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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


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


JOURNAL OF HEALTH MANAGEMENT SPECIAL EDITION VOL II: DECEMBER 2015


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.


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


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


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.



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.



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.


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


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.


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.


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


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


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


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


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.


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.


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.


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


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


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.


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-


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.


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


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)


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).


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.


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


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


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.


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


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.

References

1. Benedict, K., Benjamin, J.P. (2014).

Invasive fungal infection after natural

disasters. Emerging Infectious Diseases,

20, 349-355.

2. Centers of Disease Control and Prevention.

Infectious Disease and Dermatological

Conditions in Evacuees and Rescue

Workers after Hurricane Katrina-Multiple

States, August - September, 2005 (2005).

(cited : 7 April 2015). Available from

http://www.cdc.gov/mmwr.

3. Sapian, M., Khairi, M.T., How, S.H.,

Rajalingam, R., Sahhir, K., Norazah, A.

(2012). Outbreak of Melioidosis and

Leptospirosis co-infection following a

rescue operation. Medical Journal of

Malaysia, 67 (3), 293-297.

4. Collins English Dictionary. Rescue

worker. (Cited: 10 April 2014). Available

from http://www.collinsdictionary.com/

dictionary/english/rescue-worker.

5. Cabral JPS (2010). Water Microbiology,

Bacterial Pathogen and Water.

International Journal of Environmental

Research and Public Health, 7, 3657-

3703.

6. Michael, E., Feldacker C., Islam, M.S., Ali,

M. (2008). Seasonality of Cholera from

1974 to 2005. International Journal of

Health Geographics, 7 (31), 1-13.


7. Ang, G.Y., Choo, Y.Y., Kamarudin, B.,

Husni, T.E., Hussin, A., Hani, M.H. et al.

(2010). Molecular evidence of Cholera

Outbreak Caused by a Toxigenic Vibrio

cholera E1 Tor Variant Strain in Kelantan,

Malaysia. Journal of Clinical Microbiology,

48 (11), 3963-3969.

8. Gideon Informatics (2010). Infectious

diseases of Haiti. California, United States.

9. Sutiono, A.B., Qiantori, A., Ohta, T. (2010).

Characteristics and risk factors for typhoid

fever after the tsunami, earthquake and

under normal conditions in Indonesia.

BMC Research Notes, 3 (106), 1-9.

10. Scobie, H.M., Nilles, E., Kama, M., Cool,

J.L., Mintz, E., Kathleen, A. et al (2014).

Impact of a targeted typhoid Vaccination

Campaign Following Cyclone Tomas,

Republic of Fiji. American Journal of

Tropical Medicine and Hygiene, 90 (6),

1031-1038.

11. Hassan, M.R., Pani, S.P., Peng, N.P.,

Voralu, K., Vijayalakshmi, Mahenderkar, R.

(2010). Incidence, risk factors and clinical

epidemiology of melioidosis: a complex

socio-ecological emerging infectious

disease in the Alor Setar region of Kedah,

Malaysia. BMC Infectious Disease, 10

(32), 1-8.

12. Chen, M.J., Lin, C.Y., Wu, Y.T., Wu, P.C.,

Lung, S.C., Su, H.J. (2012). Effects of

extreme precipitation to the distribution

of infectious diseases in Taiwan, 1994-

2008. Plos One, 7 (6), 1-7.

13. Amilasan, A.T., Ujjie, M., Suzuki, M.,

Salva, E., Maria, C.P., Koizumi, N.

(2012). Outbreaks of Leptospirosis after

flood, The Philippines, 2009. Emerging

Infectious Diseases, 18 (1), 91-93.

14. Choy, S.W., Mekhlafi, H.M., Mahdy,

M.A.K., Nasr, N.N., Sulaiman, M., Lim,

Y.A., Surin, J. (2014). Prevalence and

associated risk factors of Giardia infection

among Indigenous Communities in Rural

Malaysia. Scientific Reports, 1-9.

15. Kumar, T., Onichandran, S., Lim, Y.A.L.,

Sawangjaron, N., IthoiInit, Andiappan, H.

et al. (2014).

Comparative study on Waterborne

Parasites between Malaysia and Thailand:

A new insight. American Journal of

Tropical Medicine and Hygiene, 90 (4),

682-689.


16. Hogan, N.J., Daniels, M.E., Watson,

F.G., Conrad, P.A., Oates, S.C., Miller,

M.A. et al. (2012). Longitudinal Poisson

Regression to evaluate the epidemiology

of Cryptosporidium, Giardia and Fecal

Indicator Bacteria in Coastal California

Wetlands. Applied and Environmental

Microbiology, 78 (10), 3606-3613.

17. Lack, B.J., Volk, K., Ronald, A. (2012).

Hepatitis E Virus Genotype 3 in Wild

Rats, United States. Emerging Infectious

Disease, 8 (18), 1268-1273.

18. Cowie, B.J., Adamopolous, J., Carter,

K., Kelly, H. (2005) Hepatitis E Infection

Victoria, Australia. Emerging Infectious

Disease, 11(3), 482-484.

19. Guan, D., Li, W., Su, J. (2013). Asian Musk

Shrew as a reservoir for rat Hepatitis

E Virus, China. Emerging Infectious

Disease, 19 (8), 1341-1342.

20. Baqir, M., Sobani, Z.A., Bhamani, A.,

Bham, N.S., Abid, S., Farook, J. (2012).

Infectious diseases in the aftermath of

monsoon flooding in Pakistan. Asian

Pacific Journal of Tropical Biomedicine, 2

(1), 76-79.

21. Guarro, J., Kallas, E.G., Godoy, P., Karenina,

A., Gene, Josepa. (2002). Cerebral

Aspergillosis caused by Neosartorya

hiratsukae, Brazil . Emerging Infectious

Diseases. 8 (9), 989-991.

22. Hsu, E.B., Thomas, T.L., Bass, E.C.,

Whyne, D., Kelen, G., Green, G.B. (2006).

Healthcare worker competencies for

disaster training. 6 (19), 1-9.

23. Rumsey, M, Fletcher, SM, Thiessen,

J, Gero, A, Kuruppu N, Daly, J. et al.

(2014). A qualitative examination of

health workforce needs during climate

change disaster response in Pacific Island

Countries. Human Resources for Health,

12 (9), 1-11.

24. World Health Organization. (2011). The

Interagency Emergency Health Kit 2011.

Medicines and Medical devices for 10000

people for approximately three month.

25. Jafari, N., Shahsanai, A., Memarzadeh,

M., Loghmani, A. (2011). Prevention of

communicable disease after disaster: A

review. Journal of Research in Medical

Sciences, 16 (7), 956-962.


26. The Star Online. Sabah is 3rd highest

in alcohol consumption (2013) (cited

: 30 May 2015). Available from

http://www.thestar.com.my/News/

Nation/2013/05/11/Sabah-is-3rd-highest-

in-alcohol-consumption/

27. MMWR. (2005). Health concerns associated

with disaster victim identification after

tsunami- Thailand, December 26, 2004 to

March 31, 2005. 54(14), 349-352.

28. Cummings, K.J., Ganser, J.C., Riggs, M.A.,

Edwards, N., Kreiss K. (2007). Respirator

donning in Post-Hurricane New Orleans.

13 (5), 700-706.

29. Onichandran, S, Kumar, T, Salibay, CC,

Dungca, JZ, Tabo, HA, Tabo, N et al.

(2014) Waterborne parasites: a current

status from the Philippines. Parasites and

Vectors. 7(244), 1-8.

30. Anuar, S.T., Ghani, M.K.A., Azreen,

S.N., Salleh, F.M., Moktar, N. (2013).

Blastocystis Infection in Malaysia:

Evidence of waterborne and human-to

human transmissions among the Proto-

Malay, Negrito and Senoi tribes of Orang

Asli. Parasites and Vectors, 6(40), 1-12.

31. Berger, M., Shiau, R., Weintraub, J.M.

(2006). Review of syndromic surveillance:

implications for waterborne disease

detection. Journal of Epidemiology and

Community Health, 60(6), 543-50.


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


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).


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)


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


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


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


Spent In The Flood

Affected Area

Flood Affected

Area

DASS




Severe Extremely

Severe Moderate







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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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


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


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.


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.


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.


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.


60

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.


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.


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.


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


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.


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


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


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


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


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


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.


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.


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


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


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


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


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




74





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.


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


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.


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.)


Spent In The Flood

Affected Area

Flood Affected

Area

DASS




Severe Extremely

Severe Moderate







Photo 3: Post-deployment volunteers undergoing DASS assessment before the PFA.

78



Spent In The Flood

Affected Area

Flood Affected

Area

DASS




Severe Extremely

Severe Moderate








78



Spent In The Flood

Affected Area

Flood Affected

Area

DASS




Severe Extremely

Severe Moderate









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.


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.


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.


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.


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


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.


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


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.


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


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.


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


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


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


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.

References

1. La, Motte, J. (2011). Psychotherapeutic

Techniques and Play Therapy with Chil-

dren Who Experienced Trauma: A Re-

view of The Literature Bridgewater State

University Undergraduate Review 2011,

7, 15.

2. Art Therapy: Color Meanings and

Symbolism. (cited : 14 May 2015).

Available from: http://www.artther-

apyblog.com/online/color-meanings-

symbolism/#colormeanings.

3. McKinney, Clark, K. (2015). Play Thera-

py: A Comprehensive Guide to Theory

and Practice The Gillford Press. New

York.

4. Creative Counselling 101: Interpret

Drawings for Play Therapy and Art

Counselling. (cited : 14 May 2015).

Available from: http://www.creative-

counseling101.com/interpret-drawings-

art-counseling.html.

5. Anna’s Toy Depot: The Symbolic Mean-

ing of Toys. (cited : 14 May 2015). Avail-

able from: http://www.annastoydepot.

com/index.php?main_page=page&id=7.

6. Wind, T.R., Joshi, P.C., Kleber, R.J., Kom-

proe, I.H. (2014). The effect of the post

disaster context on the assessment of

individual mental health scores. Am J

Orthopsychiatry, 84(2), 134-141.

7. Grimm, A., Hulse, L., Preiss, M., Schmidt,

S. (2012). Post- and peritraumatic stress

in disaster survivors: an explorative

study about the influence of individual

and event characteristics across differ-

ent types of disasters. Eur J Psychotrau-

matol, 3.

8. Kitamura, H., Shindo, M., Tachibana, A.,

Honma, H., Someya, T. (2013). Person-

ality and resilience associated with per-

ceived fatigue of local government em-

ployees responding to disasters. J Occup

Health, 55(1), 1-5.


9. Hawkins, R.L., Maurer, K. (2011). ‘You fix

my community, you have fixed my life’:

the disruption and rebuilding of ontolog-

ical security in New Orleans. Disasters,

35 (1), 143-159.

10. Ishikawa, M., Yamamoto, N., Yamanaka,

G., Suwa, K., Nakajima, S., Hozo, R.,

Norboo, T., Okumiya, K,. Matsubayashi,

K., Otsuka, K. (2013). Disaster-related

psychiatric disorders among survivors of

flooding in Ladakh, India. Int J Soc Psy-

chiatry, 59(5), 468-473.

11. Henry, J. (2011). Continuity, social

change and Katrina. Disasters, 35(1),

220-242.

12. Boscarino, J.A, Hoffman, S.N., Adams,

R.E., Figley, C.R., Solhkhah, R. (2014).

Mental health outcomes among vulner-

able residents after Hurricane Sandy:

implications for disaster research and

planning. Am J Disaster Med, 9(2), 107-

120.

13. Kõlves, K., Kõlves, K.E., De, Leo, D.

(2013). Natural disasters and suicidal

behaviours: a systematic literature re-

view. J Affect Disord, 146(1), 1-14.

14. Grimm, A., Hulse, L., Preiss, M., Schmidt,

S. (2014). Behavioural, emotional, and

cognitive responses in European disas-

ters: results of survivor interviews. Di-

sasters, 38(1), 62-83.

15. Apisarnthanarak, A., Khawcharoenporn,

T., Woeltje, K.F., Warren, D.K. (2013).

Hospital flood preparedness and flood-

related psychological consequences in

15 provinces in central Thailand after

implementation of a national guideline.

Infect Control Hosp Epidemiol, 34(6),

655-6.

16. Butterly, S.J., Indrajith, M., Garrahy, P.,

Ng, A.C., Gould, P.A., Wang, W.Y. (2013).

Stress-induced takotsubo cardiomyopa-

thy in survivors of the 2011 Queensland

floods. Med J Aust. 198(2), 109-10.

17. Bhamani, A., Sobani, Z.A., Baqir, M.,

Bham, N.S., Beg, M.A., Fistein, E. (2012).

Mental health in the wake of flooding in

Pakistan: an ongoing humanitarian cri-

sis. J Coll Physicians Surg Pak, 22(1),

66-68.


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,


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


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


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.


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


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


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.


References

1. World Health Organization. Control of

communicable diseases and prevention of

epidemics (2002). (cited : 15 May 2015).

Available from: http://www.who.int/water_

sanitation_health/hygiene/emergencies/

em2002chap11.pdf

2. Shabir, O. (2013). A summary case report

on the health impacts and response to the

Pakistan floods of 2010. PLoS currents, 5.

3. Alderman, K., et al. (2013). Assessment

of the health impacts of the 2011 summer

floods in Brisbane. Disaster Med Public

Health Prep, 7(4), 380-386.

4. Wade, T. J., et al. (2004). “Did a severe flood

in the Midwest cause an increase in the

incidence of gastrointestinal symptoms?”

Am J Epidemiol, 159(4), 398-405.

5. Connolly, M. A. (2005). Communicable

disease control in emergencies: a field

manual. World Health Organization.

6. Lowe, D., et al. (2013). Factors increasing

vulnerability to health effects before, during

and after floods. International journal of

environmental research and public health,

10(12), 7015-7067.

7. Warraich, H., et al. (2011). Floods in

Pakistan: a public health crisis. Bulletin

of the World Health Organization , 89(3),

236-237.

8. Ministry of Health (2008). Food Poisoning

In Malaysia 2008 - Issues And Challenges.

Kuala Lumpur.