Disaster Medicine

Preventive and Social Medicine-Family Medicine (SIPV 304) Thanjira Jiranantakan, M.D., M.P.H.

Medical Competency Assessment Criteria for National Definition License 2012 (B1.5.8 Environmental and Nutritional Diseases) (2008) SIPV 304 SIPV 604 1 Hour Lecture 2 Hour-Lecture & Discussions 1. A serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources (ISDR).

2. Situation or event, which overwhelms local capacity, necessitating a request to national or international level for external assistance (CRED).

3. A term describing an event that can be defined spatially and geographically, but that demands observation to produce evidence.

Map1: Number of natural disaster by country from 1976 to 2005

Disaster Emergency Disaster Managemen Medicine Medicine t

Disaster medicine involves multiple disciplines. It is complex hence prerequisite medical training is required. However, disasters occur unpredictably so all personnel working in emergency filed should have at least basic knowledge about disaster medicine.

There are various database of disaster. EM-DAT is an Map2: Number of natural disaster by first administrative level international disaster database hosted by Centre for boundaries in Asia from the year 1975 to October 2004 Research on the Epidemiology of Disaster (CRED). Table1: Top 10 natural disaster in Thailand for the period This organization has long history of standardized data 1900 to 2013, sorted by number of killed compilation, validation and analysis. It is WHO Collaborating Center (since 1988) and is supported by United States Academy of International Development (USAID). It provides free and open access to its data through its website. Users can customize the outputs through its searching engine. Examples of disaster statistic data are shown as Map 1, Map 2 and Table 1.

Next page: Classifications of Disasters, Disaster Cycle

Issue #: [Date] Disaster Medicine; T.Dolor Jiranantakan Sit Amet

Classification of Disasters

Disasters can be classified by the etiologies. One of the classifications is shown as Figure 1. 1. Natural disasters have predominated in frequency and magnitude over most human generated disasters. Examples include Yersinia pestis pandemic killed millions of people over years, avian flu pandemic, hurricane, cyclone, earthquake, tsunami etc. Natural disasters can be developed in sudden or progressive manners and by single or multiple causes. 2. Human generated disaster can be divided into intentional and unintentional subclasses. Examples of Figure 1: Classifications of Disasters from WHO training materials disasters in this classification include terrorist attacks to (Natural, Human, Hybrid Natural Disasters) World Trade Center in the U.S. on 11th September 2001, 1995 sarin attack on the Tokyo subway and recent Asiana Airline plane crashing in the U.S. on 7th July 2013 etc. Disaster Cycle 3. Hybrid natural disaster describes those natural disaster subsequently complicated by technology or human unintentionally generated incident. The most recent Each disaster is different but follows a general pattern example of this type is Daiichi Nuclear Power Plant demonstrated in Figure 2. Dividing disasters into phases is accident started from earthquake, tsunami and aftershock useful for planning, response and research point of view. episodes leading hydrogen-air chemical explosions and 1. Interdisaster (quiescent) phase is seen during radiological contamination measured miles from its origin. combinations of events leading to disaster. Disaster risk assessment is helpful to predict types of local hazards may result in disaster. 2. Predisaster (prodome, warning) phase represents a time during which a particular event is clearly likely to occur. It lasts a variable amount of time depending on type of disasters. Procedures to mitigate the effects, public warning and protective actions such as sheltering and evacuation can be done during this period. 3. Impact (disaster) phase can be short such as earthquake or prolonged for example famine. Usually, little can be done to decrease the impact during this period. Previous education, effective warning program, proper planning and reasonable preemptive actions contribute to great effect in decreasing the impact during disaster. 4. Emergency (rescue, relief, isolation) phase represents time that immediate assistance can save lives. People may be salvaged by first responder actions, search and rescue, and basic and advanced life-supports. This normally relies on local resource which maybe overwhelmed and incapacitated. Figure 2: Disaster cycle-5 phases : 1. Interdisaster phase, 2. Predisaster S.T.A.R.T triage is widely used for this phase (Figure 3). phase, 3. Impact phase, 4. Emergency phase, 5. Reconstruction phase

5. Reconstruction (recovery) phase consists of all required actions and elements such as emergency medical service, public health, engineering and social services needed to return the population to a functional society. It may last months or Next page: S.T.A.R.T. Triage, Public Health years. Consequences, Disaster Severity Assessment, Public Health Intervention/Management

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Issue #: [Date] Disaster Medicine; T.Dolor Jiranantakan Sit Amet

Public Health Consequences

 Death  Illness and injury  Loss of clean water  Loss of shelter  Loss of personal and household goods  Loss of sanitation and routine hygiene  Disruption of solid waste management  Public concern for safety  Increased pests and vectors  Loss or damage of healthcare system  Worsening of chronic illness  Food scarcity  Standing surface water Figure 3: S.T.A.R.T (Simple Triage and Rapid Treatment) Adult  Toxic exposures Triage, Adopted from http://www.start-triage.com • death, missing persons Effects on Health • Injuries, Illness

• damage of structural Effects on Health integrity,capacity Disaster Severity injury, death of staffs, Service any gaps Assessment • water supplies, electric power Effects on Utilities • sanitation • shelter, transportation

Public Health Intervention and Management

Public health intervention and management regarding disaster is a complex mission involving multidisciplinary approach. In summary, aspects to be covered during emergency and reconstruction phases are following.

 Environmental health: (water, sanitation-excreta disposal, hygiene and vector management, shelter)  Communicable disease control and epidemic management: (immunization, management of dead bodies, nutrition)  Mental health: This is very important during reconstruction phase. The approach to adults and children can be quite different.  Maternal and child health: Pregnant women, nursing women and children are vulnerable victims requiring special care.  Medical service: This is necessary and is commonly operated in lieu of mobile medical clinic if evacuation is done.  Public health surveillance: It is important to seek for Next page: Case Study, Summary, Emergency No., those who are affected but do not access medical care. Author’s Contacts, Suggested Readings and References Long-term health surveillance is mandatory in some

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Issue #: [Date] Disaster Medicine; T.Dolor Jiranantakan Sit Amet

Case Study: Cyclone Nargis Myanmar, 2 May 2008

Irrawadde Delta in Myanmar was struck by Cyclone Nargis , approximately 270 km/hr wind speed) on 2nd May 2008. This resulted in a 12-foot water wall, tens thousands lives lost, 60,000s people missing, hundreds thousands people became homeless and more than 2.4 million people affected as well as severe destruction of infrastructure and supplies. Myanmar became overwhelmed and incapacitated by huge loss hence international donations and humanitarian missions were accepted. Two Thai Medical Teams joined Cyclone Nargis mission during reconstruction phase to alleviate disaster effects and to help Myanmar return to its normal function soon after. Group photo: volunteers from Ministry of Public Health The journey included environmental service, medical and and Siriraj Hospital (12 physicians, 12 nurses, 1 dentist, 2 dental service, mental service and designs for dentist assistants, 1 pharmacist, 2 public health experts, 1 reconstruction of necessitated infrastructure. After the architect, 1 engineer) mission, health statistics and surveillance data was discussed and transferred to local authorities and relevant parties aiming for continuing care and the best outcomes.

Summary and Suggestions: Disaster is close to us. By its nature, it may knock on our door anytime. Each disaster may be different but all follow a general pattern. Disaster management is a complex mission requiring multidisciplinary approach and good collaborations. Everyone should understand at least basic knowledge of disaster medicine. Despite disaster medicine has been at interest and in practice for years, there is a lot to improve included but not limited to disaster planning, disaster management, disaster epidemiology, disaster surveillance and relevant researches.