We observed that they emerged
happier after therapy. ‘Art Therapy’ promoted
communication skills between children when
they interacted amongst themselves to explain
their drawings. Some of the children attended
therapy repeatedly.
‘Play Therapy’ effectively encouraged the
children to talk about the traumatizing
events that they had experienced during the
devastating flood, so that they were more
playful and enjoyed the time they spent with
their peers and the counsellors. We observed
that they became comfortable at expressing
their anxieties or problems to the counsellors
because they trusted them. It also encouraged
creativity in role-playing with the toys.
Mental health effects in disaster vary from
population to population. A lot of factors
may affect the population and more studies
are required to understand the state of mind
of a displaced population. Wind et al (2014)
explained that the types of disaster and
individual event characteristics also affect
survivors’ emotional and cognitive reactions.
Grimm et al (2012) compared survivors’
perceived post- and peri-traumatic emotional
and cognitive reactions across different types
of disasters. The authors found that there
were differences in perceived post- and peri-
traumatic emotional and cognitive reactions
with different types of disasters.
The psychological effects of disaster on
82 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
victims vary depending on fatigue and distress
in handling disaster situation. Fatigue and
psychological distress also correlated with
workload. During the Japanese Earthquake in
2011, Kitamura et al (2013) found that two-
thirds of the employees suffered fatigue and
psychological distress, which were significantly
correlated with workload but inversely
correlated with emotional stability, personality
traits and psychological resilience. Together
with substantial workload, individual differences
in emotional stability and, to a lesser degree,
in resilience were found to have an impact
on perceived fatigue. These individual factors
should be considered as potential mediators of
distress among local government employees
responding to disasters.
Intangible losses have an important
psychological effect on community
redevelopment and recovery from trauma.
Hawkins and Maurer (2010) examined the
physical and psychological loss of home and
community following Hurricane Katrina. It was
found that a breakdown in their social fabric
at the individual and structural or community
levels contributed to a sense of community
loss and social displacement, disrupting their
notion of safety, routine and trust in a stable
environment. In our experience, we observed
a somewhat resilient community at this relief
center in which the victims co-operated closely
by taking turns to cook meals and helping each
other. The teachers in the school too showed
exemplary attitude by establishing a systematic
mechanism for distributing donations. These
factors contributed to a decrease in the negative
psychological effect on the community.
Social background and character too may
be suppressive in psychiatric disorders. The
people at this relief center were positive
and co-operative. They had a strong culture
of helping each other in non-disaster times
through their village committee. In weddings
and deaths, the villagers would unite cooperate
to help each other. Perhaps this may explain
the cohesion in this community. A culture of
helping leads to greater community resilience
and indirectly less psychiatric disorders such as
acute stress disorder or post-traumatic stress
disorders (PTSD). Ishikawa et al (2013) studied
PTSD in flood victims and found that PTSD
and depression were less common in Tibetan
culture than in other cultures. The social
background and temperamental characteristics
of the Tibetan culture may play a suppressive
role in psychiatric disorders.
Following a disaster, the community’s daily
activities would be disrupted. Some social
change is bound to take place. Henry (2010)
stated that for some time, disaster studies
had looked for social change and mostly found
continuity. He argued that shifting the focus
from investigating social change to documenting
continuity may enhance the understanding and
planning of post-disaster situations especially
in industrialized societies like the United States.
The analysis of long-term recovery plans,
along with field observations and interviews
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 83
with evacuees, suggest that despite the well-
documented emergence of conflict in post-
Katrina New Orleans, the likelihood of social
change appears limited. Once the victims in
Temerloh were adapted to the changes in their
environment they would find continuity in their
daily activities.
Sleep problems, pain or suicidal thoughts
are directly related to adverse mental health
outcomes. Boscarino et al (2014) evaluated
mental health outcomes in the New Jersey
shore residents with health impairments and
disabilities after Hurricane Sandy. The authors
concluded that having physical impairments
and health conditions were not directly related
to adverse mental health outcomes following
Sandy, but having sleep problems, pain, or
suicidal thoughts were. Nevertheless, we
observed that many of the evacuees did not
get good sleep and some of them had body
aches due to the lack of a proper mattress.
Nevertheless, none of them had suicidal
thoughts.
The behavior response to a disaster would be
an interesting subject to study. The responses
are more universal, mostly adaptive and
unselfish as most need to survive. The victims
at this relief center adapted to sleeping on mats
in school classrooms. They took responsibility
for the meals and the cleanliness of the place.
Grimm et al (2014) conducted interviews in
seven countries to explore survivors’ emotional,
behavioural, and cognitive responses to
disasters. While the environmental cues and
the ability to recognize what was happening
varied in different disasters the survivors’
responses tended to be more universal across
events, and most often were adaptive and
unselfish. Several peri-traumatic factors related
to current levels of post-traumatic were also
identified. With multiple aspects potentially
affecting them, the psychological state of the
victims should be addressed.
At the relief center, no suicidal behavior was
observed. Nevertheless, further research is
needed to assess the health status of affected
residents with serious health impairments over
time following disasters. Kolves et al (2013)
showed different trends in suicide mortality
following natural disasters. Nevertheless,
there seemed to be a drop in non-fatal suicidal
behavior in the initial post-disaster period,
which has been referred to as the’ honeymoon’
phase. A delayed increase in suicidal behaviour
has been reported in some studies. However,
other factors that raise the risk of suicidal
behaviour after natural disasters have been
reported, such as previous and current mental
health problems. Furthermore, contributing
factor, such as economic status, should also
be considered. Mental health and suicidal
behaviour should continue to be monitored for
several years after a disaster.
Conclusions
Play and art therapy are useful modes of
mental therapy for children affected by disaster.
Psychological engagement should not be
neglected as disaster victims are often mentally
84 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
troubled. Without attention and observation,
this aspect may be missed. Counsellors can play
effective roles by engaging with victim in play
and art activity therapy which can help them
express themselves. Psychological engagement
would render our response more holistic
and enable the integration of psychological
management into the disaster response. This
effort is a start in the cognizance of evacuee’s
mental status. However, more studies to assess
this status in evacuees following a disaster and
the effectiveness of our intervention need to
be done.
Acknowledgements
We would like to acknowledge the Director
General of Health, Malaysia for permission to
publish this article. We also would like to thank
to all who directly and indirectly involved in this
activity.
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86 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Public Health Challenges During Flood Disaster: Managing Food Poisoning Outbreak In Pusat Pemindahan MRSM Pasir Salak Perak Tengah District
January 2015
Nor Samsiah AR, Ariza AR
Perak State Health Department
Abstract
An outbreak of food poisoning occurred on 10th January 2015 in Pusat Pemindahan (PP) MRSM
Pasir Salak in the Perak Tengah district during the flood of January 2015. PP MRSM Pasir Salak
was the biggest evacuation centre sheltering about 1061 flood victims. It involved fifty victims
which treated as outpatient. A case control study was conducted to define the epidemiological
characteristics of the outbreak and to determine the source of infection. The prominent clinical
features were diarrhoea (100%), abdominal pain (100%), vomiting (14%) and giddiness (4%).
None of them complained of fever. The onset of symptom occurred 5-14 hours after the suspected
meals and median incubation period was at 8 hours. The possible sources of the outbreak were nasi
minyak (OR=30.00, 95% CI: 9.18, 105.24, p<0.001 food attack rate 71%) and ayam masak merah
(OR=96.00, 95% CI: 18.88, 658.48, p<0.001, food attack rate 78%). However, microbiological
investigations of rectal and stool culture didn’t isolate any pathogenic organism. The food was
cooked by 2 teams of volunteers, team A and B. From our investigations, the food poisoning was
associated with food prepared by team A which involved 14 temporary food handlers. All of them
had been vaccinated with Ty2 (Typhoid-ThyphimVI) and 10 of them were trained in the food
handling. The most probable contributing factor identified was related to the poor food safety
technique practiced by food handlers. The cleanliness rate on 9th January 2015 was 79%. The
outbreak ended on 11th January 2015. All the victims received outpatient treatment, there were no
case hospitalisation or case fatalities recorded. Nevertheless this experience highlighted that the
management of an outbreak in a disaster setting was a challenge in terms of case investigation,
case handling and implementing prompt and adequate prevention control measures.
Keywords: food poisoning, outbreak, public health challenges, flood disaster
Introduction
Disaster-affected communities are particularly vulnerable to communicable diseases as its
immediate consequences reduce resistance to disease because of malnutrition, stress, fatigue and
when post-disaster living conditions are unsanitary. (1).The five most common causes of death in
emergencies and disasters are diarrhoea, acute respiratory infection, measles, malnutrition and,
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 87
in endemic zones, malaria. (1).
A flood causes damage to property, farms,
disrupts agriculture practise ad business and
increases the risk of communicable diseases
especially waterborne and vector borne
diseases. The length of time that people
spend in temporary shelters is an important
determinant of the risk of disease transmission.
Poor hygienic practice at the temporary shelter
is typical of a situation that may cause epidemic
outbreaks of infectious diseases. This report
describes how Pejabat Kesihatan Daerah Perak
Tengah managed a food poisoning outbreak
during the major flood of 2015 as well as the
related challenges.
MRSM Pasir Salak, a relief centre was the biggest
of 19 relief centres housing 1061 victims were
stayed who were provided with basic facilities
to ensure their survival. Food was provided by
the organisation in charge, cooking was done
by two teams, team A and B.
10th January 2015, was the last day that team
A prepared food for the victims. Unfortunately
on that day, 50 flood victims complained of
abdominal pain and diarrhoea and some also
complained of vomiting and giddiness. All of
them were diagnosed with food poisoning and
treated as outpatients. Notification of food
poisoning was done on 11th January 2015 at
12am. Investigations began at 9.00 am on the
morning of 11th January 2015.
The onset of the disease 5 hours after victims
had had their lunch which was at 5pm 10th
January 2015. The food served for lunch
was nasi minyak, nasi arab, ayam masak
merah, jelatah, nasi putih and sirap. The food
was cooked by team A which comprised 14
temporary food handlers and it was served to
554 flood victims.
This study describes the epidemiological
characteristics of the outbreak, including
the source of infection and the challenges of
managing an outbreak during a flood.
Materials and Methods
The Epidemiological investigation
The investigation began on 10th January 2015
and ended the next day. A case control study
was done. There were two groups involved
in this study; a control group of 65 victims
who did consume the same food prepared
by the food handlers and the affected group
of 50 victims which fulfilled the criteria of a
case; having eaten food prepared by the food
handlers and developed signs and symptoms
of food poisoning.
The source of the infection was identified as
the menu served by team A food handlers and
it was served to flood victims staying at the
MRSM Pasir Salak hall. The Rapid Response
Team (RRT) was activated and the investigation
initiated.
The cases and controls were directly interviewed
and information regarding symptoms, illness
onset, the food taken and treatment was
treatment was collected.
The analysis was done using SPSS software
version 17.0 (SPSS inc; Illinois) to determine
and the food that most probably caused the
88 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
illness.
Environmental Investigation
Team A premises were assessed by food
control team. This team was from Perak
Tengah district food safety and quality unit
and they will do the environmental assessment
included kitchen condition, cooking area, type
of water supply, water flow and drainage. They
were using a risk based form KKM-PPKM-2/09
as the assessment tools. However assessment
in method of food preparation was not done
because the premise operation was closed after
the onset of the outbreak. The assessment
of 14 temporary food handlers was done by
interviewing to determine whether they had
undergone health screening, immunization
for typhoid fever (Typhoid-ThyphimVI) or had
attended to any food handling course.
The Microbiological Investigations
A total of 10 samples was taken from
symptomatic victims for investigations (9 rectal
swabs and 1 stool sample). The rectal swab
and stool samples were sent for culture and
sensitivity. However no food holding sample
was sent for investigation because there was
no leftover food available. All the samples were
sent to the Public Health Laboratory, Ministry
of Health, Ipoh, Perak for analysis.
Results
Epidemiological investigation
554 victims were exposed to food poisoning.
However 50 cases and 65 controls were
identified. Of the 50 cases, 58% were female
and 42% were male. All of them were treated
as outpatients and no fatality was recorded.
Majority of the cases were aged between 18-
55 years old.
99
Results Epidemiological investigation 554 victims were exposed to food poisoning. However 50 cases and 65 controls were identified. Of the 50 cases, 58% were female and 42% were male. All of them were treated as outpatients and no fatality was recorded. Majority of the cases were aged between 18-55 years old.
Figure 1: Epidemic curve of distribution of 50 cases identified by onset time of illness.
Figure 1 shows epidemic curve of 50 cases distributed by onset time of illness. It displayed a point source pattern. The first onset of illness was at 5 hours and the onset time was between 5-13 hours. The median incubation period was 7 hours. The acute symptoms lasted for 18 hours and all cases recovered within a week. Clinical Manifestation Figure 2 shows the clinical manifestation of the cases in the outbreak. The main symptoms were abdominal pain and diarrhoea. Among of the 50 cases 100% of them had both main symptoms, followed by 7 victims (14%) had vomiting and 2 victims had giddiness (4%). No fever was reported.
0
2
4
6
8
10
12
14
16
12pm 2pm 4pm 6pm 8pm 10pm 12am 2am 4am 6am
↓onset
↓last onset
Time
Num
ber o
f cas
es
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 89
Figure 1 shows epidemic curve of 50 cases distributed by onset time of illness. It displayed a point
source pattern. The first onset of illness was at 5 hours and the onset time was between 5-13
hours. The median incubation period was 7 hours. The acute symptoms lasted for 18 hours and
all cases recovered within a week.
Clinical Manifestation
Figure 2 shows the clinical manifestation of the cases in the outbreak. The main symptoms were
abdominal pain and diarrhoea. Among of the 50 cases 100% of them had both main symptoms,
followed by 7 victims (14%) had vomiting and 2 victims had giddiness (4%). No fever was
reported.
Figure 2: Clinical Presentation Among The Affected Cases
Food attack rate
The menu for breakfast was nasi lemak and teh O, for lunch was nasi minyak, nasik arab, ayam
masak merah, jelatah, and air sirap and for dinner was nasi putih, kurma ayam, sayur kobis and
air sirap.
The highest food attack rates were nasi minyak and ayam masak merah (75% and 78.7%
respectively). Nasi minyak (OR=30, 95% CI: 10.0933 to 89.1680) and ayam masak merah
(OR=96, 95% CI: 20.5898 to 447.5997) showed significant association with illness (p>0.005).
From the interview feedback, majority of the victims claimed nasi minyak and ayam masak merah
were undercooked and smelt bad.
90 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Environmental Investigations
The operation of Team A’s premises ended on
10th January 2015. However these premises
were assessed by the food control team every
3 days and the rating ranged between 71-85%.
The rating was done by using risk base form
KKM-PPKM-2/09. The last assessment was
done on 9th January 2015. At that assessment
the rating for overall safety and cleanliness of
the premise was 79%.
Team A comprised 30 food handlers. However
on 10th January 2015, only 14 temporary food
handlers participated in food preparation.
100% had been vaccinated with typhim (Ty2)
and 71.4% had attended a course for food
handlers.
The 9th January 2015 assessment form showed
that the evaluation of cooking utensils rating
was moderate (score 7/10). However other
facilities such as the area the hand washing
and the garbage bin were not limited. The
toilets were clean and in good condition and
they used treated water for preparing the food.
Microbiological InvestigationsThe laboratory analysis of rectal and stool samples is shown in table 2. Suspected organisms
were Staphylococcus aureus, Salmonella, E. Coli and Barcillus Cereus. However, no pathogenic
organisms were isolated.
Table 1: Laboratory analysis of rectal and stool samples
No Samples No of sample Result
1. Rectal swab 9 Pathogenic organism was not isolated
2. Stool 1 Pathogenic organism was not isolated
Discussion
An epidemiological study was done on the
food poisoning outbreak resulting from meals
eaten on 10th January 2015 that is during the
flood in Perak Tengah last year. Fifty cases
were identified which comprised 9% of the
victims staying at MRSM Pasir Salak Evacuation
Centre. No hospitalization or case fatality was
recorded.
The management of a food poisoning outbreak
during a flood is the most challenging issue
because a study has shown that the incidence
of gastrointestinal symptoms increases during
a flood (incidence rate ratio = 1.29, 95%
confidence interval: 1.06, 1.58), and this was
more pronounced among persons with potential
sensitivity to infectious gastrointestinal illness.
(Wade, Sandhu et al. 2004).
In general, children had a higher relative risk
of gastrointestinal symptoms for most types
of flood exposure, which is consistent with
their greater susceptibility to gastrointestinal
pathogens. This finding may also be related
to a poorer hygiene among children following
exposure to floodwater and flood-contaminated
items. However this study showed that the
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 91
majority of cases were aged between 18 and
55 years.
Flooding accounts for about 40% of all natural
disasters worldwide and causes about half of
all deaths. Every year, for the past two decades
more than 400 million people on average have
been directly affected by floods. The health
impacts on and response to the 2010 flood that
occurred in Pakistan (Shabir 2013) were similar
to those in Perak Tengah. Majority of the land
was inundated with water which damaged
the houses, educational and health facilities,
communication networks, power plants and
grids, irrigation channels, agricultural land and
livestock.
This is the challenge for the public health team
managing an outbreak during a flood. The
damage to health facilities and communication
network limits the ability for the public health
team to manage the outbreak following the
standard operating procedure. In this study the
transmission was interrupted by terminating
team A’s food preparation operation. In
addition, the quick response of the investigation
team and its effort at health education of to
the victims helped to control the outbreak.
In this study 14 temporary food handlers were
involved in the preparation of the food. 100%
had been vaccinated with Ty2 and 71% of them
had attended a food handling course. However
investigation showed that nasi minyak and
ayam masak merah were the foods associated
with the infection. No pathogenic organism
was isolated but majority of the victims claimed
the dishes were undercooked and smelt bad.
Therefore the possible causes of the food
poisoning are poor cooking technique and a
prolonged holding time that lead to a high risk
of food contamination.
Food poisoning is caused by contamination
which can occur at various points of the
preparation process and these have been
classified into 4 categories. Contamination
during storage, transportation and serving
of food was found to account for 47.8% of
the entire food poisoning event, followed by
general contamination 24.6%, contamination
during cooking/secondary to processing
technique 15.0% and contamination of raw
materials 12.6%.
Most of the points of contamination identified
were related to poor food safety practices
among the food handlers such as poor personal
hygiene, inappropriate holding time and
inappropriate holding temperature. The unsafe
food safety practices among the food handlers
could be due to their lack of knowledge on
food safety (Malaysia’s Health 2008).
This poses another challenge to public health
in managing food poisoning outbreaks during
a disaster is their attitude during preparing
the foods. Even though majority of the food
handlers were trained in handling food but not
all of them practice it correctly. Interestingly,
all of them were volunteers that they were also
victims of the flood disaster. An assessment
of the health impacts of the 2011 summer
floods in Brisbane, Australia was done for
92 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
residents whose households were directly
affected by flooding. The assessment showed
flood disaster had significant impact on the
physical and psychosocial health of residents.
(Alderman, Turner et al. 2013). So in managing
an outbreak during a disaster, the public
health team must not forget the physical and
psychological status of the victims.
In this regard, health education and counselling
sessions were arranged for all the victims
including food handlers. Victims that showed
symptoms of depression or anxiety were
referred to a medical officer and a psychiatrist.
Furthermore disaster victims were constantly
trained and made aware of the importance of
proper food handling technique, hand hygiene,
information regarding infection control and
other health promotion activities.
Lastly, an issue that surfaced in previous
floods was the importance of a clean water
supply. A study done during severe flooding
in the Mid-Western United States in 2001 and
showed a marked deterioration in water quality
(Wade, Sandhu et al. 2004). However standard
precautions had been taken to monitor water
supply quality. Hence, in this study, water
supplied to the centre was safe and pathogen-
free from pathogen and not the cause of food
poisoning.
Conclusion
The food poisoning outbreak on 10th January
2015 that occurred at the MRSM Pasir Salak
settlement centre was mainly due to the poor
cooking technique and the prolonged holding
time that lead to contamination of the food.
No pathogenic organism was isolated from
samples taken from the victims. The water
supply was safe and pathogen-free. Interviews
with the victims revealed that majority of the
victims thought the meals were undercooked
and smelt bad. Even though majority of the
food handlers were trained in food handling
to not all of them practiced it correctly. The
lack of knowledge and their attitude to food
preparation was one of the issues that need
further examination to prevent food borne
disease. However the counselling sessions and
health education helped the public health team
in their effort to control and stop the outbreak.
Acknowledgement
We would like to acknowledge the Director
General of Health, Malaysia for permission to
publish this article. We would also like to thank
the PKD Perak Tengah Inspectorate staff for
their support in the writing of this article.
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 93
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