Journal of Health Management Special Edition Vol II December 2015
Journal of Health Management Special Edition Vol II December 2015
EDITOR IN-CHIEF
EDITORIAL BOARD
MANAGING EDITOR
Alzamani Mi, Siti MY, Mohd Khairi AL, Hani HH, Syed Hazran SM,
Abu HAA Emergency Department, Hospital Kuala Lumpur
Eswaran K
Clinical Research Center, Hospital Duchess of Kent
Munirah I, Norhidayah MD
Institute For Health Management
Alzamani MI, Mona KG, Nurul LR, Hafiz SM, Ahmad IKB, Abu HAA
Emergency Department, Hospital Kuala Lumpur
4
1
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Rapid Assessment of Floods in Kelantan: Information for Action
Saraswathi BR1, Fadzilah K2, Rosemawati A2
1Penang State Health Department
2Office of Deputy Director General of Health (Public Health)
Abstract
In 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.
Introduction
Kelantan, located on the north-east coast of peninsula flooding that occurs during this period; however
Malaysia has a tropical climate and experiences the magnitude of this years flooding caused these
intermittent rain throughout the year. The North- systems to fail, resulting in a displaced population
East monsoon that prevails from November to without emergency relief such as food, clean
January brings heavy rain to this region annually. clothing, clean water and access to medical aid.
Often, during this period low-lying regions get Many parts of the interior of the state and clinics were
flooded. But climate change, can result in extremes cut off, communication lines were down, and roads
that may present in the form of floods, landslides and were submerged and inaccessible. Information was
flash floods. In December, 2014, an unprecedented sketchy. The State Crisis Preparedness and Response
amount of rainfall caused massive flooding in the centre (CPRC) was in operation but to escape the
state of Kelantan. The areas affected first were floods that affected the State Health Department,
those in the coastal, riverine and low-lying areas. they had to move their operation centre several
But with the concomitant high tides larger areas times. Health staff throughout the state was limited
were affected and the destruction that followed as they dealt with their own situations: many were
came about in two waves. The first wave occurred affected by the floods with their homes submerged
on the 17th December 2014 followed by another or destroyed. Some were unable to get to work,
wave on 25th December 2014. and there was no information from the state of
Response mechanisms are in place for the annual some staff.
capacity of the health services, identify potential c. Rapid assessment surveys using
avert further risk and to recommend interventions d. Direct observation; we observed the
that may alter the course and influence the outcome procedures going on at the CPRC, at
Communication There was no alternative Satellite phones to be kept This issue is being considered
communication line in centrally and to be used in for long term planning.
areas where there was disasters.
no power nor telephone
line.
Transport Most of the vehicles were Deploy more vehicles to When staff from others
saved during the floods. the area. districts were deployed to
However there was a the State, they were asked
desperate need for more to come with their own
vehicles as they were transport and driver. This was
needed to transport staff coordinated at the Institute
to and fro from affected for Health Management.
areas. The vehicles were Transport was also sourced
also used to go into and sent to the districts for
villages carrying medical their own use.
supplies for the affected
community.
Electricity Power supply affected To supply gen sets to The National coordinating
in all districts and clinics. committee sourced for gen
many clinics and health sets and had them sent to
facilities without power. affected areas.
Water Most water supplies cut To carry out chlorination The engineering division was
as pipe lines were either of all tube wells and GFS given the task to ensure that
destroyed or submerged. source of water supply. extensive comprehensive
Many parts of Kelantan chlorination was carried out
also depends on gravity according to the specification
feed system (GFS). as set by Ministry of Health
guidelines to prevent
disease.
Personal 1. There were To supply PPE and boots to 1. Masks and boots were
Protective insufficient masks the staff in the field. mobilised to the state
Equipment for staff working in immediately.
the flood areas. 2. All volunteers and staff
2. Staff were not working in flood prone
wearing boots in area ordered to bring
spite of risk of their rubber boots and
leptospirosis and to wear them.
other infection.
Affected clinics Some were a total loss 1. Total loss clinics to 1. Engineering divisions
while others were a be replaced or to find sent to follow up on the
partial loss. Partial loss alternate sites where findings and reassess
meant that the clinic the staff can function the clinics to make sure
would be able to function with setting up of that they are able to
after cleaning. temporary tents. function as soon as they
2. Partial loss clinics to are found to be safe.
start with available 2. Identify areas where
equipment after cleaning. tents could be placed
3. Assistance in cleaning and used as temporary
clinics.
3. Central committee
coordinate with the
Ministry of Education to
assist in cleaning the
affected health facility.
Flood SOP and flood plans do To review the flood Simulation exercises are
Management not take into account management plan to being considered.
Plan severe flooding which take into account major
would not only affect disasters.
infrastructure, but
would affect staffing and
communication.
Evacuation 1. In addition to the We requested for hygiene All needs were channelled to
centres gazetted evacuation kits for the evacuees at the the respective departments
centres, there are EC that has none or limited and units. The kits as
many non-gazetted water supply. requested were prepared
centres, some and distributed.
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.
There were some measures taken by the team of the most damaging natural disasters occurred in
when they visited the districts. Disinfection was Asia in 2014. In the same year about 35 percent of
carried out at evacuation centres that we visited. all global economic losses were the result of flooding
We focused on the toilets and the drains as water - the highest rate since 2010i. The top three perils
was needed to mix the disinfectant and water was were floods, tropical cyclones and severe weather
in short supply. We also distributed hand sanitizers and these contributed for 72% of all economic
to the clinic staff. In addition, health promotion losses. Floods were overall the costliest peril.
materials were handed out: these covered food
The Kelantan floods in December 2014 also affected
and water borne disease, leptospirosis and general
other states in the county and continued into 2015.
cleanliness and precautions necessary to prevent
It hit Malaysia from 15th December 2014 to 3rd
disease during floods. In some areas, where the
January, 2015. Johore, Kedah, Negeri Sembilan,
clinics were totally gone, we were able to advice
Pahang, Perak, Perlis, Sabah, Sarawak, Selangor and
where temporary static clinics could be set up after
Terengganu were also affected. By 20th December
discussion with the local staff.
2014, most of the rivers in Kelantan Pahang, Perak
Natural disasters are a more common occurrence Twenty one people died in the floods. The state
in tandem with global climatic change. The Annual of Kelantan had the most number of evacuees
Global Climate and Catastrophe Report published 20,468. As the heavy rains continued, the situation
by Impact categorizes each event by economic loss worsened and most of the roads in Kelantan were
of Health where in tangent with our efforts there early 2015 were unprecedented and a severe
were no outbreaks of typhoid, leptospirosis, test of our services. To be better prepared in the
melioidosis or any other outbreaks associated with future we recommend that the state develop an
the floods, recorded. info blast system to alert the districts of potential
disasters and also to update them so that they
Every need that we presented from our findings was
can prepare accordingly. Evacuation facilities need
discussed at the central committee and action was
to be identified in advance and supplied with
taken to meet the needs after assessing feasibility.
the necessary items such as blankets and other
Three Public Health Physicians were sent to critical
necessities. Medical supply should also be kept on
districts to assist and replace tired staff for between
standby especially towards the end of the year as
4 to 6 weeks. This enabled the district health officers
the floods are a recurrent event. On a long term
to have much needed rest and tend to their own
basis, we suggest that future health facilities be
families who were affected by the floods. It also
built away from riverine and low-lying areas.
helped to boost the morale of the doctors involved
Disaster management is the way forward for us.
as we worked together in this disaster as a team.
To achieve this we recommend that disaster
The disease surveillance and response system
Our public health response team that carried out discussions with the evacuees and community
this assessment faced challenges in getting into the leaders. Where possible we attempted to concur
area and carrying out our own assessment: in the with our observations. Some clinics were still
long term we suggest developing a mobile public inaccessible at the time of our visit.
References
1. Aon Benfield (2014). Annual Global Climate 2. Law of Malaysia (2013). Act 342. Prevention
and Catastrophe Report, Impact Forecasting. and Control of Infectious Disease Act 1988.
(cited : 19 May 2015). Available from:
http://thoughtleadership.aonbenfield.com/
Documents/20150113_ab_i
f_annual_climate_catastrophe_report.pdf.
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 catastrophic floods. The worst affected was the
from 15th December 2014- 3rd January 2015. indigenous community in Kelantan involving a total
One of the worst hit areas affecting the aborigines of 7,995 people from 67 villages, especially those
was the inland area of Gua Musang. There were in Gua Musang. The Orang Asli Affairs Department
a number of aboriginal settlements there and they (JAKOA) had spent more than RM2 million on food
were hard hit and almost forgotten. Some 42,000 and basic necessities for the indigenous communities
indigenous people from 261 villages throughout affected by the floods. We describe our relief work
the country were reportedly affected in these in the Gua Musang Orang Asli settlements.
Main Objectives
The main aims of this mission were to provide medical and a driver was formed. The team was joined by
services and to supply basic needs, including items another 37 volunteers in a convoy of 12 four-wheel
for personal hygiene, household items, cleaning drive vehicles and a lorry and supplied water filters,
supplies and school supplies, water purifiers, beds, bedding and wellness kits worth RM126,000 to the
bedding and blankets to the villagers who had lost indigenous community in Gua Musang, Kelantan.
nearly all their belongings in the floods. The mission took 2 days from 30th-31st January
2015 and involved mainly Kampung Pasir Linggi in
Materials and Methods
Kuala Betis and Pos Tohoi in Gua Musang, Kelantan.
The project was carried out from 30th-31st January
2015 at Kampung Kuala Linggi in Kuala Betis and Results
Pos Tohoi in the district of Gua Musang. It was a The journey A convoy of 12 four-wheel drives and
collaboration between the Emergency Department a truck made their way by the East Coast Highway
of Hospital Kuala Lumpur, the National Welfare to Gua Musang, Kelantan. From Gua Musang, the
Foundation and the Department of Orang Asli Affairs convoy made its way to Kampung Pasir Linggi
and the Pahang Association for Orang Asli Concerns at Kuala Betis. The obstacles encountered were
(POAPP). The mobile medical team from the minimal as the flood had subsided considerably.
Emergency Department of Hospital Kuala Lumpur The village was damaged and furniture could be
(HKL) comprising two Emergency Physicians, one seen hanging from trees and clothes were found on
medical officer, three housemen, a health attendant electrical cables, marking the level of floods.
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
Total 476
Discussion
During the major floods, the access to the Orang they stay far inland and shy away from developed
Asli areas was cut off completely. For two days, areas. Buajaroen (2013) described volunteer work
they stayed on a hill and had limited food. In by nurses to care for those affected and assist in
the future, areas isolated by the floods should be re-establishing a functioning health care system
referred to the military or similar agencies with the following a flood in 2010. The author found that
vehicles appropriate for such emergencies. Gupta the concept and principle of health care services
et al (2012) described the damage and dysfunction management were community based and involved
of a civil hospital of Leh in the Ladakh region of home care and field hospital services. A community-
North India following flash floods. In this disaster, based approach such as the mobile teams placed
search and rescue operations were launched by the within the community as we had done proved to be
Indian Army immediately after the disaster. Mass beneficial for the Orang Asli.
casualty management was handled by the army The Orang Asli community, like any other aboriginal
doctors while relief work was mounted by the army community are a passive lot and only require
and civil administration. The authors found that basic needs for their livelihood. They rarely seek
disaster preparedness was critical, particularly in help in most situations and will do all they can
natural disasters. The Armys immediate search, to survive. Nevertheless, the National Orang Asli
rescue, and relief operations and mass casualty Affairs Department (JAKOA) - the authority in-
management effectively and efficiently mitigated charge of this community checks on them and
the impact of the flash floods, and restored normal organizes help. Despite having experienced
life rapidly. mulitiple disaster events in the past, they do not
Post-flood volunteer work must be community display the attitude of seeking help and could
based with field orientation. More often than not, easily be forgotten. In reality, they could be in dire
access to health centres may not be possible. circumstances. Stimpson et al (2008) described
Existing health centres too, may not be functional. how the frequency of exposure to a flood was
This is more so for the Orang Asli community as associated with the probability of seeking help from
References
1. Stimpson, J.P., Wilson, F.A., Jeffries, S.K. 4. Gupta, P., Khanna, A., Majumdar S. (2012).
(2008). Seeking help for disaster services after Disaster management in flash floods in leh
a flood. Disaster Med Public Health Prep, 2(3), (ladakh): a case study. Indian J Community
139-141. Med, 37(3), 185-190.
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.
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. Weils disease
water 3. Disseminated Intravascular
Coagulation symptoms
4. Haemolytic Uremic
Syndrome symptoms
5. Thrombotic Thrombocyto
penic Purpura symptoms
6. Vasculitis
Figure 1: Pathogens profiled in Malaysia: Vibrio cholera (1), Burkholderia pseudomallei (2), Leptospira
spp. (3), Cryptosporidium parvum (4), Giardia spp. (5)
37
Figure 2: Pathogens profiled at the tropics and subtropics: Vibrio cholera (1), S. typhi and S. paratyphi (2),
Burkhoderia pseudomallei (3), Leptospira spp. (4), Cryptosporidium parvum (5), Giardia spp. (6), Hepatitis E
(7), Aspergillus fumigatus (8).
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.
1 Suitable shelter l Identify geographical areas with clean water supply, sanita-
establishment by utilising tion facilities and transport.
GIS mapping25 l Innovation and use of portable clean water devices to clean
and utilise natural water sources.
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.
4 Use of appropriate Faecal l Utilise parameters from FIBs and faecal coliforms to predict
Indicator Bacteria (FIB) risk of disease outbreaks
and faecal coliform5,16
Discussion
Hydro-meteorological events such as floods flooding caused by vector-borne diseases were
have increased in frequency due to climate not emphasized. This review article focused
changes, changing patterns of precipitation on waterborne and water-related diseases.
and an increase in the sea level1. Global Moreover some evidence from this study may
warming and the El-Nino effect has enhanced not represent the entire Malaysian population
proliferation of hosts that harbour pathogens. because studies regarding diseases such as
It has also contributed to emerging and re- giardiasis were gathered from indigenous
emerging infections that are affected by Malaysian communities.
climatic changes .6
There are similarities and differences with
regards to environmental factors, vulnerable
The strength of this article is that examples of populations and hosts which affect transmission
various pathogen including bacteria, protozoa, of disease to humans. For example, increased
virus and fungi were assessed in terms of precipitation before periods of heavy rainfall
environmental factors, host, vulnerable is a common environmental factor associated
population and mode of transmission. Several with leptospirosis, melioidosis, cholera and
measures which could be taken before and cryptosporidiosis outbreaks.
after disasters were also discussed. This study The experimental infection of R. norvegicus
has several limitations. Outbreaks due to rats by HEV human strain isolated from humans
Figure 3: Example of framework or model of a water-related or waterborne disease illustrating the inter-
Figure 3: Example
play between of framework
bio-ecological or model
factors, of a water-related
vulnerability or waterborne
factors and measures disease
to reduce an illustrating
outbreak.
the interplay between bio-ecological factors, vulnerability factors and measures to reduce an
Conclusion
outbreak.
The results of this study show that a close to reduce the risk of disease transmission.
relationship exists between pathogens, the The coexistence of pathogens in a similar
susceptibility of the human host, animal reservoir environment will pose an additional challenge
42
and environmental factors when extreme water and should be taken into consideration. This
events such as floods occur. Hence, measures could be done by identifying animal reservoirs,
or frameworks can be designed taking these analysing agricultural activities, recent
factors into consideration. The identification of deforestation and environmental changes which
silent carrier or chronic carrier of pathogens occur before extreme water events. Disaster
and vulnerable groups among HCWs or management strategies are complicated by
RWs can potentially reduce transmission of pathogens which have mutated. These new
diseases during floods. In addition, identifying pathogens identified by their serotypes are
vulnerable populations among disaster victims resistant to conventional drugs. New animal
would also reduce the risk of disease outbreaks reservoirs of these mutated serotypes are being
and transmissions. identified. Outbreaks secondary to emerging
and remerging diseases will be common in
Poor planning of flood mitigation strategy and future.
an unstructured surveillance system could
undermine the ability of RWs and HCWs to Evidence pertaining to the competencies of
recognise and take preventive measures RWs and HCWs which have been collated show
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 33
that improvements can be made to reduce the Competing interests
morbidity and mortality among RWs and HCWs The author declares that he does not have any
due to disease outbreaks. There is a need to competing interest.
study the vulnerability factors of the Malaysian
Acknowledgement
population as the applicability of frameworks and
I would like to acknowledge the Director
surveillance systems has to suit environmental,
General of Health, Malaysia for permission
climatic and serotypes of pathogens which are
to publish this article. I also would like to
commonly found in Malaysia and surrounding
thank the Director of Hospital Duchess of
regions. In future, climatic changes due to El-
Kent, Sandakan, Sabah for supporting the
Nino and unscrupulous human activities will
publication and presentation of this article. A
increase the frequency and intensity of extreme
special thanks to my parents and friends for
water events such as tropical cyclones, storms
their encouragement.
and floods.
References
1. Benedict, K., Benjamin, J.P. (2014). 4. Collins English Dictionary. Rescue
Invasive fungal infection after natural worker. (Cited: 10 April 2014). Available
2. Centers of Disease Control and Prevention. 5. Cabral JPS (2010). Water Microbiology,
3. Sapian, M., Khairi, M.T., How, S.H., 1974 to 2005. International Journal of
19. Guan, D., Li, W., Su, J. (2013). Asian Musk 24. World Health Organization. (2011). The
Shrew as a reservoir for rat Hepatitis Interagency Emergency Health Kit 2011.
E Virus, China. Emerging Infectious Medicines and Medical devices for 10000
Disease, 19 (8), 1341-1342. people for approximately three month.
20. Baqir, M., Sobani, Z.A., Bhamani, A., 25. Jafari, N., Shahsanai, A., Memarzadeh,
Bham, N.S., Abid, S., Farook, J. (2012). M., Loghmani, A. (2011). Prevention of
Infectious diseases in the aftermath of communicable disease after disaster: A
monsoon flooding in Pakistan. Asian review. Journal of Research in Medical
Pacific Journal of Tropical Biomedicine, 2 Sciences, 16 (7), 956-962.
(1), 76-79.
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.
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).
160
141
140
Number of Volunteers (n)
120
100
80
60 52
40
23
20 7
0
20-30 31-40 41-50 51-60
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).
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).
27, 12%
197, 88%
Kelantan Pahang
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
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 41
51
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).
160
140 135
120
Number of Volunteers (n)
100
78
80
60
40
20 11
0
0 to 5 Days 6 to 10 Days 11 to 15 Days
54
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.
The assessment team included a senior equipment and drugs were damaged with
consultant in Emergency Medicine, two mostly beyond repair and use. The clinic
Emergency Physicians, a Matron, three was rendered non-functional. The smell of
staff nurses, one Assistant Medical Officer mud was very strong. The dried mud would
and four officers from the National Welfare also lengthened the cleaning process long
Foundation. and made it more challenging. Water-
The clinic was completely submerged in logged equipment included the ultrasound
muddy flood water during the major east machine, laboratory equipment,
coast flood of 2014/2015. The river near refrigerators and a television set. None of
the clinic rose and the water submerged the drugs at the clinic were usable. The
the clinic up to the ceiling. The clinics clinic interior was dark as there was no
sewerage system had overflowed and electricity. Tap water was not available.
contaminated the whole clinic. Furniture,
60
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.
Photo 4: Cleaning with water from water tanker & water jet required to remove thick mud
stain
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.
In order to reduce the public health risk Given that community seeks treatment at
posed by flooded buildings that have been health clinics, they should not be a source
restored, it is important to understand their of infection. Proper post-flood remediation
drying behaviour. In our experience, we lowers illnesses. Hoppe et al (2012) found,
observed that drying mud was heavy and following the Cedar River flooding that
needed shovelling. The smell was very bad proper post-flood remediation led to
as the sewerage had contaminated the improved air quality and lower exposure
already muddy water. According to Taylor among residents living in homes that had
et al (2011), floods can bring pathogens been flooded. Proper remediation of flood-
indoors and cause lingering damp and damaged homes can reduce bio-aerosols to
microbial growth in buildings, with the level acceptable levels but exposure is
of growth and persistence dependent on significantly increased while remediation is
the volume, chemical and biological in-progress leading to an increased burden
content of the flood water, the properties of allergy and allergic rhinitis. An increase
of the contaminating microbes, and the in illnesses was found in households living
surrounding environmental conditions, in flooded homes. It is feared that a clinic
including the restoration time and affected by floods would harbour
methods, the heat and moisture transport infections. A thorough cleaning is required.
properties of the building design, and the Waringet et al (2002) described
ability of the construction material to assessment of household needs during
sustain the microbial growth. The public Tropical Storm Allison, which hit landfall
health risk will depend on the interaction of near Galveston, Texas, in 2001 and caused
these complex processes and the the most severe flood-related damage ever
vulnerability and susceptibility of occupants recorded in the Houston metropolitan area.
in the affected areas. This was illustrated They found a 4-fold increase in illness
after the 2007 floods in the UK, when the among persons living in flooded homes
Pitt review noted that there was a lack of compared with those living in non-flooded
relevant scientific evidence and consistency homes. These findings suggest a need for
with regard to the management and rapid resolution of flood-related damage
treatment of flooded homes, which not only and the recommendation that residents
put the local population at risk but also should seek temporary housing during
clean-up and repair. The findings
56 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
66
withstand future storms that may be caused unnecessary delays in the
worse. restoration effort.
In order to reduce the public health risk Given that community seeks treatment at
posed by flooded buildings that have been health clinics, they should not be a source
restored, it is important to understand their of infection. Proper post-flood remediation
drying behaviour. In our experience, we lowers illnesses. Hoppe et al (2012) found,
observed that drying mud was heavy and following the Cedar River flooding that
needed shovelling. The smell was very bad proper post-flood remediation led to
as the sewerage had contaminated the improved air quality and lower exposure
already muddy water. According to Taylor among residents living in homes that had
et al (2011), floods can bring pathogens been flooded. Proper remediation of flood-
indoors and cause lingering damp and damaged homes can reduce bio-aerosols to
microbial growth in buildings, with the level acceptable levels but exposure is
of growth and persistence dependent on significantly increased while remediation is
the volume, chemical and biological in-progress leading to an increased burden
content of the flood water, the properties of allergy and allergic rhinitis. An increase
of the contaminating microbes, and the in illnesses was found in households living
surrounding environmental conditions, in flooded homes. It is feared that a clinic
including the restoration time and affected by floods would harbour
methods, the heat and moisture transport infections. A thorough cleaning is required.
properties of the building design, and the Waringet et al (2002) described
ability of the construction material to assessment of household needs during
sustain the microbial growth. The public Tropical Storm Allison, which hit landfall
health risk will depend on the interaction of near Galveston, Texas, in 2001 and caused
these complex processes and the the most severe flood-related damage ever
vulnerability and susceptibility of occupants recorded in the Houston metropolitan area.
in the affected areas. This was illustrated They found a 4-fold increase in illness
after the 2007 floods in the UK, when the among persons living in flooded homes
Pitt review noted that there was a lack of compared with those living in non-flooded
relevant scientific evidence and consistency homes. These findings suggest a need for
with regard to the management and rapid resolution of flood-related damage
treatment of flooded homes, which not only and the recommendation that residents
put the local population at risk but also should seek temporary housing during
clean-up and repair. The findings
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 57
66
underscore the usefulness of a rapid-needs clinic. A disaster plan for the clinic could
assessment as a tool to identify actual also take into account measures for early
health threats and to facilitate delivery of detection and early response for future
resources to those with the greatest and floods.
most immediate need.
Phalkey et al (2012) asserted that early
In this disaster, laboratory equipment were warning of an impending flood and the
damaged from submersion in water. The availability of counter measures to deal
water supply following the floods may also with it can significantly reduce its health
be contaminated and may damage them as impact. In developing countries, public
well. Yamada et al (2011) described the primary health care facilities are the
damage of analytical devices following frontline organizations that deal with
flood inundating Okazaki City Hospital in disasters particularly in rural settings. To
Aichi, Japan in 2008. Hospital functioning develop robust counter reacting systems,
did not stop, but some devices were evaluating preparedness capacity within
damaged by the water. There was no direct existing systems becomes necessary. The
damage to the clinical laboratory area, but authors showed that the healthcare
an abnormality in the measurement of facilities were ill prepared to handle the
Troponin-I occurred after the downpour. It flood despite being faced by them annually.
was suggested that this measurement Basic utilities like power generators and
abnormality was caused by the pollution of essential medical supplies were lacking
the water supply to the analyzer. For our during floods. Lack of human resources
health clinic, all the laboratory equipment along with missing standard operating
were damaged in this event. procedures, pre-identified communication
and incident command systems, effective
The recovery phase after disaster leadership and weak financial structure
represents an opportunity to improve were the main impending factors in
services. The Kuala Krau clinic needs to mounting an adequate response to the
acquire new equipment and materials. floods. Simple steps like developing facility
Following the cleaning exercise, it was able specific preparedness plans which detail
to function again after three days with very standard operating procedures during
few equipment salvageable. The floods and identify clear lines of command
management however, would need to will go a long way in strengthening the
obtain a budget allocation to acquire new response to future floods. Each facility
equipment and to repair and renovate the should maintain contingency funds for an
58 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
67
emergency response along with local by the Government are met in non-flood
vendor agreements to ensure stock periods in order to improve the response
supplies during floods. The facilities should during floods. Building strong public
ensure that baseline public health primary health care systems is a
standards for health care delivery identified development challenge.
Recommendation
Conclusion References
Co-ordination between stakeholders, 1. Wisitwong, A., McMillan M.
volunteers and assisting partners is Management of flood victims:
essential for the efficient and effective Chainat Province, Central Thailand.
remediation and restoration of a health
clinic. Cleaning equipment, water supply 2. Adams, H.A., Flemming. A., Lange,
and water jets and power generators were C., Koppert, W., Krettek, C. (2015).
essential in ensuring an effective cleaning Care concepts in mass casualty
exercise. Volunteers must observe the incidents and disasters. Concept for
ethics of assistance in disaster and work in primary care clinic. Med Klin
a true spirit of volunteerism. The guideline, Intensivmed Notfmed, 110(1), 27-
established from our experience, may be 36.
used as a reference for future cleaning
exercise. 3. Evans, M. (2012). Recovery mode.
Mod Healthc, 42(50), 6-7, 16, 1.
Acknowledgement
We would like to acknowledge the Director 4. Taylor, J., Lai, K.M., Davies, M.,
General of Health, Malaysia for permission Clifton, D., Ridley, I., Biddulph, P.
to publish this article. We also would like to (2011). Flood management:
thank to all who directly and indirectly prediction of microbial
involved in this activity. contamination in large-scale floods
in urban environments. Environ Int,
37(5), 1019-1029.
A major issue following a flood disaster is Vector borne diseases were a concern too,
the spread of communicable diseases. This as Malaysia is endemic for dengue
not only affects the victims, the volunteers infection, a viral disease transmitted by the
at the disaster sites as well. Largely, the mosquito. Floods would make stagnant
communicable diseases can be classified water available for the vector and cause
into two broad categories, water borne and spreading of the disease. Thus increasing
vector borne diseases. risk of dengue in the affected population
and volunteers. Multiple factors such as
Flooding causes risk escalation in the overcrowding and stagnant water will
spreading of water borne diseases such as exacerbate the outbreak.
cholera, typhoid, leptospirosis and hepatitis
A (WHO). Leptospirosis, a zoonotic It is crucial for to obtain information
bacterial infection is known to be locally regarding disaster sites as outlined by
endemic at the affected sites. Flash flood Watson JT (2007) that is the 1) endemic
releases bacteria which mainly resides and epidemic diseases that are common in
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 63
72
Introduction deep in soils and raises the likelihood of
Volunteerism is the heart of disaster volunteers being exposed to this organism.
management. A disaster spurs people from The process of cleaning disaster sites using
walks of life into volunteering to provide air-jets also increases the risk of infection,
economical, physical or emotional support as the exposure is over a prolonged time
to disaster victims. Consequently, the period. Without proper guidelines and
management of volunteers is crucial. awareness training from the management
Among other things that the effort is regarding the risks, these enthusiastic
effective and efficient, it does not burden volunteers are at risk of being infected. In
the affected local authority and volunteers this regard, Vollaard AM (2004) reported
are not compromised in any way. flooding as a significant risk factor for
diarrheal disease caused by Salmonella
The flood disaster which occurred in the enterica serotype Paratyphi A (paratyphoid
East Coast of Malaysia had opened many fever) in a large study carried out in
eyes. The flood damage was estimated at Indonesia from 1992 to 1993. In a separate
about RM1 billion and affected public study, Katsumata T (2004) evaluated the
schools, roads, homes, agriculture loss and risk posed by Cryptosporidium parvum in
causing landslides (The Malay Mail Online, Indonesia between 2001 and 2003 to be
2015). four times because of floods.
A major issue following a flood disaster is Vector borne diseases were a concern too,
the spread of communicable diseases. This as Malaysia is endemic for dengue
not only affects the victims, the volunteers infection, a viral disease transmitted by the
at the disaster sites as well. Largely, the mosquito. Floods would make stagnant
communicable diseases can be classified water available for the vector and cause
into two broad categories, water borne and spreading of the disease. Thus increasing
vector borne diseases. risk of dengue in the affected population
and volunteers. Multiple factors such as
Flooding causes risk escalation in the overcrowding and stagnant water will
spreading of water borne diseases such as exacerbate the outbreak.
cholera, typhoid, leptospirosis and hepatitis
A (WHO). Leptospirosis, a zoonotic It is crucial for to obtain information
bacterial infection is known to be locally regarding disaster sites as outlined by
endemic at the affected sites. Flash flood Watson JT (2007) that is the 1) endemic
releases bacteria which mainly resides and epidemic diseases that are common in
64 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
72
the affected area; 2) living conditions of the healthcare volunteers after their stint at the
affected population, including number, affected sites. This article examines the
size, location, and density of settlements; processes and workflow practised by CPRC
3) availability of safe water and adequate IHM in its role as a transit centre for
sanitation facilities; 4) nutritional status healthcare volunteers, with particular focus
and immunization coverage of the on the management of the post
population; and 5) degree of access to deployment activities phase.
healthcare and to effective case
management. For 20 days of operation, we received 272
post-deployment volunteers at its CPRC
CPRC IHM Post-Deployment Team IHM transit centre. 84.4% (n=224)
Healthcare volunteer management in CPRC volunteers were completed post-
IHM transit centre was phased into pre and deployment mental and physical
post deployment activities. Pre-deployment assessment at CPRC IHM while 17.6%
activities focused primarily on the mental (n=48) volunteers were decided to have
and physical status of the volunteers before their post-deployment medical and
they deploy to the assigned area. While, psychological assessment at their
post-deployment activities, assessed the respective state health offices.
physical and mental status of the
Figure
Figure 1:
Figure 1: The
1: The CPRC
The CPRC IHM
CPRC IHM Post-deployment
IHM Post-deployment team
Post-deployment team workflows
team workflows
workflows
Post-Deployment
Post-Deployment Activities
Post-Deployment Activities
Activities at at CPRC
at CPRC IHM
CPRC IHM Transit
IHM Transit Centre
Transit Centre
Centre
Post-deployment
Post-deployment activities
Post-deployment activities involved
activities involved several
involved several processes
several processes that
processes that were
that were executed
were executed by
executed by the
by the CPRC
the CPRC IHM.
CPRC IHM.
IHM.
These
These processes
These processes were
processes were based
were based
based on on the
on the Pre
the Pre and
Pre and Post-Deployment
and Post-Deployment Healthcare
Post-DeploymentHealthcare Volunteers
HealthcareVolunteers Guideline
VolunteersGuideline
Guideline
by
by CPRC
by CPRC MOH
CPRC MOH issued
MOH issued on
on 77
issued on
th
January
7thth January 2015.
January 2015. The
2015. The guideline
The guideline states
guideline states that
states that the
that the MOH
the MOH healthcare
MOH healthcare
healthcare
volunteers
volunteers who
volunteers who returned
who returned and
returned and transit
and transit at
transit at CPRC
at CPRC IHM
CPRC IHM were
IHM were required
were required to
required to attend
to attend the
attend the in-
the in- house
in- house PFA
house PFA
PFA
3.0 Post-deployment PFA Briefing and this group. As instructed by CPRC MOH,
DASS assessment DASS was the tool used for mental
The mental assessment was carried assessment at CPRC IHM. 224 post-
according to the National Guidelines for deployment underwent DASS assessment
Mental Health and Psychosocial Response and 5.3% (n=12) of them had at least two
to Disaster developed by the Ministry of abnormal scores on the scales (Table 3).
Health. Post traumatic stress disorder Volunteers who showed moderate to
(PTSD) among the post-deployment severe DASS scores were counselled by a
volunteers was the main concern. In view PFA trained counsellor. They were followed
of this, mental assessment was crucial for up two weeks later at a hospital.
78 78
78
70 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Photo 4: Counsellor giving PFA to the post-deployment volunteers
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 childrens 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 Hospitals 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
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)
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.
Figure 3: The stuffed animals used as play and communication medium between child and the
counselor
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.
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 didnt 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.
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,
Team A premises were assessed by food symptomatic victims for investigations (9 rectal
control team. This team was from Perak swabs and 1 stool sample). The rectal swab
Tengah district food safety and quality unit and stool samples were sent for culture and
and they will do the environmental assessment sensitivity. However no food holding sample
included kitchen condition, cooking area, type was sent for investigation because there was
of water supply, water flow and drainage. They no leftover food available. All the samples were
were using a risk based form KKM-PPKM-2/09 sent to the Public Health Laboratory, Ministry
as the assessment tools. However assessment of Health, Ipoh, Perak for analysis.
16
14
onset
12
10
last onset
8
6
4
2
0
12pm 2pm 4pm 6pm 8pm 10pm 12am 2am 4am 6am
Time
88 JOURNAL
Figure 1 shows epidemic OF of
curve HEALTH MANAGEMENT
50 cases distributed- by
SPECIAL
onsetEDITION VOL II: It
time of illness. DECEMBER
displayed2015
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
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.
Microbiological Investigations
The 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