MINISTRY OF HEALTH MALAYSIA

AN OVERVIEW OF DISASTER LIFE SUPPORT

IN DISASTER MANAGEMENT
All rights reserved. Published in August 2022

A catalogue record of this document is available from the MOH Library.

A copy of this document is also available from the National Library of Malaysia.

This book was developed by the Emergency and Trauma Department, Selayang Hospital
and Competency Development Division, Ministry of Health Malaysia (MOH)

MOH encourages printing or copying information exclusively for personal and

non-commercial use with proper acknowledgment of MOH. Users are restricted from
reselling, redistributing, or creating derivative works for commercial purposes without the
express, written consent of MOH.

Disclaimer: The views, interpretations, implications, conclusions and recommendations

expressed in this book are of the authors and do not necessarily represent the opinions, the
views, or policy of the Ministry of Health Malaysia.

Published by : Competency Development Division, Ministry of Health Malaysia

Blok A, Jalan Cenderasari, Tasik Perdana
50590 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur

Copyright © Competency Development Division, Ministry of Health Malaysia

CONTENTS AN OVERVIEW OF DISASTER LIFE SUPPORT
IN DISASTER MANAGEMENT

CHAPTER 1
INTRODUCTION TO DISASTER
1.1 Background  2
1.2 Definition  3
1.3 Classification  3
1.4 Disaster Management Approach  8
1.4.1 All-Hazards Approach 8
[Link] Pre-Disaster Paradigm 9
[Link] Disaster Paradigm 10
1.4.2 Disaster Management Planning at Healthcare Facilities 12
[Link] Hazard Vulnerability Analysis 12
1.4.3 Disaster Management Response in Healthcare Facilities 18
1.5 Summary  26
Bibliography  26

CHAPTER 2
INCIDENT COMMAND SYSTEM
2.1 Background  28
2.2 Basic Structure of Incident Command System in Malaysia (MKN Directive 20)   29
2.2.1 Roles and Responsibilities of Team Members 30
2.3 Hospital Disaster Activation Plan  32
2.3.1 Notification and Activation 32
2.3.2 Disaster Action Cards 34
2.4 Summary  34
Bibliography  34

CHAPTER 3
MASS CASUALTY MANAGEMENT
3.1 Background  36
3.2 General Principles of Mass Casualty Triage   37
3.2.1 Mass Casualty Triage System 38
[Link] START Triage 38
[Link] JumpSTART Pediatric Triage 39
[Link] SALT Triage (Sort, Assess, Life-saving Interventions, Treatment/Transport) 41
[Link] Triage Sieve 42
3.2.2 Population-Based Triage 43
[Link] SEIRV Triage for Biological Disaster 44
[Link] Population-Based Triage Through Risk Communication 44
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 3.2.3 Triage Categories 44
3.2.4 Limitations of Triage Systems 47
3.3 Casualty Assessment  47
3.3.1 Primary Assessment 47
3.3.2 Secondary Assessment 49
3.5 Summary  51
Bibliography  51

CHAPTER 4
NATURAL DISASTERS
4.1 Background  54
4.2 Natural Disaster Specific Considerations  56
4.2.1 Situational Awareness 57
4.2.2 Health Facility Expansion of Surge Capability 57
4.3 Pattern of Injuries and Clinical Management   58
4.4.2 Early Detection and Warning Systems 63
4.4.3 Acute Hazard and Effects 64
4.4.4 Clinical Implications 64
4.4.5 Public Health Considerations 65
4.4.6 Prevention and Mitigation 66
4.5 Heat Emergencies  67
4.5.1 Causes and Characteristics 68
4.5.2 Hazard Identification and Warning Systems 70
4.5.3 Clinical Implications 71
4.5.4 Prevention and Mitigation 73
4.6 Wildfires and Haze  74
4.6.1 Causes and Characteristics 75
4.6.2 Early Detection and Warning Systems 75
4.6.3 Acute Hazards and Effects 75
4.6.4 Clinical Implications 76
4.7.5 Public Health Considerations 77
4.7.6 Prevention and Mitigation 77
4.7 Earthquakes and Tsunamis  78
4.7.1 Causes and Characteristics 80
4.7.2 Early Detection and Warning Systems 81
4.7.3 Acute Hazards and Effects 81
4.7.4 Clinical Implications 82
4.7.5 Public Health Considerations 83
4.7.6 Prevention and Mitigation 84
4.8 Storm, Hurricanes, Cyclones and Typhoons  84
4.8.1 Causes and Characteristics 85
4.8.2 Early Detection and Warning Systems 85
4.8.3 Acute Hazards and Effects 88
4.8.4 Clinical Implications 89
4.8.5 Public Health Considerations 89
4.9.6 Prevention and Mitigation 90
4.10 Summary  90
Bibliography  91

ii
CHAPTER 5
CHEMICAL DISASTERS
5.1 Background  94
5.2 Clinical Management  95
5.3 Clinical Management  97
5.4 Causative Chemical Agents in Chemical Disaster  99
5.5 Summary  100
Bibliography  100

CHAPTER 6
BIOLOGICAL DISASTERS
6.1 Background  102
6.1.1 Chain of Infection 103
[Link] Basics of Infectious Disease Exposure and Transmission 104
6.2 Categories of Biological Agents  106
6.2.1 Category A Agents 106
6.2.2 Category B Agents 106
6.2.3 Category C Agents 107
6.3 Clues for Bioterrorism Attack  107
6.4 Clinical Decision Making  107
6.4.1 Transmission-Based Infection Control 107
6.4.2 Triaging in Biologic Events (SEIRV) 108
6.5 Biological Agents – Specific Issues  108
6.5.1 Anthrax (Bacillus anthracis) 108
6.5.2 Botulism (Clostridium botulinum) 109
6.5.3 Pneumonic Plague (Yersinia pestis) 110
6.5.4 Severe Acute Respiratory Syndrome (SARS) 110
6.5.5 Smallpox (Variola major) 111
6.5.6 Tularemia (Francisella tularensis) 111
6.5.7 Viral Hemorrhagic Fever (VHF) 111
6.6 Emerging Infectious Disease Threat  112
6.6.1 COVID-19 112
6.7 Summary  113
Bibliography  113

CHAPTER 7
RADIOLOGICAL AND NUCLEAR DISASTERS
7.1 Background  115
7.1.1 Radiological Emergency 117
7.1.2 Characteristics of Radiation 120
7.2 Human Effects of Radiation  122
7.2.1 Acute Radiation Syndrome (ARS) 122
7.2.2 Case Study: Death Caused by Internal Contamination with 210Po 125
7.2.3 Dose Limits 127
7.3 External Hazard Protection  128

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 7.3.1 Equipment for Radiological Protection 128
7.3.2 Personal Protective Equipment Gear for Radiological Events 129
7.4 Flow of Medical Care of Patients during Radiological Emergencies  136
7.5 Management of Radiological Emergencies (Hospital Phase)   140
7.5.1 Prior to Patient Arrival 140
7.5.2 Patient Arrival 142
7.6 Triaging at The Emergency Department  144
7.6.1 Assessment and Treatment of The Contaminated Patient 144
[Link] Management of the Contaminated Patient 145
[Link] Contamination Survey 145
7.6.2 Assessment and Treatment of Non-Contaminated Patient 146
7.7 Principle of Contaminated Patients Management  146
7.7.1 Decontamination of Wounds 147
7.7.2 Decontamination of Body Orifices 148
7.7.3 Repeating Survey after Decontamination 149
7.7.4 Surgical Emergencies 150
7.8 Dose assessment  150
7.9 Radiography   150
7.9.1 Principles of Management 151
[Link] Management of internal radioisotope contamination 152
7.9.2 Referrals 152
7.9.3 Removal of PPEs 153
7.9.4 Disposal of Radioactive Waste 153
7.9.5 Hospital recovery 154
7.10 Public Health Implications of Nuclear and Radiologic Disasters  154
7.11 Summary   154
Bibliography  155

CHAPTER 8
EXPLOSIVE AND TRAUMATIC DISASTERS
8.1 Background  157
8.2 Classification of Explosives   158
8.3 Types of Explosions   158
8.3.1 Nuclear Explosion 158
8.3.2 Mechanical Explosion 158
8.3.3 Chemical Explosion 160
8.4 Blast Injury from Explosions   160
8.4.1 Primary Blast Injury 161
8.4.2 Secondary Blast Injury 163
8.4.3 Tertiary Blast Injury 163
8.4.4 Quaternary Blast Injury 163
8.5 Situational Awareness   164
8.5.1 Approach to Blast Injury 164
8.5.2 Administration Issues 167
8.6 Summary  168
Bibliography  168

iv
CHAPTER 9
MASS FATALITY MANAGEMENT
9.1 Background  170
9.1.1 Mass Fatality Event Definition 171
9.2 Field Fatality Management  171
9.2.1 Morgue Operations 171
9.3 MH17: The Malaysian Experience  173
9.4 Summary  175
Bibliography  175

CHAPTER 10
MENTAL AND PSYCHOLOGICAL RESPONSE
TO DISASTER
10.1 Background  177
10.2 Stress and Psychological Trauma   179
10.2.1 Mental Health Disorders and Syndromes Associated with Disasters 179
[Link] Acute Stress Reaction 179
[Link] Chronic or Complicated Grief 179
[Link] Major Depressive Disorder 180
[Link] Generalized Anxiety Disorder 181
[Link] Panic Attack 181
[Link] Panic Disorder 181
[Link] Post-Traumatic Stress Disorder 182
[Link] Substance Abuse Disorder 182
10.3 Psychological First Aid (PFA)  182
10.3.1 Look 183
10.3.2 Listen 183
10.3.3 Link 183
10.3.4 Core Actions of Psychological First Aid 183
10.4 Resilience in Disaster   184
10.5 Mental Health of Disaster Response Workers  184
10.6 Mental Health for Children and Adolescents  185
10.7 National Guidelines for Mental Health and Psychosocial Response  186
10.7.1 Organisation of Services 187
10.8 Summary  189
Bibliography  189

CHAPTER 11
PUBLIC HEALTH EMERGENCY RESPONSE TO DISASTERS
11.1 Background  191
11.2 Public Health Agencies and Organisations  192
11.3 Public Health Role in Disaster Response   192
11.3.1 Epidemiologic Surveillance and Investigation 194
11.3.2 Enhanced Public Health Reporting 195
11.3.3 Crisis and Emergency Risk Communication 196

v
 [Link] Seven Cardinal Rules for the Practice of Risk Communication 197
11.3.4 Community Evacuation Considerations 197
11.3.5 Population-Based Surge Management 199
11.3.6 Communicable Disease Prevention and Control 199
11.3.7 Medical Logistics 201
11.3.8 Mass Care Services 201
11.3.9 Environmental Health Services 201
11.4 Recovery and Beyond   203
11.5 Community-Based Management   204
11.6 The Sendai Framework for Disaster Risk Reduction 2015-2030  205
11.7 Emergency Medical Teams (EMTs)  206
11.7.1 Field Hospital 207
11.7.2 Organisation Structure of Field Hospital 210
11.8 Summary  212
Bibliography  212

CHAPTER 12
WORKFORCE READINESS, DEPLOYMENT AND ON-SCENE MEDICAL
MANAGEMENT
12.1 Deployment  215
12.2 Pre-Deployment Preparation  215
12.2.1 Health and Mental Status 215
12.2.2 Personal items 216
12.2.3 Equipment 217
12.2.4 Education and Training 217
12.2.5 Specific Information Assigned 218
12.3 Deployment Considerations  218
12.3.1 On-Site Responder Daily Task 218
12.3.2 Documentation During Disaster Deployment 218
12.3.3 Health Monitoring and Surveillance During Response 218
12.3.4 Exposure Assessment 218
12.3.5 Injury to Responders 219
12.3.6 Field Hygiene 219
12.3.7 Insect Bites and Stings 219
12.4 Volunteerism  220
12.4.1 Advantages 220
12.4.2 Challenges and Limitations 221
12.5 Past Experiences in Managing Humanitarian Aids Distribution Process During Disaster  221
12.5.1 Problems during Aids Distribution process 221
12.5.2 Lesson Learnt from Mismanagement in Humanitarian Aids Distribution 222
12.6 Medical Supply Chain  222
12.7 Summary  226
Bibliography  227

vi
CHAPTER 13
CASUALTY DECONTAMINATION
13.1 Contamination  229
13.1.1 Chemical Hazard Transmission 230
13.1.2 Biological Hazard Transmission 231
13.1.3 Secondary Contamination 231
13.1.4 Types of Contamination 232
13.2 Decontamination  233
13.2.1 Definition 233
13.2.2 Decontamination Principles 233
13.2.3 Decontamination Methods 233
[Link] Physical Decontamination 234
[Link] Chemical Decontamination 235
13.2.4 Types of Decontamination 236
13.2.5 Incident Site Decontamination 238
13.2.6 Hospital Decontamination 239
13.3 Summary  246
Bibliography  246

CHAPTER 14
PERSONAL PROTECTIVE EQUIPMENT
14.1 Background  248
14.2 Four Levels of Personal Protective Equipment   251
14.2.1 Level A 252
14.2.2 Level B 253
14.2.3 Level C 254
14.2.4 Level D 255
14.3 CBRNE PPE  255
14.4 Air-Purifying Respirator (APR)  256
14.5 Self-Contained Breathing Apparatus (SCBA)  257
14.6 Advantages and Disadvantages of PPE  258
14.7 PPE for Biological Casualties  259
14.8 PPE for Radioactive Contamination  260
14.8.1 Principles 260
14.8.2 Radiological PPE 260
14.9 PPE For Chemical Contamination  260
14.9.1 Chemical Protective Clothing 261
14.10 Summary  262
Bibliography  262

vii
 CHAPTER 15
ETHICAL AND MEDICOLEGAL ASPECT DURING DISASTER
15.1 Background  264
15.2 Ethics in Disaster Medicine  265
15.3 Legal Aspect in Disaster Medicine  270
15.4 MKN 20 Revised Directive and Its Compliance Towards
International Disaster Management Network  272
15.5 Utilizing Legislation in Managing Disaster: Prevention and Control of infectious
Diseases Act and Regulations during a Disaster  273
15.6 Summary   275
Bibliography  276

CHAPTER 16
TRAINING, SIMULATION AND EXERCISE
16.1 Background  279
16.2 Objectives  280
16.3 Key Elements  280
16.4 Exercise Management Team  280
16.5 Tabletop Exercise  281
16.6 Drills  282
16.6.1 Drill Exercise Checklist 282
16.7 Functional Exercises  283
16.8 Full-Scale Exercises  283
16.9 Summary  285
Bibliography  285

viii
FOREWORD
 FOREWORD BY
THE MINISTER OF HEALTH MALAYSIA
From the health disaster of the COVID-19 pandemic to the environmental disaster of flash
floods in December 2021, there is now a collective recognition that disaster management is a
necessary tool to sustain our communities. Disastrous events that are usually sudden and
calamitous in nature severely disrupts the community. In order to cope with the multitude of
losses that come with each disaster, it is imperative to have a detailed and specific plan that
organisations can use to respond and function effectively during an emergency.

During the COVID-19 pandemic, the Crisis Preparedness and Response Centre (CPRC) was
activated by the Ministry of Health (MoH) and together with National Disaster Management
Agency (NADMA), the response towards the public health emergency crisis was executed and
disaster preparedness was enhanced.

The National Plan for COVID-19 which included health screenings at

all points of entry to prevent disease transmission and
establishment of the COVID-19 Fund to cushion the economic
impacts of the Movement Control Order (MCO) was done with
coordination supported by CPRC. In addition, 140 quarantine
centres in Malaysia were established and monitored by NADMA,
to assist in virus containment during the early phase of this
pandemic.

The catastrophic flash floods that occurred in December 2021

during the pandemic posed a huge challenge to communities on
how to cope with two disasters at once. The frontliners,
public, together with government and
non-government organisations stepped up with
great fortitude to save lives and provide flood relief
aid to vulnerable groups. It is vital to note that in
disaster management, multisectoral approaches
and utilisation of all readily available resources
are crucial.

With that in mind, knowledge and information

on disaster management should not be
restricted to just government personnel but it
should be disseminated to members of the
public through comprehensive and
continuous activities by government
agencies. I would like to take this opportunity
to congratulate everyone who was involved
in developing this book, ‘An Overview of
Disaster Life Support in Disaster
Management’. It is a great initiative and I
hope that our society’s ability to handle
disaster management in the future would be
enhanced with concerted effort as such.

YB KHAIRY JAMALUDDIN
MINISTER OF HEALTH MALAYSIA
FOREWORD BY
THE DIRECTOR-GENERAL OF
PUBLIC SERVICE MALAYSIA
Over the last few decades, the frequency and magnitude of disaster threats have been rising,
be it natural, biological, chemical, terrorism, or industrial accidents. Large-scale disasters are
becoming more common and the ever-changing disaster landscape has given impetus to the
need to rethink and reconfigure the disaster preparedness strategy.

Malaysia had experienced several large-scale disasters, such as the Highland Towers
collapse in 1993 and the Nipah Virus outbreak in 1998. In 2020 and 2021, we witnessed how
the scale and speed of COVID-19 transmission had crippled the whole world and the 55
deaths in the December 2021 flood were the highest in the history of flood disaster in
Malaysia.
To fight the unprecedented COVID-19 pandemic,
Malaysia had adopted the Whole-of-Government and
Whole-of-Society. This collaborative effort among the
ministries and agencies, as well as higher learning
institutions, private sector and civil society
organisations had facilitated our timely response to
manage and contain the pandemic.

One important lesson from our battle with the COVID-19

pandemic is that collaborative effort is a prerequisite in
managing disasters. We also need to share and
equip society with the knowledge of disaster
management. Therefore, the publication
of this book, An Overview of Disaster
Life Support in Disaster Management
is a demonstration of the
Government’s commitment in
upscaling our preparedness and
efficiency in disaster management.

I sincerely appreciate the valuable

contributions from all parties in
sharing their experience and
expertise and for making this
publication possible.

DATO’ SRI MOHD SHAFIQ

BIN ABDULLAH
DIRECTOR-GENERAL OF
PUBLIC SERVICE MALAYSIA
 FOREWORD BY
THE SECRETARY-GENERAL OF
MINISTRY OF HEALTH MALAYSIA

Since the beginning of 2020, Malaysia has been at war with the COVID-19 pandemic
that has significantly impacted every aspect of human life. Up to this day, we are still
facing challenges in battling against not just COVID-19 but other disasters as well. In
December 2021, several states in Malaysia experienced one of the worst flash floods
in recent history.

These unprecedented disasters and the COVID-19 pandemic have given us a

moment to measure the agility and preparedness of our country’s disaster
management system in confronting a healthcare crisis and providing dynamic
healthcare services to the public.

Advanced planning for disasters is always better than trying to

manage a disaster after it has occurred. Correspondingly, ‘An
Overview of Disaster Life Support in Disaster Management’ is
an important document which will help to improve Malaysia’s
preparedness and efficiency in disaster management. The
comprehensive content of this book on disaster
management would surely enhance the disaster
preparedness of the Ministry of Health Malaysia. The
experience shared by various experts should be used to
enrich our understanding of disaster management.

I hope that all of us will truly optimise this publication to further

improve our knowledge and skills in disaster management.
I would like to congratulate the dedicated team from the
Emergency and Trauma Department, Selayang
Hospital and the Competency Development
Division of the Ministry of Health
Malaysia for bringing this wonderful and
beneficial publication into fruition.

DATUK HARJEET SINGH

SECRETARY-GENERAL OF
MINISTRY OF HEALTH MALAYSIA
FOREWORD BY
THE DIRECTOR-GENERAL
OF HEALTH MALAYSIA
The Southeast Asian region has one of the world’s highest risks of disaster. As such, our country
needs to be ready to face the challenges of disasters. We need to be more resilient and
innovative in improving the best practices and approaches for implementing initiatives and
interventions in mitigating and managing disasters.

The COVID-19 pandemic allowed us to enable the healthcare system to transform and adapt to
ensure that every level of society will have access to and is included in healthcare interventions.
The implementation of numerous interventions such as MySejahtera, activation of the Movement
Control Order under the Prevention and Control of Infectious Diseases Act 1988, and the Whole
of Government and Whole of Society approach are examples of such innovative interventions.

It is crucial to have mastery in the overall management of

disaster at a higher level of disaster management and at the
same time have trained skilled frontliners at the scene of
disaster to provide responsive and appropriate high-quality
care.

For the disaster response to be successful, the knowledge

and mechanisms must be based on accurate data,
scientific precepts, and good practices from on-site
experiences over the years of managing numerous
disasters. Appropriate actions at all points in the disaster
management cycle will lead to greater preparedness and
reduce the vulnerability or risk of disasters during the
next iteration of the cycle.

An Overview of Disaster Life Support in

Disaster Management provides useful
knowledge for medical providers and the
community in managing disasters. I
congratulate the dedicated team from the
Emergency and Trauma Services, MOH for
their resolute effort in creating this
publication. The book was developed by
frontliners for the frontliners and society. I
trust that all healthcare providers will find this
book useful as reading material and will
appreciate the knowledge and experiences
that have been shared in this book.

TAN SRI DATO’ SERI

DR NOOR HISHAM ABDULLAH
DIRECTOR-GENERAL OF HEALTH MALAYSIA
 FOREWORD BY
THE CHIEF EDITOR
The increasing incidence of disasters around the globe reflects three factors: higher
population density in disaster-prone areas; greater presence of hazardous materials
in communities; emerging and continuing diseases; and enduring conflicts. Effective
disaster preparation and response requires a disaster mindset, both individually and
collectively, that recognises the need for mass casualty and affected population
management.

Disaster management is a comprehensive approach for us to properly manage

disasters in Malaysia. Disaster requires a multidisciplinary sector that works
hand-in-hand to cope and achieve great outcomes. Whether a natural disaster, such
as a severe weather condition or health crisis, or a disaster caused by human actions,
such as terrorism or war, it is critical for organisations to have plans in place to
manage operations during such times with minimal losses and disruptions in normal
business flow.
The Highland Tower collapse, floods in Kelantan, the Sungai
Kim Kim pollution tragedy and the recent COVID-19
pandemic are examples of disasters that Malaysians have
experienced. Therefore, disaster preparedness activities
embedded with risk reduction measures are highly
important as they can prevent disaster situations and
result in the saving of maximum lives and livelihoods,
enabling the affected population to get back to normalcy
within a short time period.

I hope that this book will enlighten everyone as disaster

waits for no man. Knowledge is power. With
knowledge comes understanding, and with
understanding comes the power to
change lives and the compassion to
help heal. Preparedness saves lives.

DATUK DR MOHAMED ALWI

BIN HAJI ABDUL RAHMAN
CHIEF EDITOR
 PREFACE

This book was developed to provide reference and guide for medical providers and
also for personnel from government agencies or non-governmental organisation that
are involved in disaster management.

The objectives and aim of this book are:

to to to
enhance the provide a improve the
awareness of the reference on the understanding of
disaster best practices of the disaster
management and disaster medicine
mitigation management: techniques
efforts;

The 16 chapters in this book was developed by the MOH frontliners for frontliners. It
is intended to serve as a comprehensive guide for the management of disasters. It
is an initiative by the MOH to support efforts in disaster mitigation. This book reflects
the MOH's ongoing concern and effort to empower its staff with the knowledge and
skills in managing disaster. MOH also believe the society needs to be empowered as
well to enable an efficient disaster management.
 LIST OF ABBREVIATIONS

AAR After-Action Review

ACE Alternate Care Environment
ACF Alternate Care Facility
AEFI Adverse Effect Following Immunisation
AELB Atomic Energy Licensing Board
AMO Assistant Medical Officer
ANFO Ammonium Nitrate Fuel Oil
AO Administrator Officer
API Air Pollution Index
ARDS Acute Respiratory Distress Syndrome
ARS Acute Radiation Syndrome
BLEVE Boiling Liquid Expanding Vapor Explosion
BMT Bone Marrow Transplant
BVM Bag Valve Mask
CBC Count of Blood Cells
CBDRR Community-Based Disaster Risk Reduction
CBRNe Chemical, Biological, Radiological, Nuclear and Explosive
CDC Centres for Disease Control and Prevention
CDCR Control of Drug and Cosmetics Regulation
CDMRC Central Disaster Management and Relief Committee
CNS Central Nervous System
CO Carbon Monoxide
COPD Chronic Obstructive Pulmonary Disease
CPM Counts Per Minute
CSSD Central Sterile Services Department
DID Department of Irrigation and Drainage Malaysia
DMAT Disaster Medical Assistance Team
DMHPRT District Mental Health and Psychosocial Response Team
DRA Disaster Risk Assessment
DRM Disaster Risk Management
DTL Deputy Team Leader
DVI Disaster Victim Identification
EMS Emergency Medical Services
EMTCC Emergency Medical Team Coordination Cell
EOC Emergency Operation Centre
EOPs Emergency Operations Plans
EOSTI End-Of-Service Time Indicator
EPU Economic Planning Unit
ETD Emergency and Trauma Department
EWS Early Warning System
GCS Glasgow Coma Scale
xvi
GDP Good Distribution Practice
GIRN Government Integrated Radio Network
GIS Geographical Information System
HAZMAT Hazardous Material
HCW Healthcare Worker
HE High-order Explosives
HFA Hyogo Framework in Action
HUSM Hospital Universiti Sains Malaysia
HVA Hazard and Vulnerability Analysis Assessment
IC Incident Commander
ICS Incident Command System
ICU Intensive Care Unit
IDLH Immediately Dangerous To Life And Health
JBPM Jabatan Bomba dan Penyelamat Malaysia
KTM Keretapi Tanah Melayu
LDS Ladder Pipe Decontamination System
LE Low-order Explosives
MAS Malaysia Airlines
MCDF Malaysia Civil Defence Force
MCO Movement Control Order
MERCY Malaysian Medical Relief Society
MIMMS Major Incident Medical Management and Support
MITI Ministry of International Trade and Industry
MiVIS The Richter Scale and The Moment Magnitude Scale
MKN Majlis Keselamatan Negara
MKN Arahan 20 National Security Council Directive No.20
MNSC Malaysia National Security Council
MOF Ministry of Finance Malaysia
MOH Ministry of Health Malaysia
MSMA Urban Stormwater Management Manual for Malaysia
MyCARE Humanitarian Care Malaysia
NADMA National Disaster Management Agency
NBAAI National Bureau of Air Accident Investigation
NCMHPR National Committee on Mental Health and Psychosocial Response
NDLS The National Disaster Life Support
NET Nuclear Emergency Team
NGOs Non-Governmental Organisations
NIMS The National Incident Management System
NIOSH National Institutes for Occupational Safety and Health
NMHR National Committee on Mental Health Response
NREC National Radiological Emergency Centre
NSC National Security Council
NWS National Weather Service
OPs Command And Operations
PACU Post-Operative Care Unit
PCID ACT Prevention and Control of Infectious Diseases Act
PDRM Polis Diraja Malaysia
PELs Permissible Exposure Limits
xvii
 PFA Psychological First Aid
PhIS Pharmacy Information System
PKOB Pusat Kawalan Operasi Bencana
PKTK Pusat Kawalan Tempat Kejadian
PPE Personal Protective Equipment
PPM Part Per Million
PTSD Post-Traumatic Stress Disorder
PTT Paediatric Triage Tape
RA Risk Assessment
REA Radiation Emergency Area
RITN Radiation Injury Treatment Centre
RNA Reverse-Transcriptase Polymerase Chain Reaction
RSMC Regional Specialized Meteorological Centres
RT-PCR Reverse Transcription Polymerase Chain Reaction
SALT Sort/Assess/Life-saving Intervention/Treatment/Transport
SARS Severe Acute Respiratory Syndrome
SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2
SCBA Self-Contained Breathing Apparatus
SCMHPR State Committee on Mental Health and Psychosocial Response
SEIRV Susceptible, Exposed, Infectious, Removed and Vaccinated
SitRep Situation Report
SMART Special Malaysia Disaster Assistance Rescue Team
SMO Senior Medical Officer
SOP Standard Operation Procedure
START Simple Triage and Rapid Treatment
TCWC Tropical Cyclone Warning Centre
TDS Time Distance Shield
UNDRR United Nations Office for Disaster Risk Reduction
WBC White Blood Count
WBGT Wet Bulb Globe Thermometer
WHO World Health Organization
WMA World Medical Association

xviii
 EDITORIAL BOARD

ADVISORS
• Dato’ Sri Mohd Shafiq Bin Abdullah
• Datuk Harjeet Singh
• Tan Sri Dato’ Seri Dr Noor Hisham Bin Abdullah
• Datuk Dr Chong Chee Kheong

CHIEF EDITOR
• Datuk Dr Mohamed Alwi Bin Haji Abdul Rahman

AUTHORS
• Dr Fatahul Laham Bin Mohamed • Dr Pak Jun Wee
• Dr Muhammad Haniff Bin Abdullah • Dr Shah Jahan Bin Mohd Yussof
• Dr Mohd Afiq Bin Mohd Nor • Dr Engku Ariff Bin Tuan Lonik
• Dr Thayaharan A/L Subramaniam • Dr Jonathan Yeap Han Hsiung
• Dr Nor Khatijah Binti Ahmad • Khutrun Nada Binti Zulkifli
• Dr Hazlina Binti Mohamad Noh • Azero Bin Azami
• Dr Nabil Muhammad Bin Al-Kuddoos • Che Mohd Khairul Fahmi Bin Che Ismail
• Dr Harris Bin Kassim • Nor Hayati Binti Abdul Hamid
• Dr Gurjeet Singh A/L Harvendhar Singh • Ruzlina Binti Abdul Rasit
• Dr Ian Tey Zhe Yuan

REVIEWERS
• Dato’ Dr Muhd Fikri bin Ujang
• Datin Dr Nazrila Hairizan binti Nasir
• Dr B. Venugopalan
• Dr Asiah binti Ayob
• Dr Arinah Wan Deh Sze

PUBLICATION COMMITTEE
• Rusli Bin Harun
• Emillia Rosnizar Binti Ahmad Hanipiah
• Shainth Subramaniam
• Mohamad Azim Bin Abdullah
• Noraiyu Binti Hashim
• Anis Romiza Binti Sulaiman
• James Anak Mathew Lidi

xix
CHAPTER
1
INTRODUCTION
TO DISASTER
 CHAPTER 1
INTRODUCTION TO DISASTER

Chapter Objectives

1. To understand the definition of disaster and categorisation of disaster

2. To recognize the level of disasters in accordance with the National Security

Council directives

3. To comprehend the concept of disaster management using the all-hazard

approach and its paradigm

4. To understand the concept of healthcare consideration of disaster management

planning and response

1.1 Background

Over the last few decades, the frequency and severity of disaster incidents have
increased across the world. The severity of a disaster event determines the demand
and sophistication of the disaster response needed to mitigate it. A big part of disaster
management is concerned with locating, coordinating, and allocating available resources
in order to mitigate the effects of a disaster.

To ensure the success of the relief operation, various agencies and organisations must
work together and follow a shared protocol. The Malaysian National Security Council
(Majlis Keselamatan Negara - MKN) is a federal agency under the Prime Minister’s
Department that is in charge of managing and coordinating the implementation of security
policies, including disaster management policy in the country.

The MKN has issued several directives to outline disaster response mechanisms and
identify the roles and responsibilities of various government and non-government
agencies during a disaster. Relief operations can be carried out in an organized, structured
way, eliminating resource waste, uncertainty, and conflicts of interest, thanks to these
directives. Three major directives that are relevant to disaster and crisis management
are:
1. NSC Directive No. 18: Crisis and Violence Management, Revised July 2002 (MKN
Arahan 18)
2. NSC Directive No. 20: National Disaster Management: Policy and Mechanism of
National Disaster Management and Relief, Revised March 2012 (MKN Arahan 20)
3. NSC Directive No. 21: Public Order and Threat Situation Management, 2003 (MKN
Arahan 21)

2 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 1.2 Definition

United Nations Office for Disaster Risk Reduction (UNDRR) defined disaster as a serious
disruption of the functioning of a community or a society at any scale due to hazardous
events interacting with conditions of exposure, vulnerability and capacity, leading to one
or more of the following aspects: human, material, economic and environmental losses
and impacts. The National Disaster Life Support (NDLS) defined disaster as

an event and its consequences that result in a serious disruption of the

functioning of a community and cause widespread human, material, economic
or environmental losses that exceed the capacity of the affected area to respond
without external assistance, to save lives, preserve property and maintain the
stability and integrity of the affected area.

Locally, according to the Arahan 20, a disaster is defined as “an incident which occurs
suddenly and complex in its nature, and that causes losses of lives, damages to property
or natural environment and brings deep effect to local activities.”

To simplify, an event is considered a disaster when the effects of the disaster outweigh
the resources available to restore the environment to its previous state.

1.3 Classification

In general, disasters can be divided into two broad classifications – natural and man-
made disaster – which then can be subdivided into major or minor disaster based on
its magnitude and impact (Table 1.1).
1. Natural disasters include floods, extreme heat, wildfires.
2. Man-made disasters include stampedes, fires, transport accidents, industrial
accidents, oil spills, terrorist attacks, nuclear explosions/nuclear radiation. War
and deliberate attacks may also be put in this category.

Table 1.1 The features of major and minor disaster

Major Disaster Minor Disaster

•• Involves or potentially involves a large area •• Limited to smaller area

•• Services around the area are affected •• Does not affect services around the
disaster area
•• Local facility unable to cope
•• Local facility able to cope
•• Require assistance from other health
facilities and other local, state or national •• Does not require assistance from
agencies other health facilities or agencies

3
Arahan 20 classifies disasters into three levels based on the magnitude and its impact on
security and services (Table 1.2).

Table 1.2 Levels of disaster based on MKN classification

Level 1 Level 2 Level 3

Localised affected area Has potential to spread to

Has spread to surrounding
and not likely to spread to surrounding area with risk
areas
other areas of threat

Occurs at district level Occurs at state level Occurs at national level

Non-complex event Complex event Highly complicated

Severe loss of lives and

Minimal loss of lives and Severe loss of lives and
property which are unable
property property
to be restored

Does not disrupt the daily Disrupts the daily activities Disrupts the daily activities
activities of population in of population in the of population in the affected
the affected area affected area area

The Ministry of Health Malaysia (MOH) however, classified disaster into four classes,
based on the nature of the events as well as the different approach in managing them:

1. Disease outbreak: The occurrence of cases of disease in excess of what would

normally be expected in a defined community, geographical area or season.
Outbreaks are maintained by infectious agents that spread directly from person to
person from exposure to an animal reservoir or other environmental source, or via
an insect or animal vector.
2. Mass casualty incident: Any incident involving a large number of victims and
death, leading to disruption or impairment of the healthcare delivery in the affected
area or to the affected victims.
3. Natural disaster: Any incident that occurs as a result of a single or combination
of natural events, such as flood, earthquake etc., and resulting in disruption in the
daily activities of the affected community, loss of life, disruption of infrastructure
and environment.
4. Chemical, biological, radiological, nuclear and explosives (CBRNE): Any
event that happened as a result of any one or a combination of the chemical,
biological, radiological, nuclear and/or explosive agent/device that may harm
people and environment.

4 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 COMMON PROBLEMS
IN DISASTER MANAGEMENT

POOR PUBLIC POOR RISK WARNING SLOW SEARCH &

COOPERATION FOR COMMUNICATION RESCUE AND
EVACUATION SYSTEM DISTRIBUTION OF AID

WEAK WEAK INFORMATION POOR COORDINATION &

MANAGEMENT OF ABOUT DISASTER CONFLICT AMONG OFFICIAL
DISASTER RELIEF VICTIMS (LOCATION) DISASTER MANAGEMENT AGENCY
CENTERS (JURISDICTIONAL PROBLEM)

WEAK INFORMATION ON POOR MANAGEMENT OF PUBLIC DISORDER,

GROUND SITUATION DELAY EMERGENT GROUPS LOOTING AND
OTHER RESPONSE (VOLUNTEERS) OR NOT ENOUGH CRIMES
OPERATIONS NUMBER OF VOLUNTEERS

Mohd Shafiq bin Abdullah, ‘Enhancing Natural Disaster Preparedness and Emergency Response 5
Management in Malaysia through a Social Capital and Shared Governance, Meiji University, Japan, 2008.
WHOLE-OF-GOVERNMENT APPROACH

The Whole-of-Government approach refers to the

collaborative and coordinated join strategies and
activities performed by multiple ministries and
government agencies or organisations to provide a
common solution to problems such as disaster.

WHOLE-OF-SOCIETY APPROACH

A Whole-of-Society approach requires the government to engage all stakeholders including

the civil society, communities, academia, media, private sector, NGOs, other voluntary
associations, families, and individuals to strengthen the resilience of communities and society
as a whole in facing a disaster.

It is about building mutual partnerships and networking in which the key to this is trust. This
approach will build strong confidence among the citizens that will ultimately help them not to
be scared, rather, help each other to come out from a disaster and adhere to the advice and
instructions given by the Government.

WHOLE-OF-SOCIETY APPROACH:
SOCIAL CAPITAL IN DISASTER MANAGEMENT

The role of social capital in disaster

management is harnessing the trust
& social relationship of the society
for efficient collective action during
disaster events.

Social relations will enhance social

norms such as goodwill, sympathy
and tolerance and improve
coordination among disaster
victims and disaster response
management organisation.

As such there will be more helping

hands to assist potential disaster
victims at every phase of disaster
management.

6 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

ENHANCING DISASTER MANAGEMENT
BY STRENGTHENING SOCIAL CAPITAL
Undertake public awareness campaign for Disaster Risk Reduction for
effective preparedness, cooperation and cohesiveness of disaster
management.
• Formal education
• Outreach programs

Integrate Disaster Risk Reduction concept and planning with and by

communities.
• NGOs, citizen associations, village communities

Prepared Disaster Hazard Maps, Community Disaster Preparedness Index

with partnership from various stakeholders.
• Accurate information about vulnerable groups & practical strategies

Multi-stakeholder partnership.
Structural changes for more shared governance and responsibility.
• Guidelines, motivation & inclusion strategy

Enhance disaster management preparedness and emergency response

coordination mechanism.
• Human resource training & skill
• ICT

THE IMPACT OF SOCIAL CAPITAL

IN DISASTER MANAGEMENT
SOCIAL CAPITAL WILL HELP TO IMPROVE:
Social ties within social units and organisations for effective
disaster preparedness and emergency response.

Formal institutional capacity for effective Disaster Risk

Reduction policy formulation and implementation.

Solidarity working relationship among organisation and

leadership in disaster network organisation.

Social ties and develop strong synergies between formal

governmental institutions, private and civil society organisations
to share responsibility & strategies for effective risk reduction.

Mohd Shafiq bin Abdullah, ‘Enhancing Natural Disaster Preparedness and Emergency Response
7
Management in Malaysia through a Social Capital and Shared Governance, Meiji University, Japan, 2008.
 1.4 Disaster Management Approach

Majority of disasters are small in size, occur in short duration and can be managed at the
local level. Sometimes, regional or national resources are needed to ensure a smooth,
proper and timely management of certain disasters. However, when the public health
infrastructure and system are disrupted as a result of a localised disaster, it can result in
a public health emergency.

Public health emergencies are defined as events that have a negative impact on the
public health system and/or its protective infrastructures (such as water, sanitation,
shelter, food, fuel and health), resulting in both direct and indirect implications to the
health of a population.

Direct consequences include the immediate injuries, illnesses and deaths that are
attributed directly to exposure to the hazard.

Indirect consequences are measured as the additional injuries, illnesses and deaths that
are caused by a lack of access to medical care. Deaths caused by indirect consequences
are often preventable and can outnumber deaths caused by direct consequences.

1.4.1 All-Hazards Approach

Dealing with disasters and public health emergencies requires an all-hazards approach
to better coordinate planning and response effort. All-hazards disaster management
approach can be represented as follows:

1. All-hazards preparedness refers to considering all potential hazards to a community

and taking steps to mitigate and prepare for any potential hazard that may affect
the community.
2. Identification of actions that can be initiated immediately when an incident has
occurred allows the operational response to begin (situational awareness). Timely
and accurate recognition of disaster is essential for an integrated response.
3. Simultaneous responses to disaster are the recovery process of the public health.
Physical, economic and community recovery may take longer duration, which can
stretch from months to years after the disaster occurs.

The NDLS highlights several fundamental components within the four phases of disaster
management, which can be divided into two paradigms – pre-disaster and disaster
paradigms.

8 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

[Link] Pre-Disaster Paradigm

Planning and Practice

P
● Preparedness of possible disaster must include planning and practice of the
planned programs.
● An effective planning requires integrated collaboration from the entire disaster
response system to include emergency management and public safety
agencies, local public health agencies, hospitals, local clinics, both private
and public emergency medical services (EMS), businesses and
non-governmental organisations (NGOs).
● Planning must include back up or contingency plans to address lack of
resources to ensure continuousness of operations.

Resilience
● Being prepared can reduce fear, anxiety and losses associated with a

R
disaster and build resilience within the community.
● Resilience is defined as “ability for individuals and communities to rebound to
a reasonable state of normalcy after exposure to disaster, serious
emergencies and other traumatic, tragic and stressful events”.
● A well-prepared community can be fostered through educating the population
about local disaster planning and response efforts and assisting residents
with development of personal and family preparedness plans.
● Communities need to be able to survive on their own at least 72 hours after a
disaster occurs before outside help arrives. Therefore, building resilience is a
key element in managing disaster.

Education and Training

E
● Effective education programs minimize the impact of disaster and build
resilience in a community.
● As the nature of disasters is complex, it may not be possible to create a
training module to cater for each disaster with specific scenarios possibilities.
● Developing extensive curricula for training disaster response health system
responders and emergencies in public health is a challenge. The subject
areas that all prospective health system responders need to learn must be
applicable to the roles they will play in a disaster.

9
 [Link] Disaster Paradigm

D
Detection
● Initial step for an effective disaster response is identification of the event to be
a disaster or mass casualty incident.
● Assess whether the need to respond overwhelms the resources available.
● It is also important to evaluate possible threats or presence of hazardous
material at the disaster site before the response process starts.

Incident Management
● Effective incident management requires the three Cs – Command,

I
Coordination and Communication.
● Communication is the key element in incident management and for an
effective chain of communication, responders need to be familiar with the
incident command system (ICS) and the respective roles within the ICS.
● Common communication systems such as landlines or mobile phones may
be affected during a disaster, making them impractical as means of
communication.
● Therefore, the principles of incident command systems with specific roles
including operations, logistics, planning and finances serve as building blocks
for a functional incident management system in response to disaster.
Information on ICS will be covered in the latter chapter.

Safety and Security

S
● Responders’ safety remains paramount in any disaster response activity and
responders should always put their safety first before anything else.
● In an event where the precise cause of the incident is unknown or if there is
suspicion of unusual threats, responders must always take the necessary
precaution and avoid putting themselves at risk. In the case of a disaster area
where it may be too dangerous for responders to enter, the evacuation and
medical response to casualties becomes secondary.
● Responders should be part of the solution, not increase the demand of
disaster response.

A
Assess Hazards
● Emergency responders must remain vigilant for additional or unknown
hazards and take appropriate precautions to protect themselves and others.
● Hazards such as structural collapse, fire, broken gas pipe, ruptured power
lines as well as potential toxic chemical, radiation and respiratory hazards
poses risk to responders and others.
● Late detection of these hazards may cause further harm, destruction and
increase fatalities including for response teams.

S
Support
● Support refers to what is needed to get the job done.
● Disaster response activity may need coordination of resources and assets
from various public and private agencies and organisations.
● This includes acquisition and deployment of essential personnel, supplies,
facilities, vehicles and other resources in preparation for surge; which is an
influx of mass casualties exceeding daily abilities for care.

10 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Triage and Treatment
● In a serious disaster, the goal of triage is to do the greatest good for the
greatest number of possible survivors.
● The general aim of an effective triage is to sieve casualties for most

T
critically injured or ill people and prioritizing them for transport from site to
receiving facilities for more definitive medical or surgical care.
● The objectives of triage and treatment are:
● to remove those uninjured and ambulating casualties away from the
scene to provide focused care on those who are severely injured.
● to sort and identify casualties with life-threatening injuries and initiate
emergency treatment immediately.
● Casualties with non-life-threatening injuries will be assessed further and
triaged for removal from scene based on the severity of injuries as well as
available resources.
● Treatment at site will resume until all casualties have been transported to
hospital or other treatment facilities or till resources have been exhausted.
Evacuation

E
● Effective community preparedness requires planning for individual and
community evacuation needs – the target population, their concerns and
safe area for relocation during evacuation.
● Evacuation plans must account for complex scenarios, such as evacuation
of schools, high-rises, hospitals, nursing homes and rehabilitation centers.
● The evacuation plan such as number of evacuates, mode of transport and
the speed of evacuation may vary with the situation.
● Evacuation begins and ends with a self-determined evacuation plan and
operational assessment.

Recovery
● Recovery is the longest phase of any disaster and may take from months
to years.
● Multiple agencies, businesses and organisations work together in providing

R
physical, economy and community recovery during this period.
● The goal of recovery is to “ensure the economic sustainability of a
community and the long term physical and mental well-being of its citizens,
to rebuild and repair the physical infrastructure and to implement mitigation
activities to reduce the effect of future disasters.
● Recovery efforts seek to restore normalcy as soon as possible and the
outcome reflects the resiliency of the community.
● Hazards such as structural collapse, fire, broken gas pipe, ruptured power
lines as well as potential toxic chemical, radiation and respiratory hazards
poses risk to responders and others.
● Late detection of these hazards may cause further harm, destruction and
increase fatalities including for response teams.

11
 1.4.2 Disaster Management Planning at Healthcare Facilities

The goal of disaster planning is to achieve a satisfactory level of preparedness to

respond to any disaster situation by strengthening government, organisation, and
community technical and managerial capabilities. Thus, awareness of possible hazards
and adequate countermeasures are essential to ensure effective preparedness. It also
requires coordinated cooperation from the entire disaster response system, which
includes emergency management and public safety agencies, local public health
agencies, hospitals and emergency medical services, businesses and non-government
organisations or community groups.

Preparedness plan must include contingency plans to address shortage of resources.

Disaster plans or Emergency Operations Plans (EOPs) vary among jurisdictions
depending on their local hazards, laws and resources. To ensure sufficient disaster
management capabilities and capacity, communities must eventually take responsibility
for coordinating and mobilizing emergency and health-care services.

[Link] Hazard Vulnerability Analysis

Disaster Risk Assessment (DRA) is a process to determine the nature and extent of
such risk, by analysing hazards and evaluating existing conditions of vulnerability that
could together potentially harm exposed people, property, services, livelihoods and
the environment on which they depend. In this way, informed decisions can be made
regarding steps to reduce the impacts of disasters.

A comprehensive risk assessment not only evaluates the magnitude and likelihood of
potential losses in case of a disaster but also provides full understanding of the causes
and impact of those losses. DRA is an integral part of the decision-making process.
It needs to engage multi-stakeholders from various disciplines and requires close
cooperation and collaboration of different organisations and institutions of the target
area. Risk Assessment (RA) consists of the following steps:

1. Hazard assessment
In this section, the goal is to identify the types of hazards that have occurred in
the area in the past or can occur in the future. This is usually the first step which
then defines future steps because for each hazard, different tools and techniques
are used for analysis and assessment. Earthquakes, for example, require different
instruments and specialisations for analysis than landslides or floods. The next step
is to determine the frequency, seasonality, magnitude, intensity, extent of hazards,
as well as their causes.

12 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

2. Vulnerability assessment
This step is performed to determine the elements at risk, its causes and degree of
vulnerability. All elements (people, building, resources etc.) that are vulnerable to the
hazard are identified, and an inventory is created. The degree of their vulnerability
is analyzed and causes of their vulnerability are determined.

Critical facility analysis is also performed by determining the critical facilities (that
plays major role in daily routine life e.g., schools, hospitals, mosques, civic center’s
etc.) at risk, causes of their vulnerabilities and analysing historical records of hazard
occurrence in the identified facilities.

3. Capacity assessment
The term "capacity assessment" refers to the process of identifying strengths and
resources that can be used to minimize risk or the impact of a disaster. In this
step, the resources of the community are evaluated by analysing the available
strengths like skills, expertise, equipment, infrastructure etc. The availability of these
resources is then evaluated to know how soon these resources can be deployed
and become available to use. Another crucial step is to determine how durable and
long-lasting these resources are, as well as the degree of organisational integrity
they possess (ability to complete tasks without supervision).

4. People's perception of risk

The process of finding out the perceptions of heterogeneous groups in the
community regarding the disasters, hazards and risks that they are facing.

A useful Hazard and Vulnerability Analysis Assessment (HVA) tool has been
developed by Kaiser Permanente and available as planning tools. A screenshot of
Kaiser Permanente tool in Figure 1.1.

The HVA tool from Kaiser Permanente evaluates potential for event and response
among the following categories using the hazard specific scale. The analysis is
divided into four major events:
i. Natural hazards
ii. Technological hazards
iii. Human hazards
iv. Hazardous material

13
 HAZARD AND VULNERABILITY ASSESSMENT TOOL NATURALLY OCCURRING EVENTS

14
SEVERITY = (MAGNITUDE - MITIGATION)
PROBABILITY HUMAN PROPERTY BUSINESS PREPARED- INTERNAL EXTERNAL RISK
EVENT IMPACT IMPACT IMPACT NESS RESPONSE RESPONSE
Time, Community/
Likelihood this Possibility of Physical losses Interruption of
Pre-planning effectiveness, Mutual Aid staff Relative threat*
will occur death or injury and damages services
resources and supplies

0 = N/A 0 = N/A 0 = N/A 0 = N/A 0 = N/A 0 = N/A 0 = N/A

1 = Low 1 = Low 1 = Low 1 = Low 1 = High 1 = High 1 = High
SCORE 0%-100%
2 = Moderate 2 = Moderate 2 = Moderate 2 = Moderate 2 = Moderate 2 = Moderate 2 = Moderate
3 = High 3 = High 3 = High 3 = High 3 = Low or none 3 = Low or none 3 = Low or none

Typhoon 0%
Tornado 0%
Severe
0%
Thunderstorm
Landslide 0%
Earthquake 0%
Tsunami 0%
Extreme Heat 0%

AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Drought 0%
Flood 0%
Wild Fire 0%
Volcano 0%
Epidemic 0%

AVERAGE SCORE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0%

*Threat increases with percentage.

RISK = PROBABILITY * SEVERITY SCAN

0.00 0.00 0.00 THIS QR CODE
to download
The Hazard and Vulnerability
Figure 1.1 The Kaiser Permanente tool Analysis Assessment (HVA)
Key components of healthcare-related disaster management, risk assessment and
planning are summarized in Table 1.3.
Key component of healthcare related disaster management, risk assessment and
planning are summarized
Table in
1.3the followingoftable:
Summary the key components

Components Considerations

i. Risk Analysis ● Assessment of hazards that may be encountered and

recognition of possibilities in specified scenarios.
● Complicated by the high degree of uncertainty both in
occurrence and consequences of disaster
● Four components of risk analysis:

Risk perception Understanding how different people

perceive and measure risk

Vulnerability Identifying particular infrastructures and

assessment populations at increased risk for
damage and harm

Hazard analysis Assessment of various hazards for a

particular geographic area and its
magnitude of impact given local
resources, to allow for prioritisation of
response and mitigation options

Capacity Identifying available resources to

assessment reduce risk, enhance survival and
assist affected populations to cope with
severe trauma

● Hazard = Anything that has potential to do harm to

property, the environment, people or animals.
● Risk = Probability of the potential hazard actually
occurring.

HVA is a disaster needs assessment for an

organisation or community. It focuses on types of
emergencies most relevant to the community or facility,
its geographic location and the needs of the
populations around.

15
 Components Considerations

ii. Population ● Disaster events often have a disproportionate impact

Vulnerability on the most vulnerable members of society i.e. the
Assessment elderly, children, pregnant women, physical and
mentally disabled, those with chronic diseases and
minority populations.
● They are already dependent on their normal daily
routine and at risk of greater barriers in terms of
access to medical care during emergency events.
● Limitation in medical supplies, equipment and
medications may pose serious challenges for those
with chronic diseases.
● People with access and functional needs must be
identified in disaster planning and have valid
emergency care plans in place.
● Children in particular may not develop coping
strategies in dealing with traumatic experiences during
disaster events.

iii. Health System Surge Capacity vs Surge Capability

Surge Planning
● Surge capacity is the ability of a health system to
rapidly expand beyond normal services to meet the
increased demand for care of patients. Includes
physical space/hospital beds, qualified personnel,
medical care and public health services.
● Surge capability combines capacity with what can be
done for the casualties. It is measured in terms of the
numbers of staff and resources truly available to
provide the services. It includes not only disaster
affected population, but also those with regular
emergencies unrelated to disaster.
● The goal of health system surge planning is to keep
the health system functioning to deliver the
highest-level care as possible to save as many lives as
possible.
● Effective health system preparedness and response
requires strategies that focus on reducing the demand
for care and the need to augment inpatient and
ambulatory care capacities and capabilities.

16 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Components Considerations

● Four key components necessary in surge-based

planning:
1. Increasing healthcare facility capacity
2. Planning for supporting acute care/sites/alternate
care facilities
3. Developing electronic registries of volunteer
healthcare providers
4. Planning for altered care delivery (crisis standard of
care)

iv. Legal and ● Emergency management and public health leaders

Ethical Planning need a clearly defined set of legal and ethical
principles to help them make sound, real-time
decisions for managing situation and allocating
potentially scarce resources during a crisis
● These principles need to have an all-hazards
approach where it can be adaptable in any type of
emergency.
● A sound ethical and legal framework is essential to
assess and justify public health actions and
intervention, fundamentally moral in nature.
Such policies are needed to maintain public
confidence and trust. Lack of public trust ultimately
hinders compliance or cooperation necessary for an
effective response to a disaster situation.

v. Exercises and ● Ongoing testing of plans, policies and procedures

Drills during exercises and drills is an important part of
disaster preparedness.
● Disaster exercises should be designed to test incident
command and control, communications, logistics,
laboratory coordination and clinical capabilities.
● Exercises and drills are conducted to reflect actual
conditions that would likely be encountered with the
resources and personnel that would be available.
All exercises should be followed by a detailed
evaluation and action plan for improvement.
● Hospitals are to conduct a hazard vulnerability
analysis, develop an emergency management plan
and evaluate this plan regularly.

17
 1.4.3 Disaster Management Response in Healthcare Facilities

The aim of disaster response is to provide immediate assistance to protect lives, preserve
health and support the morale of affected populations. The implementation of disaster
plans will immediately swing into action in the response phase once a disaster happens.
Community response plans are implemented through local incident management
structure and may be scaled according to the disaster situation.

Disaster response and recovery involves both public and private sector agencies. This
collective effort needs to be coordinated at all levels, therefore requiring experienced
leaders, trained personnel, transport and logistic support, appropriate communications
and standard operating procedures applicable in disaster situations. Key components of
healthcare-related disaster management response is summarized in Table 1.4.

Table 1.4 Key components of healthcare related disaster management response

Components Considerations

1. Situational •• Situational awareness is the capability to maintain a

Awareness constant vigil over important information, analyze the various
and Detection information and utilize it in making critical decisions.
•• It required the ability to objectively quantify the magnitude of
a disaster event and resources consumed through multiple
mechanisms in obtaining information.
•• The decision may essentially have potential effects on
personal safety, security, triage and therapeutic interventions
as well as safety of the casualties.
•• Key initial step in mobilizing an emergency response to an
affected population is to obtain information about the extent
of the population's immediate needs and status of supporting
health infrastructure.
•• Situational awareness in the early period following a disaster
often lacks accuracy and verification of information is difficult.
•• Detection is the initial recognition that a threatening situation is
imminent.
•• Key to detection of a disaster is ongoing vigilance and
situational awareness of abnormal changes in the environment
or identifying something outside the norm.
•• Early detection and reporting are critical to minimize casualties
through teamwork by public and private health and emergency
response personnel.

18 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

2. Hazard •• In any emergency response environment, it is essential to
Assessment understand that there are multiple hazards present.
•• All disasters, regardless of the primary cause, create the
possibility of secondary hazards capable of injuring anyone
at scene including responders.
•• Approach to any scene should include an evaluation of the
presence of hazardous materials in particular. Actual and
potential hazards related to a disaster must be assessed
continually.
•• Emergency responders must take appropriate precautions
to protect themselves and others. Failure to do so may
further harm and endanger multiple lives.
•• The all-hazards approach to disaster casualty management
requires awareness of the possibility of such dangers and
continuous assessment at the scene to detect and protect
against recognized and perceived threats.

3. Incident •• Establishment of an incident command post must be at a

Management substantial distance from the disaster scene.
•• Protective actions should be implemented to reduce or
eliminate exposure of the public to actual and potential
hazardous situations.
•• Principal protective action decisions are whether to shelter
in place, evacuate or relocate affected or potentially affected
populations.
•• Secondary actions include administration of medical
countermeasures and decontamination.
•• Incident command typically involves a single agency as
primary responder.
•• Large-scale disaster or public health emergencies will
require an area command structure, involving multiple
jurisdictions and agencies to determine responsibilities and
coordinate the allocation of resources.
•• Incident commander (IC) is a single designated supervisor
at the disaster scene responsible for overall management of
the situation.

19
 3. Incident •• Other key command staffs include the following officers:
Management
(Cont.) Public Provides IC with advice on the media and
Information dissemination of information. Ensure clear
Officer and unified message provided to the public

Provides IC with advice on incident safety

Safety
and ensures that operations conform to all
Officer
applicable safety rules and regulations

Liaison Contact point with all the agencies involved

Officer in supporting response operations

•• ICS applies to hospitals and other healthcare facilities. Duties

are assigned by position and include a clear chain of authority
and command.

Emergency Operation Center (EOC)

•• EOC is a location for coordination of information and resources
to support incident activities.
•• It is a central command and control location responsible or
carrying out principles of emergency management.
•• A physical location where leaders and key staff come together
to analyze response and recovery options, coordinate actions
and allocate resources.
•• Ideally not located within or adjacent to the disaster scene
but rather at a safe distance to enable management of the
situation free of chaos and confusion.
•• There may be levels of EOCs at local, regional or state levels,
each with a coordinating function for ensuring the continuity of
the chain of command.

Disaster Communications
•• A carefully prepared plan is important to protect vital
communication links among emergency responders and
ensure information interchange can continue. Therefore, all
agencies involved in responding to disaster must cooperate in
advance to identify those methods of communication.

20 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 •• All agencies must be able to communicate effectively with one
another, multidirectional, in real time and using a common
language before, during and after the event.
•• Crisis and emergency risk communication is a vital
component of any disaster communication strategy.
•• During emergencies, the public may receive information from
various unverified sources.
•• Effective communication of clear, concise and credible
information will assure the public that the situation is under
control.

Logistical Support Devices

•• A disaster situation requires the coordination of resources and
assets from various public and private sector agencies and
organisations.
•• Response time, type and amount of support can fluctuate
significantly in a disaster setting.
•• An effective disaster management centers on timely delivery
of resources to where they are needed the most.
•• Disaster support contains a spectrum of resources, from local
volunteers to large national organisations.
•• Disaster response and support begins at local government
level, then step up to state and eventually federal assistance
once resources are depleted at respective levels.

Disaster Forensics
•• If a disaster occurred as a result of criminal activities i.e
terrorism, additional role of responders is to protect evidence.
•• Rescue and resuscitation of casualties still takes highest
priority. But be mindful of the need to protect possible sources
of evidence and not disrupt crime scenes unnecessarily.
•• Local laws, rules and regulations govern many activities of the
investigation and forensic process.
•• It is important for all personnel working at disaster sites to be
aware and comply with such rules.
•• When there is conflict between preservation of evidence and
human lives, priority is always to the emergency medical care.

21
 4. Healthcare •• Disaster can impact healthcare facilities in two ways:
Facility
1. Overwhelmed by the numbers of casualties encountered
Surge
Management 2. Becoming targets of acts of terrorism or impacted by
natural disasters.
•• Disasters can reduce the capabilities of local healthcare
facilities by creating substantial additional demand for medical,
surgical and rehabilitation services.
•• Treatments are required for injuries resulting directly from
disaster, acute medical conditions unrelated to disaster as well
as chronic conditions that can be exacerbated during stressful
times.
•• Provision of medical care in a non-hospital environment may be
required if there is no capacity left in the hospital.

Space, Staffs and Supplies

•• It is important to recognize the inequality of resource supply and
demand as early as possible.
•• It is also essential to pre-emptively anticipate the likely areas in
which shortages will be encountered.
•• A framework for standards of care for any healthcare facilities
should always include consideration of crisis standards of care.
•• All the operational steps must be clearly identified and
understood by all appropriate personnel.
•• Surge capacity framework has been proposed to meet the
challenges of dealing with a significant influx of casualties from
disaster events.
•• The goal of this framework is always to maintain or return to
conventional capacity.

22 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

4. Health Care Traditional and normal patient care
Facility Conventional
facilities and staff meet their normal goals
Surge capacity
in providing care
Management
Minor adaptations are made that may
(Cont.) Contingency have minor consequences for standard of
capacity care, but not enough to result in significant
changes to standard of care

A fundamental, systematic change takes

Crisis
place into a system in which standard of
capacity
care are significantly altered

Surge-Based Healthcare Facilities

•• Health authorities may advice the public to seek care and
reassurance in alternate settings so that hospitals and
emergency care facilities can focus their resources on those
needing the most.
•• Alternate care environment (ACE) and alternate care facility
(ACF) helped to decompress traditional hospital settings by
treating those individuals who are less than critically ill or
injured.
•• ACEs can be established as mobile and temporary
units designed to admit, sort and temporarily hospitalize
casualties until they can be safely transported.
•• ACFs can be established in nursing homes, community
health centers, schools, churches, malls and other
locations that have adequate sanitary and support
capabilities.
This framework is most effective when they are identified and
planned for in advance to ensure the capability and resources
to provide adequate care.

23
 5. Recovery •• Final and usually the longest phase of disaster management
and Beyond •• Recovery begins from the moment a disaster occurs.

Continuity of Operations in Healthcare Facilities

•• Refers to how quickly the healthcare facility can get back to
business after a disaster.
•• Two important components must be considered and planned
adequately:
1. The infrastructure – must resume normal healthcare
operations and restore business continuity.
2. The people – sustainment of community medical care
may require assistance from outside the community,
coordinated through public health authorities.
•• Federal assets are best considered under recovery as local
and regional vendors may be negatively affected in supplying
resources to healthcare facilities.

After-Action Review (AAR)

•• Key element of disaster recovery is critical analysis and
review of the actual response.
•• It should be completed as soon as disaster response
operations transition into recovery operations to sustain
individuals and recollections of event.
•• It should include all stakeholders involved in the disaster
response.
•• Review of strength and weaknesses of the response must
be done and incorporated into future response planning and
operations.

Preparation and Planning for Future Events

•• AAR provides the basis for amending the response plan and
developing exercises to test the recommendation made in
the report.
•• New or revised policies, plans and procedures should be
considered and reviewed frequently.

24 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

5. Recovery Building Community Readiness and Resilience for Future
and Beyond Events
(Cont.) •• Communities build resilience by implementing policies
and practices, gaining knowledge and creating a culture of
preparedness or “bystander response”.
•• Resilient communities are ready to prevent, cope with,
and mitigate the initial stress with limited external support,
undertake recovery activities and use knowledge gained
from incidence to strengthen the ability of the community to
withstand future events.
•• The six key components of community resilience include:
1. Physical and psychosocial health of the population
2. Social well-being and connectedness of community
members
3. Level of social integration of government and non-
governmental organisations (NGOs) in planning,
response and recovery
4. Individuals’ attitudes of self-reliance and self-help
5. Effective risk communication
6. Economic stability

25
 1.5 Summary

Pre-disaster and disaster paradigm are two fundamental components in any disaster
preparedness and response. Disaster response and recovery involves public and private
sector agencies, and these agencies need to respond in a coordinated manner to ensure
a smooth response to any disaster.

Bibliography

Kaiser Permanente: Medical Center Hazard and Vulnerability Analysis. Emergency

Preparedness: Preparing Hospital for Disasters. 2017
<[Link]

Mohd Shafiq bin Abdullah, "Enhancing Natural Disaster Preparedness and Emergency
Response Management in Malaysia through a Social Capital and Shared Governance
Perspective Lessons from the Kobe Earthquake, Hurricane Katrina and the Johor Floods
Master's thesis Meiji University, Japan, 2008.

National Disaster Life Support, Advanced Disaster Life Support Course Manual 3.1, 2012

National Security Council Directive No. 20 Policy and Mechanism of National Disaster
Management. March 2012

Pelan Pengurusan Bencana Peringkat Kementerian Kesihatan Malaysia, Mac 2015

Pelan Tindakan Insiden Kecemasan dan Bencana Dalaman Bagi Hospital-Hospital KKM,
2017

World Health Organizations, Disease Outbreaks, 2022. [Link]

topics/disease-outbreaks/[Link]

26 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 CHAPTER
2
INCIDENT
COMMAND SYSTEM
 CHAPTER 2
INCIDENT COMMAND SYSTEM

Case Scenario

A bus full of passengers just got involved in an accident in Genting Highlands. Multiple
casualties involved. The 999 call was triggered by the public. First on scene was the
ambulance service from a nearby hospital. Subsequently, the police and fire services
were also involved.

1. Which government body would take the lead in this disaster situation?

2. What is the structure of the incident command system during a disaster

incident?

Chapter Objectives

1. To understand the importance of establishing a single integrated Incident

Command System (ICS) as stated in the National Security Council Directive
No. 20 (MKN Arahan 20)

2. To understand the roles and responsibilities of each position/agency in the

incident command system in disaster management

2.1 Background

The Incident Command System (ICS) was developed after a series of wildfires caused
death, damage, and destruction in Southern California in 1970. The California Fire
Services had never faced such an immense challenge and it was clear that many serious
problems existed and needed to be addressed. Investigation conducted following the
incident found that there were:

1. Lack of a common organisation

2. Poor on-scene and inter-agency communications
3. Inadequate joint planning
4. Lack of valid and timely intelligence
5. Inadequate resource management
6. Limited prediction capability

28 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

The investigation revealed the immediate need for inter-agency standardisation in
order to improve the performance of fire service performance. This spearheaded the
development of the ICS. Subsequently the system was adopted by The National Incident
Management System (NIMS) in the United States and started to use it in an all-hazards
situation.

In Malaysia, the ICS was adopted by MKN to be used nationwide in the event of disaster.
The system becomes a standardized approach to the command, control and coordination
of emergency response that provides a common structure for multi-agencies response.
Most emergency response involves multiple agencies and the situation requires the
use of unified command or area command structures. The incident command system
provides the operational structure to address the challenges and issues that disasters
create in an efficient manner through the use of the concepts of unity of command.

2.2 Basic Structure of Incident Command System in Malaysia (MKN Directive 20)

Incident Commander (IC)

Maintains overall responsibility

for disaster response

Liaison Officer Public Information Officer

Coordinates the efforts Communicates with
of all responding agencies press and public

Safety Officer
Responsible for safety
of responders

Finance Logistic Operations Planning

Supports Command Supports Command Coordinates and Coordinates
and Operations with and Operations in executes strategy support activities
administrative their use of and tactics to for incident
issues as well as personnel, supplies achieve respons planning
processing incident and equipment objectives
expenses and
acounts

Figure 2.1 Basic structure of incident command system in Malaysia

At any disaster scene, there should be a single designated leader, referred to as the
incident commander, who is ultimately responsible for the overall management of the
situation. Other key command staffs who assist in the process include safety officer,
logistics officer, liaison officer, and public information officer (Figure 2.1).

29
 2.2.1 Roles and Responsibilities of Team Members

The roles and responsibilities of the team members are as follows:

1. Incident Commander
•• Defines incident goals and operational objectives
•• Leads the overall management process during any disaster

2. Public Information Officer

•• Acts as communication coordinators between incident commander and public/
media
•• Provides accurate and timely information to the media and public as required by
law and according to the standards of their profession

3. Safety Officer
•• Manages the safety of team members and responders

4. Liaison Officer
•• Acts as a representative to liaise with representatives from other agencies
involve in the management of disaster, to ensure good coordination between
each agency.
•• Monitors incident operations to identify current or potential inter-organisational
problems

5. Finance and Administration Section

•• Supports command and operations with administration issues as well as tracking
and processing incident expenses
•• Includes issues regarding licensure requirements, regulatory compliance and
financial accounting

6. Logistics Section
•• Supports command and operations in their use of personnel, supplies and
equipment
•• Performs technical activities required to maintain the function of operational
facilities and processes

30 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

7. Operations Section
•• Establishes strategy (approach, methodology, etc.) and specific tactics (actions)
to accomplish the goals and objectives set by the incident commander
•• Coordinates and executes strategy and tactics to achieve response objectives

8. Planning Section
•• Coordinates support activities for incident planning, as well as contingency,
long-range, and demobilisation planning
•• Supports command and operations in processing incident information
•• Coordinates information activities across the response system

9. Control and Order

The immediate establishment of the On-Scene Control Post (Pusat Kawalan
Tempat Kejadian - PKTK) and Disaster Operation Command Centre (Pusat
Kawalan Operasi Bencana - PKOB) is paramount to ensure a good command,
control, coordination and communication during a disaster.

a) On-Scene Control Post (PKTK)

Once an incident is being classified as a disaster, there is an immediate need
for joint efforts by various agencies which will be coordinated by the PKTK.
The police chief from the Royal Malaysia Police (PDRM) will be responsible for
establishing the PKTK.

The Incident Commander will be responsible to establish a reliable

communications network with PKOB for the transmission of information and
also to evaluate, manage and coordinate all search and rescue operations at
the disaster site. Incident Commander should appoint a Forward Commander,
who will be responsible to lead all search and rescue operations. The Forward
Commander will evaluate and report the situation to the Incident Commander.

In the case of a disaster caused by fire or hazardous material (HAZMAT), the

Fire and Rescue Department (JBPM) will act as the primary consulting agency
to handle the situation. However, PDRM will still hold the responsibility of
incident commander and coordinate all search and rescue efforts on site.

In the case of a nuclear or radiation incident, the Atomic Energy Licensing

Board (AELB) will act as the primary consulting agency. All agencies who have
arrived at the scene of a disaster should first report themselves to the PKTK
before commencing any activities. The roles of the agencies involved during
the disaster relief activities are shown in Figure 2.2.

31
 b) Disaster Operation Command Centre (PKOB)
PKOB should be established by the disaster management and relief committee
in accordance with the level of disaster. The PKOB should at all times have
a reliable communications network with the PKTK for effective exchange of
information to ensure immediate, coordinated and effective search and rescue
efforts. All agencies involved should have an elected representative positioned
at the PKOB as liaison officer.

2.3 Hospital Disaster Activation Plan

Every hospital should have a detailed plan for the mobilisation of resources within the
hospital to respond to any major disaster. The disaster plan provides a response policy
to both internal and external situations which may affect hospital staff, patients, visitors
and the community. It also serves as a standard operating procedure (SOP) for any
emergency activities and response. A disaster and emergency management committee
should also be formed to maintain and evaluate the effectiveness of the hospital’s internal
and external activation plans.

2.3.1 Notification and Activation

Notification of an external disaster/event may come via various sources (Emergency call
system, public, rescue agencies etc.). Upon notification of the event, the Emergency
and Trauma Department (ETD) Assistant Medical Officer (AMO) in-charge will verify the
incident and relay the information to the specialist/head of the ETD. Upon confirmation
of the incident, the Head of Department will inform the Hospital Director or designee and
the decision on whether activation of the disaster plan is required or not will be made.

32 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 ROLE OF VARIOUS AGENCIES DURING DISASTER MANAGEMENT

ON-SCENE CONTROL POST

(PKTK)
On-Scene Incident Commander

SEARCH
MEDICAL SOCIAL SUPPORT SAFETY TECHNICAL
& RESCUE MEDIA
SERVICES SERVICES SERVICES CONTROL SUPPORT
SERVICES

Special Malaysia Ministry of Health Department of Social Royal Malaysia Department of Agencies with
(KKM) Welfare Malaysia District Office Police Force Information specialities related to
Disaster Assistance
and Rescue Team (JKM) (PDRM) Malaysia the disaster
(SMART)
Malaysia Armed District Municipal
Force (ATM) Ministry of Health Council Volunteers Department Department of
Malaysia (RELA) Broadcasting Provide technical
Fire and Rescue (KKM) services and specialty
Malaysia
Department support
(JBPM) Red Crescent Tenaga Nasional
Society (BSMM) Malaysia Civil Berhad - Ensure safety of
Defence Force personnel on site - News Coverage
Royal Malaysia (APM)
Police Force Malaysia Civil - Conduct investigations - Media Control
Telekom Malaysia
(PDRM) Defence Force Berhad
(APM) Red Crescent
Society (BSMM)
Malaysia Armed Malaysia Armed
Force (ATM) - Provide emergency Force (ATM)
Treatment Volunteers Department
Malaysia (RELA)
Malaysia Civil - Provide forensic Royal Malaysia
Defence Force services Police Force
(APM) (PDRM)
- Provide public health Ministry of Tourism
services
Search and rescue of Public Works
victims - Relocation of victims Department
(JKR)
Provide food for
- responders and victims
Provide assistance in
- Provide shelter for logistics, communication
victims etc. during operations
- Provide first aid
services and
counselling

33
 2.3.2 Disaster Action Cards

An action card incorporates written information, advice and orders for members of
hospital’s staff. There are many benefits of action cards in any disaster response:
1. Simplifies the distribution of hospital staff to various areas
2. Simplifies the response of staff to a disaster event
3. Clearly outlines the specific duty of staff
4. Reduces confusion and ensure completeness of disaster management

2.4 Summary

ICS is important to ensure a good intra-agency command, control and coordination during
any disaster response. PKTK and PKOB are two cells that are very important to ensure
a good inter-agencies command, control and coordination during any disaster response.
Each hospital should have a well-written Hospital Disaster Activation Plan as a standard
operating procedure (SOP) to be used in any event of disaster or major incident.

Bibliography

National Security Council Directive No. 20. March 2012

Stambler, K. Barbera, J. Engineering the Incident Command and Multiagency Coordination

System. Journal of Homeland Security and Emergency Management. Volume 8, Issue
1, Article 43. 2011

Irwin, R. Chapter 7: The Incident Command System (ICS). Disaster Response: Principles
of Preparation and Coordination. 31 july 2007
[Link]
[Link]/section/07?opendocument

National Disaster Life Support. Basic Disaster Life Support Course Manual 3.0. 2013

National Disaster Life Support. Advanced Disaster Life Support Course Manual 3.1. 2013

Hospital Selayang External Disaster Activation Plan. July 2015

34 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

CHAPTER
3
MASS CASUALTY
MANAGEMENT
 CHAPTER 3
MASS CASUALTY MANAGEMENT

Case Scenario

A group of people comprising mostly of students started having symptoms of vomiting

and diarrhea with some complaining of shortness of breath. This occurred after inhaling
an unpleasant odor coming from a chemical spill in a nearby river.

1. How would you triage a large number of casualties?

2. What are the life-saving interventions that can be done during triage?

3. How would you treat the patients involved?

Chapter Objectives

1. To demonstrate clinical casualty evaluation and management appropriate to the

context of mass casualties in all-hazards events

2. To apply triage procedure and life-saving interventions

3. To provide definite care in a mass casualty environment

4. To understand the role of inter-agency partnership and response procedures

3.1 Background

Medical disaster is defined as provision of medical care when the situation suddenly
exceeds or overwhelms the available local resources.

Clinical management of casualties might be different than during a non-disaster setting.

During a disaster, emergency medical needs are more than local resources.

The main objective is to do the best for the most number of possible survivors.

Major Incident Management:

•• Mass casualty triage
•• Mass casualty management
•• Mass fatality management

36 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 3.2 General Principles of Mass Casualty Triage

Goal of mass casualty triage is to sort casualties in a structured and reproducible process
so that:

•• Most seriously injured with the reasonable possibility to survive will be treated first
•• The presence of life-threatening, limbs threatening or vision threatening condition
will be detected early
•• Those with least severity and those with lowest chances of survival will be treated
last
•• Those with minimal injury can be set apart from others as to direct medical resources
to the needful first

Considerations when making decision during mass casualty triaging:

•• Presence of a life-threatening, limb-threatening or vision-threatening
•• Immediately available life-saving interventions that can be delivered
•• Availability of transportation assets

Disaster triage is different than in-hospital triage based on:

•• Large number of casualties
•• Limited information
•• Insufficient infrastructure
•• Potential danger to the responder
•• Possibility of hazardous material

Triage Process

Primary triage – Carried out at the scene of an accident. Should be

rapid and able to identify patients in need of life-saving intervention

Secondary triage – Usually takes place in a more permissive

environment (casualty clearing station) and where medical
intervention generally takes place

37
 3.2.1 Mass Casualty Triage System

There are many existing triage systems and mass casualty triage system differs from each
locale. The main characteristics is that it must be simple, precise, rapid and continuous.

Examples of Mass Casualty Triage Systems

Simple Triage and Rapid Treatment (START)
JumpSTART
Triage Sieve
Sort/Assess/Life-saving Intervention/Treatment, Transport
(SALT)
Pediatric Triage Tape (PTT)

[Link] START Triage

START stands for Simple Triage and Rapid Treatment (Figure 3.1). It can be used to
triage large numbers of casualties. Classification is based on three items: respiratory,
perfusion and mental status evaluation (Table 3.1).

The main benefit of using the START method is that people with little or no medical
training personnel can help with the triage process since it is fast, easy to use, and easy
to remember.

All Walking Wounded Respirations

MINOR NO YES

Position Airway Under 30/min Over 30/min

NO Respirations Respirations IMMEDIATE

DECEASED IMMEDIATE
Radial Pulse
Perfusion
Present
Radial Pulse
Over Absent Under
Mental Status
2 seconds or 2 seconds
Capillary Refill
Control
CANNOT Follow CAN Follow
Bleeding
Commands Commands

IMMEDIATE IMMEDIATE DELAYED

Figure 3.1 Simple Triage and Rapid Treatment (START) triage algorithm
Source: Adapted from MC. Bhalla et al. (2015)

38 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 R Respiration RR < 30

P Perfusion Cap refill < 2s

M Mental status Can do

commands
Patients with any of the RPM features beyond the limits
belong in the ‘red’ category.

Table 3.1 Respiratory, perfusion and mental status evaluation

[Link] JumpSTART Pediatric Triage

Children and infants are often involved in disasters or mass casualty incidents alongside
adults. Triaging pediatric patients can be challenging due to the differences in anatomy
and physiology. The previous algorithms were found to be ineffective and inappropriate
for triaging children and infants.

The JumpSTART algorithm (Figure 3.2) was created in account for the variability of
normal physiological values in pediatric patients. A wider standard range for respiratory
rate is used, and the presence of absence of pulse is used as a cardiovascular indicator.

39
 JumpSTART Pediatric Multiple Casualty Incident Triage

Able Yes
to MINOR SECONDARY TRIAGE
walk?

No

Position Spontaneous
Spontaneous airway IMMEDIATE
breathing No breathing
APNEA

Palpable No
pulse? EXPECTANT

Yes
Yes
5 rescue APNEA
breaths EXPECTANT

Spontaneous breathing

IMMEDIATE
Respiratory
Rate IMMEDIATE
<15 or >45
Neurological
15 - 45 Assessment

No A Alert
Palpable IMMEDIATE
pulse? Responds to
V
Verbal Stimuli
Yes P Responds to
Painful Stimuli
Inappropriate “P” (e.g., posturing) Unresponsive
or “U” U to Noxious
Neurological Stimuli
Assessment IMMEDIATE
(AVPU)
“A,” “V,” or Appropriate “P”
(e.g., withdrawal from painful stimulus)
DELAYED

Figure 3.2 JumpSTART triage algorithm (for children < 9 years old)
Source: Adapted from Royal College of Emergency Medicine Learning India

40 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 [Link] SALT Triage (Sort, Assess, Life-saving Interventions, Treatment/Transport)

In response to the lack of scientific data regarding the efficacy of mass casualty triage
systems, the Center for Disease Control and Prevention (CDC) formed an advisory
committee to analyze the existing systems and recommend a national standard for
disaster triage. The literature did not conclusively identify any existing triage system as
optimal, so the expert panel developed SALT (Figure 3.3) by combining the best features
of the existing systems.

SALT is endorsed by several national organisations, including the American College of

Emergency Physicians, the American College of Surgeons Committee on Trauma, the
American Trauma Society, and the National Association of EMS Physicians.

Walk
Assess 3rd
A
Wave/Purposeful Movement
Step 1: Sort Assess 2nd

Still/Obvious Life Threat

Assess 1st

B
Step 2: Assess
No
Life-saving Interventions: Breathing? Dead
● Control major Minimal
hemorrhage
● Open airways (if child,
Yes
consider 2 rescue Yes
breaths) ● Obey commands or makes All
● Chest decompression purposeful movements? Yes Minor
● Auto injector antidotes ● Has peripheral pulse? injuries
● Not in respiratory distress? only?
● Major hemorrhage is
controlled?
No
Any No
Delayed
No Likely to Yes
survive given
Expectant current Immediate
resources?

Figure 3.3 SALT mass casualty triage algorithm

Source: Adapted from MC. Bhalla et al. (2015)

41
 SALT TRIAGE SIMPLE STEPS

Step 1: Sort

SALT begins with a global sorting of patients, prioritizing them for

individual assessment. Patients who can walk should be asked to walk
to a designated area and should be assigned last priority for individual
assessment.

Those who remain should be asked to wave (i.e., follow a command)

or be observed for purposeful movement. Those who do not move
(i.e., are still) and those with obvious life-threatening conditions should
be assessed first because they are the most likely to need life-saving
interventions.

Step 2: Assess

The individual assessment should begin with limited rapid life-saving

interventions:
•• Control major hemorrhage through the use of tourniquets or direct
pressure provided by other patients or other devices
•• Open the airway through positioning or basic airway adjuncts (no
advanced airway devices should be used)
•• For a child, consider two rescue breaths
•• Chest decompression
•• Auto injector antidotes

Then assess the breathing, severity of injury and the likelihood to

survive with the available resources.

[Link] Triage Sieve

The triage sieve (Figure 3.4) was developed by Hodgetts and Mackway-Jones in 1995 as
a component of the Major Incident Medical Management and Support (MIMMS) course
for healthcare providers. It has been widely advocated in the United Kingdom and parts
of Australia. It assigns priority based on the ability to walk, airway patency, breathing rate
and either capillary refill or heart rate.

42 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Yes Priority 3
Can the patient walk? (Delayed)

No

No
Is patient breathing? Deceased

Yes

< 10 or > 29 Priority 1

Respiratory rate (Immediate)

10-29 2s
er
Ov
Under 2s Priority 2
Respiratory rate (Urgent)

Figure 3.4 Triage Sieve Algorithm

Source: Adapted from BMJ Publishing Group)

3.2.2 Population-Based Triage

Triage decisions for populations affected by biological events are based on inter-related
information including:
•• Illness severity
•• Infectiousness
•• Duration of illness

The goal of triage during a biological event is to prevent secondary transmission amongst
victims and protect the susceptible population through the following strategies:
•• Non-medical strategies (reduce exposure time, social distancing, isolation, risk
communication, personal protective equipment)
•• Medical interventions (medical treatment and vaccination)

43
 [Link] SEIRV Triage for Biological Disaster

The population-based triage model SEIRV has categorised members of community

during biologic event to prevent secondary disease transmission.
•• Susceptible: People who are not yet exposed but are susceptible
•• Exposed: People who have been in contact with an infected person; they may be
infected but are not yet contagious
•• Infectious: Casualties who are symptomatic and contagious
•• Removed: Casualties who no longer can transmit the disease to others because
they have survived and developed immunity or died from the disease
•• Vaccinated (or medicated): People who have received prophylactic medical
intervention to protect them from infection

[Link] Population-Based Triage Through Risk Communication

Most disaster management failures are related to communication shortfalls. Effective

risk communication refers to the ability to advise members of the affected group about
how to minimize the risk of exposure and where to seek medical help if necessary. In
any emergency incident, getting information out quickly and efficiently is critical to saving
lives.

Public information must reach broad audiences to publicize both immediate and
anticipated health hazards, appropriate health and safety precautions, evacuation routes
and alternatives, location of healthcare facilities, distribution and dispensing sites.

During a serious infectious disease outbreak, such as the latest COVID-19 disease
outbreak, the general public is concerned about whether they are vulnerable, exposed,
or infectious. Effective risk communication aims to assist the public in determining their
risk status and taking steps to protect themselves and others.

Those with a high-risk probability of being exposed to an infected person will immediately
be informed to be screened and then isolated.

3.2.3 Triage Categories

During a mass casualty incident, patients are triaged and grouped (Figure 3.5) into the
following categories of decreasing treatment priority (note that coding may vary with
different systems).

44 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Common color-coded triage categories are:

Immediate (Red)
Delayed (Yellow)
Minimal (Green)
Expectant (Grey)
Dead (White/Black)
Immediate (Red) Triage Categories
Immediate (Red)
•• Casualties who are most critically injured and require highest priority to receive
acute intervention care.
•• Casualties are expected to have higher chance of survival.

Delayed (Yellow)
•• Conditions which are less severe than those in the immediate group.
•• Victims who are still requiring medical attention but can wait for a certain period of
time without significantly affecting their survival [Link]) Triage Categories
•• Highest expectancy to survive even without medical attention.
•• Sustained minor or no injury.

Expectant (Grey)
•• Lowest chance of survival with currently available resources.
•• Those triaged as immediate (Red) may also be triaged as expectant (Grey) when
there are not enough resources.
•• Those triaged as expectants may be re-triaged to Red when more resources are
available.
•• Include those who are most likely won’t survive even if all needed resources are
available.

Dead (Black/White)
•• Those who show no signs of life.
•• Not breathing after basic airway opening maneuvers are done.
•• For children, primary care providers may attempt to give two rescue breaths.
However, if still has no spontaneous breathing, the patient should be pronounced
dead.
•• No attempt of resuscitation should be made.

45
 Figure 3.5 Color-coded triage categories

Table 3.2 Mass casualty triage categories

Triage Code Description Color

Requires immediate care for a good

Immediate Red
probability of survival

Requires care that can be safely delayed

Delayed Yellow
without affecting probability of survival

Sick, injured but expected to survive with

Minimal Green
or without care

Alive, but with little or no chance of

Expectant Grey
survival given current available resources

Dead A fatality with no intrinsic respiratory drive White/Black

46 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 3.2.4 Limitations of Triage Systems

•• Current triage systems focus mainly towards trauma patients.

•• Less useful for patients suffering from chemical, biological, radiological, nuclear and
explosive injuries (CBRNE).
•• Language barriers, age, and the physical and sensory impairments of casualties are
all limitations.
•• Lack of coordination between the responder or agency may cause mixing of triage
system use at the field.

3.3 Casualty Assessment

•• Thorough history-taking and detailed head-to-toe examination should be performed

once the scene is safe for the responder to enter.
•• The casualties’ medical records as well as contact information should be sought
after.
•• It is essential to record any information obtained from each casualty.

3.3.1 Primary Assessment

Airway
•• Can the patient speak? – if yes, airway is patent.
•• Is the respiration noisy? – partial airway obstruction.
•• Respiration is absent? – consider complete airway obstruction.
•• Airway management in trauma patient should include:
•• Jaw thrust and stabilisation of spine.
•• Insertion of oropharyngeal or nasopharyngeal airway.
•• Removal of foreign body.
•• Patients who are unable to protect the airway should have definite airway orotracheal
intubation or needle cricothyroidotomy.

Breathing
•• Patency of the airway does not ensure adequate ventilation.
•• The victim might have significant pulmonary injury without initially affecting the
airway.
•• Bag Valve Mask (BVM) ventilation if inadequate ventilation. If still inadequate, to
consider intubation (if possible).

47
 Circulation
•• All external bleeding should be controlled as soon as possible.
•• Techniques used include direct pressure, pressure dressing and tourniquet.
•• Patient’s haemodynamic status should be evaluated in conjunction with clinical
signs of perfusion.
•• Level of consciousness
•• Skin color
•• Temperature
•• Peripheral pulses
•• Capillary refill time
•• In cases of shock after external bleeding has been controlled, immediate resuscitation
using intravenous fluid should be initiated.

Disability
•• Healthcare providers should establish baseline neurologic status of the casualty.
•• Examine:
•• Pupil size and response.
•• Function of extremities.
•• Level of consciousness using Glasgow Coma Scale (GCS) as shown in Table 3.3
(for adult) and Table 3.4 (for children).

Table 3.3 Glasgow Coma Scale (adult)

Feature Parameter Score
Spontaneous 4
To verbal command 3
Eye opening
To pain 2
None 1
Orientated, conversing 5
Disorientated, conversing 4
Best verbal response Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Oberys verbal commands 6
Localizes to pain 5
Withdrawal 4
Best motor response
Abnormal flexion (Decorticate) 3
Extension (Decerebrate) 2
No motors response (Flaccid) 1

48 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Table 3.4 Pediatric Glasgow Coma Scale
PEDIATRIC GLASGOW COMA SCALE (PGS)
> 1 Year < 1 Year Score
Spontaneous Spontaneous 4
EYE To verbalcommand To shout 3
OPENING To pain To pain 2
No response No response 1
Obeys Spontaneous 6
Localizes pain Localizes pain 5
MOTOR Flexion-withdrawal Flexion-withdrawal 4
RESPONSE Flexion-abnormal (decorticate rigidity) Flexion-abnormal (decorticate rigidity) 3
Extension (decerebrate rigidity) Extension (decerebrate rigidity) 2
No response No response 1
> 5 Years 2-5 Years 0-23 months
Appropriate
Oriented Smiles/coos appropriately 5
words/phrases
Disoriented / Inappropriate
Cries and is consolable 4
VERBAL confused words
RESPONSE Inappropriate Persistent cries Persistent inappropriate crying and/or
3
words and screams screaming
Incomprehensible
Grunts Grunts, agiated, and restless 2
sounds
No response No response No response 1
TOTAL PEDIATRIC GLASGOW COMA SCORE (3-15):

Exposure and Environment

•• Expose patients adequately to find hidden injuries.
•• Exposure should be done visually and palpably as to not only look for evidence of
injury but also weapons, chemical contamination or forensic evidence.
•• Avoid hypothermia by warming intravenous fluid, using a warmed blanket and
removing casualties from cold environments.

3.3.2 Secondary Assessment

Casualty History
•• Use a reasonable approach such as SAMPLE history.
•• Signs and symptoms
•• Allergies
•• Medications
•• Past illness
•• Last meal
•• Event and environment
•• Alert healthcare provider to injury and illness status of the casualties.
•• Other history from bystander, primary responder and situational reports are as
important.
49
 Casualty Physical Examination
•• A thorough head-to-toe physical examination should be done to avoid missing any
significant injuries.
•• If possible, completely expose the patient in a controlled environment.
•• After the examination is done, immediately ensure casualty is covered appropriately
and kept warm.

Casualty Transport and Evacuation

•• Evacuation from the disaster scene involves both casualties and healthcare
providers.
•• Limitations regarding evacuation include:
•• No suitable location to gather casualties.
•• Limited resources to transport the casualties.
•• Not all casualties need to be transported by ambulance; responders may also utilize
other appropriate vehicles, which include ambulances from NGOs (e.g. Malaysia
Red Crescent, St John Ambulance, Malaysia Civil Defence Agency and Fire &
Rescue Department).
•• A rational and well-planned evacuation plan is essential to avoid overwhelming the
local hospital.
•• Hand-in-hand coordination between governmental entities, non-governmental
agencies, private vendors, and other rescue teams will result in a well-structured
evacuation plan.
•• Surge evacuation refers to the transfer of casualties to distant facilities.
•• It happens when local facilities are unable to cope with the current surge of casualties.
•• Providers need to continuously monitor casualties as the chances of patient’s
deteriorating increased especially during prolonged transit.

50 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 3.5 Summary

•• Mass casualty triage is a very important process in sorting out the casualty in mass
casualty incidents or disaster.
•• The main objective is to do the best for the most number of possible survivors.
•• Most seriously injured casualties with the reasonable possibility to survive will be
treated first, while those with least severity and those with lowest chances of survival
will be treated later.
•• There are many triaging systems available. The most commonly used are START,
SALT, JumpSTART, sieve and SIERV.
•• The main characteristic of the triage system is - it must be simple, precise, rapid and
continuous.

Bibliography

Garner, A., Lee, A., Harrison, K. and Schultz, C.H., 2001. Comparative analysis of multiple-
casualty incident triage algorithms. Annals of emergency medicine, 38(5), pp.541-548.

Benson M, Koenig KL, Schultz CH. Mass Casualty triage: START, then SAVE - a new
method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster
Med. Apr-Jun 1996; 11(2): 117-124

Romig L. The JumpSTART pediatric MCI Triage Tool. January 2, 2008.

<[Link]

Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis of multiple-casualty

incident triage algorithms. Ann Emerg Med. Nov 2001;38(5):541-548

Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data
and development of a proposed national guideline. Disaster Med Public Health Prep.
2008;2(suppl 1): S25-S34

Hines S, Payne A, Edmonson J, Heightman AJ. Bombs under London: the EMS response
plan that worked. JEMS. Aug 2005;30(8):58-60, 62, 64-57

Hodgetts T, Hall J, Maconochie I, Smart C. Paediatric triage tape. Prehosp Immediate

Care. 1998; 2: 155–159.

National Disaster Life Support. Basic Disaster Life Support Course Manual 3.0. 2012

National Disaster Life Support. Advanced Disaster Life Support Course Manual 3.1. 2012

Mersh, R., Triage in Mass Casualty Situations.

51
 Bhalla, M.C. et al., 2015. Simple triage algorithm and Rapid treatment and sort, ASSESS,
Lifesaving, Interventions, treatment, and Transportation mass casualty triage methods
for sensitivity, specificity, and predictive values. The American Journal of Emergency
Medicine, 33(11), pp.1687–1691.

RCEMLearning India. 2021. Paediatric Triage - RCEMLearning India. [online] Available

at: <[Link]
triage-categories/topic/paediatric-triage/> [Accessed 25 March 2021].

52 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 CHAPTER
4
NATURAL DISASTERS
 CHAPTER 4
NATURAL DISASTERS

Case Scenario

You are called to attend a disaster preparedness meeting in your local council with
several local agencies to evaluate and profile the risk of natural disaster occurring in
this district.

1. Which type of natural disaster is prevalent in your district?

2. How would you prepare your institution and local community for these
incidents?

Chapter Objectives

1. To understand the clinical issues and challenges seen in natural disasters

2. To understand the clinical and public health management for natural disasters

3. To describe prevention and mitigation strategies for different natural disasters

4.1 Background

Natural disaster is defined as any event or force of nature that has catastrophic
consequences, such as earthquake, flood, forest fire, hurricane, lightning, tornado,
tsunami and volcanic eruption which can cause great damage or loss of life.

For a natural disaster to be entered into the international database,

according to the World Health Organization (WHO) Center for
Research on the Epidemiology of Disasters (WHO/CRED), at least
one of the following criteria must be fulfilled:

•• Ten (10) or more people were reported killed.

•• Hundred (100) or more people were reported affected.
•• Declaration of a state of emergency.
•• Call for international assistance.

54 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Many individuals will be critically injured during a natural disaster; significant structural
destruction may occur; and many people may need shelter, food, and other assistance.
The magnitude of the initial number of sick and wounded, as well as the degree of damage
to the pre-existing healthcare system, would make casualty care difficult.

According to the WHO/CRED, the worldwide frequency of natural disasters has doubled
since 1995. More natural disasters occur in Asia than on any other continent, and China
experi­ences more natural disasters than any other country. The CRED database also
demonstrates that floods are the most common type of disaster throughout the United
States, Malaysia, and the world.

An overview study of the types of disasters in Malaysia showed that Malaysia had
experienced 39 disasters during the period of 1968–2004. Natural disasters accounted
for almost half of all disasters in the country, most of them resulted from heavy rains.
Table 4.1 is a summarized list of natural disasters that happened in Malaysia from 1993
until 2004. The most common form of natural disaster in Malaysia was flooding, followed
by epidemic, storms and wildfires as shown in Figure 4.1.

Table 4.1 List of natural disasters in Malaysia

Number of
Natural disasters Date Fatalities Injuries Losses
Floods, Northeastern State of Malaysia - December 25, 1993 10 13,000 people flee their
Kelantan, Pahang, and Terengganu homes, 16 houses were
swept away
Landslide in km 58, Kuala Lipis -Gua October 24, 1993 1 15
Musang Road
Landslides, Cameron Highlands December 4-7, 1994 7
Landslide, off Genting Highland road, June 30, 1995 20 22
Pahang
Mud slide, native resettlement village, August 29, 1996 44
pos dipang, kg. Sahom, Kampar Perak
Tropical storm, Greg West coast of December 26, 1996 230 4,925 houses damaged
Sabah
Enteroviral Outbreak, Sibu Sarawak April 1-30, 1997 25
Landslide at Bukit Antarabangsa, Hulu May 15, 1999 1,000
Klang, Selangor
Continuous heavy rain for several days February 2000 2 20 villages affected, 4,000
Kinabatangan district, Sabah evacuated
SARS March 14-April 22, 2003 2 3 cases recovered
Lightning struck the Drug Rehabilitation May 3, 2000 5 17
Center
Hand, foot, and mouth disease attacking September-November 2000 2 100 hospitalized, 901
children in Johor nurseries closed
Floods at Kelantan and Terengganu November 20, 2000 10
district
Floods at East Malaysia December 23, 2001 11 Thousands evacuated
Heavy rain, landslide January 28, 2002 10
Land slide, Taman Hillview 11 Malaysia November 21, 2002 8 A luxury home was
collapsed
Flood, Northern Malaysia October 5, 2003 1 10,000 fled their homes
Floods, east coast of peninsula Malaysia December 11, 2004 4 4,500 people were
evacuated
Tsunami December 26, 2004 68 767 6 people are missing
Total 1,460 821

Source: Mohamed Shaluf & Ahmadun (2006)

55
 Drought 1

Earthquake* 1

Epidemic 11

Flood 31

Mass mov, dry 1

Mass mov, wet 3

Storm 6

Wildfire 4

0 10 20 30 40
Occurence

Figure 4.1 Data of natural disaster in Malaysia from 1980 until 2010

4.2 Natural Disaster Specific Considerations

Natural disasters are normally short-lived and rarely transform into public health crises.
Responders must be alert for potential secondary emergencies following a primary natural
catastrophe, particularly where there is structural failure, impassable roads and bridges,
downed power lines, diesel leakage, ruptured gas lines, and loss of basic utilities. For
instance, a hospital that sustains structural damage after an earthquake may not show
any significant signs of damage, but it could be an impending mass casualty situation
requiring evacuation.

Natural disasters, on the other hand, can necessitate the use of a large range of resources.
For example, if a building were to collapse as a result of an earthquake, construction
crews and heavy equipment, as well as local search and rescue teams and mortuary
facilities, would need to be mobilized quickly. Long-term power outages, polluted drinking
water sources, and infectious disease outbreaks must all be taken into account. Natural
disasters pose a significant risk of disrupted connectivity, infrastructure damage, and vast
numbers of homeless people in need of food, housing, and medical treatment.

56 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 4.2.1 Situational Awareness

It is important to be able to reduce the severity of a disaster; however, most natural

disasters are unpredictable. Earthquakes and storm fronts, for example, commonly occur
without warning. Fortunately, certain natural phenomena, such as floods and heatwaves,
may be reliably monitored and tracked until they happen (Table 4.2).

In natural disasters, the importance of detection is heavily centered on pre-event

identification; adequate advance notice, prompt evacuation orders, and shelter access
are all essential factors in reducing disaster-related mortality and morbidity.

Active warning systems, such as local sirens, are the most powerful because they do
not need the target population to take action to receive the alert, as opposed to passive
systems, such as the news media, radio stations, and the Internet, which require the
target population to view this information in order to receive the alert.

Table 4.2 Early detection or warning of natural disasters

Type of Warning Definition Examples

Detected before impact Floods, hurricanes,

Early Warning
Prediction of impact volcanic eruption

Severe thunderstorm,
Volatile situations with rapidly
Limited Warning tornadoes, impending
changing course or intensity
structural collapsed

Earthquakes, wildfire*,
No Warning Undetectable, Unpredictable
industrial incidents

* There is typically no ability to detect wildfires before impact, they often persist for several
days. Therefore, those not in the immediate part of the fire may have ample warning to
evacuate.

4.2.2 Health Facility Expansion of Surge Capability

Large-scale natural disasters can cause extensive devastation, infrastructure failures,

road closures, power outages, and/or pollution of water supplies. As a result, emergency
resources must be directed to alternative treatment facilities (ACF) such as external
facilities, step-down district hospitals, private healthcare services, or recovery centers,
as part of the hospital's operations and activities which would be disrupted. Additional
space and staff are always needed for patient manage­ment of overwhelmed emergency
departments.

57
 The ACF may be large or small (i.e., a 50-bed portable field hospital in a school/stadium).
The quality and level of services are to maintain as near the community standard of care
as possible in these surge facilities. This is especially challenging during large-scale
natural disasters such as the flood incident at Kuala Krai in year 2014 when access
to supplies, including appropriate personnel, is commonly quite limited. The goal once
an ACF is operational is to immediately focus on closing it as soon as possible. This is
important, as the focus must always be on returning community healthcare delivery to the
usual standards of care and proper facilities as soon as possible.

4.3 Pattern of Injuries and Clinical Management

Most natural disasters often have predictable injury timelines and patterns (Table 4.3).
Initial injuries are often trauma-related, and most deaths occur in the early phase of a
disaster.
Table 4.3 Medical needs timeline in natural disasters
Injury/Disease
Phase after Event Treatment Needs
Process
Immediate Orthopedics/surgery/burns/Laceration
Trauma
(0–48 hours) repair/wound care
Trauma Orthopedics/laceration repair/ fasciotomy

Intermediate Exacerbation of chronic illness (Asthma,

(2 days–2 weeks) heart failure, myocardial infarction,
Acute Medical
diabetic emergencies)
Hemodialysis
Public Health Exacerbation of chronic illnesses
Communicable disease outbreak (water-
Medical
borne, diarrheal, vector-borne, person to
Long term person)
(weeks to years) Post-traumatic stress disorder
Anxiety
Mental Health
Depression
Substance abuse

Injuries and medical conditions that can be expected after a natural disaster may be
extensive. Trauma, from simple lacerations and fractures to complicated blunt and
penetrating injuries, will be present. Structural collapse may result in crush injuries
and the need for extremity amputations. Another common significant medical problem
after a natural disaster is the exacerbation of pre-existing medical conditions. Dust and
fumes can cause acute attacks in people with asthma and chronic obstructive pulmonary
disease (COPD).

Not all natural disasters will result in a similar timeline and pattern of injuries; some
natural disasters may cause different types of injuries and casualties. Specific health
consequences according to the type of natural disasters are further summarized in Table
4.4.

58 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Table 4.4 Natural hazard health consequences and considerations
Other
Natural Event Mortality Morbidity
Consideration

-- Crush injury
-- Exsanguinations -- Closed fractures
-- Asphyxiation -- Superficial trauma As many as 95%
Earthquakes/
from building of all deaths occur
Tsunami -- Exacerbation
collapse before extraction
of preexisting
-- Drowning from condition
tsunamis

-- Outbreaks of
communicable
disease
-- Exacerbation of -- Increased number
Major cause of of soft-tissue
-- Chronic illnesses
death drowning injuries
Floods (Primarily of people -- Laceration/Trauma -- Submersion
trapped in vehicles) -- Electrocution from
-- Hypothermia
downed power line
-- Trauma
-- Exposure to
hazardous
biological and
chemical agents

At-risk populations
most susceptible
Heat syncope and heat
Heat Most death due to (elderly, those with
exhaustion are more
Emergencies heat stroke chronic disease,
common
pregnant women,
and children)

-- Increase in
Most death due -- Asthma emergency
to toxic inhalation department visits.
Wildfires and -- COPD
(carbon monoxide) -- No expected
Haze
and significant burn -- Potential heat increase
injury stress in hospital
admissions.

59
 Decontamination showers at the incident site are very useful and should be taken into
account in disaster planning for natural disasters since injured individuals are frequently
covered with dirt and debris, which may impair medical assessment during prehospital
and emergency department evaluations. Wound management with adequate analgesia
should be an essential part of hospital disaster planning.

In the second phase of natural disaster (after subsequent days and weeks), the medical
profession will see an exacerbation of common chronic diseases like asthma, as well
as orthopaedic fractures and lacerations suffered during the initial clean-up operations.
Following that, as seen in Figure 4.2, is a rise in infections from untreated wounds
sustained after the initial event.

HOW CLIMATE CHANGE AFFECTS YOUR HEALTH

EXTREME
WEATHER

RESPIRATORY
SYNDROME
increases by 25%
Increased More during wildfires
Flooding Intense
& Storm Wildfire

51% of
WATERBORNE
OUTBREAKS
followed extreme
precipitation events

Water Property Infrastructure

Contamination Loss Damage

Extreme weather 159 DEATHS

events led to from Superstorm Sandy
OVER 200 DEATHS in October 2012
in the last 2 years

Waterborne Injury & Death

Illness

Figure 4.2 Clinical impact of natural disaster (extreme weather)

60 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

As a result, every natural disaster recovery strategy should include mental health
services. People at risk for anxiety, depression, stress disorders, and other behavioral
health issues can benefit from early intervention, which allows mental health providers to
diagnose and handle them (e.g., suicide ideation, substance abuse).

4.4 Floods

Flood is the most common natural disaster in the world as well as in Malaysia. Malaysia
has been hit by floods every year at the end of the year as a result of the northeast
monsoon, especially in the states of Kelantan and Terengganu (Figure 4.3). These floods
are a natural hydrological phenomenon in Malaysia, affecting an average of 29,000 km²,
4.82 million inhabitants (22 percent of the population), and causing RM 915 million in
annual damage.

The flood that happened in Malaysia from 15 December 2014 until 3 January 2015 was
described as the worst flood in decades. More than 200,000 people were affected while
21 were killed. Due to the heavy rain and worsening condition, several Keretapi Tanah
Melayu (KTM) intercity train services along the East Coast route were disrupted following
the floods. Most roads had to be closed due to the rising water level. Schools were closed
and hundred thousand of people had been evacuated to various flood relief centers.

Figure 4.3 Flood in Kelantan state in 2014

In 2014, 102 health facilities in West Malaysia were affected. In Hospital Kuala Krai
(Kelantan), anesthesiologist had to intubate a baby in the dark after a diesel generator
ran out of fuel. Helicopters were used to evacuate patients from Kuala Krai Hospital as the
flood worsened. The 180 hospital staff worked tirelessly for over 5 days. The hospital also
doubled as a temporary relief center for flood victims. Universiti Sains Malaysia Hospital
(HUSM) in Kubang Kerian, Kelantan, experienced a blood shortage due to overwhelming
life-saving demands. Medical students were also mobilized to assist medical officers on
duty at HUSM. Shortage of food supplies, electricity, clean water, banking services, and
erratic communication problems continued to affect flood victims after the flood started
to recede.

61
 Lack of banking services has caused some petrol stations to run out of small change.
Some victims survived on donated relief items while other desperate flood victims started
to fight or steal for food and valuables from abandoned homes. Prices of essential items
were raised.

4.4.1 Types of Floods and Its Causes

Floods can be categorised as regional, flash, debris or landslides, mudflow, and sea-level
rise. The regional geographic conditions that make a particular type of flooding more
likely are important for situational awareness, warning system as well as for planning and
overall operational preparedness.

1. Regional floods
Occur seasonally when the winter or spring rains coupled with melting snow or
rainy season during the monsoon. These types of floods are usually associated
with slow-moving, low-pressure, or frontal storm systems.

2. Flash floods
Occur in a matter of minutes to several hours with little or no warning. They
can cause flood waves in excess of 30 feet and can occur miles from an actual
rainfall area. These types of floods are particularly dangerous because they can
produce large and dramatic rises in water levels and have flow velocities capable
of propelling large quantities of debris. Even relatively small quantities of water or
water rushing at low speeds can be dangerous, as it takes just 2 feet of water to
move an automobile.

Urban areas like Kuala Lumpur are prone to flash flooding because of the high
percentage of surface area that is covered by streets and buildings, preventing
water from being absorbed into the ground. Because underwater debris and road
damage increase the potential for injury and death, flash floods are also known as
blind traps.

3. Debris and landslide floods

Generally caused by the accumulation of debris, mud, rocks, logs or other large
objects that converge in a channel or narrowed area and form a temporary dam
that prevents the normal flow of water. As water pressure builds up behind the
dam, it eventually overwhelms the darn, breaches it, and becomes a flash flood.

4. Sea-level rise floods

This is directly tied to a rise in sea level. Sea-level rise is generally caused by a
variety of factors including monsoon rain or storm-related activities such as hurri­
canes, typhoons, tsunamis, or the timing of tides. There is a growing concern that
climate change may also play a factor in sea levels rising. Floods of this type can
destroy shorelines through erosion and cause salinity intrusion, leading to soil and
aquifer contamination.

62 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 4.4.2 Early Detection and Warning Systems

By monitoring the local and national weather, a warning system can be established to
provide warnings for floods. The effectiveness of every flood warning system would be
determined by a number of factors, including the exposed population's knowledge of flood
risks, the amount of advance warning provided, the availability of qualified personnel and
equipment, and the warning system's efficiency and reliability. A well-informed population
is best prepared to respond to a flood warning. Flood-prone communities, especially
those at risk of flash floods, should be aware of their vulnerability.

In Malaysia, the Department of Irrigation and Drainage Malaysia (DID) has established
an Internet-based National Flood Monitoring System known as Public Infobanjir (Figure
4.3) that can be accessed from [Link] in which rainfall and
water level data can be collected across the whole country. Besides that, the government
also has been working closely with the Canadian government to establish the GEOREX
Monsoon Flood System for the Kelantan River Basin, a flood monitoring system integrating
remote sensing, hydrological model and geographical information systems (GIS). This
system allows the merging of hydrological data, such as river water levels and potential
flooded areas, with geographical data on demography and transportation infrastructure.

Figure 4.3 Public InfoBanjir website by DID

Flash floods from intense thunderstorms are becoming a very common phenomenon,
especially in urban areas. Under a program of the Asian Development Bank, a flood
forecasting and warning system known as Flood Watch has been established as a powerful
forecasting and warning tool with GIS. Recently, an Urban Stormwater Management
Manual for Malaysia (MSMA) has been introduced to contribute to flood mitigation in
urban areas. The MSMA was formulated by incorporating best practices for stormwater
control measures such as runoff quantity and quality controls.

63
 4.4.3 Acute Hazard and Effects

Floods will destroy homes, houses, drainage systems, power grids, bridges, and
roadways, among other things. Humans and animals can also be injured, sick, or die
as a result of them. Floods can cause significant economic downturn in affected areas
due to massive physical destruction and loss of human labor productivity. Costs of
reconstruction, higher food prices due to grain shortages, and a drop in tourism will all
lead to economic hardship. Such natural disasters, such as earthquakes and hurricanes,
will also cause floods, compounding the consequences of those events.

Additional consequences of flooding include contaminated drinking water and resulting

scarcity, crop and nutrient shortages, and local extinction of intolerant plant and animal
populations. Contamination of the water system can result in unsanitary conditions,
which may lead to a rise in disease prevalence. Waterborne (typhoid fever, cholera,
leptospirosis, and hepatitis A) and vector-borne (malaria, dengue and dengue hemorrhagic
fever, yellow fever, and West Nile fever) infections are associated with floods. Tetanus is
common during large flooding because of the extensive structural damage.

Figure 4.4 Images of Hospital Kuala Krai during flood in 2014

4.4.4 Clinical Implications

Injuries during floods will vary depending on several factors, including the flood
characteristics (e.g., depth and velocity of flood waters), the location of people during
a flood (e.g., indoor, outdoors, in vehicles), and population characteristics (e.g., age,
health, concentration of people, special needs groups). More densely populated areas in
flood-prone locales are more likely to suffer higher numbers of injuries and death. Flood
warnings with subsequent evacuation become a key factor in averting and reducing
death and injury.

Injury patterns and deaths during flooding frequently involve motor vehicle accidents in
which individuals drown after being submerged in roadways or streams. It only takes 6
inches of water to reach the bottom of most modern automobiles, which can result in
sudden loss of control. When water levels reach 1 foot, many vehicles will begin to float.

64 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Rushing water only 2 feet deep will carry away many vehicles, including most sport utility
vehicles and small trucks. Serious injuries or deaths are often caused by the force of fast
water flow, various forms of debris and vehicles being swept away by floodwaters. In
the initial flood, morbidity and mortality are generally attributed to typical soft tissue and
traumatic injuries and drowning.

4.4.5 Public Health Considerations

Health effects of a flood are not limited to the traumatic injuries acquired as a direct result
of the flood waters or debris. Secondary contamination of water supplies from sewage
and vector overgrowth from pooling of water are issues of concern over the long term. In
the days to weeks after a flood, there is potential for increased fecal-oral transmission of
disease, especially in areas where the population did not have access to clean water and
sanitation. With a lack of sanitation and increased prevalence of stagnant water, there
are also increased rates of vector-borne diseases (e.g., diseases spread by mosquitoes
or rodents). In areas with increased chemical loads, especially industrial chemicals, there
is an increased opportunity for chemical exposure and contamination.

Diarrheal diseases begin just weeks after flooding, especially if the affected individuals
stay in their flooded homes or if there is standing water in the yard. This holds true in
developed countries as well as underdeveloped nations. Typical diarrheal illnesses seen
after flooding include cholera, cryptosporidiosis, non-specific diarrhea, poliomyelitis,
rotavirus, typhoid and paratyphoid. The risk of outbreak is even higher when the relief
center has no proper sewage system or too crowded with residents as shown in Figure
4.5. Mold exposure is a lasting health hazard following flooding. Mold can develop in as
short a time as 24 to 48 hours after water exposure. Although it is a naturally occurring
substance, it can be detrimental to human health. It may cause allergic reactions, asthma
episodes, infections and other respiratory problems. Continued exposure to mold may
result in nasal or sinus congestion; eye, nose, or throat irritation; and adverse effects on
the nervous system.

Figure 4.5 Examples of relief centers during the flood in Kelantan year 2014

65
 4.4.6 Prevention and Mitigation

The National Disasters and Relief Committee was formed after the disastrous flood of
1971, and responsible for planning, coordinating, and supervising relief operations during
floods. Most of the committee members are governmental departments/agencies and
social organisations that are able to provide shelter, rescue, food, and medical supplies.
Through the nationwide State Security Committee, police, the armed forces, social and
welfare departments, and various voluntary organisations, the task of rescuing and
evacuating flood victims to predetermined relief centers could be organized effectively.

A number of flood mitigation projects were done, such as canalisation of rivers, raising
river embankments and multipurpose dams. The financial involvement for such projects
was increased in Malaysia’s five yearly development allocations. Government machinery
allows the Economic Planning Unit of the Prime Minister’s Department to coordinate all
aspects of planning, design and implementation of water resources in the country.

Structural measures consist of controlling flood flows (Figure 4.6), whereas non-structural
measures such as land conservation regulate human activities to mitigate the impact
of flooding. Another indispensable non-structural measure is the adoption of a flood
forecasting and warning system. With this in mind, policy guidelines for implementing
flood mitigation measures will include the following aspects:

1. Implementation of structural flood mitigation in terms of engineering and socio-

economic environment
2. Implementation of complementary non-structural measures
3. Implementation of non-engineering measures where there is no engineering
solution
4. Continuation effort on strengthening flood forecasting and warning systems

66 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Figure 4.6 New design and invention for flood prevention
(Water-Gate, Flood Block unit)

Nevertheless, reducing the impact of floods is both a personal and a community

responsibility. Education is a key factor in understanding the potential impact of floods on
people. Communities need to engage in activities to reduce the effect of flooding, such
as aggressive public information programs, mapping and regulating areas that are flood
prone, and having flood damage reduction strategies. Communities also need to plan for
the aftermath of flooding. This includes consideration of populations such as the elderly,
the mentally ill, and others who may have difficulty accessing disaster relief agencies.

Personal measures that can be taken before a flood include avoiding building in flood-
prone areas; elevating and reinforcing foundations if building in flood-prone areas is
unavoidable; elevating electrical panels, furnaces, and ventilation systems; installing
check valves in sewer traps to prevent floodwaters from backing up into household
drains; sealing basement and foundation walls to prevent or reduce water seepage into
homes; knowing and practicing evacuation routes before a flood occurs; and having a
family plan in place.

4.5 Heat Emergencies

Heat emergencies typically occur after prolonged exposure to excessively hot and
humid weather (heat waves). As a tropical country located near the equator, Malaysia
has constant hot weather throughout the year. Therefore, cases of heat-related illnesses
are not uncommon. However, many cases have been overlooked and undiagnosed
especially those presented with the milder end of the spectrum of illnesses.

In 2007, nine policemen were admitted to the emergency department of Hospital Kuala
Lumpur for exertional heatstroke after a special force selection program. Another common
situation seen for heat emergencies is an individual that was trapped inside a locked
vehicle. On 11th April 2006, an unfortunate girl was found locked inside a van for almost
three hours and died of heatstroke. Recently in the year 2018, the training involved
selection for the Special Action Unit of Polis Diraja Malaysia at Bukit Sentosa Police
Training Centre in Kuala Kubu Baharu had resulted in 60 police personnel suffering from
heatstroke.

67
 The weather in Malaysia is constantly hot with a humidity of up to 70%–80% daily. When
humidity is above 35%, convection alone does not adequately dissipate heat from the
body, therefore heat emergencies should always be one of the differential diagnoses for
patients with high temperatures. Equinox, a phenomenon where the sun is positioned
on top of the head in the equatorial region, is expected to have an impact on Malaysia’s
weather and climate (Figure 4.7).

Indication

Perlis Kelantan
● Normal
>35 C
0

and safe
Chuping Machang temperatures

● LEVEL
Kuala Jerai
Kedah Jeli 1 (Alert)
Sik >35 C - 37 C
0 0

Pendang
Pahang
Normal and safe
Penang Bentong
temperatures

Perak
Hulu Perak
Maran
Temerloh
Jerantut
● LEVEL 2 (Heat Wave)
>37 C - 40 C
0 0

Kinta for 3days continuously

Selangor
Petaling ● LEVEL
>40 C
0
3 (Emergency) Sabah

Kuala Lumpur Johor

for 3days continuously In Malaysia, a heat
Kepong Tangkak wave occurs when
daily maximum
Negeri Sembilan temperatures
Jempol exceed 370C for
Melaka three consecutive
Sarawak
days

Figure 4.7 Possible heat wave from the Equinox in March 2019
HEAT A period of extraordinary high temperatures, exceeding the maximum daily
WAVE
In view
average, with the hot weather condition persisting for several days or weeks.
of Malaysia having increasing popularity in outdoor sports activities, especially
in motorsports such as the Formula 1 Race, the MotoGP Race, the Japan GT Race as
well as reality shows, extreme sports and adventurous challenges, clinicians need to be
aware that we may be seeing an increasing number of heat-related illnesses in Malaysia.

4.5.1 Causes and Characteristics

A heatwave, as the name implies, is a prolonged period of high temperatures and

humidity. Extreme heat events are defined as temperatures and humidity levels that are
significantly higher than the region's average high values over a comparable period.
Extreme heat events are defined not only by the absolute temperature, but also by other
environmental factors like humidity, air circulation, and temperature variations at night.
Hundreds, if not thousands, of people may require treatment for heat-related illnesses at
large outdoor gatherings.

68 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

During heat waves, illness happens as the body's temperature control homeostasis is
disrupted by the increased ambient temperature. The most important factor causing the
onset of heat-related illness is ambient temperature, but humidity and air movement may
also play a role.

Human body has several mechanisms for cooling (Figure 4.8):

•• evaporative heat loss is cooling through perspiration;
•• conduction is heat loss through contact with cooler surfaces;
•• convection is heat loss through water or air motion around a person’s body;
•• radiation heat loss is ther­mal radiation being released from the body.

Physics of Heat Loss from the body

Walls
Evaporation (22%)

Radiation (60%)
heat waves

Conduction to air (15%)

Air currents
(convection) Conduction
to objects (3%)

Figure 4.8 Mechanisms of heat loss from body

When the air temperature approaches normal human body temperature, most heat loss
occurs through evaporative cooling. Greater humidity levels slow the body's ability to
perspire effectively, so the combination of high humidity levels and high air temperature
can result in serious heat illness.

Several factors may contribute significantly to an individual's likelihood of developing heat-

related illness. Groups at risk include the elderly; the very young children; individuals with
comorbid conditions; those with cognitive impairment or who are taking psychotropic-
neuroleptic medication; and those who live in poorly ventilated buildings that do not
shelter them from direct sunlight.

69
 Groups at risk of developing heat-related illnesses:

•• the elderly
•• the very young children
•• individuals with comorbid conditions
•• those with cognitive impairment or who are taking psychotropic-
neuroleptic medication
•• those who live in poorly ventilated buildings that do not shelter them
from direct sunlight.

The spectrum of heat-related illnesses can range from minor syndromes such as heat
cramps, heat edema, heat syncope, heat exhaustion to the more severe and life-
threatening heat stroke.

4.5.2 Hazard Identification and Warning Systems

Individuals who are exposed to extreme heat or work in hot environments are always at risk
of heat stress. Workers at risk of heat stress include outdoor workers in hot environments
such as firefighters, bakery workers, factory workers and others. Hazard identification
involves recognizing heat hazards and the risk of heat illness due to high temperature,
humidity, sun and other thermal exposures. Identification tools include a Wet Bulb Globe
Thermometer (WBGT) which is a measure of heat stress in direct sunlight that takes into
account temperature, humidity, wind speed, sun and cloud cover.

In the United States, the National Weather Service (NWS) will initiate an alert if the local
heat index is expected to rise above 105°F to 110°F for at least 2 consecutive days. The
alert procedures include giving heat index values with zone and city forecasts and issuing
special alert notices to the public detailing the heat risk, who is most at risk, and safety
tips. The NWS will also assist state and local health officials in preparing civil emergency
messages, if needed, and release information to the media and via radio stations.
The hazards and effects from a heat-related disaster are the combined effects of
environmental temperature, humidity, and the duration of exposure. Contributing factors
include hydration status, degree of work-stress effort, and underlying health status. The
use of personal protective equipment (PPE) and working in enclosed or poorly ventilated
spaces may also be contributing factors.

70 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 4.5.3 Clinical Implications

Heat illnesses can span a continuum from minor to life-threatening illnesses. The following
is a list of commonly seen heat illnesses.

Table 4.5 List of commonly seen heat illnesses

•• Heat cramps are pain and cramping, thought to be an effect of
hyponatremia.
•• Physical examinations and body temperature are normal in most
cases.
•• Blood may show hyponatremia, hypokalemia, hypomagnesemia or
Heat
respiratory alkalosis.
cramps
•• Rhabdomyolysis may present after similar exposure and should
rule out this condition and its complications through laboratory
testing.
•• Treatment includes rest in a comfortably cool area, oral or
parenteral fluid, and electrolyte repletion as needed.
•• Heat-related swelling of hands and feet related to peripheral
vasodilation.
•• Physical examination will show extremity edema but no other
Heat edema
physical findings that are more consistent with heart failure.
•• Treatment includes avoidance of excessive heat and elevation of
the legs.
•• Syncope due to exposure to extreme temperature elevation is
thought to be secondary to peripheral venous pooling, which results
in orthostasis.
Heat
•• It can occur after either prolonged standing or quickly rising from a
Syncope
seated or supine position.
•• Treatment is lowering the individual to ground followed by
rehydration.
•• Caused by excessive perspiration or diaphoresis in extreme heat.
•• Symptoms include malaise, copious perspiration, fatigue, nausea
and vomiting, lightheadedness, and headache.
Heat •• Physical examination will demonstrate a diaphoretic, alert and
Exhaustion orientated patient who may also be tachycardic and hypotensive,
with an elevated core body temperature less than 40°C.
•• Treatment should include cooling, removal from hot environment,
and oral or parenteral rehydration.

71
 •• Most serious form and can be fatal.
•• Typically has a core body temperature of 40.5°C or greater.
•• Physical examination will show abnormal mental status and
tachycardia.
•• Other associated complications can include coagulopathy,
thrombocytopenia, hepatic failure, and heart failure.
Heat Stroke •• Treatment consists of rapid, aggressive cooling including ice packs
to the groin and axilla, spray mist, fans, as well as parenteral fluids.
•• Core body temperature should be closely monitored.
•• Other resuscitative measures to support airway, breathing, and
circulation should be taken as needed.
•• Rapid sequence induction medications should not include paralytics
that might induce hyperkalemia, such as succinylcholine.

The distinction between heat exhaustion and heat stroke is not always clear-cut although
heat stroke differs from heat exhaustion in three clinical aspects. Firstly, heat stroke
usually has a core temperature of greater than 40.5°C and heat exhaustion usually has
a core temperature of 40°C or less. Secondly, heat stroke results in central nervous
dysfunction as evidenced by delirium, convulsion and coma. Thirdly, heat stroke usually
has anhidrosis on the basis of thermoregulatory failure. However, in terms of patient
management, especially first aid and emergency management in the emergency
department, the principles are almost similar. The distinction between heat stroke and
heat exhaustion, therefore, is important only in terms of prognostication as well as how
expeditious cooling should be done.

The following advices may be given to the public who are at risk during heat emergency:
•• Stay indoors as much as possible and limit exposure to the sun.
•• Stay on the lowest floor out of the sunshine if air conditioning is not available.
•• Drink plenty of water and limit intake of alcoholic beverages.
•• Consider spending the warmest part of the day in public buildings such as libraries,
schools, movie theaters, shopping malls, and other community facilities.
•• Dress in loose-fitting, lightweight, and light-colored clothes that cover as much skin
as possible.
•• Protect face and head by wearing a wide-brimmed hat.
•• Never leave children or pets alone in closed vehicles.
•• Avoid strenuous work during the warmest part of the day. Use a buddy system when
working in extreme heat, and take frequent breaks.
•• The mainstay of treatment is to avoid from the heat, cooling down the body
temperature and rehydrating the subject as shown in Figure 4.9.

72 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Use a fan to lower
temperature
Elevate feet

Apply cold
compresses

Give fluids

Have the person lie down

Figure 4.9 Measures taken in the treatment of heat emergencies

4.5.4 Prevention and Mitigation

Heat-related illnesses and deaths are typically preventable. The public health system
can mitigate the potential for illness and death secondary to extreme heat events by
implementing a number of measures. Alert systems can be activated that provide early
warnings of the expected extreme heat to the public and emphasize the potential health
risks and how to avoid them. Public cooling centers or air-conditioned shelters can be
established, taking care to target their use towards those most at risk in the population.

At a building design level, policies should include comfortable cooling, adequate ventilation,
and mechanical aids to assist radiant and convective heat loss. Indoor workplaces may
be cooled by using air conditioning or increased ventilation. Other methods to reduce
indoor temperature include providing reflective shields to redirect radiant heat, insulating
hot surfaces, and decreasing water vapor pressure, e.g., by sealing steam leaks and
keeping floors dry. The use of fans to increase the air speed over the worker will improve
heat exchange between skin and air, unless the air temperature is higher than skin
temperature.

Public education regarding the need to take “heat breaks”, away from the hot environment
and getting into air-conditioned areas from time to time is important. Heat breaks in an
air-conditioned area for a short period of 2 hours a day can decrease the rate of heat
stroke. Drinking plenty of water during hot weather is important. Dehydration of as little
as one percent can impair heat dissipation.

73
 Besides that, parents need to be educated too regarding the child's safety of not leaving
their children unattended inside the car under a hot environment. Individuals can take
precautions against heat-related illness by wearing light-colored and lightweight clothing,
staying inside a cool environment during the hottest hours of the day, ensuring adequate
fluid intake, and avoiding alcohol intake.

For occupational and athletic pursuits that may increase risk of heat-related illness,
recommendations include institution of pre-event medical examinations, provision
of adequate cool rest areas and fluids, and modification of the work-rest or exercise-
rest cycle to adapt to higher outdoor temperatures. An important point is protecting the
disaster workforce from heat-related illness. The austere and challenging environmental
conditions and the use of PPE may contribute to the onset of heat-related illness in
this group during many typical response scenarios. Continual monitoring and preventive
action steps should always be implemented.

4.6 Wildfires and Haze

In Southeast Asia, wildfires and haze have always been a major source of air pollution.
Bushfires arising from illegal slash-and-burn operations, mostly on the Indonesian islands
of Sumatra and Kalimantan, are primarily to blame for the haze (Figure 4.10). Several
countries in the ASEAN region, including Malaysia, Indonesia, Brunei, Singapore,
Southern Thailand, Vietnam, and the Philippines are affected which leads into an
international crisis.

Indonesia ratified the ASEAN Agreement on Transboundary Haze Pollution in September

2014. The agreement requires Indonesia to take measures to address the issue on its
own or with foreign assistance, or risk legal action depending on the haze's effect on its
Southeast Asian neighbors.

Figure 4.10 Wildfires in the forest in Indonesia

74 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 4.6.1 Causes and Characteristics

Wildfires occur because of either human actions or natural events. Human causes are
more common and include slash-and-burn practices, faulty machinery releasing sparks,
discarded cigarettes, burning of leaves, downed power lines, and destruction of forest
lands. Natural causes of wildfires include lighting strikes (most common), volcanic activity,
falling rocks (causing sparks), spontaneous combustion, and coal seam fires.

In Southeast Asia, wildfires are mainly caused by firms and farmers engaging in illegal
slash-and-burn practices as a relatively inexpensive means to clear their land of unwanted
vegetation and peat. Sumatra and Kalimantan possess large areas of peatland, which
is highly combustible during the dry season. The haze has been more severe in 2015
due to the El Niño phenomenon, which has caused drier conditions, allowing the fires to
spread more.

4.6.2 Early Detection and Warning Systems

Early warning systems can mitigate fire-related problems and escalating fire suppression
costs. Fire danger rating based on daily weather information is commonly used to provide
early warning of the potential for serious wildfires. The rating is often determined on the
basis of satellite data, such as hot spots for early fire detection, with spectral data on land
cover and fuel conditions. Fire danger rating systems can provide a 4- to 6-hour warning
of the highest fire danger for any day for which the weather data is supplied. However, by
using forecasted conditions from advanced numerical weather models, extended early
warning (i.e., 1 to 2 weeks) can be provided.

4.6.3 Acute Hazards and Effects

Wildland firefighters work at enormous risk to personal safety, and there has been much
research indicating their high rates of morbidity and mortality. As with all firefighters, physical
fitness and comorbid conditions are factors. The threat of fatal and severe thermal burn
injury is ever-present. The environmental issues (e.g., wind direction changes, continued
dry ambient conditions) remain prominent in hazard risk assessment. Smoke inhalation
and asphyxia are issues, as many firefighters may not use a self-contained breathing
apparatus. Some will use particulate masks (or just a wet bandana over their mouths),
and there is a risk of longer exposure periods for firefighters who work 12-hour shifts for
several days and spend rest periods in smoke-filled base camps. Close monitoring of the
air quality index (Table 4.6) should be emphasized at the surrounding area.

75
 Air Quality Index
Numerical
Levels of Health Meaning
Value
Concern
Air quality is considered satisfactory, and air pollution poses little
Good 0 to 50
or no risk.

Air quality is acceptable; however, for some pollutants there may be

Moderate 51 to 100 a moderate health concern for a very small number of people who
are unusually sensitive to air pollution.

Unhealthy for Members of sensitive groups may experience health effects. The
101 to 150
Sensitive Groups general public is not likely to be affected.

Everyone may begin to experience health effects; members of

Unhealthy 151 to 200
sensitive groups may experience more serious health effects.

Health warnings of emergency conditions. The entire population

Very Unhealthy 201 to 300
is more likely to be affected.

Hazardous 301 to 500 Health alert: everyone may experience more serious health effects.

Table 4.6 Level of air quality index

4.6.4 Clinical Implications

A variety of injury patterns are seen by healthcare providers when humans come in
contact with wildland fires. Civilians and wildfire firefighters are both at risk of smoke and
dust exposure with subsequent respiratory complaints, exposure to toxic combustion
products (CO, cyanide, and hydrochloride acid), thermal injuries (burns), bites and stings
from wild animal contact, heat and cold stresses, psychological stressors, exhaustion,
eye complaints, dehydration, musculoskeletal injuries, lacerations, and trauma from
many sources including falls and automobile/traffic-related incidents. Causes of wildfire-
related death included burn-over, acute coronary syndrome, motor vehicle crashes and
snags (fallen branches) (4%).

Civilians are more prone to other injury patterns as well, depending on whether they
evacuated or attempted to fight fires while protecting their homes. One specific respiratory
issue to contend with is contact with superheated air. This can lead to facial burns, nasal
hair singeing, facial edema, stridor, and respiratory distress. If a person was trapped in
a burning area, injuries could be more severe. Also, morbidity can be delayed for up to
24 hours. Direct visualisation of larynx and early intubation are advised in patients with
respiratory distress.

Heat stress and thermal injuries are also common sources of morbidity and mortality. Heat
stress can occur because of environmental issues, less water consumed than lost, and
exertion of physical stress. Heat cramps and heat exhaustion are common; symptoms
include fatigue, dizziness, weakness, vomiting, headache, and cramps.

76 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

As core temperature rises and central nervous system (CNS) involvement occurs, heat
stroke, rhabdomyolysis, and renal failure become problems. Treatment consists of cooling
and correcting water deficits as described in earlier part of this chapter.

4.7.5 Public Health Considerations

Injury patterns are not limited to the period directly following exposure. Long-term
implications can include exacerbation of chronic illnesses and issues with medical
infrastructure disruptions (e.g., dialysis clinic closed). Smoke contains carbon monoxide
(CO), aldehydes, and other compounds that cause local airway irritation. Prolonged
exposure can be a health issue, particularly at higher altitudes. Apart from that, mental
health services were also one of the most frequently identified healthcare needs that
were lacking. Following the wildfires and haze, there is always a rise in the number of
admissions due to respiratory illnesses.

A study assessed the health impacts of transboundary smoke haze pollution in Kuala
Lumpur and adjacent areas in the state of Selangor, Malaysia. Collected data from 2005,
2006, 2008, and 2009 for 14 haze-related illnesses from four hospitals shown that on
average, there were 19 hazy days each year during which the air pollution levels were
within the Lower Moderate to Hazardous categories. A smoke haze occurrence was
associated with an increase in inpatient cases by 2.4 per 10,000 populations, representing
an increase of 31% from normal days.

4.7.6 Prevention and Mitigation

Wildfire management consists of multiple activities existing at the urban-wildland interface.

Behind-the-scenes activities include jurisdictional bathers, mutual aid agreements, zoning,
legal mandates, building codes, insurance, environmental actions, and public education.
These strategies can roughly be divided into three categories (which have varied over the
years): prevention (including controlled burns), detection, and suppression. Controlled
burns reduce fuel levels and create buffer strips or firebreaks.

Individuals and local communities can set firebreaks around houses/buildings, not storing
potential fire fuels (farm machine fuel, dry firewood) next to housing, cleaning gutters
and leaves, developing personal fire plans, involvement of local emergency managers,
evacuation and traffic management planning, and continuation of normal EMS and
healthcare services as people are displaced. Public education can be done through
social media (Figure 4.11) to create awareness in the community. During the period of
haze, free face masks should be distributed to residents in areas worst affected by the
haze. When the air pollution index (API) > 200, schools will be closed. Cloud seeding
needs to be conducted to reduce the air pollution and put off wildfires.

77
 HIGH-RISK GROUPS
Persistent haze will have adverse effects on everyone especially children, the elderly, pregnant women,
heart & respiratory patients as well as those who are sensitive to dust, smokers and those who work
outside the office or home
API LEVEL OF PREVENTION & API LEVEL OF PREVENTION &
READINGS POLLUTION CONTROL READINGS POLLUTION CONTROL
0-50 Low & not a • There is no activity 201-300 High, affecting • Stay indoors, refrain
Good health hazard restriction for all Very people’s from doing outdoor
groups Unhealthy health & can activities
• Practise a healthy exacerbate • Wear mask when
lifestyle the symptoms going out
experienced • Those who are unwell
51-100 Moderate & by those at should consult a
Moderate usually does high risk doctor
not endanger • National Operations
public health Room is open during
office hours or
according to the
101-200 May affect the • Reduce outdoor directive of the
Unhealthy health of activities (Health) Steering
individuals at • Wear mask when Committee
high risk going out • Drink lots of water
• Regularly wash face
& parts of the body
exposed to haze

301-400 Very high & • Stay indoors

Hazardous dangerous • Always wash face &
to health parts of the body
401-500 exposed to haze with
Hazardous clean water
• Wear mask when
going out

Over 500 Extremely • Similar measures as

HEALTH ADVICE
Haze high & for API level 301-400
Emergency dangerous • Follow the instructions
to health of the National

DURING HAZE
Security Council &
developments on haze
through the media

Figure 4.13 Healthcare advice during haze by Ministry of Health, Malaysia

4.7 Earthquakes and Tsunamis

Earthquakes are one of nature's most powerful and potentially destructive events.
When it happens in the oceans or rivers, there is often the possibility of massive water
displacements, which can result in a tsunami.

Every year, around 500 000 earthquakes occur around the world, with just around 20%
of them being felt. The potential for catastrophe arises only where an earthquake or its
subsequent tsunami occurs in a location that causes destruction or loss of life.

The number of earthquakes that do cause significant damage is increasing yearly. In

2009, there were 91 earthquakes that affected large populations and had magnitudes
greater than 5.9 on the Richter scale (Figure 4.12). Of these, 28 generated tsunamis.
The 2010 Haiti earthquake measuring 7.0 Richter scale is estimated to have caused
more than 200,000 deaths and many more injuries. The 2011 Japan earthquake with
an estimated magnitude of 9.0 on the Richter scale and the associated tsunami have
caused more than 12,000 deaths, with as many or more people still unaccounted for.

78 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Richter Scale of Earthquake Energy
Each level is 10 times stronger than the previous level

Description Occurrence In Population Movement

1 Small Daily Every minute Small

2 Small Daily Every hour Small

3 Small Daily Every day Small

4 Small Daily Every week Moderate sudden

5 Moderate Monthly Every 10 years Strong sudden

6 Moderate Monthly Every 30 years Strong sudden

7 Major Monthly Every 50 years Severe sudden

8 Great Yearly Every 100 years Very Severe

9 Great Yearly Every 300 years Very Severe

10 Super Rarely Every 1000 years Extreme

Earthquake magnitude scale

8.0 or greater
Great earthquake that can totally
destroy communities near its epicenter
Great (8)
7.0 to 7.9
Major earthquake causing
serious damage
Major (7)
6.1 to 6.9
May cause major damage in
populated areas
Strong (6)
5.5 to 6.0
Slight damage to buildings

Moderate (5)

2.5 to 5.4
Light (4) Often felt, but only causes
minor damage

Minor (3)

2.5 or less
Usually not felt but can be
recorded by seismograph

Figure 4.12 Richter scale of earthquake energy

79
 4.7.1 Causes and Characteristics

One widely cited method to explain the phenomenon that triggers an earthquake's energy
release is the elastic-rebound theory. The Richter scale and the moment magnitude
scale (MiVIS) are two widely used scales to describe the strength of an earthquake. Both
scales, though, are logarithmic and vary from 0 to 10. A rise of one "point" on either scale
corresponds to a 10-fold increase in the earthquake's shaking amplitude.

Earthquakes with a magnitude of 6.0 or higher are commonly considered major

earthquakes with the ability to cause extensive destruction. In the globe, 70 to 75
destructive earthquakes occur each year. From Japan to Indonesia, the Asian Pacific
Rim, also known as the Ring of Fire, is the world's most seismically active area. Malaysia,
thankfully, is not in this active zone.

Tsunamis are caused by the displacement of huge quantities of ocean or sea water, and
are normally caused by undersea earthquakes (Figure 4.13). Tsunamis are most common
during subduction zone earthquakes, which occur as one plate shifts vertically relative to
the other. At the epicenter of the earthquake, this vertical displacement displaces a huge
amount of water. As the displacement enters deeper water, however, the wave's crest
will build to several metres in height. A "drawback," or a negative movement of water,
frequently precedes a tsunami's increase in sea level, revealing parts of shoreline that
are usually submerged.

Individual waves in a tsunami are spread out: The distance between two wave
peaks, called the wavelength, can be hundreds of kilometers long. Each
wave’s amplitude, or height, is rarely more than 0.9 meters (3 feet) at first.

An underwater earthquake occurs; the

seafloor snaps up,lifting a column of
water above it. Gravity pulls the water
back down, fanning waves outward.

As waves meet the continental

1 slope and shallower water,
wavelength decreases and
wave amplitude rises.

Figure 4.13 Formation of tsunami

80 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

The majority of tsunamis occur in the Pacific Ocean. The destruction caused by tsunamis
is related both to the height of the actual tidal wave and to the subsequent rise in sea
level, which can cause devastating flooding in heavily populated coastal areas. This was
demonstrated dramatically during the 2011 Japan earthquake and tsunami, which at the
time of this writing was responsible for an estimated 20,000 deaths.

4.7.2 Early Detection and Warning Systems

Many earthquakes occur with little to no notice, and they can happen at any time of
year or day. Despite ongoing monitoring of seismic activity and geological features, the
potential to anticipate or diagnose a large earthquake in order to alert communities and
minimize its impact is minimal. Preventing loss of life can become more realistic in the
future as our knowledge of how to forecast earthquake timing and location improves. At
the moment, though, the only feasible way to minimize the effects of earthquakes is to
amend building codes and strengthen land use and engineering regulations.

Tsunamis lend themselves more readily to warning and alert systems because they
are activated and followed by other geologic activities. Tsunami warning systems use
seismographs to track earthquakes and then use the information to alert people about
the possibility of a tsunami. Although tsunami waves can reach speeds of up to 1000
km/h, seismic waves can reach speeds of over 14,000 km/h. As a consequence, an
earthquake can be detected before a tsunami arrives.

This prediction of seismic activity is supplemented by tracking of conditions at sea using

advanced buoy devices, such as the Deep Ocean Assessment and Reporting of Tsunamis
([Link] in a full tsunami warning and response scheme. Both
ocean surface portion that monitors sea levels and ocean floor pressure sensors are
used in these buoys. Unfortunately, it is difficult to determine which earthquakes can
cause tsunamis with 100% accuracy. As a result, these programs generate a significant
number of false positive warnings.

Naturally, an appropriate alert system must be capable of not only detecting earthquakes
and tsunamis, but also communicating the threat to at-risk communities. In the Northeast
Atlantic, Mediterranean, and related seas, there are many regional and international alert
systems, including the Pacific Tsunami Warning System, Indian Ocean Tsunami Warning
System, and Tsunami Early Warning and Mitigation System.

4.7.3 Acute Hazards and Effects

In addition to the physical damage to buildings and other facilities, earthquake forces
destroy gas lines, power grids, water sources, networks, and other infrastructure materials.
Such natural disasters, such as earthquakes, landslides, avalanches, tsunamis, and
events involving human-made infrastructure, may be triggered by these major geologic
energy releases (e.g., fires, leaking of toxic materials, and downed electrical wires).
After any earthquake that strikes near a human population center, these examples of
secondary disasters are a major worry.

81
 4.7.4 Clinical Implications

Healthcare demand is strongest in the hours and days after an earthquake, with reports
indicating peaks between 12 hours and 3 days after the incident. The extremely young
and the elderly are most likely to be seriously injured, according to data from the 1995
earthquake in Nishinomiya, Japan, and the 1999 earthquake in Taiwan. The data also
suggests that people with pre-existing conditions are more likely to be injured, perhaps
due to their failure to evacuate falling buildings easily or efficiently free themselves.

Malaysia is located out of the active earthquake zone. However, recently Ranau, Sabah
state was struck by an earthquake in June 2015 with a magnitude of 6.0 Richter which
lasted for 30 seconds. A total of 187 climbers of Mount Kinabalu were impacted in which
137 victims were stranded but subsequently rescued (Figure 4.14). Eighteen fatalities
were reported, all occurring on Mount Kinabalu, including nine Singaporeans, six
Malaysians, and three miscellaneous nationals.

Figure 4.14 Search and rescue at Mount Kinabalu after the Sabah earthquake in 2015

In many instances, healthcare infrastructure has been damaged and therefore cannot
be relied on to provide aid for casualties. If local hospitals are still operational after an
earthquake, emergency departments are likely to see a surge of patients within the first
24 to 48 hours after the event, highlighting the need for patient surge planning at medical
centers that may be involved in disaster response. The common surgical procedures
were fasciotomy, tube thoracostomy, and open reduction with internal fixation. In addition
to orthopedic injuries, hypothermia and other forms of exposure injury may be prevalent
after an earthquake.

Care for earthquake casualties in the immediate situation typically focuses on orthopedic
and soft tissue trauma, including wound care, operative and closed management of
fractures. Due to typical increase in prevalence of head injuries and high demand of
surgical intervention, neurosurgeons and anesthetists are also important in the post-
earthquake medical care. Deep sedation for surgical procedures and pain management
with narcotic medication are important elements of care to earthquake injuries.

82 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

In the period immediately after an earthquake, crush injuries, long-bone fractures, head
trauma, and superficial injuries such as lacerations and contusions predominate. Most of
these injuries are caused by collapsing structures.

Crush injuries are one of the most common types of injury after an earthquake. Crush
syndrome is a specific, complicated pathophysiologic condition precipitated by reperfusion
of crushed tissue and release of potassium, myoglobin, and other intracellular molecules
and electrolytes.

Asphyxiation from dust and debris created by the collapse of structures has also been
hypothesized to be a significant cause of mortality after earthquakes, especially among
those trapped in collapsed structures. This is supported by findings of oropharyngeal
soot identified in the bodies of many casualties in the Armenian earthquake.

Length of time trapped also affects survival probability. A study of mortality after the 1980
southern Italy earthquake suggests that the probability of live rescue drops from 87.9%
on the day of the earthquake to 35.3% 24 hours after the event to nearly 0% at 4 days out.
Most successful rescues were made immediately after the earthquake, in many cases by
ordinary people using unsophisticated means of extrication.

4.7.5 Public Health Considerations

Health effects of the event can last for weeks or months. Several studies suggest
that exacerbation of chronic disease, often untreated in the immediate aftermath of
earthquakes is an important contributor to morbidity and mortality in displaced population.

In a study of patients presenting to a Red Cross hospital in Banda Aceh, Indonesia,

after the 2004 tsunami, 21% of cases seen in a 2-week period beginning 22 days after
the tsunami were related to respiratory disease, 17% were related to a variety of chronic
illnesses, 9.8% were related to trauma, and 9% were related to gastrointestinal complaints.
This corroborates that within 1 to 2 weeks after the tsunami or earthquake, infectious
disease complaints and conditions related to chronic illness will begin to account for the
bulk of new patient consultations and that traumatic injury will remain an important source
of illness for some time.

One study suggests that those living in temporary shelters were almost 1.7 times as likely
to seek care as those living in permanent shelters. The health needs of people in smaller,
less organized temporary camps are generally greater than those of people living in
larger, better organized systems of dwellings.

Earthquakes also produce significant psychological effects in the populations that

experience them. After the 2007 earthquake in Pisco, Peru, more than 25% of one study
population exhibited symptoms of post-traumatic stress disorder (PTSD). These data
emphasize the need for psychological first aid (PFA) as parts of effective earthquake
response.

83
 4.7.6 Prevention and Mitigation

To render structures more earthquake-prone, a range of methods are used. The capacity
of a substance to deform to a considerable degree until collapsing is critical to building
safety. The use of reinforced concrete, which is concrete with steel beams inserted in
the slabs, is the most basic measure to minimize earthquake risk. The significant loss of
life witnessed in the 2010 Haiti earthquake is believed to be due to a breach of building
codes and the infrequent use of reinforced concrete in home construction.

Base separation, which is the decoupling of a building's above-ground superstructure

from its floor, and vibration dampening, which aims to reduce building movement by
balancing the structure's weight transfer, are two sophisticated innovations. By allowing
versatility between the building framework and the foundation, base isolation eliminates
ground disturbance propagation through the building. To minimize the total movement of
the structure, one type of vibration dampening employs large pendulums in the interior of
the building that travel in the opposite direction of the rest of the structure.

4.8 Storm, Hurricanes, Cyclones and Typhoons

Hurricanes, cyclones, and typhoons are subcategories of a rapidly spinning storm system
with a low-pressure core, high winds, and a spiral arrangement of thunderstorms that
bring heavy rain (Figure 4.15). Cyclones are named after them in the Indian Ocean;
typhoons are named after them in the Western Pacific; and hurricanes are named after
them in the Atlantic and Eastern Pacific Oceans.

Source: [Link]
Figure 4.15 Formation of hurricane/storm

84 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Typhoons and storms are among nature's most damaging and dangerous occurrences,
capable of causing severe injury, destruction, and significant property and infrastructure
harm. Between 1900 and 2004, 77 hurricanes affected the planet, each killing at least
1000 people. Developing nations bear the brunt of the death toll, with 50 of the storms
hitting Southeast Asia and another 15 hitting the Caribbean and Central America.

Malaysia, especially the northern region of the peninsula has been struck several times
by local tropical storms such as Tropical Storm Kai-Tak in 2017 and Tropical Storm Pabuk
in 2019. One person was killed by drowning in Malaysia due to Storm Pabuk. Elsewhere,
many tourists were forced to evacuate coastal areas of Thailand and Storm Pabuk killed
8 people in Thailand (3 of the victims were killed by flying debris and the storm surge).
Storm Pabuk’s damage in Thailand was estimated to be US$156 million. Generally, this
rapidly rotating storm system may cause strong winds, rough seas, stop of ferry services,
continuous rainfall, floods and landslides. Even just the tail end of the Typhoon Lekima
that struck Thailand in August 2019 has caused a massive destruction of up to 2000
homes, schools and building damage in Kedah state.

4.8.1 Causes and Characteristics

According to the Saffir-Simpson scale, hurricane intensity and magnitude are rated
from 1 to 5. For each one-point rise on this scale, the damage sustained by a hurricane
increases by around four times. On this scale, hurricane categories are measured by
wind speeds ranging from up to 95 miles per hour for category 1 to more than 155 miles
per hour for category 5. Significant hurricanes are those of a category of 3, 4 or 5. In
general, more extreme category 5 storms do more damage, but even less strong "tropical
depressions" and "tropical storms" can be devastating, owing to the floods, landslides,
and torrential rain that occur, rather than the high wind speeds and storied winds.

4.8.2 Early Detection and Warning Systems

Most of the deaths caused by storm surge may have been preventable today through the
use of hurricane warning systems. There are six Regional Specialized Meteorological
Centers (RSMCs) worldwide as shown in Table 4.7. These organisations are designated
by the World Meteorological Organisation and are responsible for tracking and issuing
bulletins, warnings, and advisories about tropical cyclones in their designated areas of
responsibility. In addition, there are six Tropical Cyclone Warning Centers (TCWCs) that
provide information to smaller regions. These services use a variety of detection and
monitoring technology to monitor and predict storms, including satellite images and land-
based Doppler radar. These prediction systems have drastically reduced morbidity and
mortality caused by hurricanes.

85
86
AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT
Figure 4.16 Tropical cyclone centers and their regions
(Image courtesy of the World Meteorological Organisation)

Source: [Link]
 Table 4.7 List of Regional Specialized Meteorological Centers (RSMCs)

Region Description Links to Centers (RSMC and TCWC)

Atlantic and Eastern

I-II U.S. National Hurricane Center (RSMC Miami)
Pacific

U.S. Central Pacific Hurricane Center (RSMC

III Central Pacific
Honolulu)

IV Northwest Pacific Japan Meteorological Agency (RSMC Tokyo)

India Meteorological Department (RSMC New

V North Indian Ocean
Delhi)

Southwest Indian
VI Météo France (RSMC La Réunion)
Ocean

VII: Australian Bureau of Meteorology (TCWC

Perth)
Southwest Pacific and VIII: Indonesian Agency for Meteorology (TCWC
Southeast Indian Jakarta)
VII-XI
Ocean IX: Australian Bureau of Meteorology (TCWC
Darwin)
X: Papua New Guinea (TCWC Port Moresby)
XI: Australian Bureau of Meteorology

XII: Fiji Meteorological Service (RSMC Nadi)

XII-XIII South Pacific XIII: Meteorological Service of New Zealand, Ltd.
(TCWC Wellington)

Source: [Link]

In Malaysia, the public can easily access the Malaysian Meteorological Department
official website ([Link] Figure 4.17) or through the handphone
application to get the latest update on the weather forecast, cyclone or storm warning
alert as well as strong wind, rough sea, earthquake or tsunami forecast or update. A good
monitoring and detection system can forecast accurately; an early warning system can
alert the community to do early preparation and mitigation plans to reduce the impact or
damage caused by a storm.

87
 Figure 4.17 Official website of Malaysian Meteorological Department

4.8.3 Acute Hazards and Effects

Tropical cyclones or storms out at sea cause large waves, heavy rain, flood and high
winds, disrupting international shipping and, at times, causing shipwrecks. On land, strong
winds can damage or destroy vehicles, buildings, bridges, and other outside objects,
turning loose debris into deadly flying projectiles. The storm surge, or the increase in sea
level due to the cyclone, is typically the worst effect from landfalling tropical cyclones,
historically resulting in 90% of tropical cyclone deaths. The broad rotation of a landfalling
tropical cyclone, and vertical wind shear at its periphery, spawns tornadoes.

Over the past two centuries, tropical cyclones have been responsible for the deaths of
about 1.9 million people worldwide. Large areas of standing water caused by flooding
lead to infection, as well as contributing to mosquito-borne illnesses. Crowded evacuees
in shelters increase the risk of disease propagation. Tropical cyclones significantly
interrupt infrastructure, leading to power outages, bridge destruction, and the hampering
of reconstruction efforts.

In general, the effects of hurricanes are not limited to the morbidity and mortality directly
attributable to the storm itself. In the days and weeks afterward, flooding can cause
large standing pools of water, which contribute to the spread of waterborne and vector-
borne illnesses. Crowding in shelters can lead to a poor standard of health and increased
transmission of disease. Massive damage to infrastructure and widespread displacement
of people from their homes and jobs can make it difficult to rebuild, greatly affecting the
recovery process of the community, families, and individuals.

88 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 4.8.4 Clinical Implications

Studies of hurricane morbidity and mortality note that most injuries are associated with
structural hazards such as downed power lines and motor vehicle accidents. A study
of cause of death during the 2004 and 2005 hurricane seasons in Florida showed that,
despite the violent winds and storm surge associated with the landfall of hurricanes, only
31% of deaths occurred during the actual impact phase of storms, while the post-impact
phase accounted for 60%. Importantly, elderly people, especially those 75 years and
older, were more likely to be storm victims.

Clinical management of casualties in the acutely affected communities is the initial

concern. In preparing to care for these individuals, it is vital to understand injury and
mortality patterns to design interventions and plan responses. Analysis of presentations
to emergency departments and Disaster Medical Assistance Team (DMAT) service
locations in Mississippi after Hurricane Katrina found that the greatest proportion of
presentations were for traumatic injuries, accounting for 21.8% of visits. Of these, most
(91.6%) were for minor injuries such as lacerations and contusions. The most common
illnesses identified in this study were skin and wound infections, respiratory infections,
rashes, and gastrointestinal complaints.

The most common complaint during the first three days was wound management;
however, also seen were acute gastrointestinal illness and acute exacerbations of
chronic illness, notably from asthma, diabetes mellitus, and cardiovascular disorders. In
this setting, management of chronic disease was also an important part of the medical
response in many locations. Hypothermia and exposure-related illness is another
important consideration after hurricanes.

Clinical management of sheltered populations is an important consideration after

evacuation for hurricanes. Because of the potential for massive infrastructure damage,
individuals may be displaced for long periods of time, and the local healthcare infrastructure
may be too badly damaged to continue caring for them.

4.8.5 Public Health Considerations

Few studies done demonstrated that the true impact of a storm or hurricane is often
a long-term public health emergency. As with other disasters, excess morbidity and
mortality due to cardiovascular disease has been observed after hurricanes and likely
contributes to long-term increased mortality. The need for medical intervention for this
type of illness is another important component of disaster medical response.

Growing body of literature supports the inclusion of and focuses on care of psychological
and mental health illness after disasters. Studies of people living in the United States
after Hurricane Katrina have found that more than half of those surveyed reported mental
health distress as long as 2 years after the disaster. These figures suggest that disaster
responders will benefit from familiarity with psychological first aid (111A) or other acute
counseling and mental healthcare techniques.

89
 As other disasters, hurricanes involve displacement of water and have a risk of large-
scale infectious disease outbreaks especially endemic vector-borne disease. Specifically,
in tropical areas where diseases such as malaria and dengue fever are already endemic,
several studies have shown that hurricanes can increase the burden of these diseases
dramatically. One such example was Hurricane Flora, which is estimated to have
contributed to 75,000 additional cases of malaria above baseline in Haiti in 1963 and
1964.

4.9.6 Prevention and Mitigation

Early warning systems can effectively predict storm or hurricane landfall and intensity.
Proper planning for evacuation and response are critical to minimize injury and loss of
life. Clearly marked evacuation routes, evacuation drills, and awareness of the general
public of routes, warning sirens, and emergency shelter locations will help to mitigate
morbidity and mortality associated with these storms.

4.10 Summary

Natural disasters are the most common type of disaster that happens in our country.
Even though it is short-lived, it has a high probability to turn into secondary public health
emergencies, such as infectious diseases and social facility systems or structural failure
which leads to loss of basic utilities.

Early detection and warning systems are important to understand causes and character
of natural disaster impact thus help responders to anticipate clinical implications and
reduce severity of incident.

As per public health concern, natural disaster is a transformative event in designing

prevention and mitigation plans, thus bridging opportunities to build new and more
sustainable relationships between people and their environment in the aftermath of
disaster.

90 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Bibliography

National Disaster Life Support. Basic Disaster Life Support Course Manual 3.0. 2012.

Mohamed Shaluf, I. & Ahmadun, F.R., 2006. Disaster types in malaysia: An overview.
Disaster Prevention and Management: An International Journal, 15(2), pp.286–298.

Disaster Statistics - Asia – Malaysia – Asia – Countries & Regions

<[Link]

Malaysia Natural Disaster Profile.

<[Link]
pdf>

44 Statement by H.E. Tran Sri Muhyiddin Mohd Yassin Deputy Prime Minister Head of
Delegation Malaysia, to the Third United Nations World Conference on Disaster Risk
Reduction.
<[Link]
pdf>

Floods Hit North-East Malaysia. ABC News online. Posted 26 Dec 2012, 4:50pm
<[Link]
[Link]/>Disaster Prevention and Management, Vol. 23 No. 4,
2014 pp. 455-468.

Clinical Guidelines on Management of Heat Related Illness at Health Clinic and

Emergency and Trauma Department, Ministry of Health, Malaysia, March 2016.

Indonesian haze: Why do forests keep burning? Posted 16 September 2019

<[Link]

Ragan P, Schulte J, Nelson S, Jones K. Mortality surveillance 2004 to 2005 Florida

Hurricane related deaths. Am J Forensic Med Pathol. 2008; 29:148-153.

Brunkar J, Namulnada G, Ratard R. Hurricane Katrina deaths, Louisiana. Disaster Med

Public Health Prep. 2005; 2:215-223.

Baxter PJ, Aspinall WP, Neri A, et al. Emergency planning and mitigation at Vesuvius: A
new evidence-based approach.

91
 CHAPTER
5
CHEMICAL DISASTERS
 CHAPTER 5
CHEMICAL DISASTERS

Case scenario:

HOW
March 6
Chemical
CHEMICAL
March 7
103 victims
dumped
DUMPING
affected
March 11
106 victims Pasir Gudang

March 12
260 victims March 13
506 total victims
All 111 schools in
Pasir Gudang closed

Chemical Spill in Sungai Kim Kim, Johor (March 2019)

On the morning of 7 March 2019, a lorry tanker dumped approximately 2.5

tonnes of chemical waste into Sungai Kim Kim. In the same morning, 35 people
- mostly students - were sent to hospital with complaints of breathing difficulties
after being exposed to an unpleasant odor in their school compound. Two
schools near the site were closed. The tally of victims spiralled alarmingly, and
within a week more than 2,700 people were reported to have fallen ill. Victims
complained of nausea, shortness of breath and vomiting spells. Hundreds of
them needed immediate medical attention and had to be rushed to hospital.
111 schools in the Pasir Gudang district were closed. Several first responders
were admitted to the hospital, including an ambulance driver who required
ICU admission. Officials had identified at least 15 different types of chemicals
- included the colourless and extremely poisonous hydrogen cyanide – which
were found in the heavily polluted river.

1. What is the role of the local and state council in response to this
environmental crisis?

2. How did this incident affect the local population and healthcare providers
in this region?

3. What are the lessons learned from this incident?

93
 5.1 Background

Chemical emergencies usually involve unintentional exposure to toxic industrial

chemicals in various manufacturing and maintenance facilities. It can also entail
chemical weapons that have been developed, although they have been prohibited
under international law.

Possible clues of a chemical involvement

•• Rapid onset of symptoms

•• Unexplained illness in previously healthy individuals
•• Unusual increase in the number of individuals seeking medical care
•• The presence of an odor or vapors at the scene
•• Presence of odors from ill individuals
•• Clusters of illness in individuals who have common characteristics
•• Unexplained death of plants, fish or animals
•• Sudden unexplained weakness, collapse, apnea or convulsions in
previously healthy individuals
•• Blurring of vision
•• Hypersecretions syndrome
•• Inhalation syndrome
•• Burn-like syndromes

Detection of some of these chemicals can be done using sophisticated devices by the
Hazardous Materials (HAZMAT) response teams. Examples of these devices include
multi-gas meters, oxygen sensing equipment, combustible gas indicators, radiation
detectors, photoionisation detectors and special chemical detectors.

These devices are however not 100% accurate. Clinical judgement and scene assessment
are still important in helping to determine the chemical involved.

These specific chemicals are regarded as potential agents of terrorism. However, they
can also be a hazard through unintentional industrial and transportation related disasters.

94 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 5.2 Clinical Management

These agents are categorised by their general mechanism of action:

1. Choking agents
Choking agents are chemical weapon agents designed to impede a victim's ability
to breathe. They operate by causing a build-up of fluids in the lungs, which then
leads to suffocation. Exposure to the eyes and skin tends to be corrosive, causing
blurred vision and severe deep burns. Inhalation of these agents causes burning
of the throat, coughing, vomiting, headache, chest tightness, chest pain, and
respiratory and circulatory failure.

(i) Chlorine
Chlorine is an industrial chemical, used to make pesticides, rubber, and
solvents. It was used in World War 1.

(ii) Phosgene
It is an odorless gas. It is the most dangerous choking agent used. It is
denser than air, so it stays in the air longer. It causes massive pulmonary
edema, with maximal effect after 12 hours.

2. Blister agents
Are substances that cause chemical burns resulting in painful water blisters on the
affected areas. They can also cause tearing, conjunctivitis and corneal damage

(i) Sulphur mustards

A family of sulfur-based agents, including mustard gas.

(ii) Nitrogen mustards

A family of agents similar to sulphur mustards but based on nitrogen.

(iii) Lewisite
A blister agent that was developed during World War 1 but was never used.

95
 3. Blood agents
Blood agents are substances that affect the body by being absorbed into the blood.
They can either be inhaled or ingested. They are usually disseminated as aerosols
in chemical weapons.

(i) Cyanide
The symptoms of blood agent poisoning depend on concentration and
duration. Exposure to small amounts of cyanide has no effect. Higher
concentrations cause dizziness, weakness and nausea, which cease with
the exposure, but long-time exposure can cause mild symptoms followed
by permanent brain damage and muscle paralysis. Moderate exposure
causes stronger and longer-lasting symptoms, including headache, that
can be followed by convulsions and coma. Stronger or longer exposure will
also lead to convulsions and coma. Very strong exposure causes severe
toxic effects within seconds, and rapid death.

4. Nerve agents
They are a group of chemicals that disrupt nerve conduction by disrupting the
function of acetylcholinesterase at the nerve endings of the affected individuals.
Poisoning by a nerve agent leads to constriction of pupils, profuse salivation,
convulsions, and involuntary urination and defecation, with the first symptoms
appearing in seconds after exposure. Death by asphyxiation or cardiac arrest may
follow in minutes due to the loss of the body's control over respiratory and other
muscles.

(i) Sarin
It is an extremely toxic synthetic organophosphorus compound. It was used
in the Tokyo subway attack in 1995 by the group Aum Shinrikyo.

(ii) VX
VX is an extremely toxic synthetic chemical compound in the
organophosphorus class. It was developed for military use in chemical
warfare after translation of earlier discoveries of organophosphate toxicity
in pesticide research.

96 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 5.3 Clinical Management

Different chemical agents require different ways to manage. Table 5.1 shows the clinical
management of selected chemical agents.

Table 5.1 Selected chemical agents and ways to manage them

Mechanism of Clinical
Chemical action findings
Decontamination Management

Nerve agent: Anticholinesterase: Cholinergic crisis Vapor: Do not delay antidotal

Tabun (GA) Muscarinic, with either: Move to fresh air therapy if nerve agent
Sarin (GB) nicotinic and CNS a) Sudden collapse, Remove clothes Wash exposure is suspected:
Soman (GD) effects coma, apnea, and hair
Cyclosarin (GF) convulsions Mild effects: Atropine
VX(0-ethyl S-[2- OR Liquid: Moderate effects:
(diisopropylamino)ethyl] b) Progression from Remove clothes Use Atropine5 and pralidoxime
methylphosphonothioate) local effects (see Reactive Skin Severe effects: Atropine,
below) to Decontamination Liquid pralidoxime, and a
generalized for spot benzodiazepine (eg,
systemic effects decontamination valium, lorazepam, or
(fasciculations, Irrigate skin with water midazolam)
coma, seizures, or soapy water
paralysis): Irrigate eyes and
wounds with
Local effects from sterile saline or water
vapor inhalation:
Miosis, rhinorrhea,
salivation, difficulty
breathing Local
effects from liquid
on skin: Local
sweating, twitching,
and fasciculations

Cyanide [AC] Cytochrome Tachypnea Coma Fresh air Do not delay antidotal
oxidase inhibition: Seizures Skin: Soap and water therapy if cyanide
Cellular anoxia, lactic Apnea poisoning
acidosis is suspected:

Hydroxocobalamin
(Cyanokit) OR Cyanide
antidote kit: Amyl nitrite
perles for inhalation and
intravenous preparations
of sodium nitrite and
sodium thiosulfate
Pulmonary, type I Type I: Various Type I: Fresh air Provide humidified oxygen
(central, eg, hydrogen chloride, mechanisms Airway noise Skin: Irrigate with water Inhaled racemic
hydrogen fluoride) or causing irritation (coughing, epinephrine for stridor or
combination agents (eg, (including irritative sneezing, upper airway obstruction
chlorine) laryngospasm) and hoarseness, Pulmonary toilet
partial to total airway inspiratory stridor, Bronchoscopy for severe
obstruction Combina- wheezing) Irritation upper airway
tion: In addition to type of eyes, nose, and Give
I, various reactions throat antibiotics only after
causing fluid Irritative identification and testing of
leakage and pulmonary laryngospasm causative organism
edema For combination agents,
Combination: as above, and:
Type I findings Strict bed rest
Delayed onset chest Positive pressure
tightness or ventilation, as
shortness of breath needed to support
breathing
Admit to a pulmonary ICU

97
 Mechanism of Clinical
Chemical action findings
Decontamination Management

Type II pulmonary agents (eg, Type II: Various Delayed onset chest Fresh air Strict bed rest High flow
phosgene[GG]) or combination reactions causing fluid tightness and Skin: Irrigate with water nasal cannulat, nasal
agents (eg, chlorine) leakage and pulmonary shortness of breath CPAPt, or positive
edema Combination: In Combination, rapid pressure ventilation, as
addition to type II onset of: needed to support
effects, various Airway noise breathing
mechanisms (coughing, Admit to a pulmonary ICU
causing irritation sneezing, For upper airway
(including irritative hoarseness, symptoms:
laryngospasm) and inspiratory stridor, Provide humidified oxygen
partial to total airway wheezing) Irritation Pulmonary toilet Inhaled
obstruction of racemic epinephrine for
eyes, nose, and stridor upper airway
throat obstruction Bronchoscopy
Irritative laryngo- for severe upper airway
spasm obstruction
Give
antibiotics only after
identification and testing of
causative organism

Riot control agents: Alkylation Eye: Tearing, pain, Skin: Flush with water Ophthalmic analgesic
CS Release of substance P blepharospasm or soapy water topically (e.g.,
CN (mace) (OC) Nose and throat Eye: Water irrigation or proparacaine 0.5 percent
OC (pepper spray) irritation air blown onto eyes one drop to each eye)
Type I pulmonary Avoid bleach Symptomatic care As for
effects if very type I pulmonary agents if
concentrated severe exposure with
exposure signs of upper airway
compromise
Mustard compounds (eg, sulfur Alkylation Skin: Erythema, Skin: Soap and water Symptomatic and
mustard [H]) vesicles Eyes: Water (only supportive care for partial
Eye: effective if done within thickness burns, corneal
Inflammation minutes of exposure) toxicity, and bone marrow
Respiratory tract: suppression
Inflammation
Lewisite [L] Skin: Erythema, Skin: Soap and water Symptomatic and
vesicles Eyes: Water (only supportive care as for
Eye: effective if done within partial thickness burns
Inflammation minutes of exposure) Dimercaprol [BAL] 3 to 4
Respiratory tract: mg/kg IM every four to six
Inflammation hours for systemic effects
in severe cases
BZ (3-quinuclidinyl benzilate) Competitive antago- Anticholinergic Benzodiazepines as
nism of acetylcholine at effects: needed for agitation
muscarinic Physostigmine for patients
receptors Peripheral: with peripheral and
Dilated pupils moderate to severe central
Dry mouth effects (eg, delirium with
Flush skin danger to self or others or
Tachycardia seizures) by providers
Hypertension familiar with its use
Absent bowel
sounds
Urinaru
retention

Central:
Delirium
Seizures

98 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 5.4 Causative Chemical Agents in Chemical Disaster

Respiratory distress?

Yes No
Noisy breathing, stridor, wheezing,
hoarseness, aphonia or laryngospasm?

Yes No
Onset shortly Delayed onset of chest
after exposure tightness or shortness of breath

Yes No Yes No
Persisting? Type II Collapse with apnea
pulmonary agent or convulsions?
Yes No
Yes No
Cholinergic Low-dose type I pulmonary agent
findings? High-dose type II pulmonary agent Cholinergic Antichlolinergic
Combination pulmonary agent findings? findings?
Riot control agent
Yes No
Yes No
Nerve agent Cyanide
Nerve agent Immediate intense
stinging skin pain
Cholinergic Yes No
Yes No findings?
BZ (3-quinuclidinyl Tearing,
Phosgene Skin pain after 1 to 2 benzilate) blepharospams?
minutes and eventual blisters?
Yes No
Yes No Riot control Unexposed or
Low-dose nerve agent Skin pain after 1 to 2 agent low dose exposure
vapor or liquid exposure minutes and eventual blisters?

Yes No Yes No
Lewisite Combination pulmonary Low-dose Sulfur
agent (eg,chlorine) Lewisite mustard

Figure 5.1 Algorithm in identifying possible causative chemical agents in chemical disaster

99
 5.5 Summary

Chemical agents can be viewed as a continuous spectrum. Each of these hazards is

characterized by qualities of toxicity, latency of action, persistence, and transmissibility.
The incident and medical responses to release of any agent is determined by these
characteristics. Within an organized and protected perimeter, triage and decontamination
can proceed while emergency medical care is provided at the same time. The provision
of advanced life support in this zone by protected and trained medical responders now is
technically feasible using specially designed ventilation equipment. Leaving life support
until after decontamination may have fatal consequences.

Bibliography

Bernama News. (n.d.). Update on chronology of chemical pollution in Sungai Kim Kim,
Pasir Gudang. Retrieved July 23, 2020, from
<[Link]

Madsen, J. (n.d.). Chemical terrorism: Rapid recognition and initial medical management.
Retrieved July 23, 2020, from <[Link]
rapid-recognition-and-initial-medical-management>

Malay Mail. (2019, March 14). 2.43 tonnes of chemical waste collected from Sungai
Kim Kim on first day: Malay Mail. Retrieved July 23, 2020, from <[Link]
com/news/malaysia/2019/03/14/2.43-tonnes-of-chemical-waste-collected-from-sungai-
kimkim-on-first-day/1732623>

Swienton, R. E., & Subbarao, I. (2012). Basic Disaster Life Support: Course Manual 3.0.
Place of publication not identified: National Disaster Life Support Foundation.

Centers for Disease Control and Prevention (CDC). Recognition of illness associated
with exposure to chemical agents - united states, 2003. MMWR Morb Mortal Wkly Rep.
2003;52:938-940. <[Link]

US Army Medical Research Institute of Chemical Defense. Chemical Casualty Care

Division: Medical Management of Chemical Casualties Handbook. Aberdeen Proving
Ground, MD: Chemical Casualty Care Office, Medical Research Institute of Chemical
Defense; 2000

Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for
Cyanide <[Link]

Arnold JL. Chemical Warfare. E-medicine J. 2001;2(10)

100 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

CHAPTER
6
BIOLOGICAL
DISASTERS
 CHAPTER 6
BIOLOGICAL DISASTERS

Case Scenario

In 1998, several patients were admitted to Ipoh General Hospital after developing
respiratory symptoms, followed by encephalitis. As the outbreak unfolded, it was noted
that the affected patients were associated with the pig farming industry. Initially, it was
assumed that the pig outbreak was caused by the classical swine fever virus, while
the human disease was caused by contact with the Japanese encephalitis virus (JE).
Measures were taken to reduce mosquito populations by spraying, and immunizing
workers with a JE vaccine. Neither measure slowed the epidemic.
It was later on discovered that the causative pathogen was a new Hendra-like virus,
subsequently named Nipah Virus after the town of Kampung Sungai Nipah. The
epidemic in Malaysia was brought to an end when 1.1 million pigs were slaughtered,
and the disease in Singapore was eradicated when pig imports from Malaysia were
prohibited. A total of 283 human cases were reported, with 109 deaths (39% fatality).

1. Under what circumstances will you suspect a biological disaster/outbreak?

2. How will you prepare your institution for a large-scale biological outbreak?

Chapter Objectives

1. To understand the chain of infection

2. To identify potential clues to suggest of a biological disaster

3. To discuss role of infection control measures, clinical management and public

health safety in a biological disaster

6.1 Background

Biological agents are organisms or toxins that can kill or incapacitate people, livestock
and crops. Infectious diseases pose a constant threat to humans globally. Societal,
technological and environmental factors can facilitate the emergence of new diseases,
reemergence of old ones, and transmission of these diseases. Bioterrorism refers to the
deliberate use of biological agents to influence, intimidate and coerce governments and
its people.

102 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 6.1.1 Chain of Infection

When an infectious disease outbreak occurs, public health personnel and infection control
units will try to identify what the infectious agent is, how it is being transmitted, and who
or what is transmitting it by mapping the chain of infection. The transmission occurs when
the agent leaves its reservoir or host through a portal of exit, is conveyed by some mode
of transmission, and enters through an appropriate portal of entry to infect a susceptible
host. It is important to identify the continuity of transmission in order to break the chain.

For example, knowing the portals of exit and entry and modes of transmission will help to
provide basic information in determining the right control measures. In general, preventive
measures are usually directed against the segment in the infection chain that is most
susceptible to intervention, unless practical issues dictate otherwise. Interventions are
directed at:
•• Controlling or eliminating agent at source of transmission
•• Protecting portals of entry
•• Increasing host’s defenses

Next Sick Person Germs

(Susceptible Host) (Agent)
• Babies • Bacteria
• Children • Viruses
• Elderly • Parasites
• People with a
weakened immune
system
• Unimmunized people
• Anyone

How Germs Get In

(Portal of Entry) Chain Where Germs Live
(Reservoir)
• Mouth
• Cuts in the skin of • People
• Animals/Pets

Infection
• Eyes (dog, cats, reptiles)
• Wild animals
• Food
• Soil
• Water

Germs Get Around How Germs Get Out

(Mode of Transmission) (Portal of Exit)
• Contact (hands, toys, sand) • Mouth (vomit, saliva)
• Droplets (when you speak, • Cuts in the skin (blood)
sneeze or cough) • During diapering and
toileting stool

Figure 6.1 Chain of infection

103
 [Link] Basics of Infectious Disease Exposure and Transmission

INFECTIOUS the greater virulence, invasiveness and pathogenicity,

the greater possibility the organism will cause
AGENTS infection. (Bacteria, Viruses, Parasites).

can be a living or non-living being (person,

animal/pets, wild animals, plant, soil, water or
substance) in which the infectious agent normally
RESERVOIRS lives and multiplies, on which it is primarily dependent
for survival and where it can reproduce and spread to
susceptible hosts.

PORTAL OF methods for biological agent to leave the reservoir

(Mouth - cough, vomit, saliva; Nose - sneeze, Cuts in
EXIT the skin - blood; During diapering and toileting stool).

the method by which the infectious agent spreads

MODE OF which can be via several means (e.g., airborne, droplet,
direct and indirect physical contact, fecal oral
TRANSMISSION transmission, vector mediated transmission).

PORTAL OF methods in which the infectious agents enter the host

(e.g., skin, mucous membrane, lungs, gastrointestinal
ENTRY tract).

The final link in the chain of infection is a susceptible

host. It depends on genetic or constitutional factors,
SUSCEPTIBLE specific immunity, and nonspecific factors that affect
an individual’s ability to resist infection or to limit
HOST pathogenicity (baby, children, elderly, patients with
co-morbids and immunocompromised disease).

104 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Modern demographic and ecological conditions that favor the spread of infectious
diseases:
•• Frequent and faster movement across international boundaries by tourists, workers,
immigrants, and refugees
•• Rapid population growth
•• Increasing poverty and urban migration
•• Alterations in the habitats of animals and arthropods that transmit disease
•• Increasing numbers of persons with impaired host defenses
•• Changes in the way that food is processed and distributed.
•• Ability of microorganisms to mutate and adapt rapidly, which has facilitated
•• Reemergence of communicable diseases (e.g., tuberculosis)
•• Emergence of new diseases
•• Evolution of antimicrobial resistance

Epidemics and Pandemics

Epidemic: an illness or other health-related issue that occurs

in higher numbers than would be expected normally within a
country or region.

Pandemic: Epidemic of an infectious disease which covers a

wide area, affecting several countries and populations. The WHO
declares a pandemic when a disease’s growth is exponential.
Three conditions must be met for a pandemic to occur:
•• A new disease emerges to which a population has little or
no immunity
•• The disease is infectious for humans
•• The disease spreads easily among humans

105
 6.2 Categories of Biological Agents

The United States Centers for Disease Control and Prevention (CDC) has ranked various
pathogens into these categories based on their potential to cause harm.

6.2.1 Category A Agents

are the highest priority. They can cause high mortality,

CATEGORY A can be grown easily in large quantities, and are
resistant to destruction. They are also well suited for
AGENTS airborne dissemination and thus can infect larger
numbers of people.

Variola major (smallpox)

Bacillus anthracis (anthrax)
Yersinia pestis (plague)
Clostridium botulinum toxin (botulism)
Francisella tularensis (tularemia)
Filoviruses (Ebola, Marburg)
Arenaviruses (Lassa, Junin and related viruses)

6.2.2 Category B Agents

CATEGORY B are the second highest priority. They are moderately

easy to spread but generally cause less morbidity and
AGENTS mortality as compared with Category A agents.

Coxiella burnetii (Q fever)

Brucella spp. (brucellosis)
Burkholderia mallei (glanders)
B. pseudomallei (melioidosis)
Chlamydia psittaci (psittacosis)
Rickettsia prowazekii (typhus fever)
Alphaviruses (eastern equine encephalitis,
western equine encephalitis, Venezuelan equine encephalitis)
Ricin toxin
Epsilon toxin of Clostridium perfringens
Staphylococcus enterotoxin B
Salmonella spp.
Shigella dysenteriae
Escherichia coli O157:H7
Vibrio cholerae
Cryptosporidium parvum

106 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 6.2.3 Category C Agents

CATEGORY C include pathogens that could be engineered for mass

dissemination and have significant potential
AGENTS morbidity and/or mortality.

Nipah virus
Hantaviruses
Tick Borne hemorrhagic fever viruses
Tick Borne encephalitis viruses
Yellow fever
Multidrug-resistant tuberculosis

6.3 Clues for Bioterrorism Attack

Bioterrorism attack can be detected when there are:

1. Increase in unexplained deaths
2. Unusual age distribution of patient
3. Unusual seasonality
4. Unusual manifestation of disease or occurrence of animal die-off

6.4 Clinical Decision Making

6.4.1 Transmission-Based Infection Control

1. Droplet Precautions
Applied for organisms transmitted by large-particle droplets (> 5 μm), which
can be produced during coughing, sneezing, and talking.

Healthcare workers (HCW) should wear surgical masks

when they are within 3 feet of the infected person.

2. Contact Precautions
Transmitted by direct or indirect contact with contaminated surface.

HCW should wear clean gloves upon entry to the patient's room,
a gown, and wash hands with antimicrobial agents.

107
 3. Airborne Precautions
Used to limit transmission of airborne droplet nuclei (small particles [5 μm
or smaller] of evaporated droplets containing microorganisms that remain
suspended in the air for long periods of time) or dust particles that contain an
infectious agent.

•• HCW should use N95 respirator or powered air-purifying respirator.

•• Patients should be nursed in an airborne infection negative-
pressure isolation room with a minimum of six air exchanges per
hour, its exhaust directly to the outside or through a high-efficiency
particulate air filter.
•• If diagnosis is unknown, HCW should apply contact precautions
and N95 or better respirator.

6.4.2 Triaging in Biologic Events (SEIRV)

Population-based triage called SEIRV should be used:

•• Susceptible: person not yet exposed but susceptible
•• Exposed: susceptible person and have in contact with infected person, they may be
infected but not contagious
•• Infectious: symptomatic and contagious person
•• Removed: people who no longer transmit disease as they survived or died
•• Vaccinated: people who had prophylactic medication intervention in order to protect
them from infection

6.5 Biological Agents – Specific Issues

6.5.1 Anthrax (Bacillus anthracis)

Bacillus anthracis is the etiologic agent of anthrax, which is a common disease of livestock
and, occasionally, of humans.

Anthrax is one of the most likely agents to be used as a biological weapon as anthrax
spores are easily found in nature, and can be easily produced. It can also be released
quietly and without anyone knowing. Powders, sprays, food, and water could all contain
the microscopic spores.

108 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Anthrax has previously been used as a drug. Anthrax spores were spread via the US
postal service in 2001, affecting twenty-two people and killing five. There are four routes
of transmission of anthrax:

1. Cutaneous: usually from a cut, the mildest form of infection and rarely fatal.
Presents itself as a raised, itchy bump resembling an insect bite that quickly
develops into a painless sore with a black center and a swelling in the sore and
nearby lymph glands.
2. Gastrointestinal: from eating undercooked infected meat. Signs and symptoms
include nausea, vomiting, abdominal pain, headache, loss of appetite, fever,
severe, bloody diarrhea in the later stages of the disease, sore throat and difficulty
swallowing and swollen neck.

3. Inhalation/pulmonary: from breathing anthrax spores. The most lethal form of

infection. Initial signs and symptoms of inhalation anthrax include flu-like symptoms,
such as sore throat, mild fever, fatigue and muscle aches, which may last a few
hours or days, mild chest discomfort, shortness of breath, nausea, coughing up
blood and painful swallowing. As the disease progresses, the victim may experience
high fever, difficulty in breathing, shock and symptoms of meningitis.

4. Injection: most recent form of infection, from injecting contaminated illegal drugs.
Only reported in Europe so far. Initial signs and symptoms of injection anthrax
include redness at the area of injection (without an area that changes to black)
and significant swelling. As the disease progresses, there may be shock, multiple
organ failure and meningitis

Treatment consists of a 60-day course of antibiotics. Treatment is most effective if started

as soon as possible. Advanced inhalational anthrax may not respond to treatment.

6.5.2 Botulism (Clostridium botulinum)

Botulism is caused by a toxin produced by the bacteria Clostridium botulinum. It causes

prolonged paralysis in affected individuals. It can be aerosolized or used to contaminate
food/water sources.

Victims usually present with drooping of the eyelids, blurred vision, dry mouth, difficulty
speaking, and trouble swallowing. The paralysis is of a descending pattern. Symptoms
rapidly depend on the amount of toxin absorbed. They would subsequently develop
symmetric skeletal muscle paralysis. Death from paralysis of respiratory muscles.

Treatment is usually supportive with ventilatory support with fluids and treatment of
secondary infections.

109
 6.5.3 Pneumonic Plague (Yersinia pestis)

Pneumonic plague is caused by Yersinia pestis bacteria. It has high potential to be used
as a bioterrorism weapon because it is easy to grow, can spread from person to person
and has a high mortality rate. It can also be aerosolized.

Patients usually present with high fever, chills, malaise, shortness of breath, cough
with bloody sputum and sepsis. They subsequently develop severe rapidly progressive
pneumonia.

Diagnosis is done by chest X-ray, blood culture and Gram staining. Antibiotics are used
to treat the condition. People with pneumonic plague are contagious. Droplet precautions
should be observed for the first 48 hours until the patient’s condition improves.

6.5.4 Severe Acute Respiratory Syndrome (SARS)

SARS is a zoonotic respiratory viral disease caused by SARS Coronavirus (SARS-CoV).

It was first laboratory confirmed in Hong Kong in March 2003, and it quickly spread to the
rest of the world, resulting in over 8000 infections and a 10% mortality rate.

While the disease was eradicated in July 2003 as a result of effective infection control
measures, many experts believe that a similar disease will resurface in the future.

Patients present with flu-like prodrome symptoms (e.g., fever, headache, muscle ache,
diarrhea) initially, which develops to cough, shortness of breath and respiratory distress
on day 3–7 of illness. The clinical case definition used by the WHO includes:
•• A history of fever or documented fever and
•• One or more symptoms of lower respiratory tract illness (cough, difficulty breathing,
shortness of breath) and
•• Radiographic evidence of lung infiltrates consistent with pneumonia or acute
respiratory distress syndrome (ARDS) or autopsy findings consistent with the
pathology of pneumonia or ARDS without an identifiable cause and
•• No alternative diagnosis fully explaining the illness

Laboratory diagnostic tests that are required include one or both of the following:
•• Detection of virus by an assay for viral RNA (reverse-transcriptase polymerase
chain reaction) present in two separate samples or by virus culture from any clinical
specimen.
•• These two samples can be obtained from either two separate sites (eg,
nasopharyngeal and stool) or from the same site but at different times (eg,
sequential nasopharyngeal aspirates).
•• Detection of antibody (a rise in antibody titer, either from negative to positive or
at least a fourfold increase) by enzyme-linked immunosorbent assay and/or
immunofluorescent assay.

110 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

There is no proven treatment or prophylaxis for SARS and treatment is mainly
supportive.

6.5.5 Smallpox (Variola major)

Smallpox was once a very deadly infection with a mortality rate up to 30%. It was
eradicated with an aggressive vaccination program around the 1980s. Since its
eradication, vaccinations have stopped. Now there is a large population that is susceptible
to this disease. Patients usually present with fever, myalgia, generalized body weakness,
nausea and vomiting. These prodromal symptoms are the key differentiating factors
between smallpox and chickenpox.

The rash comes 2 to 3 days after that and it is very distinctive. It starts at the face and
extremities and spreads to the trunk. They start as macules, then evolve to papules,
vesicles, and finally pustules. All lesions are at the same stage of development (unlike
chicken pox which are in crops of different stages of maturity). Diagnosis is clinical although
confirmatory tests are available. Affected individuals need to be isolated. Treatment is
supportive, with antibiotic treatment to cover for secondary infections. Smallpox vaccine
is effective if given within 3 days of exposure.

6.5.6 Tularemia (Francisella tularensis)

Tularemia is a bacterial infection and is spread by ticks or biting flies and occasionally
from direct contact with infected animals. It was previously used by some countries as
a biological weapon, which can be used via aerosolized bacteria, resulting in typhoidal
tularemia with or without pneumonia. Clinical features include acute fever, with or
without conjunctivitis or skin ulcer with adenopathy. Chest X-rays may show evidence
of pneumonia in 80% of cases. Diagnosis is made by blood and sputum culture, which
may take weeks, would show Gram negative coccobacillus. Treatment is with antibiotics.

6.5.7 Viral Hemorrhagic Fever (VHF)

These viruses are transmitted to humans by contact with an animal or arthropod vectors.
Sporadic outbreaks of these infections have occurred in Africa, but it can be weaponized in
an aerosolized form. Mortality rates have been reported from 0.5% in Omsk hemorrhagic
fever to 90% for Ebola. Incubation period ranges from 2 to 21 days.

Presentation can be a nonspecific prodrome of fever, headache, myalgia, arthralgia,

abdominal pain and diarrhea. They may present with a rash. They subsequently develop
progressive generalized bleeding problems including mucous membrane hemorrhage
such as bruising, nose bleeds, vomiting blood, coughing up blood and bloody stools,
as well as shock. Diagnosis is clinical. Thrombocytopenia and leukopenia are common.
Confirmatory blood tests can be done. Notification should be done immediately. Treatment
is supportive care. Isolation is imperative due to the highly contagious status of these
viruses, usually via blood and bodily fluids.

111
 6.6 Emerging Infectious Disease Threat

6.6.1 COVID-19

COVID-19 is a coronavirus disease caused by a severe acute respiratory syndrome

coronavirus 2 (SARS‑CoV‑2). The outbreak was first identified in Wuhan, China, in
December 2019. The World Health Organization declared the outbreak a Public Health
Emergency of International Concern on 30 January 2020 and a pandemic on 11 March.

The virus is spread mostly by small respiratory droplets by talking, sneezing and coughing.
Most will fall to the ground after a certain distance but some smaller ones can stay and
travel longer in the air. It can also spread from touching contaminated surfaces and then
touching their faces.

The most common symptoms are fever, dry cough and lethargy. Other symptoms that are
less common and may affect some patients include aches and pains, nasal congestion,
headache, conjunctivitis, sore throat, diarrhea, loss of taste or smell or a rash on skin
or discoloration of fingers or toes. The symptoms are usually mild and begin gradually.
Most only develop mild symptoms. Around 20% develop severe symptoms with difficulty
in breathing. People with premorbid conditions such as diabetes, hypertension, chronic
lung diseases and cancers are more susceptible, but younger patients with no premorbid
conditions can also develop severe disease.

COVID 19 can be diagnosed by symptoms and using reverse transcription polymerase

chain reaction (RT-PCR) tests using respiratory secretions collected using a
nasopharyngeal swab. Serological tests are also available, which detects antibodies
in response to infection. Chest X-rays and CT images of people who are symptomatic
include asymmetric peripheral ground glass opacities without pleural effusions.

Prevention can be done by maintaining personal hygiene, hand washing, avoiding

touching the eyes, nose or mouth with unwashed hands, coughing and sneezing into a
tissue. It is advisable to wear a mask in public, practice physical distancing and prevent
mass gatherings. Many countries enforced travel restrictions to prevent the spread of
the virus to the community. As of March of 2021, there were 124,680,000 cases, with
2,742,000 reported deaths.

As vaccines were started to be available at the end of December 2020, a massive

immunisation program was conducted worldwide.

112 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 6.7 Summary

•• Biological disaster is related to agents like organisms or toxins that can kill or
incapacitate people, livestock and crops, and pose a constant threat to humans
globally. It is important to identify the continuity of transmission in order to break the
chain of infection and determine the right control measures need to be taken.

•• The method by which the infectious agent is transmitted or spread will help responders
to decide the appropriate infection control precautions - airborne, droplet or contact.

•• SEIRV Triage system can be utilized as a tool in biological disaster.

•• Biological disaster now becomes one of the threats to the world as the infective
agents have an ability to mutate, adapt and resist rapidly, and re-emerge as a new
disease.

Bibliography

Burkle FM. Population-based triage management in response to surge-capacity

requirements during a large-scale bioevent disaster. Acad Emerg Med. 2006;13:118-
129 Waterer GW, Robertson H. Bioterrorism for the respiratory physician. Respirology.
2009;14:5-11

Kortepeter MG, Cieslak TJ. Bioterrorism: plague, anthrax and smallpox. In: Baddour L,
Gorbach SL, eds. Therapy of Infectious Diseases. Philadelphia, PA: Saunders;2003

Henretig FM. Cieslak TJ, Kortepeter MG, Fleisher GR. Medical management of the
suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient.
Emerg Med Clin North Am. 2002; 20:351-364

Bioterrorism Agents / Diseases. Centers for Disease Control and Prevention [last reviewed
4 april 2018]<[Link]

Principles of Epidemiology in Public Health Practice, Third Edition: An Introduction to

Applied Epidemiology and Biostatistics [Link] dsepd/ss1978/
lesson1/[Link]>

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

WHO Coronavirus (COVID-19) Dashboard

<[Link] Number of confirmed cases of the novel coronavirus infection
Covid-19 in Malaysia <[Link] malaysia-covid-19-
daily-cases/>

113
 CHAPTER
7
RADIOLOGICAL
AND
NUCLEAR DISASTERS
 CHAPTER 7
RADIOLOGICAL AND NUCLEAR DISASTERS

Case Scenario

The Chernobyl tragedy was a nuclear disaster that occurred on April 26, 1986, at
the Chernobyl Nuclear Power Plant's No. 4 reactor near Pripyat in the Ukrainian
Soviet Socialist Republic. The accident occurred during a safety test on a nuclear
reactor, which eventually triggered uncontrolled nuclear chain reaction due to
several unstable conditions and reactor design flaws. In the accident's acute
aftermath, 237 people suffered from acute radiation sickness, of whom 31 died
within the first three months. An exclusion zone of up to 30 kilometers radius from
the nuclear reactor was created, with more than 115 000 people evacuated.

1. What are the major incidents that occurred here?

2. What are your initial steps before the disaster happens? How do you prepare
for these incidents?

3. Discuss what type of command structure should be established. What is the

command structure needed to deal with this incident?

4. What is the action that will be taken at this time?

Chapter Objectives

1. To understand and differentiate radiological and nuclear disasters

2. To define basic radiation types, units of measurement for radiation exposure

and contamination

3. To identify signs and symptoms of acute radiation sickness

4. To discuss role of time, distance and shielding in radiation protection

7.1 Background

Radiologic event refers to an event that releases radioactive materials into human
populated areas without a nuclear explosion. It causes panic and environmental
contamination but not necessarily human injury. Radiologic material can contaminate
food and water and could be dispersed into the air.

115
 Nuclear event involves a nuclear detonation and resulting massive explosion, devastating
fireball, mass fires, shock wave, pulse of gamma radiation, and a radioactive fallout.
People who are affected will sustain extensive thermal burns, trauma and short-term or
long-term radiation injuries. Ionizing radiation is a type of radiation that carries sufficient
energy to detach electrons from atoms or molecules, thereby ionizing them. Ionizing
radiation is made up of energetic subatomic particles, ions or atoms moving at high
speeds, and electromagnetic waves on the high-energy end of the electromagnetic
spectrum.

Alpha particles have a very short range and are easy to shield against. Alpha radiation
can be easily blocked by a few pieces of paper. Beta particles have a longer range and
are harder to shield against. They can penetrate the outer layers of skin. Gamma particles
have a very long range and are very difficult to shield against. They are electromagnetic
waves similar to X-rays. It can penetrate through the whole body.

IONIZING RADIATION

alpha:
fast-moving helium nucleus, stoppedby skin
or paper

beta:
high energy electon,
stopped by aluminium plate

gamma high energy:

photons, stopped by dense material

TYPES OF RADIATION

Alpha Rays

Beta Rays

Gamma Rays
X-Rays

Neutrin Rays

Aluminium Lead Water or

Concreate

116 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Fact Sheets on Commonly Encountered Radionuclides
Radiation Type
Name Atomic Number Alpha Beta Gamma
Americium-241 95 ● ●
Cesium-137 55 ● ●
Cobalt-60 27 ● ●
Iodine-129 & -131 53 ● ●
Plutonium 94 ● ● ●
Radium 88 ● ●
Radon 86 ●
Strontium-90 38 ●
Technetium-99 43 ● ●
Tritium* 1 ●
Thorium 90 ● ●
Uranium 92 ● ●

7.1.1 Radiological Emergency

The use of sources of radiation is growing daily. Emergencies involving

radiological sources occur more frequently than nuclear emergencies.
Unlike nuclear emergencies, the impact of radiological emergencies is
generally limited to a small number of people. But the risk of deterministic
effects is high. Radiological emergencies are those emergencies involving
radioactive material that can occur anywhere and include:
•• Uncontrolled (abandoned, lost, stolen or found) dangerous sources;
•• Misuse of dangerous industrial and medical sources (e.g., those used
in radiography);
•• Public exposures and contamination from unknown origins;
•• Serious overexposures;
•• Malicious threats/acts; and
•• Transport emergencies.

117
 Threat (Hazard) Assessment in Malaysia
Threat
category Description Remarks

Reactors with power levels equal to or greater

1 N/A
than 100 MW(th)
Reactors with power levels equal to or greater
2 N/A
than 2 MW (th) and less than 100 MW(th)
• 1 research reactor (Bangi)
3 Reactor with power levels of less than or equal
• 5 irradiator facilities -
to 2 MW(th) Irradiator Facilities
Selangor, Melaka and Kedah
Mobile source with potential if shielding is lost.
Satellites with dangerous sources.
Transport of radioactive material that would be dangerous
4 if not controlled. Large scrap metal processing facilities. Throughout Malaysia
National border crossings.
Facilities with fixed gauges with dangerous sources.
Products with a significant likelihood of becoming
5 contaminated as a result of events at facilities in Threat Trans boundary Accident
Category I or II
A graded approach to establishing and maintaining adequate arrangements for preparedness
and response by establishing requirements that are commensurate with the potential
magnitude and nature of the hazard as identified in a threat assessment

Human radiation exposure is generally characterized as total or partial body exposure,

external contamination and internal contamination.

Dose equivalent
measured in rem (sievert)

Intensity of gamma rays measured

in roentgen (gray in air)

Radioactive material Absorbed dose measured

measured in curie (bequerel) in rad (gray)

118 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 RADIATION CONTAMINATION VERSUS EXPOSURE

EXTERNAL CONTAMINATION
External contamination occurs when radioactive material
comes into contact with a person's skin, hair, or clothing.

RADIOACTIVE MATERIAL

In the air

Solid

Liquid

INTERNAL CONTAMINATION
Internal contamination can occur when radioactive
material is swallowed or breathed in.

Internal contamination can also occur when

radioactive material enters the body through
an open wound.

Different radioactive materials can

accumulate in different body organs.

RADIATION EXPOSURE A person exposed

Another word for radiation exposure is irradiation. to radiation
is not necessarily
Radioactive materials give off a form contaminated with
of energy that travels in waves or particles. radioactive material.

For a person to be
contaminated,
radioactive material
must be on or
inside of his
or her body.
When a person is exposed to certain types
of radiation, the energy may penetrate the body.

Source from [Link]

119
 Total or partial body exposure occurs when the body is exposed to a radiation source
either superficially or deep into the internal organs. They are not radioactive and therefore
cannot give their caregivers any radiation.

Contamination occurs when the radioactive source gets onto the individual’s skin or
internally via their lungs or gut. The person who is contaminated will be radioactive until
the source is removed.

Radiation exposure is related to the time that you’re exposed to the source, the distance
between you and the source and any shielding between you and the source.

Radiation exposure may causes DNA damage. DNA damage would either be repaired, or
becomes dysfunctional, becomes carcinogenic or causes cell death. The extent of injury
is proportional to the dose received by the body.

Ionizing
Radiation

Seconds Minutes Hours One Day Weeks Years

Radiation Cellular Cell

damage response function/
fate

● DNA strand ● Gene Cell death Acute syndromes

breaks expression Drives medical
changes: Organ failure consequences
● Oxidative mRNA, Cancer
damage protein Genome
instability Birth defects
● Protein
modification Gene pool

7.1.2 Characteristics of Radiation

•• Silent
•• Invisible
•• Odorless
•• Can only be detected with specialized equipment
•• Does not cause immediate signs/symptoms

120 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Radiation Accidents

Cause Does not cause

Medical/ biological effects Immediate death

Environmental effects Immediate symptoms

(burns wounds)
Psychological effects
Contaminations alone:
Social problems
Not immediate threat to patient
Economical
Not threat to responders or other

Externally Externally
Exposed Contaminated

Not contaminated
Combined or injured
Injury
“Worried-well”

Injured Internally
(Burn, Contaminated
Trauma)

Figure 7.1 Effects of radiation emergency

121
 7.2 Human Effects of Radiation

In-utero
Mental retardation BM injury
effects

ARS* GIT injury

Acute
Skin Erythema Nerve injury
effects

Epilation

Somatic Sterility
effects

Cataract

Late Cancer
effects

Leukemia

Genetic Genetic disease * acute radiation syndrome

effects

7.2.1 Acute Radiation Syndrome (ARS)

A combination of clinical syndromes occurring in stages during a period of minutes hours

to weeks after exposure, as injury to various tissues and organs is expressed. ARS is
caused by brief exposure of a major part of the body to more than approximately 1 Sv.

ACCIDENT Time

MANIFEST DEATH OR
PRODROMAL LATENT
ILLNESS RECOVER

• Asymptomatic
• Anorexia
• Nausea
• Vomiting • Infection
• Diarrhea • Hemorrhage

Time Course of Acute Radiation Syndrome

122 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Acute Radiation Syndromes
Whole Body Radiation from External Radiation or Internal Absorption

Phase Feature Subclinical range Sublethal range Lethal range

0-100 rad 100-200 rad 200-600 rad 600-800 rad 600-3000 rad >3000 rad
(cGy) (cGy) (cGy) (cGy) (cGy) (cGy)
Prodromal Nausea and vomiting none 5%-50% 50%-100% 75%-100% 90%-100% 100%
Phase
Onset 3-6 hrs 2-4 hrs 1-2 hrs <1 hr <1 hr
Duration <24 hrs <24 hrs <48 hrs <48 hrs <48 hrs
Lymphocytes <24 hrs <100 @ 24 hr <500 @ 24 hr <500 @ 24 hr <500 @ 24 hr

Latent Phase Duration >2 weeks 7-15 days 0-7 days 0-2 days None

Illness Phase Sign and Symptoms none moderate severe leukopenia, purpura, diarrhea, fever convulsions,
leukopenia hemorrhage,infection electrolyte ataxia, tremor,
disturbance lethargy
Onset >2 weeks 2 days - 2 weeks 2-3 days 1-48 hrs
Organ System none hematopcietic and Gl tract, CNS
respiratory (mucosal) mucosal
systems systems
Hospitalisation 0% <5% 90% 100% 100%
45-60 days 60-90 days 90+ days 2 weeks
Fatality 0% 0% 0%-80% 90%-100% 90%-100%
Time of Death 3 weeks - 3 months 1-2 weeks 1-2 days

123
 Acute skin changes with localised radiation dose

Acute skin effect Dose (Gy) Onset

Early transient erythema 2 Hours

Faint erythema; epilation 6-10 7-10 Days

Definite erythema;
12-20 2-3 Weeks
hyperpigmentation

Dry desquamation 20-25 3-4 Weeks

Moist desquamation 30-40 4 Weeks

Ulceration >40 6 Weeks

Symptoms of Radiation Exposure Do Not Appear Soon After Exposure

3 weeks 4 weeks 11 weeks

124 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

7.2.2 Case Study: Death Caused by Internal Contamination with 210Po

Patient: 44-year-old male

(Born 1961)

Nov 1/06: The patient who is an intelligent officer at Country X become ill
and spends the night with vomiting

Nov 4/06: Sickness and admitted to the hospital

Chief complaint: Abdominal pain, vomiting, diarrhoea for 2 days

Past history: Unknown

Present illness

Day 1:
Abdominal pain, vomiting, and diarrhea

Day 3:
Admitted to the Accident and Emergency department of the hospital.

Physical Examination
•• Appeared dehydrated
•• Afebrile
•• Normal pulse and blood pressure
•• Epigastric tenderness

125
 Provisional Diagnosis
•• Gastroenteritis, possibly of infective origin

Day 7
•• Identification of Clostridium difficile toxin
•• Secondary to ciprofloxacin
•• Possibility of being poisoned
•• Feared that he had been poisoned by infection with C difficile

Day 9 :
•• Neutropenia with a neutrophil count 1.1 x 10⁹/L
•• Thrombocytopenia fallen from normal levels to 63 x 10⁹/L
•• Viral gastroenteritis or a consequence of ciprofloxacin toxicity

Day 11:
•• Neutrophil count < 0.5 x 10⁹/L
•• Spiked fever
•• Screen with a standard Geiger counter
•• Only background value

Day 13 :
•• Alopecia and mucositis
•• Screen with a standard Geiger counter
•• Only background value

Day 15 :
•• Acellular bone marrow

Day 16 :
•• Heavy metal screen
•• Slightly increased urine thallium (30 nmol/L; normal <10 nmol/L)
•• Below the toxic concentration (800-1000 nmol/L)

Day 17:
•• Transferred to the haematology unit
•• Prussian blue (ferric ferrocyanide; 4 g, every 8 h)

126 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Day 18
•• Jaundice with normal alanine transaminase levels

Day 19
•• Heart Rate: irregular, inverted T-waves
•• Normal Troponin levels

Day 20-22
•• Renal function deteriorated

Day 22:
•• γ-ray spectrometry measurements on a urine sample

Day 24/06:
•• Announced that the patient was poisoned with Polonium Traced back to tea
pot in a bar

7.2.3 Dose Limits

Dose Limits ICRP-60 mSV/yr

Occupational - (Whole Body) Dose 20

Lenses of Eye 150

Skin or Extremities 500

Public 1

ICRP’s new recommendations related to emergency and existing exposure situations:

Reference level of 100mSv or below.

127
 7.3 External Hazard Protection

Time Distance Shield - TDS

Time Distance Shielding

1/2 time → 1/2 dose 2 x distance → 1/4 dose Increase

shielding → reduce dose

7.3.1 Equipment for Radiological Protection

•• Self
•• PPE (personal protective equipment)
•• Personal dosimeter

Example of personnel equip with PPE and personal dosimeter

128 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

•• Scene
•• Radiation detector/Geiger-Mueller (GM) Survey Meter
•• Time, Distance, Shield

Example of Radiation detector / Geiger-Mueller (GM) Survey Metre

•• Patient (victim) contamination

•• External exposure

7.3.2 Personal Protective Equipment Gear for Radiological Events

•• Protective clothing
–– Keep bare skin free of contaminants
–– Against contamination but not external exposure

129
 Ring
Dosimeter

TLD
Badge

Surgical
Gloves
(2 pairs)

Tape

Outer Outer
Plastic Gown
Apron

Example of Layers of Personal Protective Equipment

130 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Cap

Eye Protection

Mask
Tape

Glove

Gown

Waterproof
Shoe Covers

Example of PPE

131
 Example of How to Wear Equipment PPE with Personal Dosimeter

Things to note:
Avoid contaminating personal dosimeter
Dosimeter should be placed inside the personal protective clothing

•• On-Scene

NATIONAL PLAN ON RADIOLOGICAL AND NUCLEAR

EMERGENCY Directive 20

National Security Council (NSC), Prime Minister Department; any

event on radiological and nuclear emergency:
•• AELB - lead agency (Hotline No.: 1-800-88-7999)

•• First Responder – Royal Malaysian Police, Fire & Rescue
Dept., Medical Service Dept., SMART Team, JPAM, etc.

•• Supporting Agencies – Malaysia Nuclear Agency, Metrological
Dept., Public Work Dept., Public Welfare Dept., etc.

132 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 AELB - NATIONAL RADIOLOGICAL EMERGENCY CENTRE
(NREC)

•• Public Information
•• Press/media release
•• Respond the detection alarm and environmental monitoring;
preview and interpret the data
•• Emergency Equipment Room
•• Emergency & Monitoring Vehicle
•• Accommodation Facility
•• Nuclear Emergency Teams (NET)
•• Search, locate and identify the materials
•• Recovery and disposal of the materials

IAEA - SUGGESTED INNER CORDONED AREA (SAFETY PERIMETER) FOR A

POTENTIAL RADIOLOGICAL EMERGENCY

Situation Initial inner cordoned area

(Safety perimeter)

Initial determination - Outside

Unshielded or damaged potentially dangerous source 30 m around

Major spill from a potentially dangerous source 100 m around

Fire, explosion or fumes involving a potentially 300 m radius

dangerous source

Suspected bomb (potential RDD) exploded or 400 m radius or more to protect against
unexploded an explosion

Initial determination - Inside a building

Damage, loss of shielding or spill involving a Affected and adjacent areas, floors
potentially dangerous source above and below

Fire or other event involving a potentially dangerous Entire building and appropriate
source that can spread materials throughout the outside distance indicated above
building (e.g. through the ventilation system)

Expansion based on radiological monitoring

Dose rate of 100 μSv/h Wherever these levels are measured

133
 CONTROL POINT
On-Scene Response

● Vehicle
marshalling area
● Reception area for
Staging response
area ● Public Information
Centre

Prevailing wind Incident

direction command
post
Safety perimeter

Triage
Medical
Inner area
response
cordoned
Outer cordoned base
area Decontamination
area area
Security
access
control point
Safety access
and contamination
control point

Security
perimeter

134 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Safety
EMERGENCY SCENE perimeter
(possibly contaminated)
Security
perimeter Inner
cordoned
area Victims
Clean
area

Field triage

Not seriously injured Seriously

Outer or uninjured injured
cordoned
area
Stabilisation (if necessary)

Stabilisation
Contamination
survey

Non
contaminated Contaminated Immediate
contamination
survey
Field decontamination (if possible)
(if possible/applicable) Life-threatening
Uninjured injury

Contamination Field
survey decontamination
Injured (if possible/
applicable)
Non contaminated Contaminated
uninjured injured

Contaminated
uninjured

Nearest
Decontamination hospital
Registration Area Area
Hospital

135
 7.4 Flow of Medical Care of Patients during Radiological Emergencies

Step 1: Triaging of Casualties

•• Sorting of victims depending on condition, urgent needs and number.

•• A victim with life threatening injuries should be transported to hospital immediately,
even if a contamination survey has not been performed.
•• Decontamination can be done before, during or after initial stabilisation, depending
on the severity.

Step 2: Remove Contaminated Clothing on Site (Dry Decontamination)

•• Removing a patient’s outer clothing: decontamination up to 90% or more of their

external contamination.

136 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Step 3: Perform Gross Decontamination

•• Perform only if needed and also if it does not interfere with critical care.
•• Identify decontamination priority:
1. Wound
2. Orifices (eyes, mouth, nose, ears)
3. High level intact skin
4. Low level intact skin
•• Cover contaminated wounds with sterile dressings before transport to hospital
emergency room.

137
 Step 4: Transport of Casualties to Hospital

•• Cover victims by folding a sheet or blanket over them.

•• Put coverall on victims.
•• Contamination control on transport.
•• Cover equipment on the ambulance or transport.

138 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Step 5: Contamination control on site

•• Before leaving the contaminated area, first responders should be checked for
contamination and change clothing if needed.

SCAN
THIS QR CODE
to watch
Contaminated
Wound
Management

139
 7.5 Management of Radiological Emergencies (Hospital Phase)

7.5.1 Prior to Patient Arrival

● Facilities and capabilities for receiving patients

● Facilities and capabilities for radiological decontamination
● Medical facilities able to handle patients with ARS

Requirements for ● Availability of decorporating drugs

PLANNING ● Number and availability of radiological survey teams

and instruments

● Staff, radiation emergency response team

● Disaster manual/education

● Protective clothing

● Instrumentation and dosimeters

● Material for securing the area and controlling

Supplies to be contamination (i.e rope and signs)

PREPARED ● Materials for bioassay

● Material for decontamination

● Life support and other medical equipment supplies

● Decorporating agents

What should be done at the hospital?

•• Save life
•• Organisation of hospital radiological emergency response team
•• Facility preparation and staff training
•• Patient reception and triage
•• Decontamination and decorporation procedures
•• Radiological monitoring and contamination control
•• Bioassay sampling (urines, feces)
•• Biodosimetry sampling (lymphocytes, chromosome)
•• Post-emergency activities

140 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

•• Follow up on patients with significant whole-body irradiation or internal
contamination
•• Counsel patients and family about potential long-term risks/effects
•• Proper documentation
•• Reporting to authorities
•• Reporting to district and state health department
•• Proper management of information

Radiation emergency response team members

● Physicians
● Radiation protection officer/
● Nurses radiation safety officer

● Administrator
- telephone operators
- news media WORLD NEWS
- security
● Other technologists
- lab technicians

Information that should be included before patient arrival

•• Number of accident victims
•• Each victim's medical status and type of injury
•• Whether first aid or other treatment has been provided or not
•• Radiological status of victims (exposed and or contaminated)
•• Whether victims have been surveyed for contamination or not
•• Identification of contaminant, if known
•• Whether KI/DPTA/other medicine has been prescribed or not
•• Estimated time of arrival

141
 7.5.2 Patient Arrival

Arrival of radiation accident victims at the hospital

•• Consider contamination until proven otherwise
•• Remove patients and non-essential personnel from room before using it
•• Separate part of radiation emergency area (REA) for patient decontamination
•• Meet victims on ambulance or other transport vehicle at hospital entrance
•• Instruct ambulance personnel to stay with vehicle until surveyed and released by
radiation safety officer if victims stabilized

Establishing radiation control area (Figure 7.2)

•• Consider area control
•• Outside entrance with easy access
•• Away from main traffic flow
•• Availability and storage capacity for equipment and supplies
•• Sufficient rooms for treatment and decontamination

142 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Figure 7.2 Plan of emergency department in radiation emergency management

Preparation for contamination control

•• Cover floor from ambulance to decontamination room, and treatment area with
wide, strong rolled plastic
•• The floor covering, it should be taped securely to the floor
•• Rope off route and mark “radiation area”
•• Establish control line at entrance to decontamination
•• Prepare decontamination table and materials
•• Cover door handles and light switches to reduce contamination that might be
spread by hand
•• Procedures for handling radiation contamination are similar to those infected

Principles for handling contaminated patients

•• Treat life threatening conditions first without regard to radiation or contamination

•• Isolate patient and restrict access to the treatment/evaluation area
•• Maintain contamination control
•• Internal contamination is never immediate life threatening

143
 7.6 Triaging at The Emergency Department

Medical assessment and triage at the hospital

First aid and resuscitation

Medical stabilisation

Radiological assessment

7.6.1 Assessment and Treatment of The Contaminated Patient

•• Assess level of consciousness and vital signs on arrival

•• Contaminated patients may have radioactive material deposited on clothes, hair,
skin in wounds or internally (ingested, inhaled or absorbed)
•• Reassess contaminated patient’s airway, breathing and circulation first and stabilize
medical condition as needed
•• After examining patient and identifying all injuries, conduct complete radiological
survey (including nasal swabs and skin smears)
•• Conduct blood examination (full blood count with differentials, renal profile, liver
function test, thyroid function test, chromosomal analysis)
•• Conduct urinalysis
•• Test excreta for radioassay
•• Sample:
•• Label with patient’s name ID, samples site and time
•• RPO monitors entire patient including back areas and amount of contamination
are recorded on anatomic chart
•• Take all sample of contaminated areas

144 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Initial Assessment of Patient - Triage

[Link] Management of the Contaminated Patient

•• Ensure stabilisation of patient

•• Survey whether patient is contaminated
•• Identify decontamination priority
•• Wound
•• Orifices (eyes, mouth, nose, ears)

[Link] Contamination Survey

•• Survey with GM survey meters (γ/ β)

•• Use a head-to-toe radiation survey technique
•• Probe held at several cm from surface
•• Move at a rate of 2.5 to 5 cm per second
•• Document readings in counts per minute (cpm)
•• Record contaminated area and readings of survey meter

145
 7.6.2 Assessment and Treatment of Non-Contaminated Patient

•• Care for non-contaminated patients is like any other emergency case

•• Victims of external exposure without contamination has no radiological hazard
•• If exposure is known or suspected, order blood cell count in particular to determine
absolute lymphocyte count and chromosome analysis
•• Record the exact time the blood sample is taken

7.7 Principle of Contaminated Patients Management

•• Admit the patient to a specially prepared area

•• Any radiation survey meter reading above background radiation levels

Possibility of contamination

γ radiation: easily detected

β radiation: more difficult to detect
α radiation: may not be detected

Contamination of body surface and/or internal

•• When contamination of fingers/orifices, internal contamination should be suspected
•• Internal contamination is accompanied by external one

146 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Treatment of contaminated wound
•• Decontaminate wounds prior to intact skin
•• Assume that uptake (internal contamination) has occurred
•• Important factors:
•• Half-life
•• Radiotoxicity
•• Amount of radionuclide

7.7.1 Decontamination of Wounds

How to decontaminate wounds?

•• Drape contaminated wounds with a waterproof material to limit the spread of
radioactivity
•• Gently irrigate wounds with saline or water (more than one irrigation)
•• Monitor after each irrigation
•• Remove contaminated drapes, dressings and others before each monitoring for
accuracy
•• Drape contaminated wounds with a waterproof material
•• To limit the spread of radioactivity
•• Gently irrigating with saline or water (more than one irrigation)
•• Monitor after each irrigation
•• Remove contaminated drapes, dressings & others before each monitoring for
accurate results

Retain and analyse the waste water Monitor after each irrigation

147
 How to keep samples

•• Place all samples in separate,

labeled containers

•• Specify name, date, time of

sampling and other important
information

Indication of conventional debridement of the wound

•• Debridement may be considered only when decontamination is not successful and
acute effect may occur (contamination level is still seriously high)
•• Decontaminate the area around the wound before suturing or other treatment

7.7.2 Decontamination of Body Orifices

Pay special attention to contaminated body orifices.

Rapid absorption of radionuclide: Mouth, nose, eyes, and ears
•• Oral cavity:
•• Brushing the teeth with toothpaste and frequent rinsing of the mouth
•• Pharyngeal region:
•• Gargle with a 3% hydrogen peroxide solution
•• Swallowing radioactive materials:
•• Gastric lavage (gastric tube)
•• Contaminated eyes:
•• Rinse by directing a stream of water
•• Inner canthus → Outer canthus of the eye
•• Contaminated ears:
•• Rinse externally rinsing, if the tympanic membrane is intact

148 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Decontamination of face - from inner canthus to outer canthus

7.7.3 Repeating Survey after Decontamination

Acceptable level of decontamination is

•• 2–3 times background or
•• skin shows evidence of irritation or
•• no improvement with decontamination efforts

Decontaminate again if level is not acceptable.

149
 7.7.4 Surgical Emergencies

Combined injury requires all urgent surgery to be completed within 72 hours of irradiation.
Any life-threatening emergency requiring immediate surgery should not be deterred due
to external contamination.

7.8 Dose assessment

1. Initial (primary assessment)

i. Prodromal symptoms; frequency, severity
ii. Blood cell count focusing on lymphocyte count
iii. Level of amylase (for exposure of head/neck)
iv. Whole body counting (for neutrons)
v. Urine, stool

2. Intermediate assessment
i. Chromosome analysis
ii. Count of blood cells (neutrophils, platelets)

3. Full assessment
i. Reconstruction of accident (mathematical)

4. Symptoms
i. Type of symptoms
ii. Time of onset
iii. Severity and frequency

5. Clinical findings
i. Count of blood cells (CBC) with differential
•• Repeat in 4-6 hours, then every 6-8 hours for 24-48hours
ii. Chromosome analysis: use heparinized syringe

7.9 Radiography

•• Project the head of the portable X ray machine into the hot zone
•• Place the film cassette in the plastic bag
•• Remove the clean cassette from the contaminated bag, then hand it outside of the
hot zone.

150 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

If radioactive contamination is discovered after patient has been admitted:
•• Secure entire area where victim and attending staff have been present
•• Do not allow anyone or anything to leave area until cleared by radiation monitor
•• Completely assess patient’s radiological status
•• Remove contaminated clothing before exiting area and be resurveyed before
leaving area

Treatment of whole-body exposure

•• The damage is already done!
•• Provide supportive care
•• Reconstruct accident to estimate the exposure level (biologic dosimeters)
•• Fluid and electrolyte maintenance
•• Follow blood levels of platelets and white blood count (WBC)
•• If exposure is high, consider bone marrow transplant (BMT)
•• Cytokine therapy

7.9.1 Principles of Management

•• Palliative care
•• Manage the thrombocytopenia
•• Manage the neutropenia
•• Manage the infection and its related clinical problems

Management of radiation sickness based on early symptoms

No Vomiting Vomiting Vomiting in <1 hour,

vomiting >2 hours after 1-2 hours after diarrhea, hypotension,
exposure exposure hyperthermia, erythema,
(central nervous system
symptoms at >10 Gy)

<1 Gy 1-2 Gy 2-4 Gy >4 Gy

Outpatient Surveillance Hospitalisation Hospitalisation

surveillance in a general in a department in a centre of
(3-5 weeks) hospital of haematology radiopathology

151
 [Link] Management of internal radioisotope contamination

•• Isotope determination
•• Organ Scanning
•• Nose sampling
•• Urine and Excreta Sampling
•• Bioassays
•• Decorporation techniques and countermeasures
•• Lavage
•• Blocking deposition
•• Elimination

7.9.2 Referrals

If a physician specializing in radiation therapy assistance is required i.e., Nuclear Medicine

Specialist or an oncologist, then referral can be made to the following centers:
•• Institut Kanser Negara
•• Hospital Kuala Lumpur
Who needs to be referred?
•• Patients exposed to high doses of radiation.
•• Patients with severe symptoms (Acute Radiation Syndrome) or organ
manifestation
Purpose of Referral
•• To isolate patients presenting with contamination or presenting with a combination
of injuries due to radiation and nuclear disasters
Referrals
The ability to accept referrals will depend on the size of the incident and the capacity of
regional RITN (radiation injury treatment center).

Criteria for considering RITN center consultation/referral include:

•• Absolute neutrophil count less than 1,000/μL
•• Absolute lymphocyte counts less than 1,000/μL
•• Severe nausea, vomiting and/or anorexia
•• A localised cutaneous radiation injury that requires extensive management
•• Suspected or known internal contamination (e.g., involving a wound, the lung or
GI tract)
•• Current facility not equipped to provide irradiated, leukoreduced blood products
152 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT
7.9.3 Removal of PPEs

•• Confirm that all personnel need to be surveyed before leaving the controlled area
•• Take off outside gloves, and tapes
•• Roll up surgical gown from inside to outside
•• Roll up shoe cover from inside to outside, put foot on non-contaminated area
•• Take off cap and mask
•• Survey

7.9.4 Disposal of Radioactive Waste

•• Collect radioactive waste in plastic bags or containers

•• Survey bags periodically to prevent high radiation levels in work area
•• Use walls and or distance to protect against radiation from radioactive waste
•• Call the AELB team to take the waste and send it to the Malaysian Nuclear Agency.

153
 7.9.5 Hospital recovery

•• An area of holding or storage of radioactive waste from the decontamination

procedures should be identified.
•• Remove waste from emergency department and triage area
•• The waste will be taken by AELB (Atomic Energy Licensing Board) to the Malaysian
Nuclear Agency
•• Survey facility for contamination
•• Decontaminate as necessary
•• Normal cleaning routines (mop, strip waxed floors) typically very effective
•• Periodically reassess contamination levels

7.10 Public Health Implications of Nuclear and Radiologic Disasters

•• Food and water safety/security

•• Safe accommodation
•• Maintenance of socioeconomic status
•• Crisis and emergency risk communication
•• Mental and behavioral health considerations
•• People with functional, access or other special needs
•• Age-related vulnerabilities, both children and elders
•• Risk to pregnant women and fetuses

7.11 Summary

•• Radiologic disasters are different from nuclear detonations.

•• Identification of the type of radioactive material involved is important for guiding

response.

•• Employing disaster management principles improves response to radiological

disasters.

•• Casualties should be stabilized prior to decontamination.

•• Access to medical countermeasures is important for reducing mortality.

•• Acute radiation syndrome can manifest in multiple ways.

154 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Bibliography

World Health Organinisation (WHO). Effect of Nuclear War on Health and Health Services.
2nd ed. Geneva: WHO; 1987

Cockerham LG, Walden TL, Dallas CE, Mickley GA, Landauer MR. Ionizing radiation.
In: Wallace Hayes A, ed. Principles and Methods of Toxicology. 5th ed. Boca Raton, FL:
CRC Press; 2007

Dallas CE. Nuclear detonation. In Keyes C, Burnstein JL, Swienton R, Schwarts R, eds.
Medical Response to Terrorism. New York, NY: Linppincott; 2004

Bell WC, Dallas CE. Vulnerability of populations and the urban health care systems to
nuclear weapon attack - examples from four American cities. Int J Health Geographics.
2007;6:5

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

Atomic Bombings of Hiroshima and Nagasaki.

<[Link]
nagasaki/>

155
 CHAPTER
8
EXPLOSIVE AND
TRAUMATIC DISASTERS
 CHAPTER 8
EXPLOSIVE AND TRAUMATIC DISASTERS

Case Scenario

On 23 June 1992, a chemical tanker Chong Hong 3 caught fire and exploded at
Malaysia’s Port of Klang, discharging 400 tons of xylene, an additive used in making
gasoline, at a Shell Oil chemical complex. The fire then spread through underground
lines and ignited tanks onshore. The disaster resulted in 13 casualties involving crew
members.

1. What are the effects of blast injuries?

2. What are the differences between explosions involving chemical, nuclear or

radioactive materials?

Chapter Objectives

1. To differentiate different types of explosive types and types of blast injuries

2. To gain situational awareness in an explosion incident

8.1 Background

An explosion has the capacity to inflict multisystem, life-threatening injuries on a single or

multiple patients at the same time. This type of incident presents healthcare providers with
difficult triage, diagnostic and intervention problems. The size and pattern of casualties
sustained by an explosion are determined by a variety of factors, including the volume
and composition of explosive material used (e.g., the presence of shrapnel or loose
material that can be propelled, radiological or biological contamination).

Blast injuries occur on various scales. In 2018, 32,110 deaths due to explosions were
reported globally. Explosive weapons cause deaths, injuries and damage by projecting
explosive blast, heat and often fragmentation around a point of detonation. Improvised
explosive devices account for at least 42% of all civilian casualties from the 2018 report.

157
 On a global scale, explosive devices are used as a means of terrorism. An analysis of
mass casualty in terrorist bombing revealed an overall of 3% mortality and 34% hospital
admission. The impact of terrorist bombings include:
1. Higher injury severity score
2. Higher immediate mortality (about 29% for closed space bombing)
3. Greater hospital mortality rate (6% vs 3% for other trauma)
4. More frequent case needs surgical prevention
5. Longer hospital stays and greater use of critical care

8.2 Classification of Explosives

Explosives are classified as high-order explosives (HE) or low-order explosives (LE)

depending on a few characteristics. HE and LE also cause different injury patterns.
1. High-order explosives (HE)
•• Produces strong supersonic pressure wave
•• Includes CN4, TNT, Semtex, nitroglycerin, dynamite, ammonium nitrate fuel oil
(ANFO) and some homemade explosives
2. Low-order explosives (LE)
•• Produces subsonic explosion and lack the high-order explosive blast wave
•• Includes firecrackers, fireworks, pipe bombs and gunpowder

8.3 Types of Explosions

There are three types of explosions: nuclear, mechanical and chemical. Each of them
has different severity and causes.

8.3.1 Nuclear Explosion

Nuclear explosion is the most powerful type of explosion resulting from the release of
nuclear energy by altering atomic and subatomic structures of nuclear compounds.

8.3.2 Mechanical Explosion

Mechanical explosion is the result from physical process instead of nuclear or chemical
reactions. An example of a mechanical explosion is the boiling liquid expanding vapor
explosion (BLEVE) as shown in Figure 8.1.

158 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 VAPOR CLOUD EXPOSED
BY PRESSURE RELIEF

VESSEL DAMAGED VESSEL DAMAGED

DUE TO CORROSION
VAPOR
VAPOR P>>
LIQUID BOILS,
LIQUID CAUSES EXCESS
LIQUID PRESSURE

VESSEL DAMAGED BY HOT

TEMPERATURE, EXPOSED
BY EXTERNAL FIRE

Figure 8.1 Cause of boiling liquid expanding vapor explosion (BLEVE)

159
 8.3.3 Chemical Explosion

Chemical explosion is the most common type of explosions. It involves mixtures of

compounds that can undergo rapid chemical conversion, resulting in liberation of heat
and development of pressure effect. It can also be further classified into low- and high-
energy explosives, based on speed of explosions.

Overpressure (kPa) Effects

7 Damage to ordinary buildings and windows break

14 Slight risk of tympanic membrane perforation

100 50% chance of tympanic membrane perforation

275 Reinforced buildings suffer significant damage

480 50% chance of marked pulmonary injury

900 50% chance of death

8.4 Blast Injury from Explosions

There are 4 mechanisms of blast injury:

Primary blast injury Secondary blast injury

(blast wave) (fragments)
Tertiary blast injury
(bodily displacement)

Quaternary blast injury

(burns)

160 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 8.4.1 Primary Blast Injury

Primary blast injury is caused by the blast wave from high-order explosives moving
through the body. The injury can be subtle with a delayed presentation with no obvious
signs on initial presentation. However, it can damage air-filled, hollow organs much more
extensively.

•• Tympanic membrane ruptures a middle ear

•• Bleeding from the ears can raise suspicion of another hollow
organ damage
Blast ear •• > 6.9 kPa (or psi) in the ear can lead to ossicle dislocation,
fracture, and or permanent damage
•• Suspected in blast victims with hearing loss, tinnitus, vertigo or
bleeding from the ear

•• > 276 kPa (40 psi)

•• Pulmonary contusion
•• Pneumothorax
•• Air embolism
•• Interstitial parenchymal damage
•• Subcutaneous emphysema
Blast lung
•• Suspect in blast victims with dyspnea, hemoptysis, chest pain
•• Treatment:
•• Establish airway early
•• Administer oxygen
•• Mechanical ventilation
•• Avoid excessive positive ventilation

161
 •• Colon is most common site
•• Intestinal perforation may be delayed
•• Solid internal organs can be bruised or lacerated, but less
common
Blast belly
•• Diagnosis: Ultrasound, peritoneal lavage, plain radiography, CT
imaging
•• Suspect in blast victims with abdominal pain, nausea +/-
blood, rectal pain, testicular pain, unexplained hypovolaemia,
abdominal distention, abdominal rigidity

•• Suspect in blast victims with eye pain, swelling, orbital

ecchymosis, ocular hemorrhage, decreased vision, blindness
•• Uncontrolled hemorrhage possible. May require surgical
intervention
Blast eye
•• Avoid positioning and movements that increase the intraocular
pressure if possible
•• Need surgical specialist evaluation for preservation of vision
•• Prevent nausea and vomiting

•• Traumatic brain injury without physical sign of head injury

•• No single mechanism for all cases
•• Accelerated mechanisms
•• Direct cranial transmision
•• Vascular surge
•• Treatment/clinical management
Blast brain •• No specific treatment algorithm
•• Treat similarly to general TBI with individual patient
modifications based on patient response to therapies
•• Monitor electrolytes closely
•• Surgical interventions
•• Suspect in blast victims with headache, fatigue, confusion/ poor
concentration, amnesia, decreased LOC, depression, anxiety
or insomnia

162 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 8.4.2 Secondary Blast Injury

Secondary blast injury is caused by penetrating debris from the blast wind. It is the cause
of majority of injuries and mortality from an incident. Debris may be from the device or
from around the device. Injuries include:
•• fractures
•• amputation
•• lacerations
•• dislocations
•• soft tissue injury

8.4.3 Tertiary Blast Injury

Tertiary blast injury occurs when the victim is propelled through the air by the blast wind
or when a structure collapses with resultant casualties.

8.4.4 Quaternary Blast Injury

Quaternary blast injury refers to all injuries not captured in the primary, secondary, or
tertiary blast categories, which are additional injuries beyond primary, secondary and
tertiary injuries. Examples are burns, smoke/dust/fume inhalation and radiation.

163
 Overview of Explosive-related Injuries

8.5 Situational Awareness

It is important for first responders to ensure that the scene has been declared safe by
authorized officials, e.g., the Fire and Rescue Department or HAZMAT team, before
entering the disaster scene.

8.5.1 Approach to Blast Injury

Injuries tend to be unexpected. It may occur outside working hours with large number of
casualties. In case of blast injury:
•• Hospital plan for MCI should be activated
•• Obtain details about explosion (size type, open or closed, structure collapse,
associated fire or smoke, toxic agent released, etc.)
•• Triage based on urgency

164 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Criteria for the Triage in Bomb Injuries

Severely Injured Lightly Injured

Airway compromise
Minor wounds
Breathing difficulty
Burns, degree I-II
Hemodynamic instability
Isolated trauma to a limb
Altered level of consciousness
Anxiety states
Vascular trauma
Most walking patients
Extensive second- or third-degree burns

Overall Treatment and Management

Life-saving interventions:
•• Control major hemorrhage
•• Open airway
•• Needle chest decompression
•• Auto-inject antidotes

Depends of specific Injuries

Effects can be delayed
Admission and Monitoring
Many Severe Injuries Die on Scene
Early Intubation for Inhalation Injuries
Judicious Fluid Administration
•• Laboratory Ix: FBC, coagulation studies, basic metabolic profile, urinalysis
•• Radiology standard trauma radiographs:
•• Lateral cervical spine, chest, and pelvic X-rays, FAST, CT scan.

In general, treat as per ATLS protocol.

Airway, Breathing, Circulation
5A:
1. Align
2. Analgesia
3. Antibiotics
4. ATT
5. Hemorrhage control

165
 Copious irrigation and disinfection of wound must be performed urgently. Definitive
debridement and closure can be done at a later time

Criteria for admission

•• All patient with significant burns

•• Suspected air embolism
•• Radiation or chemical contamination
•• Abnormal lung findings, clinical or radiographic evidence of pulmonary
contusion or pneumothorax
•• Abdominal pain, vomiting
•• Penetrating injuries to the thorax, abdomen, neck or head

Patient can be discharged

•• Asymptomatic patient can be discharged after 4-6 hours observation

•• Provide proper follow-up instruction
•• Return for evaluation if developed breathing problems, abdominal pain, or
vomiting (as symptoms of pulmonary contusion and intestinal hematoma may
take 12–48 hrs to develop.
•• Provide relevant follow-up instruction in writing including:
•• ENT follow-up
•• Wound care
•• Medications
•• Psychological support
•• Social services

166 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 8.5.2 Administration Issues

Patient can be discharged

•• Receiving hospital
•• Safety of Emergency Department (ED) staff:
•• Any possibilities for secondary explosive devices?
•• Possibilities of wunexploded material brought to ED?
•• Transmittable disease involving body fluid exposure or needle sticks during
stressful and rapid work.
•• Contamination by radiological/chemical or biological hazard either accidentally
or intentionally caused by the perpetrators.
•• Post-traumatic stress disorder.

At disaster field
•• Information management with the receiving center and other agencies at scene
including media.
•• Forensic management.
•• Forensic issues.
•• Police, crime scene investigators and other security services, have legitimate
interests in securing forensic and other information.
•• Efforts should be made to accommodate them, but never at the expense of
medical care

Prior coordination with all relevant authorities should establish protocols, such as who
and how many persons from all these agencies are allowed in, when, into which parts of
the ED, who controls them and who is empowered to limit their entry and work.

Psychological Issues Tips for Responders

Sequelae from an explosive event •• Promote safety
•• Anger •• Promote calm
•• Frustration •• Promote connectedness
•• Helplessness •• Promote self-efficacy
•• Desire to seek revenge •• Promote hope

167
 8.6 Summary

Explosion can occur unintentionally or as a result of a conflict or terrorism. Across the

globe, the threat of terrorism involving the use of explosive agents in urban or otherwise
crowded environments has become reality. Explosive events are inherently unpredictable.
Despite widespread concerns regarding biologic and chemical attacks, conventional
explosives are the most commonly used terrorist weapons because they are the easiest
to create, obtain, and use. The medical consequences of the detonation of a conventional
explosive include death and acute injury, as well as destruction of critical infrastructure
such as buildings, roads and utilities. Healthcare needs include immediate emergency
trauma care, follow-up medical and surgical care, forensic disposition of bodies and body
parts and mental healthcare.

Bibliography

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

Toh CL, 2013. Manual On Mental Health Psychosocial Response to Disaster pp.

Explosions and blast injuries: A primer for clinicians,Centers for Disease Control and
Prevention; US Dept. of Health and Human Services (2013) <[Link]
masstrauma/preparedness/[Link]>

Gans, L. and Kennedy, T., 1996. Management of unique clinical entities in disaster
medicine. Emergency medicine clinics of North America, 14(2), pp.301-326.

Mellor, S.G. and Cooper, G.J., 1989. Analysis of 828 servicemen killed or injured by
explosion in Northern Ireland 1970–84: the Hostile Action Casualty System. British
journal of surgery, 76(10), pp.1006-1010

Ministry of Health Malaysia. (2013). Manual on Mental Health and Psychosocial Response
to Disaster in Community.

168 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

CHAPTER
9
MASS FATALITY
MANAGEMENT
 CHAPTER 9
MASS FATALITY MANAGEMENT

Case Scenario

Malaysia Airlines flight MH17 from Amsterdam to Kuala Lumpur was shot down over
Ukraine on July 17, 2014, killing all 283 passengers and 15 crew on board. The recovery
operation, however, was delayed due to the military conflict at the disaster site. Most
of the recovered remains were heavily fragmented, decomposed, and/or thermally
altered, which necessitated numerous re-examinations because of commingling and
cross-contamination.
If you were part of the recovery team, how would you handle the remaining recovery
process?

9.1 Background

Fatality management is the ability to coordinate with other organisations to ensure the
proper recovery, handling, identification, transportation, tracking, storage, and disposal
of human remains and personal effects; certify cause of death and facilitate access to
mental and behavioral health services to the family members, responders and survivors
of an incident. The organisations involved are law enforcement, healthcare, emergency
department and medical examiner/coroner.

Remnants of the deceased need to be removed when they are blocking the search and
rescue activities. Casualty management shifts its focus to fatality management after all
surviving casualties, including expectant, are removed from the scene. Local authority
elected to handle fatality management is responsible for:

•• Taking charge of dead bodies and human remains associated with the disaster
•• Identifying and examining remains
•• Moving the deceased to the morgue
•• Maintaining custody of the body until released
•• Determining cause of death
•• Returning personal items to family members
•• Making final disposition for the bodies
•• Determining and documenting cause of death
•• Issuing death certificate

170 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 9.1.1 Mass Fatality Event Definition

Mass fatality is defined as follows:

•• Number of deaths exceeds the ability of local authorities to cope with them
•• There is no predefined number of deaths
•• Depends on the availability of resources

9.2 Field Fatality Management

In field fatality management, rescuers have to locate, sort and remove bodies as well as
personal belongings away from the scene and transport them to an identification center.
The steps include:
•• Create a temporary morgue which may require cooling technology.
•• Treat the bodies with respect.
•• Keep bodies away from public view and scavenging animals.
•• Tag the bodies or body parts.
•• Unless cleared, always assume all incident sites to be a crime scene.
•• Maintain chain of custody during handling the bodies.
•• Keep proper documentation.

9.2.1 Morgue Operations

Remains Remains documentation

Case
Body/remains Triage number Photography
Storage assigned Body/remains radiography
Personal effects

Wreckage
Personal and debris
effects

Family Assistance Center Postmortem Data Collection

Data entry Autopsy/pathological exam
Antemortem data collection
and Anthropological examination
DNA reference sample
management Fingerprint examination
collection
Dental examination
DNA specimen collection

Identification Section Release to

Compares antemortem and Family Holding
notification Area funeral
postmortem information home

Figure 9.1 Morgue operational plan

171
 •• Setup various station to ease:
•• Evaluation of cause of death.
•• Collection of evidence.
•• Identification bodies through documentations.
•• Conformation of bodies needs to be done by medical expertise.
•• Setup special areas for family members to view/visit the remains.
•• Access to the morgue needs to be controlled accordingly as overflowing crowds
may happen.
•• All records regarding morgue operations need to be kept meticulously.
•• Bodies need to be kept in a cool environment to forestall decomposition.

MORTUARY LAYOUT Team Muslim Body Prep

1

Police
Specimen Team Police
Room Specimen 2 Specimen
AUTOPSY

Hospital Storage Area Body Refrigerators

Support Non-Muslim
Service Body Prep
Team
Kadiology Area

3
Prayer
Room Specimen
Dirty Processing Anthropology
Utility
Chemical Room Regular
Store Cases
Forensic
Supervisors Ops Centre
Work Pantry Room
Station

Staff
Entrance
And Exit

Medical Interview
Staff Rest Officer Room Room
BSL 3
(Coontology) And Male Female
Change Change
Histophatology Briefing Head of Public
Lab Room Department Washrooms
Room

DVI Body
Entrance Police Ops Area
And Exit

Figure 9.2 Mortuary layout example

172 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 9.3 MH17: The Malaysian Experience

Flight MH17, a Malaysian Airlines (MAS) flight in airworthy condition, departed from
Schiphol International Airport in Amsterdam, the Netherlands at 1320 UTC on the 17th
July 2014. The aircraft was a Boeing type 777-2H6ER, registration 9M-MRD, carrying
283 passengers and 15 flight and cabin crew members, heading for Kuala Lumpur
International Airport, Malaysia. The National Bureau of Air Accident Investigation of
the Ukraine (NBAAI) was notified by the Ukrainian State Air Traffic Service Enterprise
(UkSATSE) that communication with the flight crew had been lost at 0600 UTC 18th July
2014 and later it was confirmed that Flight MH17 had crashed at Hrabove, Donetsk, East
of Ukraine approximately 50 km from the Ukraine-Russia border.

Following the instruction of the Prime Minister of Malaysia, the Malaysia National Security
Council (MNSC) held a coordination meeting to discuss the necessary preparations for
the delivery of the Special Malaysia Disaster Assistance Rescue Team (SMART) to
the disaster area and to involve other agencies in this mission i.e. for coordination and
search and rescue, Disaster Victim Identification (DVI), news and information coverage
and management and repatriation of the human remains. In view of the scene being
located in an area of conflict, the army and security control forces were also called to
participate in this mission. The mission was led by the Secretary of the MNSC acting as
the Head Coordinator.

Figure 9.3 The parade square was used as a temporary body storage area

173
 Figure 9.4 The multipurpose hall was used as a temporary mortuary

Temporary
Front
COLD STORAGE SQUARE Office
Mortuary
(PM Centre)

Changing
Room
(boot)

Changing
Vehicle Room
Parking (all-
cover)

Security
Check
Security
Check

Red Zone
Orange Zone
Green Zone

Figure 9.5 Zones surrounding the DVI operation

174 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

The MH17 incident was an aviation tragedy that involved victims of many nationalities.
There were no survivors and occupants of the aircraft were citizens from the Netherlands
(193), Malaysia (43), Australia (27), the Republic of Indonesia (12), the United Kingdom
(10), the Federal Republic of Germany (4), Belgium (4) the Republic of the Philippines
(3), Canada (1) and New Zealand (1). The occurrence took place over open farmland
southwest of the village of Hrabove in eastern Ukraine. At the time of the occurrence, an
armed civil conflict was ongoing in the Ukraine, between armed groups and Ukrainian
armed forces. The aircraft parts and wreckage came down in an area that was under the
control of the armed groups.

9.4 Summary

Mass fatality management is an important aspect in managing the remains of victims

of a disaster. Authorities should conduct proper recovery, handling, identification,
transportation, tracking, storage, and disposal of human remains and personal effects;
certify cause of death; and facilitate access to mental/behavioral health services to the
family members, responders, and survivors of an incident. DVI science has limitations
that must be explained to family members and society because their expectations can be
at odds with scientific capabilities. When families believe that identifications will happen
quickly, scientists must convey realistic expectations to the families about the timeframe
and associated complexities.

Bibliography

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

"Malaysia Airlines flight crashes in Ukraine". [Link]. Retrieved 17 July 2014

"Malaysian Plane 'Shot Down' With 295 On Board". Sky. Retrieved 17 July 2014

Malaysian J Pathol 2016; 38(1) : 1 – 10,MH17: the Malaysian experience

World Health Organization (WHO). Management of dead bodies in disaster situations.

Disaster manuals and guidelines series, No 5.

Mohd Noor MS, Khoo LS, Zamaliana Alias WZ, Hasmi AH, Ibrahim MA, Mahmood MS.
The clandestine multiple graves in Malaysia: The first mass identification operation of
human skeletal remains. Forensic Sci Int. 2017 Sep; 278:410.e1-410.e9. doi: 10.1016/j.
forsciint.2017.05.014. Epub 2017 May 27. PMID: 28698062.

175
CHAPTER
10
MENTAL AND
PSYCHOLOGICAL
RESPONSE
TO DISASTER
 CHAPTER 10
MENTAL AND PSYCHOLOGICAL RESPONSE
TO DISASTER
Case Scenario

The December 2004 earthquake and tsunami was one of the worst humanitarian
disasters which had claimed an estimated 232,000 lives. The earthquake generated
a tsunami 20 feet high which damaged lives and properties of residences. In the
local context, Malaysia has witnessed various forms of incidents such as building
collapses, terrorism, landslide and floods. Disaster inflicts psychological distress.
It may lead to significant life changes and uncertainty which has potential to cause
mental health issues. There is a growing interest in the well-being of both first
responders and victims during disaster response. Rescuers undertake stressful tasks
during recovery operations, including evacuation of bodies and body parts that may
have been decomposing for days, rescuing persons from rubble where amputation
can be the only possibility for rescue. It is important to acknowledge and appreciate
that exposure to a disaster setting can have short- and long-term mental and physical
consequences to both first responders and victims. Vulnerable populations such
as children, the elderly, and people with chronic illness may experience substantial
difficulties in coping with disaster and its consequences.

1. How would you address psychosocial effects of disasters?

2. What are the common mental health disorders in disasters?

3. What are the efforts to reduce psychological distress and promote resilience?

4. How would you address vulnerable populations such as children and

adolescents having psychological distress after a disaster?

10.1 Background

Everyone who encounters a disaster will have psychological, psychosocial, and/or

behavioral responses to the event. This normal expectation should be reflected in all
emergency planning documents. There are certain segments of the society that need
more attention.

Those populations in need of psychosocial and mental health support includes:

•• Those with underlying psychiatric issue
•• Those with severe psychological response to trauma
•• Those who have significant problems who have witnessed the disaster brutality and
losses

177
 Disaster plans should:
•• identify locations where people may obtain care for psychosocial needs and
screening. A referral system algorithm should be implemented.
•• serve specific cultural needs and responses of ethnic minorities, as well as of
vulnerable individuals, such as children, the frail elderly, and people with disabilities.

Key planning elements to address psychosocial effects of disasters and other mass
trauma events include:
•• Basic resources including food, shelter, communication, transportation, information,
guidance, and medical services
•• Interventions and programs to promote individual and community resilience and
prevent adverse psychological effects
•• Surveillance for psychological consequences, including distress responses,
behavior changes, and psychiatric illness, and markers of individual and community
functioning before, during, and after a disaster or public health emergency
•• Screening of psychological symptoms at the individual level
•• Treatment for acute and long-term effects of trauma
•• Response for longer-term general human service needs that contribute to
psychological functioning (e.g., housing, financial assistance when the event
creates job loss)
•• Risk communication and dissemination of information to the public, media, political
leaders, and service providers
•• Training of service providers (in medical, public health, emergency, and mental
health systems) to respond to a traumatic event and to protect themselves against
psychological harm
•• Capacity to handle a large increase in demand for services to address psychological
consequences in a disaster or public health emergency
•• Case-finding ability to locate individuals who have not utilized mental health services
but need them, including underserved, marginalized, and unrecognized groups of
people (e.g., undocumented immigrants, homebound individuals) and others with
unidentified needs

178 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 10.2 Stress and Psychological Trauma

Common emotional and behavioral responses include:

•• Fear
•• Helplessness
•• Worry
•• Anger
•• Confusion
•• Difficulty concentrating
•• Fatigue
•• Tension
•• Changes in sleep patterns
•• Loss of appetite
•• Stress

10.2.1 Mental Health Disorders and Syndromes Associated with Disasters

Disasters and trauma may result in various syndromes and diagnosis for those who
fail to cope. A proper understanding of these symptoms may help emergency response
personnel in a proper referral. The aim is to foster resiliency, prevent chronic emotional
problems, and minimize long-term deterioration in quality of life.

[Link] Acute Stress Reaction

Acute stress reaction is a transient process that develops in response to a traumatic

event which can manifest as:
•• Withdrawal
•• Disorientation
•• Amnesia
•• Agitation or over activity

[Link] Chronic or Complicated Grief

An intense period of grief normally lasts for several weeks to months. The individual is at
risk for a complicated grief reaction if it lasts for more than a few weeks or months. This
syndrome usually cannot be assessed by the initial responder. Those who take care of
the individual must be aware of this condition.

179
 Acceptance
Exploring options
New plan in place
Moving on
Denial
Avoidance
Confusion Depression
Elation Anger
Shock Frustration Overwhelmed
Fear Irritation Helplessness
Anxiety Hostility
Flight
Bargaining
Struggling to find meaning
Reaching out to others
Telling one’s story

Information and Emotional Guidance and

Communication Support Direction

Figure 10.1 Kubler-Ross grief cycle

[Link] Major Depressive Disorder

For major depressive disorder, five or more of the following symptoms have been present
during the same two-week period (either depressed mood or loss of interest or pleasure):
•• Depressed mood most of the day
•• Marked diminished interest or pleasure in all or most activities
•• Significant weight loss
•• Decrease or increase in appetite
•• Insomnia or hypersomnia
•• Psychomotor retardation
•• Fatigue
•• Feeling of worthlessness
•• Diminish ability to think or concentrate
•• Recurrent thoughts of death

180 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 [Link] Generalized Anxiety Disorder

It is normal to feel anxious from time to time, especially in a disaster environment.

However, excessive, ongoing anxiety and worry that are difficult to control and interfere
with day-to-day activities may be a sign of generalized anxiety disorder. It warrants a
psychiatrist referral if symptoms persist.

[Link] Panic Attack

Panic attack refer to a sudden episode of intense fear that develops for no apparent
reason and triggers severe physical reactions. It usually occurs without warning and can
occur at any time. Physical associated symptoms include:
•• Impending doom
•• Palpitations
•• Shortness of breath
•• Sweating
•• Trembling
•• Chills and hot flashes
•• Nausea
•• Headache
•• Chest pain
•• Tightness in the throat
•• Dizziness or faintness
•• Difficulty swallowing
•• Abdominal pain

Symptoms may resolve over time or require pharmacotherapy and/or psychotherapy if

they persist.

[Link] Panic Disorder

Individuals with multiple recurrent panic attacks cause a change of behavior or cognition
and affect individual function. This disorder often requires a psychiatrist referral.

181
 [Link] Post-Traumatic Stress Disorder

A disabling maladaptive response of at least 1-month duration to a traumatic event. It is

characterized as a long-lasting anxiety response following a traumatic event, witnesses
a traumatic event, serious injury to oneself or others. It arises from trauma. Among the
key symptoms includes:
•• Intrusion
•• Avoidance
•• Hyperarousal
•• Negative alteration in mood and cognitions
Treatment options for PTSD include antidepressants (selective serotonin reuptake
inhibitors) in combination with psychotherapy and empowering individuals grounding and
relaxation techniques.

[Link] Substance Abuse Disorder

Individuals who experience traumatic events may often experience an increase in the
use of alcohol and other psychoactive drugs. Men are typically more at risk of attempting
to cope with a traumatic event through substance abuse.

Abuse may be defined as recurrent use in situations that may be physically dangerous,
such as driving; use of the involved substance causing a failure to fulfil normal major
role obligations and responsibilities; or use of a substance that causes recurrent legal
problems.

10.3 Psychological First Aid (PFA)

PFA is an intervention tool, not treatment. PFA is an evidence-based approach process

that describes a humane, supportive response to a fellow human being who needs
support or who is suffering. Its main objective is to establish a connection with survivors
in a non-intrusive, compassionate manner. These interventions are also intended to
provide comfort and reassurance to individuals and ultimately provide them with a sense
of empowerment and safety.

PFA is considered as the intervention of choice in the immediate aftermath of a disaster.

The three basic action principles of PFA are look, listen and link. These action principles
will help guide anyone to safely enter a crisis situation, approach affected people and
understand their needs, and link them with practical support and information.

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 10.3.1 Look

The first action principle is look, which refers to the following actions:
•• Check for safety
•• Check for people with obvious urgent basic needs
•• Check for people with serious distress and reactions

10.3.2 Listen

The second action principle is to listen, which refers to the following actions:
•• Approach people who may need support
•• Ask about their people needs and concerns
•• Listen to people and help them to feel calm

10.3.3 Link

•• Help people address basic needs and access services

•• Help people cope with problems
•• Give information
•• Connect people with loved ones and social support

10.3.4 Core Actions of Psychological First Aid

•• Contact and engagement

•• Safety and comfort
•• Stabilisation
•• Information gathering
•• Practical assistance
•• Connection with social supports
•• Information on coping
•• Link with other services

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 10.4 Resilience in Disaster

Resilience can be defined as adaptive capacities of individuals or communities in

response to adversities. Some factors that will help in fostering resilience includes:
•• Good social and natural support
•• Preserve family system
•• Altruistic behaviors of community leaders
•• Minimal materialistic needs
•• Religious faith and spirituality
•• Learning from experience
•• Getting connected with family, friends and community

10.5 Mental Health of Disaster Response Workers

Disaster response workers experience a combination of stressors such as occupational,

hazards and personal situations which includes:
•• Exposure to unpredictable danger
•• Long hours, erratic work schedules
•• Extreme fatigue
•• Role ambiguity
•• Communication breakdown
•• Cross cultural differences between workers and community
•• Encounter with suffering of others
•• Personal injury
•• Self-expectation
•• Previous traumatisation

The mental health needs of disaster response workers should be given priority. This
should include appropriate training, surveillance during deployment and post deployment
measures. Organisations should adopt approaches to manage stress among their
workers. The following ways can be used to empower disaster response workers and
minimizing stress:
•• Proper goal, expectation and purpose setting
•• Adequate information gathering and training
•• Living accommodation should be personal and comfortable

184 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 •• Getting enough sleep and eat regular meals
•• Excessive use of alcohol and coffee should be avoided
•• Team leaders identify and respond to stress in personnel
•• Educating team members of potential harmful effects
•• Clear chain of command
•• Suggested shifts no longer than 12 hours
•• Functionally defined roles
•• Buddy system for support and monitoring
•• Positive atmosphere of support and tolerance

10.6 Mental Health for Children and Adolescents

Children are also affected not only by their own reaction to the trauma of the event but
by the emotions and behaviors exhibited by parents and others. Any effects of trauma on
adults can exacerbate the psychological effect on children or first be appreciated in the
child’s behavior.

Responders must be aware that children will not exhibit the same behaviors as adults in
response to the event and often will not be capable of verbally expressing their emotions.
Behavior indicative of the potential need to intervene include regressive behaviors such
as:
•• Whining
•• Clinging
•• Fighting
•• Irritability
•• Feeding problems
•• Sleep problems

Other children may exhibit their emotional pain by attempting to be excessively good or
compliant. The response of younger children is characterized by:
•• Regressive behaviors
•• Increased temper tantrums
•• Symptoms of clinginess
•• Difficulty with separation or sleep.
•• Even infants whose lives have been disrupted by a disaster manifest symptom of
crying and irritability, separation anxiety, and a hyperactive startle response.

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 School-age children may exhibit:
•• Depression
•• Anger
•• Despair
•• Problems at school
•• Somatisation symptoms, typically with complaints of headache or abdominal pain

For adolescents, these symptoms may be common:

•• likelihood of engaging in risk-taking behaviors such as drug abuse or sexual
relationships.
•• vulnerable to impulsive behaviors including drug or alcohol use and suicide.
•• may try to hide their feelings or symptoms for fear of being perceived as abnormal.

It is imperative that these symptoms not be minimized or overlooked because adjustment

reactions left unrecognized and untreated can lead to lifelong behavioral and emotional
problems.

Responders should not be afraid to talk to children in a clear, honest, empathic, and
accurate manner, allowing the child to take the lead in the discussion. Assisting parents
in their emotional responses to the event will often help their children adjust in a healthy
fashion. A child’s developmental stage characterizes his or her response to a disaster
and is responsible for the wide degree of variability in adjustment to traumatic events.

This means that therapeutic interventions should be developmentally appropriate.

10.7 National Guidelines for Mental Health and Psychosocial Response

This guideline is to facilitate a planned and coordinated mechanism in the management

of mental health and psychosocial response before, during and after disasters. The
organisation and appropriate management of the psychosocial response will improve
the coordination, adequacy and clarity of the measures taken by both government,
non-governmental organisations and volunteers involved in the overall response in line
with the National Security Council Directive No. 20 (Appendix 1: Organisational chart of
Mental Health and Psychosocial Response to Disaster).

186 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 10.7.1 Organisation of Services

The management of mental health response in disasters in Malaysia is carried out as in

Figure 10.2.

Terms of Reference of the Committees are:

•• Assess and plan psychosocial needs
•• Coordinate the management of mental health and psychosocial response
•• Collaborate and liaise with other agencies
•• Provide technical advice to DG/Minister of Health
•• Provide training and support for the response personnel
•• Establish and maintain database of resources

The National Committee on Mental Health and Psychosocial Response (NCMHPR) is

responsible for:
•• The management of mental health and psychosocial response to disasters at Level
3.
•• Assisting the government and the Ministry of Health in formulating policies,
regulations and any directive at all levels. It is also responsible for Coordinating and
providing supervision when needed at other level disasters.

The State Committee on Mental Health and Psychosocial Response (SCMHPR) is

responsible for coordinating mental health and psychosocial response teams at state
level during level 1 and 2 disasters.

The District Mental Health and Psychosocial Response Team (DMHPRT) is for
coordinating mental health and psychosocial response teams at district level with support
from the state.

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 ORGANISATIONAL CHART FOR MOH SERVICES

Disaster Operation Post

HEALTH AND MEDICAL

Emergency
Treatment
DG Health
Forensic
Public Health
(Psychiatric
Services)
National Committe On Mental Health Response
(NMHR Committee)
Co-Chair Director NCD /
National Head of Psychiatric Services)

Healthcare and Allied

Health Profesional
State Committee Mental Health Response
(TPKA/State Head of Psychiatric Services)

District Mental Health Response Team

(MnHO/ Psychiatrist)

Figure 10.2 Organisational chart for MOH services

When a disaster is declared, depending on its level – national, state or district –

Committees on Mental Health Psychosocial Response are responsible for the following
aspects:

•• Assessment of the situation to determine the level and extent of the disaster
•• Determine the capacity to manage the disaster
•• Determine the type of assistance required
•• Recommend the plan of action in the management of Mental Health Response
•• Provide necessary resource
•• Evaluate after a disaster on the effectiveness of the intervention provided with a
view to suggest further improvements

188 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 10.8 Summary

Mental and psychological response in disaster is an important aspect in managing

stress and psychological trauma. Early recognition of mental stress and psychological
trauma is important, and authorities should identify syndromes associated with both
disasters within the emergency response team workforce and the community. Mental
health considerations in special populations involved in disasters e.g., children and
adolescents are also an important part of psychological well-being to facilitate access to
mental/behavioral health services to the family members, responders, and survivors of
an incident.

Bibliography

Butler, A.S., Panzer, A.M. and Goldfrank, L.R., 2003. Preparing for the psychological
consequences of terrorism: A public health strategy.

Manual on Mental Health and Psychosocial Responses to Disaster in Community,Mental

Health Unit Non-Communicable Disease Section Disease Control Division Ministry of
Health Malaysia 2013

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0, 2012

National Guidelines for Mental Health and Psychosocial Response to Disaster, Mental
Health Unit Non-Communicable Disease Section Disease Control Division Ministry of
Health Malaysia In collaboration with World Health Organization, Ministry of Health
Malaysia 2013 <[Link] › moh › National_Guidelines_Disaster>

Safran, M.A., Chorba, T., Schreiber, M., Archer, W.R. and Cookson, S.T., 2011. Evaluating
mental health after the 2010 Haitian earthquake. Disaster medicine and public health
preparedness, 5(2), pp.154-157.

Tol, W.A., Barbui, C., Galappatti, A., Silove, D., Betancourt, T.S., Souza, R., Golaz, A.
and Van Ommeren, M., 2011. Mental health and psychosocial support in humanitarian
settings: linking practice and research. The Lancet, 378(9802), pp.1581-1591.

189
CHAPTER
11
PUBLIC HEALTH
EMERGENCY
RESPONSE
TO DISASTERS
 CHAPTER 11
PUBLIC HEALTH EMERGENCY RESPONSE TO
DISASTERS

Case Scenario

The Public Health Sector has been heavily involved in handling the COVID-19 outbreak
in our country by ensuring epidemiologic surveillance in the midst of a pandemic.
Preparing all elements to ensure adequate physicians and healthcare providers in
urban and rural areas while ensuring logistics is a challenge faced by many public
health sectors across the globe.

11.1 Background

The public health system protects the nation against injury, disease and myriad of
environmental and occupational health hazards. The public health system focuses on
populations:
•• Assessing and monitoring health problems
•• Informing the public and professionals about health issues
•• Developing and enforcing health-protecting laws and regulations
•• Implementing and evaluating population-based strategies to promote health and
prevent disease
•• Ensuring the provision of healthcare services

The public health system has been defined as a complex network of individuals and
organisations that, when working together, can represent what we as a society do
collectively to ensure the conditions in which people can be healthy. This includes:
•• Government public health agencies
•• Healthcare delivery system
•• Public health and health sciences academia
•• Community entities such as schools, religious groups and businesses
•• Media

The public health infrastructure is the underlying foundation that supports the planning
delivery and evaluation of public health activities and practices. This infrastructure makes
it possible to respond to disasters and public health emergencies, as well as to perform
essential ongoing public health services.

191
 The basic components of the public health infrastructure are maintained and protected by
the public health workforce, laws and regulation:
•• Surveillance
•• Information and data systems
•• Social protection agencies
•• Organisational capacities
•• Primary health care
•• Laboratory capacity and capability

These are the building blocks that support the work of the public health systems to prevent
epidemics and the spread of disease, protect against environmental and occupational
hazards, prevent injuries, promote and encourage healthy behaviors and mental health,
respond to disasters and assist communities in recovery, and ensure the quality and
accessibility of health services.

The public health workforce is represented by a diversity of skill sets, educational

backgrounds and expertise, including specialists in medicine, nursing, epidemiology,
social work, health education, outreach, environmental health, laboratory sciences, and
mental health and substance abuse counselling.

11.2 Public Health Agencies and Organisations

The capacity to respond effectively to a serious mass casualty situation depends on

a well-prepared and flexible public health system at all government levels and on the
vigilance of healthcare workers, who may be the first to observe and report unusual
diagnoses.

Public health agencies have a direct role in helping to ensure appropriate care for all
populations through health monitoring, disease surveillance and laboratory sciences.
Additionally, they provide an expert system for tracking, predicting, and developing
response tactics to curtail or mitigate disease outbreaks of other health threats

11.3 Public Health Role in Disaster Response

In a disaster, rapid and effective action is needed to save lives, protect health and stabilize
the situation to avoid making it worse. Critical public health actions include:
•• Supply basic life-sustaining commodities, such as food, water and shelter
•• Enhanced surveillance
•• Distribution of vaccines and medications
•• Implementation of environmental control
•• Legal interventions to restrict the movement of affected populations

192 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 •• Emergency risk communications
•• Provision of essential treatment and preventive clinical services

To respond rapidly, public health authorities must have the capacity to act on emerging
information with the full range of necessary tools. These include the legal framework for
action as well as adequate medical care facilities and treatment capabilities.

It is not possible to define a universally applicable order of priorities for emergency public
health actions, as each situation demands a specific response. The large majority will fit
within problems related to acute or chronic compromises in water, sanitation, access of
availability of essential health services, adequate shelter, food, or energy to ensure heat
during cold-related crises.

The priorities following a population displacement in southern Africa, where a cholera

epidemic may be imminent, are likely to be different from the priorities following a tornado
in the United States. To make rational decisions about priorities, and to revise those
priorities as the situation changes, an adequate assessment must be combined with
basic public health and epidemiologic principles. In practice, several priorities need to
be addressed simultaneously, as they are closely related, both epidemiologically and
operationally.

Overall public health priorities in the immediate response phase include:

•• Ensure access to food, shelter, healthcare, water supplies, and

sanitation facilities
•• Control of communicable diseases
•• Public health surveillance
•• Risk assessment and communication
•• Containment or removal of chemical or radiological contamination
•• Evacuation to ensure that people are no longer exposed to
hazardous situations

Mass trauma experienced by disaster responders and affected populations can lead to
widespread mental and physical health challenges. The public health system has a role
in communicating coping strategies as well as information about self-care and evacuation
or shelter-in-place strategies during a crisis.

While immediate attention will be directed to the care of sick or injured casualties and
prevention of secondary mortality and morbidities, public health workers also coordinate
with mortuary services to address the disposition of human remains and with animal care
and control agencies for the care of live animals and the disposal of dead animals.

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 11.3.1 Epidemiologic Surveillance and Investigation

Epidemiology is the basic science fundamental to the practice of public health and
preventive medicine. It is defined as the study of the distribution and determinants of
health-related status and events in specified populations and the application of this study
to the control of health problems. Epidemiologic studies are important for:
•• Disease control and prevention
•• Evaluation of program operation
•• Developing science-based policy

Public health surveillance and epidemiologic investigations are directed to the systematic,
ongoing assessment of the health of a community. Epidemiologists at the local, state,
and federal levels conduct investigations of suspected or confirmed patterns of disease,
death and injury in communities and populations. In some cases, an epidemiologist may
suspect an outbreak by noticing unusual patterns or clusters of a disease in a routine
surveillance area. Well-developed epidemiologic expertise can improve community
intervention strategies and lead to more effective prevention services.

It is additionally essential to monitor the effect of a disaster or public health emergency,

managing public health concerns and evaluating the impact of public health response.
In a disaster or public health emergency, health assessment and monitoring programs
increase dramatically.

Public health readiness depends on timely and accurate situational awareness to inform
mitigation and response strategies. In a disaster, situational awareness is the perception
of environmental elements in a given time and space and the ability to comprehend their
meaning and potential effects in the present and near-term future.

Surveillance data and survey assessments of affected communities and healthcare

systems may help to increase situational awareness by detecting the presence of new
and expected risk factors and unexplained clusters of injury and disease. All public health
surveillance systems must assure that individual’s privacy rights are not violated.

A delicate balance exists between the “right to privacy” and the “need to know” regarding
health-related data contained in individual medical records or maintained by the
government. This balance must be addressed by health surveillance programs and is
covered in state and federal legislation.

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 11.3.2 Enhanced Public Health Reporting

Malaysia has laws that require physicians to report certain disease and injuries to a
district health office which will then referred to the state health office. Many extend
these requirements to nurses, dentists, veterinarians, laboratories, school officials,
institution administrators, and police officials. State laws require reporting of some or all
communicable diseases, vital events such as births and deaths, cancer, and occupational
and environmental conditions and injuries.

Under certain emergency situations, surveillance activities may be initiated with additional
reporting requirements that may be justified by the general charge to, and powers of
state and local public health agencies to protect public health. Many of these reporting
programs form the basis of modern public health preparedness sentinel warning systems.
In a disaster, reporting to public health authorities is mandatory to provide information to
best serve and protect community health.

As such, reporting may include the number and types of casualties, suspected exposures
and exposure routes, and therapeutic interventions such as the number of patients
receiving mechanical ventilation. Such information will help guide public healthcare
needs of affected individuals and populations.

The list of notifiable diseases and conditions differs by state, which reflects the public
health priorities and concerns of each state. In general, a disease is listed if it causes
serious morbidity or death, has the potential to affect a large number of people, and can
be controlled or prevented with proper interventions.

In addition to specific diseases or conditions that have been established reportable

within a given state, health department regulations commonly specify two additional
circumstances that require reporting:
•• The occurrence of any outbreak or unusually high incidence of any disease
•• The occurrence of any unusual disease of public health importance

Increasingly, basic surveillance efforts are being directed at collecting public health
information in electronic formats such as from computerized clinical laboratory reports,
medical records systems and managed care databases.

Despite these advances, the need for direct involvement of clinicians will continue for
immediate reporting of clinical syndromes, unusual disease presentations and disease
clusters to trigger the necessary rapid public health response to prevent disease spread
and to control diseases for which there are no confirmatory laboratory tests.

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 11.3.3 Crisis and Emergency Risk Communication

An essential component of any public health system is a robust information and

communication system able to disseminate timely, credible, and reliable information
before, during, and after a disaster. It is imperative to share up-to-date guidelines,
recommendations, surveillance data, and health alerts with public and private health
organisations, the media, and the population at-large.

Because disasters can cause great fear and uncertainty in the population, public health
officials need to provide appropriate and complete information as quickly as possible and
involve the public in any decision making that will affect their health, safety, and well-
being.

Sound and thoughtful risk communication can allay fears and help public health officials
mitigate the effects of fear-driven and potentially damaging public responses to events
such as infectious disease outbreaks and acts of terrorism.

When delivered appropriately, public health risk communication can foster public trust and
confidence and subsequently improve health outcomes related to the disaster. Because
of the varied psychological, psychosocial, and behavioral effects of traumatic events, it
is not sufficient to give facts about a situation and tell the public what to do, and expect
that they will actually process the information and take recommended protective actions.

High distress levels can keep people from engaging in protective behaviors. Effective
crisis and emergency risk communication aims to help people channel distress into
productive and protective behaviors rather than destructive ones.

People will be more able to make appropriate decisions about safeguarding their health
and safety when their concerns and fears are acknowledged than when they are told not
to be fearful. Some things that people need to know are not easy for them to hear: that
people are dying, that the risks and severity are not really understood, that it is not known
when the emergency will be over, and that decisions may have to be made with imperfect
information.

196 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 [Link] Seven Cardinal Rules for the Practice of Risk Communication

Crisis and emergency risk communication can empower individuals, stakeholders,

or communities to make good decisions to protect the health and safety. Effective
communication of clear, concise, and credible information is essential to reassure the
public that the situation is being addressed competently.

Effective public information must reach broad audiences to publicize both immediate
and anticipated health hazards, appropriate health and safety precautions, the need for
evacuation or sheltering in place, and alternative travel routes.

Effective risk communication efforts should:

1. Accept and involve the public as a legitimate partner.

2. Be planned carefully and evaluated systematically.

3. Be responsive to the specific concerns of the public and

correct misinformation.

4. Be honest, frank, and open.

5. Coordinate and collaborate with other credible sources.

6. Meet the needs of the media.

7. Involve clear and compassionate messaging.

11.3.4 Community Evacuation Considerations

Evacuation involves the temporary transfer of a population (and, to a limited extent,

property) from areas at risk of disaster to a safer location. Effective public health
emergency management requires planning for individual and community evacuation
needs, understanding the target population, their concerns and nuances, and where they
can be safely relocated to during a disaster.

The number of people to be evacuated, the available modes of transportation, and the
rapidity with which the evacuation occurs vary with each disaster situation. Evacuation
plans must account for complex scenarios, such as the evacuation of schools, high-
rises, hospitals, critical-care ventilator-dependent patients, and long-term care facilities
(nursing homes, rehabilitation facilities).

197
 Mechanisms must be in place to help relatives, neighbors, and emergency management
personnel identify persons who may still be in danger and require assistance. This
includes mechanisms to help reunite families and loved ones after an event, as well as
assist efforts to identify missing persons.

If a disaster can be monitored or predicted, local authorities can order and execute an
evacuation before the event occurs, usually on the advice of emergency managers. This
will allow individuals to escape unharmed in a timely fashion and allow a more orderly
evacuation as routes and resources may not yet be limited by the event. Examples include
a forest fire encroaching on a neighborhood several miles away or a distant hurricane.

For many other disaster situations, such as earthquakes, chemical releases, bombings,
and nuclear explosions, there is no advance warning, and the disaster may be completely
unexpected. If potentially hazardous exposures are immediately present (exposure to
chemical or radiological materials), local authorities may provide instructions for people
to shelter in place (at home, work, school) for a specified period of time.

Government agencies, the American Red Cross, the Salvation Army, and other disaster
relief organisations will assist by providing temporary shelter and emergency supplies.
Determinations need to be made about the safety of evacuation routes to facilitate the
movements desired. Questions that need to be addressed include the following:
•• Is evacuation the best course, or should shelter in place be considered?
•• Where will populations be evacuated to?
•• How will they get there?
•• Who will manage and communicate updates to them while they are temporarily
housed?
•• What about companion animals? (Many people simply will not leave without the
family pet.)

Special provisions need to be made to move disabled, elderly, and dispossessed (e.g.,
homeless) persons, children, and institutional populations such as those in schools,
hospitals, and prisons.

Hospital evacuations are often facilitated by predetermined mutual aid agreements

with other community medical facilities. These agreements may increase capacity for
personnel, equipment, or space for evacuated patients.

Hospital evacuation challenges are compounded when the structure is a high-rise. The
evacuation of a “stable” ventilator-dependent patient from an intensive care unit, down
several flights of stairs, using manual or portable means to provide respiratory support,
while continuing critical intravenous medications is extremely challenging. The potential
for increased morbidity, mortality, and liability in these situations is significant.

198 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 11.3.5 Population-Based Surge Management

Large-scale disasters and public health emergencies inherently cause a scarcity of

available resources and disproportionately affect populations with functional and access
needs (e.g., pregnant women, children, those with chronic disease, the elderly, the
disabled, and the dispossessed).

Facility-based or “surge-implace” solutions maximize healthcare facility capacity for

patients during a disaster. When these resources are exceeded, community-based
solutions, including the establishment of off-site hospital facilities, may be implemented.

The only method to mitigate such an impact is to have plans in place that effectively
allocate scarce resources among casualties, based on need, availability of resources,
and anticipated outcomes.

Many states and communities now recognize and plan to access satellite healthcare
facilities such as dental, podiatric, and veterinary surgery centers, which normally have
surgical supplies and equipment. These satellite offices can serve as critical force
multipliers when primary and regional hospital infrastructures are overwhelmed.

11.3.6 Communicable Disease Prevention and Control

The potential impact of communicable diseases is often presumed to be high following

a disaster. Increases in endemic diseases and the risk of outbreaks depend on many
factors that must be evaluated systematically. This allows the prioritisation of interventions
to reduce the post-disaster impact of communicable diseases:
•• Diarrheal disease outbreaks can occur following contamination of drinking
water and have been reported following flooding and disaster-related population
displacement.
•• Natural disasters, particularly weather-related events can affect vector breeding
sites and vector-borne disease transmission. The risk of vector-borne disease
outbreaks (e.g., malaria, dengue) can be influenced by other complicating factors,
such as changes in human behavior (increased exposure to mosquitoes while
sleeping outside, movement from non-endemic to endemic areas, a lapse in
disease control activities, overcrowding), or changes in habitats that promote insect
breeding (landslide, deforestation, river damming and rerouting).
•• Crowded living conditions, as is common among people displaced by natural
disasters, facilitate disease transmission and necessitate attention to immunisation
coverage levels (e.g., measles, hepatitis) to prevent outbreaks.
•• Tetanus is not transmitted from person to person but is caused by a toxin released by
the bacterium Clostridium tetani. Contaminated wounds, particularly in populations
in which routine vaccination coverage levels are low, are associated with morbidity
and mortality from this disease.

199
 •• Power outages related to disasters may disrupt water treatment and supply plants,
thereby increasing the risk of water-borne diseases. Lack of electric power also
may affect proper functioning of food storage facilities, increasing the likelihood for
spoilage and microbial contamination.

Ensuring uninterrupted provision of safe drinking water is the most important preventive
measure to be implemented following a disaster. Chlorine is widely available, inexpensive,
easily used, and effective against most waterborne pathogens.

Shelter and settlement planning must provide for adequate access for water and
sanitation needs, and meet minimum “per person” space requirements, in accordance
with international guidelines.

The risk of transmission of endemic communicable diseases, such as acute respiratory

and diarrheal diseases, is increased in displaced populations due to associated crowding,
inadequate water and sanitation, and poor access to healthcare. Access to primary care
is critical for prevention, early diagnosis, and treatment of a wide range of diseases, as
well as providing an entry point for secondary and tertiary care.

Rapid detection of potential epidemic diseases is essential to ensure rapid control.

Improved detection and response to communicable diseases is important to monitor the
incidence of diseases, to document their impact, and to help quantify the risk of outbreaks
following disasters.

The detection of biologic or other potentially hazardous agent begins with a high index
of suspicion, which then needs to be confirmed through epidemiologic and clinical
investigation.

Public health surveillance and early warning systems should be established quickly to
detect outbreaks and monitor priority endemic diseases. Guided by epidemiologic data,
state and local public health authorities will implement the most appropriate measures
to minimize disease transmission. This includes the internet, television and radio
station news broadcasts, and public service announcements to transmit health-related
information, stressing the importance of personal prevention and protective measures.
Local health authorities will work closely with clinicians and community leaders to develop
dedicated community hotlines and communication systems to advise local residents
about the situation as it evolves.

If agents of transmissible (contagious) diseases are involved, basic hygiene and infection
control measures (e.g., washing hands after contact, avoiding direct contact with
secretions from infected individuals, keeping exposed persons away from public places
and isolating suspected or symptomatic cases) is essential in limiting secondary spread.

The communication of even this basic information on infection control precautions to

healthcare provider and the public will be an important public health control strategy.

200 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 11.3.7 Medical Logistics

Medical logistics is the logistics of pharmaceuticals, medical and surgical supplies,

personal protective equipment, medical devices and equipment, and other products
needed to support doctors, nurses, and other health and dental care providers. Medical
logistics functions comprise an important part of the healthcare system; after staff costs,
medical supplies are the single most expensive component of healthcare.

11.3.8 Mass Care Services

After a disaster, mass care involves the coordination of non-medical services including:
•• Sheltering of displaced persons
•• Food and water distribution
•• Provision of emergency first aid
•• Communication regarding casualties and the missing
•• Bulk distribution of emergency relief items

It also includes human services such as mental health counseling, identification and
provision of services for people with access and functional needs, the processing of
claims, and expediting of mail services in affected areas.

Sheltering, food, and water are often the most immediate and essential needs of
populations affected by a disaster. Adequate housing involves the provision of short and
long-term housing options for displaced persons.

11.3.9 Environmental Health Services

Nearly every disaster requires some level of environmental health assessment and
response. Public health authorities provide needed services for the monitoring and
evaluation of human and environmental health hazards and for ensuring that appropriate
actions are taken to protect the health and safety of responders and affected populations.

These include the provision of shelter, water supplies, sanitation, vector control (control
of insects and rodents), and the burial of the dead, as well as measures to protect food,
control epidemics and communicable disease, limit exposure to chemical and radiation
hazards, and remediate contaminated environments.

When critical infrastructure such as water and waste systems are affected, public health
workers ensure that temporary or alternative systems are in place and operational to
prevent disease outbreaks. Proper management of human waste is a public health
priority for affected individuals and emergency response personnel.

201
 Sanitation efforts are focused on reducing fecal contamination of food and water supplies
to control the spread of disease. Disease outbreaks can result from:
•• Breakdowns in environmental safeguards
•• Crowding in temporary shelters or camps
•• Malnutrition
•• Inadequate surveillance
•• Limited availability of medical treatment services.

Communicable diseases can be transmitted directly from person to person or indirectly

through contaminated food and water or disease vectors. Children are particularly
vulnerable to dehydration from diarrheal illness characteristic of post-disaster
gastroenteritis.

Public health authorities will take necessary action to prevent or control disease vectors
such as flies, mosquitoes, and rodents and to inspect indoor and outdoor environments
for health hazards.

Although the most effective environmental health measure in most disasters, in terms of
public health impact, is ensuring safe water and sanitation for the affected population as
a whole, serving hospitals and feeding centers may be more urgent when a large number
of people are injured or ill or when a significant portion of the population depends on
mass feeding centers.

Refuse collection and disposal, drainage, and vector control are usually lower priorities
than water supply and waste disposal. Infectious diseases, such as malaria and cholera,
may rapidly become the most important health risks after a disaster, and environmental
and human health surveillance systems should be established to enable a rapid response
to disease outbreaks.

Community emergency plans must address the delivery of food and water to support
clinical facilities, feeding centers, and other public health activities. Priorities will differ
from situation to situation and will change for each disaster as it evolves. This underscores
the need to adhere to sound public health epidemiologic and surveillance principles and
practices.

202 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 11.4 Recovery and Beyond

After a disaster, the affected community needs to be brought back – hopefully, by applying
lessons learned – to a better state preparedness. Recovery measures, both short and
long term, include returning vital life support systems to minimal operating standards;
sheltering and housing; public information; health and safety education; reconstruction;
counselling programs; and impact studies.

The reconstruction of housing, water supply sanitation and other environmental systems
(heating and ventilation) are priorities. Once damaged systems have been repaired and
services to the disaster-affected population are adequate for protecting safety and health,
longer-term reconstruction should be planned.

A critical element in community recovery is re-establishing public health and healthcare

infrastructures and ensuring access to preventive, treatment, and rehabilitative programs
and services. Increasing the capacity of people to offset risk, absorb tragedy, and meet
contingencies is central to the goal of sustainable recovery.

Reconstruction of a damaged area is not limited to the construction of new buildings. An

integrated development process is required that should embrace the full redevelopment
of the affected area according to the needs of the affected population.

Long-term recovery from a major disaster is inevitably a slow and difficult process. No
society is ever the same after a disaster, nor should it be. Disasters reveal weaknesses
and deficiencies in a community’s ability to protect itself, especially its more vulnerable
members.

Public health personnel will participate in after-action reviews to evaluate overall response
operations and identify strategies to enhance the resilience and responsiveness of
community health systems and infrastructures. This includes drawing out the more
general lessons that will result in prevention and mitigation to enhance preparedness for
future events.

Disasters and public health emergencies often provide an opportunity for new voices
to be heard (e.g., emergent community-based organisations expressing the needs of
disaster-affected people) and can become a force for societal change, catalyzing a more
rapid and effective transition from the emergency phase to sustainable development
once the event subsides.

As part of disaster management and recovery effort, new legislation and establishment
of new institution and programs are required. These may include:
•• Adoption of new or revised building codes
•• Regulations for land use
•• Controls on dangerous industrial processes and the transportation of toxic chemicals

203
 •• Insurance provisions to reduce vulnerability
•• Improved early-warning systems
•• Increased preparedness efforts
•• Improved coordination of emergency response functions

11.5 Community-Based Management

Risk management in a community

Community-based management is part of risk management within a community in

a disaster situation. Involvement of an integrated strategy is important to identify and
mitigate risks involved in the community which is vulnerable to disasters.

Community-based management strategy would involve identifying, mitigating, and

planning a management strategy to prevent loss of lives, supplies and damage to spaces.

Physical, social and economic damage to a community in disaster

Population growth around the world has left many spaces that are vulnerable to disasters
now occupied. This has led to increased physical, social and economic integration within
communities in areas prone to disasters.

The damage to communities which leads to injuries and physical disabilities, social
disintegration and economic damage are particularly felt in underdeveloped areas, and
developing countries. The damage can be felt in the short term in response and recovery
from a disaster to long term such as in the economic development process.

Community preparedness

Multilevel involvement in community preparedness such as household, communities,

districts, state and national levels should be implemented in high risk communities.
Warning alarms when hazards are identified will help the community know what to do
when warning is issued. Raising public awareness, deployment of effective warning
signals, and effective communication strategy is integral.

Community empowerment

Communities at “disaster-fronts” must be empowered to be able to respond to threats

themselves effectively. Encouragement of integration of the population and capacity
building with involvement of government and non-government organisation is a major
factor in community empowerment.

204 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Special population in community-based disaster management

This type of management uses a special population approach, considering children

and women and harnessing the capacity of all people living in the community. A special
population approach can help strengthen roles of women and children in a disaster. It
can also be used to elevate the role of women as leaders who can drive a risk reduction
agenda in support of community development goals.

11.6 The Sendai Framework for Disaster Risk Reduction 2015-2030

Four Priorities

01 02 03 04
Enhancing disaster
Strengthening preparedness for
disaster risk Investing in disaster effective response,
Understanding governance to reduction for and to "Build Back
disaster risk manage disaster resilience Better" in recovery,
risk rehabilitation and
reconstruction

7 Targets

1. Substantially reduce global disaster mortality by 2030, aiming to lower the

average per 100,000 global mortality rates in the decade 2020–2030
2. Substantially reduce the number of affected people globally by 2030, aiming
to lower the average global figure per 100,000 in the decade 2020–2030
3. Reduce direct disaster economic loss in relation to global gross domestic
product (GDP) by 2030
4. Substantially reduce disaster damage to critical infrastructure and disruption
of basic services, among them health and educational facilities, including
through developing their resilience by 2030
5. Substantially increase the number of countries with national and local
disaster risk reduction strategies by 2020
6. Substantially enhance international cooperation to developing countries
through adequate and sustainable support to complement their national
actions for implementation of the present framework by 2030
7. Substantially increase the availability of and access to multi-hazard early
warning systems and disaster risk information and assessments to people
by 2030

205
 11.7 Emergency Medical Teams (EMTs)

Emergency medical teams (EMTs) is a groups of health professionals providing direct

clinical care to populations affected by disasters, outbreaks and/or other emergencies as
a surge capacity to support the local healthcare.

They come from governments, non-governmental organisations/charities (NGOs), the

military, international humanitarian networks, including the International Red Cross and
Red Crescent Movement. EMTs historically have had a trauma and surgical focus, but
Ebola has shown the need for outbreak response and other form of emergency.

EMTs has different types depending on the capacity.

TYPE DESCRIPTION CAPACITY

•• Mobile outpatient teams

1 Mobile •• Remote area access teams •• > 50 patients / day
for the smallest communities

•• Outpatient facilities +/-

1 Fixed •• > 100 patients / day
tented structure

•• > 100 outpatients and 20

•• Inpatients facilities with inpatients
2
surgery •• 7 major and 15 minor
surgeries / day

•• > 100 outpatients & 40

inpatients
•• Referral-level care, inpatient
3 facilities, surgery and high •• 4–6 ICU beds
dependency
•• 15 major or 30 minor
surgeries/day

•• Any direct patient care-

related service can be
•• Teams that can join national
termed a specialist cell
facilities or EMTs to provide
Specialist Cell when given in emergency
supplementary specialist
response by EMT providers,
care services
such as rehabilitation,
pediatrics or surgery

Table 11.1 Types of emergency medical team

206 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 11.7.1 Field Hospital

The objective of this field hospital is to provide acute medical/surgical care services to
disaster victims whereby the nearest hospital facility is too far or the existing hospitals
wipe out and cannot function as usual in order to reduce morbidity and mortality among
the victims.

Reconnaissance/Recce teams need to be identified to do preliminary field investigations

on the proposed location(s) and logistics requirement of field hospital. They will inspect
the suitability of a few proposed sites of the field hospital; to identify local suppliers for
drugs, non-drugs, and food; accommodation for field hospital staff; and transportation
requirements.

Field hospital is a mobile, self-contained and self-sufficient healthcare facility capable

of rapid deployment and expansion or contraction to meet immediate emergency
requirements for a specified period of time. It can be set up in an existing structure or in
a structure, tent or similar structure.

Field hospitals is EMTs type 1 fixed and above. It serves a crucial part in disaster relief
efforts. A field hospital will temporarily replace or help the local medical facility and provide
emergency medical care to the people.

These facilities are the primary drivers for reducing the human life consequences of
disaster, and helping survivors recover more quickly as well. Adequate equipment and
staffing of field hospitals is key to their ability to provide the necessary speed, level of
treatment and capability to save as many lives as possible.

Field hospitals are self-sufficient and self-contained facilities that are designed for the
rapid implementation and if necessary, expansion of healthcare. Generally, these facilities
are used for emergency requirements during a specified period of time.

Field hospitals are normally clearly marked, since the Geneva Convention dictates that
conflicting parties are forbidden from attacking any people or buildings that display a Red
Cross or Red Crescent emblem. Any such attack is considered a war crime.

207
 Figure 11.1 Malaysian field hospital at Cox bazar Bangladesh

Figure 11.2 A Malaysian field hospital in Cox Bazar, Bangladesh

which costs RM3.5 million and caters to Rohingya refugees since December 2017
Source: Utusan Melayu

208 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Pharm Ambulance Entry Point
Wait Area

Water Pharmacy ED
Ops Rm
Well Waiting
Central Area
Store LAB
OPD
Female X RAY
Quarters
Entry
Point
Male CSSD OT PACU
Quarters

PH Store LR
Ward 1
Pantry
Generators
Ward 2 Temp
Store
Water Rm

Toilets
Washing Area

Visitors / relatives Entry Point

Figure 11.4 Layout of a field hospital

Field hospital facilities (depends on mission and objectives) consist of:

1. Emergency Department/Resuscitation Unit
2. Outpatient Clinic
3. Command and Operations (Ops) Room (Administrative Office)
4. Laboratory and Blood Bank
5. Radiology Unit
6. Operation Theatre (OT)
7. Central Sterile Services Department (CSSD)
8. Post-operative Care Unit (PACU)/Intensive Care Unit (ICU)
9. General Ward
10. Labour Room/Delivery Suite
11. Maternity and Paediatric Ward
12. Pharmacy and Pharmaceutical Store

209
 13. Male Quarters
14. Female Quarters
15. Public Health (PH) Working Area
16. Pantry

11.7.2 Organisation Structure of Field Hospital

The MFH shall be headed by the Team Leader (TL) who is responsible for the overall
management of the hospital, supported by the heads of clinical and non-clinical
departments.

The field hospital management is aided by hospital committees namely Core Management
Committee, Clinical Head Committee, and Logistics Committee. The Deputy Team Leader
(DTL) is in-charge of general administration, finance, patients’ record keeping and data
management and daily situation report (SitRep), whereas the Administrative Officer (AO)
is in-charge of public relations besides administrative works.

The paramedics are supervised by the Field Hospital matron or sister, and a senior
assistant medical officer (AMO). The supervisors are also directly responsible for other
tasks and services such as daily patients’ census and returns, meals for inpatients,
infection control, linen and laundry.

Figure 11.5 ATM and Civil Field Hospital (Selayang Hospital)

during COVID-19 crisis in Klang Valley

210 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Team Leader
(TL)

Deputy Team Leader

(DTL)

Senior Medical Administrator

Officer (SMO) Officer (AO)

Services Specialities Logistic

Outpatient Emergency Electricity

Triage/Emergency Medicine Water

Inpatient Surgery Transport

OT Orthopaedics General
Maintenance

ICU Obstetrics &

Gynaecology

CSSD Paediatrics

Labour Room Anaesthesia

Pharmacy Psychiatry

Laboratory Public Health

X-Ray

Forward
Medical Team

Figure 11.6 The organisational structure of a field hospital

211
 11.8 Summary

Public health plays an important role in managing emergency response to disasters.

The public health sector together with multi-agency collaboration and organisation
involvement is needed for an integrated approach. Role of public health to implement
strategies to improve surveillance, investigations, communication and enhanced
reporting will improve surge management of the population during the disasters. Other
sectors e.g., communicable disease prevention and control, mass care services and
environmental health services are needed services to be provided by the public health to
ensure a complete coverage in a disaster setting. All these initiatives and changes offer
public health planners and administrator’s opportunities to promote community health
and safety, and all are part of the overall recovery process.

Bibliography

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

Abdallah, S. and Burnham, G., 2000. The Johns Hopkins and Red Cross. Red Crescent
Public Health Guide for Emergencies.

Lerner, E.B., Cone, D.C., Weinstein, E.S., Schwartz, R.B., Coule, P.L., Cronin, M.,
Wedmore, I.S., Bulger, E.M., Mulligan, D.A., Swienton, R.E. and Sasser, S.M., 2011.
Mass casualty triage: an evaluation of the science and refinement of a national guideline.
Disaster medicine and public health preparedness, 5(2), pp.129-137.

Garshnek, V. and Burkle Jr, F.M., [Link] of telemedicine and telecommunications

to disaster medicine: historical and future perspectives. Journal of the American Medical
Informatics Association, 6(1), pp.26-37.

Disaster risk management, UNDRR, United Nations,

[Link]

Brauch, H.G., 2003. Urbanisation and natural disasters in the Mediterranean: Population
growth and climate change in the 21st century. Building safer cities, p.149.

de la Poterie, A.T. and Baudoin, M.A., 2015. From Yokohama to Sendai: Approaches to
participation in international disaster risk reduction frameworks. International Journal of
Disaster Risk Science, 6(2), pp.128-139.

212 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 CHAPTER
12
WORKFORCE READINESS,
DEPLOYMENT AND
ON-SCENE MEDICAL
MANAGEMENT
 CHAPTER 12
WORKFORCE READINESS, DEPLOYMENT AND
ON-SCENE MEDICAL MANAGEMENT

Case Scenario

You are working in a local hospital facility during a respiratory infection outbreak of an
unknown source. The emergency department has admitted 40 patients over 3 days, all
with the same complaints and presentations, and required extensive PPE precautions.
The emergency department is starting to receive more patients that are coming in with
critically ill conditions and many of the patients need ICU level care. As a member of
the disaster committee of your hospital you are called to make recommendations to
best utilize available staff and redeploy them to cover the viral units. The hospital has
a negative pressure ICU, infection control ward and has closed all operating rooms
and is working to control flow into the hospital.

The medical workforce you have available to redeploy and train for an expected surge
consists of:

•• 10 Internists
•• 8 Emergency Physicians
•• 25 Nurses
•• 2 Radiologists
•• 2 Anesthesiologists
•• 8 Internal medicine residents
•• 2 Urology residents
•• 5 Surgeons

1. How will you redeploy your current available workforce to meet the demands of
the hospital?

2. Discuss how will you train your redeployed workforce? Create job action sheets
and discuss training requirements.

3. Address the concerns around accepting volunteer medical and non-medical

persons who want to assist in the response.

214 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 12.1 Deployment

A process of systematically activating and mobilizing reserved resources, either personnel

or supplies, to a position into action. It should be a quick-responding process to mobilize
the trained, and competent professionals, paraprofessionals, supporting staff and to
distribute the needed and relevant equipment as well as supplies during an emergency
or disaster.

The deployment usually involves first responders, emergency management specialists,

physicians, military or specialized response teams (e.g., SMART Team). The coordination
and arrangement of deployment can be varied, depending on:
•• Location
•• Duration
•• Number of casualties
•• Magnitude of event
•• Hazards
•• Number of organisations involved
•• Organisational structure

12.2 Pre-Deployment Preparation

All responders have a responsibility to be:

•• Prepared to perform their duties for 12 hour or greater shifts for several days
•• Fit enough to respond effectively
•• Able to perform designated duties in less-than-ideal environments
•• Ensure personal matters are attended and make necessary arrangements
•• Agreement with employers on their sudden absence from work

12.2.1 Health and Mental Status

Responders selected for disaster assignments must be physically, mentally and

emotionally capable of performing these duties. Resilience is the ability to quickly
rebound and adapt to physical and psychological stress and directly related to physical
and psychological health.

Their baseline health status or underlying chronic illness must be cleared by a physician,
prescribed medication that would not impair duties and have sufficient supplies throughout
deployment.

215
 Responders also should be vaccinated according to the type of disaster and area to be
deployed. For example, volunteers who were deployed at Malaysian field hospital at Cox
Bazar, Bangladesh were given typhoid, hepatitis A, hepatitis B, influenza, DTaP, and
cholera vaccination.

In addition, they were also given oral doxycycline 100 mg tablets daily from two days
prior to departure, which then was consumed daily throughout the mission period, and
continued daily for two weeks after returning to Malaysia as a chemoprophylaxis against
malaria.

12.2.2 Personal items

Selected personnel to be deployed must prepare certain essential basic items, documents
and supplies. They should always be in a situational awareness mindset to fit the changes.
•• Personal identification readily available at all times such as driver's license, passport,
identification card from the disaster response organisation, health validation status,
updated professional license and training verification certification (e.g., completion
of basic and advanced life support training).
•• Clothing, toiletries and other personnel daily items need to match the weather
conditions in the disaster area.
•• Pre-packed bag or suitcase (i.e., "go-kit") can always be in ready-state to take at a
moment's notice. It should not be assumed that an individual will remember to pack
all essential items in the potentially hectic hours preceding deployment, nor can it be
assumed that items can be purchased on arrival at an assigned destination.

Practical tips to consider when preparing a pre-packed bag or suitcase (go-kit):

•• Use a suitcase or bag that can fit under a cot and light as volunteers need to carry
their own luggage from place to place.
•• Protect the items from moisture and insects (e.g., use plastic ziplock bags; package
like items together).
•• Pack a "fanny pack" or money belt to contain personal identification papers, money,
cellular phone, and contact phone numbers.
•• Bring a backpack to carry drinking water, food and snacks, PPE, hand hygiene
products, personal medications, flashlight, and other essential supplies when in the
field.
•• Pack sturdy, practical, comfortable, protective shoes with extra socks (this is not the
time to break in new shoes).
•• Professional equipment (e.g., stethoscope).
•• Standardize batteries, whenever possible, to reduce the need to carry multiple
types.

216 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 12.2.3 Equipment

Unless otherwise stated, the responder is responsible for properly using, caring for, and
protecting all equipment to be brought along during the deployment against loss, theft or
damage.
•• Responders should ensure that received equipment is functional before accepting
it and should report any loss, theft, damage, destruction, or misuse of equipment to
the assigned supervisor.
•• When returning assigned equipment, the responder may be liable monetarily if
negligent in performing, maintaining, and securing items.
•• It is important that incident command (usually the logistics section chief) be aware
of and updated on all equipment that is being taken or transported for field or
deployment use.
•• Equipment considerations include storage requirements, electrical support (battery
vs. continuous power), up-to-date safety inspections, safety, stability and compliance
with transportation guidelines.

12.2.4 Education and Training

Responders need to complete education and training requirements prior to deployment.

Once deployed, responders should be receptive to "just-in-time" training to acquire
additional knowledge and skills specific to the assignment.

The level of training depends on their expected role and functions in disaster. Training
can include skills learned prior to a disaster and after a disaster, which might be focused
on site-specific hazards, operating procedures, and available resources.

The education and training provided should cover:

•• Understanding the triage principles is important during the deployment
•• Learning the various strategies to provide effective clinical and public healthcare
settings with limited resources
•• Basic knowledge on primary importance of safety and security
•• Some basic knowledge on physical and mental health needs
•• Knowledge on how to coordinate responses with other agencies and organisations
involved
•• Understanding the importance of teamwork in disaster preparedness, response and
recovery

217
 12.2.5 Specific Information Assigned

Responders deployed should know what is the job assigned, destination, contact person,
important phone numbers, reporting time and directions. Responders also should be
aware of their limit in position, authority and expertise.

12.3 Deployment Considerations

12.3.1 On-Site Responder Daily Task

•• Identify the response roster for a disaster

•• Understand the job or new assigned job
•• Involves personnel identification, accountability, and tracking

12.3.2 Documentation During Disaster Deployment

•• It is important to write down every single incident

•• Consider which forms and documents will require approval prior to demobilisation
•• Create a record of events

12.3.3 Health Monitoring and Surveillance During Response

All responders are responsible for maintaining personal health before and during
deployment. They should ensure disease prevention by:
•• Control personal risk factors
•• Recognizing early warning signs
•• Early detection screening
•• Guarding against environment potential risk
Exposures and health changes are documented and sequelae more easily tracked or at
a minimum will prove changes in health status.

12.3.4 Exposure Assessment

•• It is important to consider the many biological, chemical, and physical hazards a

responder might be exposed to.
•• This exposure information can then be linked with health data to implement controls.

218 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 12.3.5 Injury to Responders

•• If a responder is injured while deployed, appropriate incident reports need to be

completed. All treatments and hospitalisations should be recorded carefully even if
care is started in the field or deployed environment.
•• It is strongly recommended that the injured responder also obtain copies of all
supporting documentation.
•• Coordination of care with the responder's regular primary care or specialty physicians
is important as soon as possible or circumstances allow.

12.3.6 Field Hygiene

•• Response personnel should clean their hands frequently.

•• Waterless, alcohol-based sanitizers may be used when soap and water are not
available and when hands are not visibly soiled.
•• An adequate supply of alcohol-based hand sanitizer is essential.
•• Another hygiene practice that warrants attention is bathing. Responders should
always use their own soap; liquid soap is preferred, as bar soap is difficult to air dry.

12.3.7 Insect Bites and Stings

Insect-borne diseases (e.g., malaria, dengue) may be endemic in the area. Insect bites
can be prevented by the following measures:
•• Using insect repellent
•• Wearing lightweight long-sleeved t-shirt, long pants and hat
•• Remained indoor
•• Sleeping in bed covered by bed net
•• Spraying room with product effective against flying insects

219
 12.4 Volunteerism

Every day, volunteers are involved in humanitarian missions that reach out to millions
of helpless people, regardless of their nationality and which part of the world they are
in. Among the various volunteer groups (non-governmental organisation) present in
Malaysia for disaster response are:

1. Malaysian Medical Relief Society (MERCY Malaysia)

2. Malaysian Red Crescent
3. St. John Ambulance
4. Humanitarian Care Malaysia (MyCARE)
Volunteers may add confusion to the already chaotic situation, however providing
volunteer groups with disaster training might speed up the process of recruitment,
activation, deployment and demobilisation.

12.4.1 Advantages

While the majority of the NGOs contribute more in recovery, reconstruction and
rehabilitation of the post-disaster period, some of the organisations promote disaster risk
reduction, mitigation and preparedness. These groups have a lot of volunteers manpower
from various pools of society who have been engaged by them.

Disaster Packing & Handling Over

Strikes Deployment EMTs are expected
The turnover time to submit a final
between team report to the MOH
assembly & before leaving
Arrivals deployment should
Report to EMT be from 6-12 hours
Coordination
Cell (EMTCC)

Treatment of
Patients
Location EMTs are expected Regular
Assignment to start treating Reporting
patients as soon as & Monitoring
Based on the current they arrive at their
need, once teams are location
approved & have their Submit daily report
medical license
(if operating in foreign Quality assurances
country) visit by MOH

Figure 12.1 The EMT Deployment Process

(Adapted from WHO EMT Initiative, Nov 2016).

220 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 12.4.2 Challenges and Limitations

The main concerns about the volunteers are the level of education, training and
experience they have. The lack of this aspect would create more disaster for the team
if the volunteers who join the mission do not have a basic knowledge in giving first aid.

12.5 Past Experiences in Managing Humanitarian Aids Distribution Process During

Disaster

12.5.1 Problems during Aids Distribution process

1. Information
i. Redundancy of information on the disaster
ii. Data on the disaster might be fraudulent reports from malicious persons

2. Communication
i. Failure of communication channels, whether conventional phone lines, cell phone
systems or radio channels, which can severely harm the emergency response
(Martin et al., 2016).
ii. This lack leads to duplication of humanitarian aid between the NGOs (Baitenmann,
1990).

3. Collaboration
i. Lack of collaboration tools that can be used to manage disaster management
information. Most of the disaster management team, especially the NGOs, do not
know how and where to share and retrieve the disaster information with or from
others (White et al., 2009).
ii. Lack of collaboration in providing knowledge-sharing on a disaster within the
disaster management team. The disaster management team have their own plan,
SOP or activities in managing the humanitarian aid distribution process (Gao,
Wang, et al., 2011; Nik Nazli et al., 2014).

4. Coordination
i. Lack of coordination among the disaster management team. The current practices
of disaster management are often unable to be harnessed effectively due to lack
of coordination & efficient knowledge-sharing between the Government agencies
and NGOs (Mohd Rodzi et al., 2016).
ii. Lack of coordination tools to manage real-time information on a disaster within the
disaster management team. Real-time information is hard to deliver in a chaotic
situation. There is a need for a tool that could coordinate disaster information
despite the chaotic situation during a disaster occurrence (Gao, Wang, et al.,
2011).

221
 5. Cooperation
Lack of cooperation between the disaster management team and disaster victims. One
of the challenging issues faced by Government agencies is to achieve cooperation with
the disaster victims in terms of relocating them to the disaster-proof areas, especially
in relocation phases (Joshi et al., 2016).

12.5.2 Lesson Learnt from Mismanagement in Humanitarian Aids Distribution

1. Evacuation centers become overloaded and clogged with non-critical items

resulting in waste and duplication (Husain et al., 2014);
2. A chaotic process of delivering goods to the disaster victims (Husain et al., 2014);
3. Delay in the decision-making process for resolving immediate needs during a
critical situation (Husain et al., 2014);
4. Wastage and duplication of donated goods caused by improper inventory
management (Husain et al., 2014);
5. Duplication of supply to the same group of disaster victims while other affected
disaster victims are left empty-handed (Husain et al., 2014);
6. Disaster victims are scattered with low life support on water, foods, energy, and
healthcare supplies (Husain et al., 2014; Mat Taib et al., 2014; Yazid et al., 2014);
7. The negative impact in terms of monetary and other limited resources (Zakaria et
al., 2014).

12.6 Medical Supply Chain

Supply chain networks are usually very complex and dynamic. It is related to the handling,
transport and chain management of multiple and varied products, the vast majority of
which require specific conditions in their logistics. Disaster supply chain flow will usually
experience a disruption especially in distribution and transportation section. Thus, proper
management strategy should be established to effectively handle medical supply during
crisis and disaster.

Preparedness phase
Ensuring essential medications procurement, education, training with disaster
management teams, knowledge about national stockpiles, and participating in disaster
preparedness efforts.

Response Phase
Give logistical support of supplies for patients with chronic diseases, refilling emergency
medical supply and also distribute national stockpiles if necessary.

Recovery phase
Restoring normal stock level and waste management.

222 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Ministry Of Health (MOH) Medical Supply Chains

A. REGULATIONS AND STANDARD

•• Poison Act 1952: consolidate the law regulating the importation, possession and
sale of poisons.
•• Control of Drug and Cosmetics Regulation 1984 (CDCR) says all pharmaceutical
products must be registered with the Drug Control Authority before it can be used
in Malaysia.
•• Good Distribution Practice (GDP) ensuring the quality and integrity of pharmaceutical
products during all aspects of the distribution process.

B. GOVERNMENT PROCUREMENT

•• Government procurement regulations stipulated by the Ministry of Finance (MOF)

Treasury Instructions.
•• During an emergency, procurement will be done centrally at the MOH headquarters
level through the Emergency Procurement Procedure to accelerate the availability
of medicines.
•• Collaboration inter-ministerial example with the Ministry of International Trade and
Industry (MITI) were done to obtain approval for the pharmaceutical manufacturers
and related companies to operate like normal at full force during the Movement
Control Order (MCO).
•• Government to government engagement example with India, Japan and China
to allow exportation of pharmaceutical product including active pharmaceutical
ingredients (API) to Malaysia.

C. STOCK RECEIVING AT HEALTH FACILITY STORE

•• Receiving from supplier at Logistic Pharmacy Unit shall follow Tatacara Pengurusan
Stor and Garis Panduan Pengurusan Stor Farmasi Logistik.
•• During COVID-19, MOH has received an overwhelming amount of donation
items, such as PPE, face shields, face masks and hand sanitizers from the non-
governmental organisations (NGO), companies and public. Therefore, an adequate
and suitable storage space for the goods is needed to keep and evaluate the
donation goods.
•• Donations where the intended recipient is a government affiliated entity should
strictly follow the guidelines stipulated in the
1. Public Service Circulars [Surat Pekeliling Perkhidmatan Bilangan 5 Tahun
2008: Pihak Berkuasa Meluluskan Penerimaan Hadiah oleh Jabatan Kerajaan,
2. Garis Panduan Penerimaan Hadiah oleh PTJ DI KKM [Guidelines for Receiving
Gifts by PTJ at MOH

223
 D. INVENTORY MANAGEMENT

•• According to Good Distribution Practice (GDP)

•• MOH Crisis and Disaster Management Plan for Pharmaceutical Services (Pelan
Pengurusan Krisis dan Bencana bagi Perkhidmatan Farmasi), First Edition, is
available, providing overall guidance on management of pharmaceuticals and
vaccines during crisis and disaster
•• Inventory system available in government health facility helps to manage and
monitor supply example Pharmacy Information System (PhIS)

E. STOCK DELIVERY

•• Delivery of medical supply in MOH is done ‘door to door’ basis by supplier

•• Planning is done according to goods and their requirements
•• Delivery during crisis or disaster might also involve different agency such as
TUDM and NADMA

F. STOCK MONITORING AND REPORT

•• Disposal
•• Quality related report example Product Complaint, Adverse Effect Following
Immunisation (AEFI)
•• Audit

FOR FURTHER INFORMATION ON DISTRIBUTION, STOCKPILES

AND MEDICAL SUPPLY DEPLOYMENT MANAGEMENT

SCAN
THIS QR CODE
SCAN
THIS QR CODE
to browse the website to browse the website
Pelan Pengurusan The Sphere
Krisis Bencana Handbook
Perkhidmatan Farmasi

224 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Figure 12.2 Distribution of PPE to the districts in the state of Pahang

Figure 12.3 Unloading PPE stocks from the Royal Malaysian Air Force airplane
to be distributed to all hospitals and health clinics in Sabah

225
 Figure 12.4 PPE donations to MOH

12.7 Summary

•• The existence of humanitarian aid distribution processes could lighten the burden of
disaster victims by providing for their needs, shelters and emergency rescue.
•• The establishment of a disaster management team in Malaysia shows that the
Malaysian government has striven to address disaster management issues.
•• All roles and responsibilities of the government agencies have been well-defined in
Directive No. 20 but not those of the NGOs.
•• There is a need to propose a SOP for the roles and responsibilities of NGOs as
supporting members in managing humanitarian aid distribution processes.
•• Therefore, further research will be needed to formulate a proposed SOP that
will highlight the roles and responsibilities of NGOs as supporting members in
humanitarian aid and developing systematic tools in order to address the issues in
managing humanitarian aid distribution processes.

226 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Bibliography

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

Local Rohingya community applauds Msias move to build hospital in Cox’s Bazar,
Farhana Syed Nokman, Alia Mior, october 17, 2017

Alexander, D.A. and Wells, A., 1991. Reactions of police officers to body-handling after a
major disaster: a before-and-after comparison. The British Journal of Psychiatry, 159(4),
pp.547-555.

James, J.J., Benjamin, G.C., Burkle, F.M., Gebbie, K.M., Kelen, G. and Subbarao, I.,
2010. Disaster medicine and public health preparedness: a discipline for all health
professionals. Disaster medicine and public health preparedness, 4(2), pp.102-107.

Coyle, G.A., Sapnas, K.G. and Ward-Presson, K., 2007. Dealing with disaster. Nursing
management, 38(7), pp.24-29.

Buenaventura, Joel & Martin, Bronte & Alonso, Juan & Harbou, Kai & Robinson, Louise
& Fuente, Luis & Nsenga, Ngoy & Buddh, Nilesh & Emmler, Oliver & Saaristo, Pannu
& Skelton, Pete & Parker, Richard. (2018). Emergency Medical Teams Coordination
Handbook.

Norton I, Von Schreeb J, Herard P, Aitken P, Lajolo C (2013) Classification and minimum
standards for foreign medical teams in sudden onset disasters: Foreign Medical Team
Working Group, Global Health Cluster, World Health Organization

227
 CHAPTER
13
CASUALTY
DECONTAMINATION
 CHAPTER 13
CASUALTY DECONTAMINATION

Case Scenario

Incident of Sarin Gas attack in Tokyo in 1995 had caused a mass casualty incident
with 13 people dead and about 5500 people suffering various degrees of injuries.
The attack on the railways transport system by the terrorist had caused fear and
panic among the passengers and local community. Hospitals were unprepared for
the decontamination procedure and PPEs were unavailable as patients arrived at the
Emergency Department.

1. The role of early identification of hazards and deployment for decontamination

on-site was difficult and unavailable. How do we mitigate this issue?

2. What are the early warning systems (EWS) and Standard Operating Procedure
(SOP) that hospitals must have to prepare for such an event?

3. Transmission of information may be incomplete and even unavailable at the

beginning of the crisis that may put healthcare providers at risk. How can
decontamination prevent more casualty?

Chemical, biological, radiological, nuclear and explosive (CBRNE) decontamination is the

removal of material from equipment and humans. The objective of the decontamination
is to reduce radiation burden, salvage equipment, and material, remove loose CBRNE
contaminants, and fix the remaining in place in preparation for protective storage or
permanent disposal work activities.

13.1 Contamination

Contamination with hazardous material can occur in daily healthcare as a result of natural
or man-made disasters. It causes a wide variety of injuries ranging from mild irritation to
life threatening emergencies.

Presentation of the hazard depends on how it may affect the body, its physical state,
amount and mode of release.

229
 Table 13.1 Type of hazards and their effects

Aerosols, vapors
Liquids Solids
and gases

•• Acts on the skin upon •• Less reactive

contact •• Low risk as a dermal hazard
•• Affects more •• Harder to remove •• Respirable particles may
rapidly •• A highly liquid- pose as a respiratory hazard
•• Easier to remove contaminated casualty •• Powders should be brushed
poses more risk to off before washing casualties
•• Dissipate responders/receivers as wetting them enables
before casualty compared to minimal chemical reactions.
movement [6] contamination.
•• The smaller the particle size,
•• More difficult to the more difficult it will be to
decontaminate decontaminate

13.1.1 Chemical Hazard Transmission

Chemicals in gas or liquid form can cause irritation or burns on contact. Others may
alter physiologic processes (e.g., heart rate, blood pressure, or fluid secretion).

Table 13.2 Chemical hazard transmission

Methods Examples

Transfer
Casualty to workers
▪▪ Move from one surface to another

Spread
▪▪ Spread of contamination on same Contaminated hand touches clean face
surface

Desorption Chemical agent trapped in porous

▪▪ Absorbed liquid gives off vapor material off-gases

Vapor and aerosol

Casualty off-gassing
▪▪ Carried through air

230 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 13.1.2 Biological Hazard Transmission

Classes of pathogens: Bacteria, viruses, fungi, parasites, and prions.

Modes of transmission vary by type of organism, with some infectious agents being
transmitted by more than one route. Not all infectious agents are readily transmitted from
person to person.

Direct: casualty body fluids

via mucous membranes or broken skin
Indirect contact: contaminated Herpes Simplex Virus, respiratory
intermediate syncytial virus, Staphylococcus aureus
Hand or objects spreads to another
person

Respiratory droplet: cough, sneeze or

COVID-19, Influenza virus, Bordetella
talking
pertussis
Contact hazard expelled up to 6 feet

Airborne: Droplets or particles

Carried through the air over long Mycobacterium tuberculosis
distances

Blood-borne: via percutaneous or Hepatitis B and C, human

mucous membrane exposure immunodeficiency virus

13.1.3 Secondary Contamination

Preventing hazard transmission from contaminated casualties to workers and other

casualties is one of the most important features of medical response to chemical,
radiologic, and biologic threats. Principles to minimize secondary contamination:
•• Avoidance
•• Limit direct contact with contaminants.
•• Protective equipment
•• Wear barrier garments to prevent self-contamination.
•• Good technique
•• Limit transfer and spread of contaminants of PPE.

231
 •• Decontamination
•• Removal: remove contaminated clothing.
•• Dilution: reduced concentration of harmful substances to safe levels with water.
•• Absorption: pick up spilled substance with an inert absorbent material.
•• Degradation: alter chemical structure of harmful substances with an active
chemical agent.
•• Isolation
•• Bag and clearly identify material that cannot be successfully decontaminated.
•• Casualties with infectious diseases should be isolated in environmental controlled
rooms.
•• Disposal
•• Move harmful substances to an approved disposal site.
Considerations for preventing secondary contamination:
•• Type and amount of contaminant present
•• Available resources
•• Type of protective equipment needed to safely perform the task

13.1.4 Types of Contamination

•• Primary
The direct transfer of hazardous materials to persons, equipment and the environment in
the hot zone is due to direct contact with a hazardous material.
•• Secondary
The contamination of people, equipment or environment outside the hot zone occurs,
the contaminant is carried from the hot zone by clothing worn by the personnel or tools,
air currents and runoff water. lf personnel are not decontaminated before leaving the hot
zone, they can contaminate others and whatever they touch after that.
•• Surface
The contamination of the surface of a material occurs but does not penetrate, permeate
or soak into materials.
•• Permeation
The penetration of a contaminant is below the surface of a material.

232 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 13.2 Decontamination

13.2.1 Definition

Decontamination is the process of reducing and preventing the spread of contaminants

from a hazardous-materials scene. It is performed when a victim, responder, animal or
equipment leaves the hot zone.

In a mass casualty decontamination event, only 20% of people will have clinically
significant contamination. All public presenting as casualties will require evaluation and
some form of decontamination.

Majority of casualties will self-refer to hospitals and arrive without formal decontamination.
Non-ambulatory casualties will arrive later by emergency medical services but it should
not be assumed that they have been decontaminated.

Mass casualty decontamination is logistically more demanding because:

•• It requires trained decontamination teams that consist of clinical and nonclinical
trained personnel.
•• Clinical personnel must be conserved for triage and emergent treatment.
•• Practice through team drills is essential for demonstrating the ability to perform
mass casualty decontamination and should involve a realistic number of casualties.

13.2.2 Decontamination Principles

Chemical agent contamination should be avoided when possible. When this is not possible,
emergency personnel conducting decontamination should consider the following factors:
•• Speed: Conduct decontamination operations as quickly as possible
•• Need: Decontaminate only what is necessary
•• Priority: Decontaminate the most essential items first.
•• Limited Area: Perform decontamination operations near the area where
contamination occurs

13.2.3 Decontamination Methods

Decontamination methods can be divided into two basic categories: physical and
chemical.

233
 [Link] Physical Decontamination

Physical methods generally involve physically removing the contaminant from the
contaminated person or object. Household items such as water, soap and flour can be
used to decontaminate an area. Some of the methods are as follows:

•• Dry decontamination (scratching): The contaminated area can be scratched with

plastic or wooden sticks to remove chunks of agents.

SCAN
THIS QR CODE
to watch
Mass Casualty
Decontamination
Process

234 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 •• Wet decontamination (water or aqueous solutions): A fire hose or a spray
nozzle can be used as large quantities of water can wash away contaminants in the
contaminated area.

•• Absorbent: They can be used to reduce the number of chemical agents being
absorbed by the skin. Powder detergent, dirt and flour can come in handy in case
of an emergency.
•• Soap/water cleaning: Washing with soap and water can remove or lower the
concentration agents.

[Link] Chemical Decontamination

This is the process of removing or reducing the threat from a specific contaminant by
rendering it less harmful through a chemical change. Some of the methods are as follows:
•• Neutralisation: It is typically used when the corrosives of an acid or base need to
be minimized to somewhere within the pH range of 6 to 8.
•• Solidification: A chemical process causes a hazardous liquid to solidify.
•• Disinfection: The process is used to destroy disease-carrying microorganisms,
excluding spores (anthrax, for example).
•• Sterilisation: Biological agents are the most logical candidates for decontamination
by sterilisation.
•• Dilution: The process commonly uses plain water to fully rinse off a contaminated
person or object in an attempt to weaken the concentration of the hazard.

235
 13.2.4 Types of Decontamination

•• Emergency Decontamination
The process of getting the bulk of the contaminants off a victim as rapidly as
possible in potentially life-threatening situations without the formal establishment of
a decontamination corridor.

•• Mass Decontamination
A way of performing emergency decontamination on a large number of people,
ambulatory victims anywhere, with the goal of removing the contaminants as quickly
as possible.

•• Gross Decontamination
The process of removing quickly the worst surface contamination, usually by rinsing
with water from handheld hose lines, emergency showers or other water sources.
Gross Decontamination is performed on:
•• Entry team members before their technical decontamination;
•• Victims during emergency decontamination
•• Person requiring mass decontamination.

•• Technical Decontamination
The physical or chemical process of deliberate decontaminations aims to achieve
thorough cleansing and removal of contaminants from responders and their equipment.
It is conducted within a formal decontamination line or corridor following a gross
decontamination. Examples of technical decontamination methods are absorption,
adsorption, chemical degradation, dilution, neutralisation, sterilisation and washing.
•• Self-Decontamination Procedure
Emergency decontamination is conducted on oneself, usually by rinsing with water or
using a blotting/absorption method.

•• Buddy Decontamination
Decontamination is performed on team members in order to decontaminate each
other. It is easier and allows for a more thorough rinsing of places that are difficult to
reach such as at the back, buttocks and the back of the legs and knees.

236 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

237
 13.2.5 Incident Site Decontamination

Most patients will likely present to the hospital for decontamination rather than waiting
at the scene to be decontaminated. Decontamination can be performed near the area of
release by fire or HAZMAT teams using low-pressure water from fire hoses or portable
decontamination shelters.

Location for performing mass casualty decontamination at a hospital would be far enough
away from normal treatment areas to prevent contamination of other patients, workers
and the facility itself. The site should be downwind and downhill from the healthcare
facility

Mass casualty decontamination area will require approximately 0.5 to 1 acre. It should
include clearly delineated contaminated and clean areas.
Triage, immediate treatments, and casualty and technical (personnel) decontamination
will occur in the contaminated areas. Clean areas will be used for staging, worker
rehabilitation, and casualty transfer/registration.

A minimum of 20 people will be required to staff a mass casualty decontamination area.

For the contaminated area, 10 to 12 people dressed in PPE will be needed and another
10 people (capable of wearing PPE if needed) will be needed in support roles for the
clean area.

The area should have access to utilities (lights, water, and power) and should provide
shelter. Ground surface should be reasonably flat and paved to prevent contamination
into the ground. Runoff should be controlled, and there must be a plan for managing
contaminated wastewater.

238 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 13.2.6 Hospital Decontamination

The pathway of hospital decontamination is as follows:

1 Set up the decontamination

and support areas

Conduct decontamination triage

2 (for mass casualty incidents)

Decontaminate the victims

Segregate victims 4
for observation or 5
treatment
Release the victims afterwards

Once the initial isolation and protective action distances (the Hot, Warm, and Cold Zones)
have been established, set up the decontamination and support areas. These include:

FIRST AREA SECOND AREA THIRD AREA FOURTH AREA

Primary Secondary
decontamination decontamination Safe refuge/ Medical triage
corridor corridors observation area area
(if necessary)

The decontamination and support areas are established within the Warm Zone, also
referred to as the Contamination Reduction Zone.

Decontamination involves thorough washing to remove contaminants. It should be

performed in an area upwind of the Hot Zone. An area that is uphill, with good drainage,
and easily accessible for responders is preferred.

239
 In mass casualty incidents, decontamination corridors can be set up that consist of high-
volume, low-pressure water deluges. An effective and expedient method for setting up a
water shower deluge is to use the Ladder Pipe Decontamination System (LDS):

•• Position two fire engines parallel to each other and approximately 20 feet apart to
create a corridor of water spray from both sides using hose lines and deck guns
•• Position an additional truck with a ladder pipe to provide high-volume, low-pressure
water flow from above
•• Assign personnel to decontamination stations to control and instruct victims when
they enter the decontamination area

If the contaminant was a liquid — especially an oily liquid (e.g., sulfur mustard) —
then secondary decontamination with an emulsifier (such as soap) may be necessary.
Secondary decontamination corridors should be set up between:
•• The primary decontamination corridor and the medical triage area
•• The primary decontamination corridor and the safe refuge/observation area
•• If sufficient resources are available, multiple LDSs may be used to:
•• Lengthen decontamination corridors to accommodate larger groups of victims
•• Decontaminate different groups separately (for example, ambulatory vs. non-
ambulatory victims)
•• Decontaminate victims at hospitals

The decontamination system should be designed for:

•• Children of all ages
•• Parentless children
•• Non-ambulatory children
•• Children with special needs

It should also allow families to stay together. Use step-by-step, child-friendly instructions
that explain to children and parents what they need to do, why they are doing it, and what
to expect.

Take into consideration that infants are slippery when wet. You may need an inventive
way to get them through the decontamination process using plastic buckets, car seats,
or stretchers.

240 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 DECONTAMINATION STATION OPERATION
Wind

Primary Decon Rinse Monitoring

Wash Wash
Patient
Transport
Monitoring Area

Decon
Clothing Decon
&
y Removal Shower
t or Redressing
ula

Vehicle
b
m
al eA
M
Monitoring Clean
Triage NonAmbulatory Clothing Decon
& Treatment
Area Removal Shower
Fe Redressing Area
m
ale

HOT ZONE
Am

WARM ZONE
bu
lat Monitoring
Monitoring
or
y Clothing
Clothing Decon
Decon &
&
Removal
Removal Shower
Shower Redressing
Redressing
Hot Contamination
Line Control
Line

241
 Algorithm for Chemical Decontamination in a Hospital Setting

Activate Emergency
Notification
Event Management Plan Initial
From the Field
(HOT and Hospital Triage
or Patient Self
Zone) Decontamination
Presentation Protocols
Consider
Life Saving
Is There Treatment
A Life Yes and/or
Threatening Medications
Condition?

No

Patient to Patient to
Decontamination Decontamination
Yes Required? No Treatment
Area Area

Decontamination
Triage

WARM
Assisted Self Zone
Decontamination Decontamination

Undress Patient Self COLD

Providing Privacy Decontamination Zone

Staff Collects Collects

Belongings & Belongings &
Preserve Evidence Preserve Evidence Redress
Patient with
Clean
Decontamination Patient Self Covering
Patient Decontamination

Secondary
Triage
Decontamination
No Adequate? Yes
Treatment
Area

Repeat Admit Discharge Transfer

Decontamination
in a Secondary
Decontamination
Station

Note: This document is not intended to stand alone but is part of an overall emergency management
plan for decontamination. This algorithm is a general decontamination guide and should be customized
to meet unique decontamination needs of the facility and the CBRNE event.

242 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

Traffic
•• The ingress and egress routes should also be controlled and coordinated with public
safety agencies.
•• Decontamination sites should not impede normal ambulance traffic.

In cold environments
•• Casualties become at risk for hypothermia during or after the wet decontamination
process in an external temperature less than 18 degrees.
•• Body heat is lost at a greater rate as wind speed increases.
•• Cold water causes heat loss 26 times faster than ambient air of the same temperature.
Therefore, heated water must be used in cold environments.
•• Signs and symptoms of hypothermia should be monitored during and after the
decontamination process.
•• At body temperatures
•• lower than 37 degrees, people will feel cold and shiver
•• less than 35 degrees, physical and mental impairment begins
•• less than 30 degrees, shivering stops and loss of consciousness occurs

Considerations for Proposed Decontamination Sites

1. Is there enough space at the proposed sites?
2. Where is the decontamination logistics located relative to the proposed site?
3. Are there appropriate traffic routes adjacent to the proposed site?
4. Is the proposed site in proximity to the point of casualty entry into the hospital
without compromising care of non-contaminated/decontaminated casualties?
5. What is the water source for the proposed site?
6. What is the drainage from the proposed site?
7. How are contaminated clothes managed from the site?
8. How are potentially contaminated casualties triaged before and after
decontamination?
9. How is security maintained at the site?
10. What is the impact of weather (wind, rain, ambient light at the site?

243
 Wind

Technical Staging and

Decontamination Rehabilitation
Triage Clothing
Area Removal Ambulatory Registration
Decontamination and Transport
EXIT

Non-ambulatory Emergent
Decontamination Treatment

EXIT
Clean Zone

Immediate Decontamination
Treatment Area Zone

Wind Layout Of A Typical Casualty Receiving Station

HOT WARM COLD

ZONE ZONE ZONE

Ambulatory Decon Delayed (Yellow)

Delayed Patients Patients’ Care
Incident

Warm Litter Decon Cold Immediate (Red)

Site

Triage Immediate Patients Triage Patients’ Care

Litter Decon Minimal (Green)

Delayed Patients Patients’ Care

Entry/Exit Control Points Located At Each Line

244 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 Decontamination Algorithm

Position Airway / Expectant, Lowest

Respiratory Effort? Decontamination Priority

Respirations
Compromised?
IMMEDIATE Decon and
Interventions
Circulatory System
Intact?

Non-Ambulatory
Are Processed First

Serious Signs / Symptoms, YES Urgent Treatment &

Chemical or medical Rapid Decon (1st)
NO
Moderate Signs / Symptoms, YES Urgent Treatment &
Liquid Exposure? Rapid Decon (2nd)
NO
Minimal Signs / Symptoms, YES Delayed Decon and
Vapor Exposure? Treatment (3rd)

Ambulatory May Be Processed

Concurrently or Second

Serious Signs / Symptoms, YES Urgent Treatment &

Chemical Exposure? Rapid Decon (1st)
NO
Moderate Signs / Symptoms, YES Urgent Treatment &
Poss, Liquid Exposure? Rapid Decon (2nd)
NO
Minimal Signs / Symptoms, YES Delayed Decon and
Poss, Vapor Exposure? Treatment (3rd)
NO
No Signs / Symptoms, Psychological Decon
No Exposure? (Last)

245
 13.3 Summary

Decontamination can be accomplished in a variety of ways. The exact approaches to be

used will be determined by a thorough examination of many factors. Since the existence
and degree of contamination varies by place, there is no one holistic technology that can
work in all circumstances and with all types of contamination. As a result, to obtain the
best degree of decontamination, a mixture of techniques from different available methods
is used consisting of good water supply, EWS/SOP, hazard detection equipment, and
appropriate PPE according to type of hazards.

Bibliography

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

Transitioning to Safer Chemicals: A Toolkit for Employers and Workers. OSHA, (2013).
OSHA <[Link]

Institute of Medicine (US) Committee on R&D Needs for Improving Civilian Medical
Response to Chemical and Biological Terrorism [Link] (DC): National
Academies Press (US); 1999. <[Link]

Medical response for radiation emergency Hospital Kuala Lumpur 2017 Edition. <www.
[Link] › content>

National Disaster Life Support, Advanced Disaster Life Support Course Manual 3.1,2012

Kumar, V., Goel, R., Chawla, R., Silambarasan, M., & Sharma, R. K. (2010). Chemical,
biological, radiological, and nuclear decontamination: Recent trends and future
perspective. Journal of pharmacy & bioallied sciences, 2(3), 220–238. [Link]
org/10.4103/0975-7406.68505

Guidelines for Mass Casualty Decontamination during an HAZMAT/Weapon of Mass

Destruction Incident: Volumes I and II (U.S. Army ECBC)

The Emergency Response Safety and Health Database (CDC/NIOSH)

Zhao X, Dughly O, Simpson J. Decontamination of the pediatric patient. Curr Opin

Pediatr. 2016 Jun;28(3):305-9.

Johnson HL, Ling CG, Gulley KH. Curriculum Recommendations for Disaster Health
Professionals. The Pediatric Population. (PDF - 684 KB) (National Center for Disaster
Medicine & Public Health, Uniformed Services University of the Health Sciences. 2014)

Ling SG, McBee EC, Johnson HL. Curriculum Recommendations for Disaster Health
Professionals. The Geriatric Population. (PDF - 313 KB) (National Center for Disaster
Medicine & Public Health, Uniformed Services University of the Health Sciences. 2014)
Patient Decontamination in a Mass Chemical Exposure Incident: National Planning
Guidance for Communities (DHS)
246 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT
CHAPTER
14
PERSONAL
PROTECTIVE
EQUIPMENT
 CHAPTER 14
PERSONAL PROTECTIVE EQUIPMENT

Case Scenario

You are working in an Emergency Response Service provider center when you
receive a call on 2 separate incidents: an explosion in a chemical plant, and a
collapsed bridge in the city. You have decided to deploy your response team to
attend to both incidents.

•• What are your considerations in deciding the types of PPE to be deployed?

•• How are you going to advice your subordinates on the choice of PPE to be
used?

14.1 Background

PPE is designed to protect responders from hazardous material. It is an equipment worn

to minimize exposure to serious workplace injuries and illnesses that may be due to
contact with chemical, radiological, physical, electrical, mechanical, or other workplace
hazards.

Hazardous materials can enter our body via four main routes by inhalation, absorption,
ingestion, and injection. PPE consists of gloves, safety glasses and shoes, earplugs or
muffs, hard hats, respirators, or coveralls, vests and full body suits.

When an incident involving dangerous goods and hazardous substances occurs, the
incident commander will determine the appropriate level of personal protection required
after conducting a risk assessment of the scene, identifying the hazards associated
with the material involved and level of personal protection will be based on information
collected at the site and on the evidence received from specialist sources.

When selecting and using PPE

Choose products which are CE marked in accordance with the Personal Protective
Equipment Regulations 2002 – suppliers can advise you. Choose equipment that suits
the user – consider the size, fit and weight of the PPE. If the users help choose it, they
will be more likely to use it. If more than one item of PPE is worn at the same time, make
sure they can be used together, e.g., wearing safety glasses may disturb the seal of a
respirator, causing air leaks. Instruct and train people how to use it, e.g., train people to
remove gloves without contaminating their skin. Tell them why it is needed, when to use
it and what its limitations are.

248 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

249
250 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT
 14.2 Four Levels of Personal Protective Equipment

Selection Consideration
•• Unknown/known conditions
•• Chemical hazard recognition
•• Physical hazard recognition
•• Chemical concentration
•• Work function/location
•• Weather conditions
•• Training

The levels consist of levels A, B, C and D and are defined by OSHA and the US
Environmental Protection Agency. PPE provides an increased level of respiratory
and dermal protection. OSHA and the National Institutes for Occupational Safety and
Health (NIOSH) have specified respiratory protection levels based on concentrations of
chemicals
•• Immediately dangerous to life and health (IDLH)
•• Permissible exposure limits (PELs)

251
 PPE can pose limitations to the responder such as:
•• Touch – impedes by gloves
•• Smell – impedes by breathing apparatus used
•• Hearing – type of breathing apparatus used, hearing protection and loud noises
•• Sight – impedes by breathing apparatus used, narrowed visual field peripherally.

Respirator effectiveness is rated by the fit protection factor. For example, when fit
protection factor of 100 is worn and exposed to a contaminant that has a PEL of 1 part per
million (ppm), it will offer protection in an atmosphere with up to 100 ppm or 100 times the
PEL. A self-contained breathing apparatus has the highest rating, and negative-pressure
air-purifying respirators have the lowest protection ratings.

14.2.1 Level A

For Unknown Environments:

•• Level A PPE provides complete whole-body

percutaneous) and respiratory protection against
chemical agents in liquid and vapor state, as
well as biological agents in dry and liquid form,
for the duration of the self-contained breathing
apparatus SCBA.
•• It should be used for entry into unknown
environments and is to be selected when
the highest level of skin, respiratory and eye
protection is required.
•• Level A are cumbersome to use and typically
provide less than 1 hour of work time when self-
contained air tanks are used.

•• Level A consists of:

•• Positive pressure, full-face piece self-contained breathing apparatus (SCBA)
•• Totally encapsulating chemical-protective suit (liquid and vapor-resistant)
•• Outer and inner chemical-resistant, steel toe and shank
•• Hard hat (worn under suit, optional)
•• Two-way communications equipment, worn inside encapsulating suit

252 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 14.2.2 Level B

For Known Environments:

•• Level B PPE should be used when the highest

level of respiratory protection is necessary, but a
lesser level of skin protection is needed if:
•• The type and atmospheric concentration of
substances have been identified.
•• Concentrations dangerous to life and health
(IDHL) are present and represent severe
inhalation hazards.
•• Associated vapors and gases not suspected
of containing high levels of chemicals harmful
to the skin are present.
•• The atmosphere contains less than 19.5%
oxygen.

Level B consists of:

•• Positive pressure, full face-piece self-contained breathing apparatus (SCBA)
•• Hooded chemical-resistant clothing
•• Outer and inner chemical-resistant gloves
•• Boots, chemical-resistant, steel toe and shank
•• Hard hat (worn under suit, optional)
•• Two-way communications equipment worn inside encapsulating suit

253
 14.2.3 Level C

For Known Environments

•• Level C protection should be

selected when the type of airborne
substances is known, concentration
is measured, criteria for using
air-purifying respirators are met
and skin and eye exposures are
unlikely.
•• This involves a full-face piece,
air-purifying, canister-equipped
respirator and chemical-resistant
clothing. It provides the same level
of skin protection as that of Level
B but is a lower level of respiratory
protection. It should be used in and
atmosphere containing at least
19.5% oxygen and with no known
inhalation hazard.
•• It should be used in an atmosphere
containing at least 19.5% oxygen
and with no known inhalation
hazard.

Level C consists of:

•• Full-face or half-mask, air purifying respirator (NIOSH approved)

•• Hooded chemical-resistant clothing
•• Coveralls (worn under suit, optional)
•• Outer and inner chemical-resistant gloves
•• Boots, chemical-resistant, steel toe and shank
•• Hard hat (worn under suit, optional)
•• Boot covers, chemical-resistant (disposable, optional)
•• Escape mask (optional)
•• Face shield (optional)

254 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

14.2.4 Level D

For Known Environments

•• Level D is primarily a work uniform. It should

not be worn on any site where respiratory or
skin hazards exist. It provides no respiratory
protection but only minimal skin protection.
•• Level D consists of:
•• Coveralls or other substantial work
clothing
•• Gloves, leather or chemical-resistant, as
seen appropriate
•• Chemical-resistant (if necessary) steel
toe and shank boots/shoes
•• Goggles or safety glasses
•• Hard hat

14.3 CBRNE PPE

•• CBRNE specific PPE are protective suits

containing one or more layers of activated
carbon.
•• Provide protection in vapor, liquid, gaseous
and particulate agent environments.
•• Used when the concentration(s) and or the
type(s) of airborne substance(s) are known,
the criteria for using air purifying respirators
are met, and an air-purifying respirator with
the capability to filter the contaminants is
available.
•• CBRNE PPE is supplemented by specially
designed bromobutyl over-boots and
multiple layers of rubber gloves (Latex and
Bomobutyl).
•• The wearer should avoid prolonged contact
with products such as gasoline, diesel or
aviation fuel.

255
 14.4 Air-Purifying Respirator (APR)

•• The respirator should only be used

when the oxygen content of the
atmosphere is 19.5% or above.
•• It is made of Bromo butyl rubber and
can be decontaminated and sanitized
with commercially available anti-
bacterial products (i.e., Dettol).
•• The respirator incorporates a drinking
tube assembly with a “quick disconnect”
that allows for safe and easy drinking
from the canteen fitted with the proper
drinking tube adaptor.
•• Filter canisters remove CBRNE
contaminants (including vapors) from
inhaled air.
•• Activated charcoal is one of the most
efficient absorbents, and relies on a
process known as activation.

256 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 14.5 Self-Contained Breathing Apparatus (SCBA)

•• They are open-circuit positive pressure

apparatus with a tight-fitting full-face
respirator (Subpart H) and compressed air
cylinders.
•• An SCBA consists of a harness, a
compressed air cylinder, first and second
stage regulators, a hose, and a facepiece.
The harness has adjustable shoulder
straps and a waist belt, which pivots and
adjusts to give the user more freedom of
movement.
•• SCBAs are mainly used in HAZMAT
situations and in unknown, toxic, low-
oxygen environments or atmospheres that
may be immediately dangerous to life or
health (IDLH).

•• IDLH is defined as an atmospheric concentration of any toxic, corrosive or

asphyxiant substance that poses an immediate threat to life or would cause
irreversible or delayed adverse health effects or would interfere with an individual's
ability to escape from a dangerous atmosphere
•• The air cylinder can range in volume from 3.4 to 6.7 liters and in pressure from
2,216 to 5,500 pounds per square inch and deliver 30 to 75 minutes of air to the
facepiece
•• End-of-service time indicator (EOSTI) or low-air alarm indicates when the air
supply in the cylinder is low.
•• Verbal communication while wearing an SCBA is difficult.

Safe work practices

•• Keep hands away from face

•• Work from clean to dirty
•• Limit surfaces touches
•• Change garments when torn or heavily contaminated
•• Wash hands with soap and water

257
 14.6 Advantages and Disadvantages of PPE

Level Equipment Advantages Disadvantages

▪▪ A full-face mask with ▪▪ Use limited by

air supplied from a supplied air
tank or a tether line availability
▪▪ Highest ▪▪ Very hot to work
level of in
▪▪ Totally encapsulating
LEVEL A airway ▪▪ Most bulky
chemical protective
and skin ▪▪ Most expensive
suit
protection ▪▪ Communication
is very difficult
▪▪ Gloves and boot are ▪▪ Extensive
part of suit training required
▪▪ A full-face mask with
air supplied from a
tank or a tether line ▪▪ Highest
level of ▪▪ Use limited by
▪▪ Impermeable splash- airway air available
LEVEL B and vapor resistant protection ▪▪ Bulky
suit ▪▪ Communication
▪▪ Good skin is difficult
▪▪ Separate or protection
incorporated gloves
and boots
▪▪ Good
▪▪ Mask or hoods ▪▪ Filters only
airway
(positive or negative protect against
protection
pressure) with air specific hazards
▪▪ No risk of
filters ▪▪ Not for use in
running out
▪▪ Splatter and vapor low oxygen
LEVEL C of air
resistant suit levels
▪▪ Good skin
▪▪ Permeable or ▪▪ Hot to work in
protection
impermeable ▪▪ Bulky
▪▪ Less
▪▪ Separate gloves and ▪▪ Communication
training
boots is difficult
needed
▪▪ A work uniform
affording minimal
▪▪ No respiratory
protection ▪▪ No special
protection
LEVEL D ▪▪ Universal precautions training
▪▪ Limited skin
in a healthcare facility required
protection
(gown, hat, mask, face
shield, gloves)

258 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 14.7 PPE for Biological Casualties

Guidelines for Reducing Transmission of Infectious Disease

(adapted from Hostler et al13)

Fluid
Mask and eye Environmental
Precautions Impermeable Nitrile gloves
cover controls
Gown

Surgical
Wear if mask and eye
Wear if touching blood, cover should
Routine
contact with body fluids, be worn for
cleaning and
Standard bloods or contaminated activities likely
disinfection of
body fluids is items or to generate
surface
expected mucous splashes or
membranes sprays of blood
or body fluids

Wear for all

Wear for all
interactions Single patient
interactions with
with per room
patients and
patient and preferred; If
Contact contaminated As per standard
contaminated not possible
environment;
environment; consider
don before
don before cohorting
entering room
entering room

As above plus
Don surgical
use of curtains;
mask on
As per patients should
Droplet As per standard entering room;
standard wear a mask
eye cover per
when out of
standard
room

Wear fit-tested
Place patient
N95 respirator
in negative
or powered
As per pressure
Airborne As per standard air-purifying
standard isolation room
respirator when
with 6-12 air
entering patient
exchanges/h
room

259
 14.8 PPE for Radioactive Contamination

14.8.1 Principles

•• Keep the airway, skin, and personal clothing free from droplets and particulate
contaminants.
•• Waterproof barrier garments limit alpha and beta rays but not gamma rays.
•• A brief exposure to radiation through penetrating garments is of little risk to the
healthcare provider. However, if the provider is contaminated by the source of
radiation and receives a larger ongoing exposure over time, he is exposed to more
major risks.
•• Thicker garments are preferred over lead aprons.

14.8.2 Radiological PPE

•• It is similar to biological PPEs with the addition of waterproof shoes and a head
cover
•• Two pairs surgical glove must be worn in a radiological event
•• Inner gloves with taping under the arm cuff
•• Outer gloves without taping over the inner glove
•• A radioactive dosimeter must be attached at the neck of the surgical gown for each
team.
•• Gloves must be monitored periodically for contamination with a survey meter.

14.9 PPE For Chemical Contamination

•• It offers both respiratory and dermal protection.

•• PAPR-stops particulate matter and adsorbs or neutralizes toxins that are too small
to filter.
•• Optimal garment materials for the first receiver protects against a wide range of
chemical contaminants, yet it is also flexible, durable and lightweight for the purpose
of physically active work.
•• Protection against gas is less important due to the dissipation of gas before the
casualty arrives at the hospital.
•• It is important that the designed suit is tested for chemical breakthrough time and its
ability to withstand physical abrasion.
•• Suitability of the type of PPE depends on the situation and hazard encounter.
•• Selection of the suit must be compatible with the respirator.

260 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 •• No single glove or boot will protect against every substance.
•• Butyl rubber gloves are better than nitrile gloves for chemical warfare agents
and most toxic industrial agents.
•• Foil based gloves are highly resistant to a wide variety of hazardous substances.
•• Double layer gloves from 2 different materials or foil-based gloves protect against
the widest range of chemicals.

14.9.1 Chemical Protective Clothing

Chemical protective clothing is worn to prevent harmful chemicals from coming in

contact with the skin and eyes. It includes head protection, eyes, face protection, and
foot protection.

The effectiveness of CPC can be assessed by the following aspects:

•• Chemical degradation
•• Permeation
•• Penetration

No One Material Affords

Maximum Protection Against
All Chemicals

Degradation Permeation Penetration

Chemical Spill

261
 14.10 Summary

PPE is designed to protect responders from hazardous material. It is an equipment

worn to minimize exposure to serious workplace injuries or illnesses that may be due to
contact with chemical, radiological, physical, electrical, mechanical, or other workplace
hazards. When an incident involving dangerous goods and hazardous substances
occurs, determining the appropriate level of personal protection equipment is required
after conducting a risk assessment of the scene and identifying the hazards associated
with the material involved.

Bibliography

Greenfield, P.A., 2019. Using an AR Simulation for Hospital Spill Cleanup Training in
Highly-Infectious Disease Holding Units.

National Disaster Life Support, Basic Disaster Life Support Course Manual 3.0,2012

National Disaster Life Support, Advanced Disaster Life Support Course Manual 3.1,2012

Personal Protective Equipment, types safety and training (emedicinehealth), 2018

Role of Bomba, CICM, 08/2019 <[Link]

[Link]>

262 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 CHAPTER
15
ETHICAL AND
MEDICOLEGAL ASPECT
DURING DISASTER
 CHAPTER 15
ETHICAL AND MEDICOLEGAL ASPECT DURING
DISASTER

Case Scenario

A cyclone with the wind speed of 315km/h hit the island of Tacloban, Philippines in
[Link] international humanitarian team responded to the disaster in a very short
time. The Emergency response team with different specialties responded to support
the field hospital and hospital in a remote district of the island. There were conflicts on
coordination and command in the early stage of workforce deployment. Certain issues
on ethical and legal requirements were questionable.

•• Which agency takes command on coordination and communications?

•• What are the resources required during this disaster and who will coordinate on the
workforce deployment?
•• What are the responsibilities of the response team from other countries and what
are the important information that the local incident command system coordinators
expect from this international team?

15.1 Background

Disasters can bring up ethical issues that are not always present in usual medical practice.
Furthermore, disaster situations are more closely linked to public health ethics than
medical ethics, and as a result, achieving a balance between individual and collective
rights may necessitate a greater effort. Disasters vary considerably with respect to their
time, place and extent; therefore, ethical questions may not always have `one-size-fits-
all` answers. Integrating ethical values and principles into every aspect of healthcare,
on the other hand, is critical. Among the most important steps are reviewing legal and
organisational rules, creating healthcare-related guidelines and disaster recovery plans,
forming on-call ethics committees, and providing appropriate in-service training for ethical
competence to healthcare workers. It is only by making efforts before disasters, that
ethical challenges can be minimized in disaster responses.

Modern bioethics is founded on four basic principles, which are:

1. Beneficence
2. Non-maleficence
3. Autonomy
4. Justice

264 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

The priority of these principles may shift depending on the situation, such as in disasters,
which can often present problems that are not typical of medical practice. Furthermore,
disaster situations are more closely linked to public health ethics than to medical ethics, and
as a result, achieving a balance between individual and collective rights may necessitate
a greater effort. In public health, there is often a conflict between individual autonomy and
the need to protect and improve population health. This “dual loyalty”, which also exists
in many disaster situations, stands in the middle of most ethical dilemmas.

15.2 Ethics in Disaster Medicine

Ethics in disaster medicine is concerned with ethical problems and dilemmas that arise
during natural and man-made disasters. Disaster ethics is a broad field in the sense that
it covers a wide range of subjects from individual to collective ethics; however, it is more
concerned with macro-ethics than micro-ethics.

Disaster ethics is usually addressed in three phases:

•• Pre-disaster (pre-event) or preventive phase
•• Disaster (event/crisis) and early response phase
•• Post-disaster (post-event) or rehabilitation phase

Although each phase may pose different ethical dilemmas, the main topics of
interest in these phases can be summarized as follows:
•• preventive ethics,
•• disaster triage,
•• informed consent,
•• communicable disease surveillance,
•• risk communication,
•• quarantine/isolation,
•• vaccinations,
•• refusal of medical treatment,
•• euthanasia,
•• allocation of resources,
•• linguistic,
•• religious and cultural differences,
•• vulnerable groups,
•• community participation,
•• division of labor,

265
 •• healthcare workers` duty to treat,
•• obligations to disaster relief workers,
•• participation of health-care workers in war crimes/torture/death penalty,
•• relations with industry and media,
•• disaster response and development,
•• disaster research.

It is worth noting that, in spite of this wide range of ethical issues in disasters, codes of
ethics that are specific for disasters remain to be scarce around the world.

Main ethical principles in the provision of health services during the event and early
response phase of disasters are the principles of non-maleficence, beneficence, justice,
and the respect for autonomy. In this phase, reaching the disaster site as quickly as
possible is the most crucial step. In line with the principles of the ethical practice of public
health, “Public health institutions should act in a timely manner on the information they
have within the resources and the mandate given to them by the public”. If the health
authorities and health-care workers act slowly, ignoring the fact that time is vital, they
may be late in saving lives and violate the principle of doing no harm.

Triage, as the second most important step, is often considered critical in the distribution
of limited medical resources, where highest priority should be given to the principles
of beneficence and justice. In selecting the patients who may be saved, the physician
should consider only their medical status, and should exclude any other consideration
based on non-medical criteria. Ongoing discussions on triage decisions with respect to
the victim's age, gender, social status, ethnic origin or profession (e.g., health workers)
also conflict with the basic right to live at the individual level and justice principle, in
general. Ideological issues must not eclipse the humanistic priorities embodied in ethical
rules.

The priorities should be set for treatment that will save the greatest number of lives and
restrict morbidity to a minimum. In connection with this, some patients, whose condition
exceeds the available resources, may be classified as "beyond emergency care". It is
ethical for a physician not to persist in treating individuals "beyond emergency care".
However, the physician must show such patients compassion and respect for their dignity,
for example by separating them from others and administering appropriate pain relief
and sedatives”. Healthcare has to be equitably distributed rather than equally, with each
victim receiving care according to medical need. On the other hand, critical questions on
when and how to apply disaster triage still remain. Current disaster triage, which is based
on the concept of utilitarianism, aims to maximize benefit of the society, at the expense
of individual needs, which may not be acceptable in modern society.

Informed consent, which is used frequently in daily medical practice, is another important
ethical challenge in disasters. If the patient is unconscious or otherwise unable to express
his/her will, informed consent must be obtained, whenever possible, from a legally

266 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

entitled representative. If a legally entitled representative is not available, but a medical
intervention is urgently needed, consent of the patient may be presumed, unless it is
obvious and beyond any doubt on the basis of the patient’s previous firm expression or
conviction that he/she would refuse consent to the intervention in that situation. On the
other hand, there might be exceptions to informed consent, such as in disaster and other
public health emergency situations. In a disaster response, it should be recognized that
there may not be enough time for informed consent to be a realistic possibility.

Although health professionals in disaster relief are expected to make every effort to
start and sustain available treatments according to priority, some victims might refuse
treatment. In that situation, the mental health state of the victim should be assessed.
If there is any doubt, the treatment should be continued to avoid any medical or legal
consequences. If the examination reveals no significant mental problem, then health
professionals may try to convince the person for the recommended treatment, whenever
possible. If time permits, the last option might be to ask the victim to sign a document
indicating that he or she does not accept the treatment.

Pandemic disasters may also pose other ethical dilemmas with respect to the autonomy
of individuals. Although the World Medical Association (WMA) International Code of
Medical Ethics (1949) states that “A physician shall owe his/her patients' complete
loyalty”, it is generally accepted that physicians may in exceptional situations have to
place the interests of others above those of the patient. Mandatory reporting of patients
who suffer from designated diseases is one such exception. Physicians should fulfil their
duty to report, although patients should be informed that such reporting will take place.
When meeting public health requirements, every effort should be made to minimize any
harm to individuals. Securing patients` identity information during reporting will both help
to ensure privacy and protect individuals from infection-related stigma and discrimination.

Public health measures in pandemic disasters, such as vaccination campaigns, risk

communication, quarantine and isolation are also worth noting with respect to potential
ethical dilemmas. In all of these dual-loyalty situations, protection of the public from
harm is usually regarded as a superior goal than respect for autonomy. In the case
of vaccination, it is widely accepted that risk-benefit ratios must be calculated for all
immunizing agents. Although vaccines can carry some health risks, the risk of harm from
vaccines are much less than the risks of morbidity and mortality from infectious diseases.
For this reason, the ethical approach should be to prioritize the common good, but also to
inform the public about potential benefits and risks before beginning mass vaccinations
in disaster situations.

Scientists working in emergency situations like a pandemic, have an ethical duty to be

open in dealing with the public as the public has the right to know what the experts
know. Within this scope, implementing the principles of risk communication to avoid
unnecessary fear and anxiety among the public is of vital importance. One of the ethical
issues that arises in risk communication is the risk of stigmatisation in certain sub-groups.
The ethical approach should be to minimize generalisations about high-risk groups,
whenever possible.

267
 In disaster situations, delivery of appropriate and updated information to healthcare
workers on a regular basis is also critical to minimize misinformation, mistrust and refusal
of public health measures among the public. If ethics are clearly built into pandemic
plans in a transparent manner, the plans carry greater trust, authority and legitimacy.
Information helps survivors make informed decisions that are intrinsically related to their
life arrangements and future well-being.

Pandemic disasters may sometimes require stronger measures such as closing schools,
imposing isolation and quarantine, which restrict freedom. Identifying and isolating
cases for the common good is an accepted feature of communicable disease control.
Nevertheless, all existing data should be monitored carefully and the risk of stigmatisation
of isolated individuals or groups should be discussed before taking such measures.
Decision makers are recommended to make decisions in a fair manner, use the least
restrictive method without discrimination, explain the rational and provide support services
to the people affected by the restrictive measures.

The ethical guide assembled by the Working Group for pandemic

influenza includes 10 substantive values, which are:

•• individual liberty,
•• protection of the public from harm,
•• proportionality,
•• privacy,
•• equity,
•• duty to provide care,
•• stewardship,
•• solidarity,
•• trust,
•• reciprocity.

Decisions in pandemic situations are to be based on reasons, as well as decision-making

processes to be open, transparent, inclusive, responsive and accountable. Allocation of
resources also creates ethical dilemmas in disasters. Physicians may sometimes have to
give priority to the principle of justice over their patient's autonomy and to avoid delivery
of unnecessary health services.

In circumstances where a choice must be made between potential patients for a particular
treatment that is in limited supply, all such patients are entitled to a fair selection procedure

268 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

for that treatment. That choice must be based on medical criteria and made without
discrimination. Development of clinical practice guidelines in the pre-disaster phase and
using these guideline-based criteria in health resource allocation in the response phase
may minimize potential ethical conflicts that arise during decision-making in disasters.
Governments and the healthcare sector should engage the public, and other partners in
determining the criteria to make resource allocation decisions, and should ensure that
rationales for allocation decisions are publicly accessible.

In many devastating disasters, international or non-governmental organisations come

to the affected area to give assistance in different fields and to contribute to the overall
disaster relief; however, they usually have different mandates and principles of working.
International or non-governmental organisations also vary considerably on their ethical
values, which motivate them. Likewise, it is expected that countries with different social
structures and beliefs have different perspectives on international ethics of assistance.

The division of labor among organisations and institutions is considered as one of the
ethical aspects of disaster response. Accordingly, every effort should be made to assign
laborers according to the expertise of each organisation. Networking with other service
providers is both an ethical and an operational need. Spending available financial
resources, as another ethical issue in disaster response, should also be considered.
Millions of ringgits are spent on salaries, transportation, and other costs for the disaster
relief experts of countries other than the affected country; however, disaster response
spending should primarily be done by contracting services from the affected communities
themselves.

A healthy workforce is one of the most important human resources in disaster response.
On the other hand, this workforce might be negatively affected by disaster conditions
(e.g., pandemic outbreaks, environmental pollution, military conflicts), which may pose
significant threats for the relief workers` own safety and health. Hesitation of healthcare
workers to perform their duty in pandemic disasters is one such example. Many studies in
literature indicate that health professionals constitute a significant proportion of the victims
in pandemic situations. In addition, numerous literature findings reveal unwillingness of at
least some health professionals` to treat patients with communicable diseases. In daily
practice, medical codes of ethics make no exception for infectious patients with regard to
the physician’s duty to treat all patients equally; however, disaster conditions might have
their own unique risks. Respect for diverse values, beliefs, and cultures in the community
constitutes one of the principles of the ethical practice of public health.

Disasters generally create situations, in which some health services are delivered by
healthcare workers who are originally not from the affected area. Foreign healthcare
workers, whether from the affected country or from another country may have difficulties
in communicating with the patients or treating them. Besides interfering with optimum
healthcare, cultural, religious and linguistic barriers may also have significance with
respect to creating ethical dilemmas. If health professionals and patients do not speak
the same language, every effort should be made to find interpreters. However, in the
presence of cultural or religious differences, interpreters may not be enough to overcome
communication problems. Without any preparation, international relief workers may be

269
 at risk for delivering culturally inappropriate services, such as distribution of condoms to
adolescents of a conservative community. Such interventions might negatively affect the
overall relief efforts.

Therefore, foreign professionals have an ethical duty to be aware of any cultural and
religious differences, when delivering preventive and curative health services. The
physician must respect the customs, rites and religions of the patients. In this respect,
community participation in disaster relief efforts is a useful approach in planning services,
which are ethically sound and widely accepted by the affected community. Ensuring an
opportunity for input from community members is also one of the principles of the ethical
practice of public health. This approach helps to deliver services on a needs-based basis.

Media plays an important role in dissemination of information for both the general
community and disaster victims. In addition, disasters covered by the media receive more
attention; however, media news may interfere with the private life of the victims. In the
Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs
in Disaster Relief; it is stated that in the information, publicity and advertising activities,
the disaster victims should be recognized as dignified humans, but not as hopeless
objects. In addition, the WMA Statement on Medical Ethics in the Event of Disasters
(1994) states that the physician has a duty to each patient to ensure confidentiality when
dealing with third parties. It is also important to designate healthcare workers, who are
experienced in media relations. Another ethical issue with media relations is that some
organisations tend to work in disaster relief primarily for the media coverage, since they
link future funding options with their image in the media. Here, the ethically appropriate
approach would be to provide assistance with the primary and only goal to help disaster
victims, which will eventually be followed by positive responses from both donors and the
public in general.

15.3 Legal Aspect in Disaster Medicine

Malaysia has a disaster law that focuses on emergency preparedness and response
to natural and technical hazards, as well as early warning and recovery components.
These laws tend to be found in countries (i) with low hazard exposure, or (ii) with higher
exposure but effective risk governance through sectoral laws, or (iii) with higher exposure
but limited law-making and institutional capacity due to poverty and/or conflict. It was
established in 1972 under the National Security Council (NSC) Directive No. 20, or MKN
Arahan 20 (MKN 20). It recently completed a review of its Disaster Risk Management
(DRM) system's preparedness and response capabilities and passed the Civil Defense
(Amendment) Act 2016.

MKN 20 was issued as a policy to provide guidelines on the management of disasters

including the responsibilities and functions of the various agencies involved. The
directives have shaped the environment of disaster management in Malaysia. Due to the
increasing complexity and new emergence of disasters, adding up with the increasing
number of agencies involved in disaster management in Malaysia, the revised version
of MKN 20 was published with many significant changes towards the old directives. The
objective of MKN 20 is summarized as, to establish a management mechanism and

270 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

at the same time, to determine the roles and responsibilities of government agencies,
statutory bodies, voluntary bodies and private sector to manage disaster; to reduce
casualties and minimize the damages towards assets and preserving the environment;
and to coordinate relief and rehabilitation of victims in returning to normalcy.

The 2016 law, which complements the existing system, makes important changes to
the Civil Defense Force Act 1951. It is now a key responsibility for the Malaysia Civil
Defense Force (MCDF) under the patronage of the Prime Minister’s Department along
with the National Disaster Management Agency (NADMA) to adopt a multi-hazard
approach in disaster risk management. The MCDF is one of the responders besides the
Royal Malaysian Police and Fire and Rescue (RMPFRD) department. This includes the
implementation of Community-Based Disaster Risk Reduction (CBDRR) to pursue public
involvement in Disaster Risk Reduction (DRR) efforts.

The new NADMA was established in 2015 as a new entity in managing disaster at the
national level. The new law, as well as NSC directive, are detailed in that they create
national, district, and local committees, as well as their responsibilities, in three levels
of disaster, with a fourth level on the way, though the system remains focused on
preparedness and response. NADMA has been consulting with stakeholders to pass
a new disaster risk management law since taking over the DRM portfolio from NSC in
2015.

Under the administratively-established DRM system, sub-national structures are:

•• State Disaster Management and Relief Committee
•• District Disaster Management and Relief Committee

Since the 2016 reforms, small units are being placed at the community or village level,
making a fourth tier.

Malaysia’s funds for disaster risk management are budgeted annually through the
Economic Planning Unit (EPU) and also at the state and district level. NADMA also has
a specific fund for disaster risk management.

The Central Disaster Management and Relief Committee (CDMRC)/NADMA, is authorized

“To get expert assistance from local authorities or foreign countries to help in managing
a disaster.” (NSC Dir No. 20 Appendix A Art. B (5)) The Civil Defense (Amendment) Act
2016, allow that member of the Civil Defense Force may be required to serve outside
Malaysia, and may also be attached to a civil defense force or organisation outside
Malaysia (Arts. 4 E and 4F).

271
 15.4 MKN 20 Revised Directive and Its Compliance Towards International Disaster
Management Network

The updated MKN 20's goal now includes procedures for prevention, preparedness,
response, and recovery. As a result, the revised MKN 20 appears to be more detailed
in terms of disaster management concept than the previous version. The following are
the major revisions to MKN 20 that incorporate the international disaster management
framework:

1. Identification and involvement of multi-agency involved in disaster management

in Malaysia. Within the Hyogo Framework in Action (HFA) priorities of action, it is
emphasized that relevant agencies and institutions at all levels are to be involved
in every process of disaster risk reduction. This include disaster recovery where
respective government agencies, statutory & voluntary bodies, private sector are
responsible for damage and loss assessment and recovery and reconstruction;

2. The revised MKN 20 objectives now cover preparedness, response and recovery
process. MKN 20 defines the process of prevention within the preparedness where,
preparedness process by all agency (including government agencies, statutory and
voluntary bodies and private sector) involved prevention and reduction of disaster,
preparedness for disaster and public awareness and education on disaster and
disaster management;

3. Early warning system which has already been developed and maintained by
respected government agencies has also been added to the revised MKN 20.
HFA stated that early warning system should be designed to be people centered,
implemented into governmental policy and well-coordinated while involving all
relevant agencies and personnel;

4. Improvement towards disaster management organisation structure mechanisms

where emphasis is made towards chain of command rather than change of
command. At the same time, this improvement has simplified the command and
control for On-Scene Control Post/Pusat Kawalan Tempat Kejadian (PKTK) and
Disaster Operation Control Center/Pusat Kawalan Operasi Bencana (PKOB)
with improved roles and responsibility of agencies involved in disaster and relief
management on Site especially with the involvement of other allowed agencies
(statutory bodies, voluntary bodies and private sector);

5. The implementation of Government Integrated Radio Network (GIRN) by all

responding agency as primary communication system may need to be revised as
HFA suggested the use of recent communication technology and be prepared with
alternative communications;

6. Capability of requesting assistance and use equipment from any government

agencies, statutory and voluntary bodies, private sector or individual. This is in line
with HFA where assistance to be identified at all level of community;

272 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

7. Include international humanitarian assistance and disaster response assistance
as suggested in HFA especially for a disaster-prone country;

8. Improvement on fund management as suggested by HFA where the Federal and

State Government are responsible to allocate funds for disaster management and
disaster risk reduction.

The revised MKN 20 includes improvements to the disaster management concept

while also advancing Malaysia from Level 3 to Level 5 in disaster risk reduction (Global
Framework for Disaster Risk Reduction, 2014).

15.5 Utilizing Legislation in Managing Disaster: Prevention and Control of infectious

Diseases Act and Regulations during a Disaster

In Malaysia, the government can gazette a new regulation under the Prevention and
Control of Infectious Diseases Act 1988 (PCID Act) and the Police Act 1967 (Police Act)
during an outbreak which involves the whole country.

1. Control of Movements
No person shall make any journey from one place to another within any infected
local area except for the following purposes:

•• to perform any official duty;

•• to make a journey to and from any premises providing essential services;
•• to purchase, supply or deliver food or daily necessities;
•• to seek healthcare or medical services; or
•• such other special purposes as may be permitted by the Director General
of Health.

Furthermore, the Regulations also restrict movement between one infected area to
another, unless the prior written permission of a police officer is obtained.

2. Premises Providing Essential Services

Government and private sector premises will be closed, with the exception of
premises involved in the provision of essential services. The Regulations further
refine this restriction to allow any premises providing essential services to be
opened as long as the number of personnel and patrons at the premises are kept
to a minimum number. Essential services are defined to be:
•• banking and finance;
•• electricity and energy;
•• fire;

273
 •• port, dock and airport services and undertakings, including stevedoring,
lighterage, cargo handling, pilotage and storing or bulking of commodities;
•• postal;
•• prison;
•• production, refining, storage, supply and distribution of fuel and lubricants;
•• healthcare and medical;
•• solid waste management and public cleansing;
•• sewerage;
•• radio communication including broadcasting and television;
•• telecommunication;
•• transport by land, water or air;
•• water;
•• e-commerce;
•• defense and security;
•• food supply;
•• wildlife;
•• immigration;
•• customs;
•• hotels and accommodations; and
•• any services or works determined by the Ministry of Health as essential or
critical to public health or safety.

3. Restriction on Gatherings
The Regulations implement a complete prohibition of any gathering within Malaysia
whether for religious, sports, recreational, social or cultural purposes. However,
funeral ceremonies with minimal numbers of attendees may still be held.

4. Health Examination upon Arrival in Malaysia

All citizens and permanent residents in Malaysia returning from overseas shall
undergo a health examination upon arrival in Malaysia before proceeding for
immigration clearance at any point of entry.

274 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

5. International Travel and Border Controls
Measures that are designed to limit and/or control the spread of infection across
entry points to a country (by road, air, sea, etc.). They can include travel advisories
or restrictions, entry or exit screening, reporting, health alert notices, collection and
dissemination of passenger information.

6. Isolation and quarantine

The separation, for the period of communicability, of infected persons (confirmed
or suspected) in such places and under such conditions as to prevent or limit the
transmission of the infectious agent from those infected to those who are susceptible
or who may spread the agent to others.

7. Social-distancing measures
A range of community-based measures to reduce contact between people (e.g.,
closing schools or prohibiting large gatherings). Community-based measures may
also be complemented by adoption of individual behaviors to increase the distance
between people in daily life at the worksite or in other locations (e.g., substituting
phone calls for face-to-face meetings, avoiding handshaking).

15.6 Summary

Legal structures for disaster response affirm that effective disaster response is first local,
then moves in stages to state and federal resources. Responsibilities of healthcare
professionals around disaster response include the duty to care for those affected
and reciprocal obligations of society to protect those serving in disasters; support for
restrictions on individual liberties, such as isolation and quarantine, when necessary to
protect the larger community while ensuring respect for affected individuals; and rationing
decisions made through crisis care operations that are different from normal operations,
yet that are based on the same ethical principles that govern usual care.

275
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277
CHAPTER
16
TRAINING,
SIMULATION
AND EXERCISE
 CHAPTER 16
TRAINING, SIMULATION AND EXERCISE

16.1 Background

Training, simulation and exercise are the key elements in the preparedness plan of the
disaster phase. Training teaches a specific skill and task or the knowledge and attitude
towards disaster preparedness. Training also is one of the ways to educate and train
people to understand and appreciate the disaster plan and guideline. It can be conducted
by simulation such as tabletop exercise or practical on the ground such as drills, functional
exercise or large-scale exercise.

Exercises are the most useful tools for evaluating and testing the effectiveness of the
preparedness and response plans. They also can reveal any planning weaknesses as
well as resource gaps in a controlled environment. It clarifies roles and responsibilities,
improves the command system, communication and coordination. It also develops
leadership and teamwork skills.

One may have a chance to familiarize with new functions, to test the equipment, evaluate
the plans and procedure, including guidelines and standard operating procedures
(SOPs). Exercises are not one-off events but should be designed as a well-structured
and continuous program to address the objectives of the preparedness plan.

The other components included within the preparedness cycle other than training and
exercise are as shown in Figure 16.1.

ng e Pl
ki iv an
Ta rect n Or ni
ng
r io ga &
Co Act g ni
tin zin
lua g
Eva

Preparedness
Cycle
ng
Exe

cati

ning
rcis

&
Edu

Trai
es

Equipping

Figure 16.1 Preparedness cycle components

279
 16.2 Objectives

1. To increase the knowledge, skills and familiarity of the preparedness and response
plan among the responders.
2. To improve the command, communication and coordination system developed in
the plan.
3. To validate the relevance and effectiveness of plans, protocols, procedures,
guidelines, and other operational mechanisms for emergency preparedness and
response.
4. To evaluate the decision-making capacity of personnel responsible for emergency
and disaster preparedness and response.
5. To assess the relevant expandable resources and facilities required as part of the
preparedness plan.

16.3 Key Elements

1. What are the objectives to achieve?

2. What type of emergency to be simulated?
3. Where does the location of the simulated event occur?
4. Which type of exercise is relevant to the event?
5. How many participants will be involved?
6. What are the available resources to be utilized?

The exercise scope and objectives should be practical and realistic, meet the
requirements of the targeted participants and within the capacity and available resources.
It is important to select the right and relevant type of exercise to achieve the objectives
of the preparedness plan.

16.4 Exercise Management Team

1. Director
2. Administrator or financial officer
3. Technical design of scenario
4. Controller
5. Evaluator
6. Facilitator
7. Role player/actor
8. Liaison officer
9. Logistic officer
10. Safety officer
280 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT
How to conduct

There are 3 main phases to conduct exercises:

•• Phase 1: Pre-exercise
•• Planning
•• Design modules and materials
•• Setting up the modules

•• Phase 2: During exercise

•• Conduct the exercise
•• Briefing
•• Facilitate
•• Debrief

•• Phase 3: Post exercise

•• After Action Review
•• Evaluation
•• Corrective Action

16.5 Tabletop Exercise

It is a type of facilitated discussion of an emergency simulated scenario, conducted in an

informal setting, indoor round-table seating or online and in a low-stress environment. It
includes key decision makers responsible for the plan or policies being exercised (e.g.,
emergency managers, incident commanders, and other command and general staff
personnel for an exercise involving resource management at incident).

Tabletop session is to elicit participants to discuss the management, give opinion, identify
and resolve problems as well as refine the existing operational plans. The duration of the
exercise is usually 0.5 to 1 day. It requires minimal cost, a small amount of resources and
a short duration to prepare.

281
 16.6 Drills

Drills are usually exercises which are organized, coordinated and supervised to test
a single specific operation and function. It includes personnel responsible for the type
of drill (e.g., building managers for evacuation drills, senior personnel from agencies
reporting for response call drills).

The exercise aims to train and practice to get familiarized and better understand the
possible scenarios as well as the response plan. The drills can be conducted as short as
2 hours and up to 5 hours, and require low to medium cost, resources and preparation
time, depending on the type of the drills.

16.6.1 Drill Exercise Checklist

̉̉Brainstorm and decide for the concept

̉̉Form the Exercise Management Team
̉̉Define the project management roles and
Planning scope
̉̉Identify the participants
(1-2 months ̉̉Define the evaluation strategy
prior to ̉̉Manage administrative tasks and
exercise) logistics
̉̉Set the media, press release and
communications strategy
̉̉Assess safety and security

Pre-Exercise ̉̉Review the concept

Developing
̉̉Research the context & gather reference
module
materials
̉̉Write the master scenario
(at least 3
̉̉Develop the injects and inject matrix
weeks prior to
̉̉Develop evaluation material
exercise)
̉̉Develop the exercise handbook and/or
briefings

Setting up ̉̉Setup the exercise venue

̉̉Setup the exercise control room
(1 day prior) ̉̉Check all equipment
̉̉Brief the exercise management team

282 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 ̉̉Brief participants on the simulation exercise
̉̉Start the exercise
̉̉Run/control the exercise
Exercise During the ̉̉Capture the outcomes
Conduct exercise ̉̉End the exercise
̉̉Conduct a debrief of the exercise to
participants
̉̉Close the exercise

̉̉Debrief the Exercise Management team

After Action
̉̉Debrief senior-level management
Review
̉̉Develop the Exercise Report
Post Exercise ̉̉Close project administrative tasks, costing and
(Not more than
logistics
7 days post
̉̉Improvement activity and taking corrective
exercise)
action

16.7 Functional Exercises

A functional exercise is a fully simulated interactive exercise that tests the capability of an
organisation to respond to a simulated event. It includes people responsible for the function
being tested (e.g., communication managers if the exercise is testing communications,
individuals who may serve as incident commanders if the exercise would normally occur
at an incident scene).

The exercise tests multiple functions and layers of the organisation’s operational plan. It is
a coordinated response to a situation in a time-pressured, realistic simulation. A functional
exercise focuses on the coordination, integration, and interaction of an organisation’s
policies, procedures, roles and responsibilities before, during, or after the simulated
event. The exercise usually will take 1 to 2 days and it requires extensive planning and
preparation up to a few weeks. The cost is higher and more resources are needed.

16.8 Full-Scale Exercises

A field or full-scale exercise simulates a real event as closely as possible and is designed
to evaluate the operational capability of emergency management systems in a highly
stressful environment and simulate actual response conditions.

This exercise includes all people with the expert knowledge in the various roles,
responsibilities, and procedures to be followed by any of the exercise players (e.g.,
personnel from hazardous material response team, representatives from authority, local
council, district health officer, fire, law enforcement and emergency medical services,

283
 representatives from private industry and those around the incident site used). It also
involves the mobilisation and movement of emergency personnel, equipment and
resources.

Ideally, the full-scale exercise should test and evaluate most functions of the emergency
management plan or operational plan and usually will be conducted in a course (1 to
3 days). This exercise requires a large amount of resources, higher cost and longer
duration to prepare.

Full Scale
Exercise
CAPACITY AND RESOURCES

Functional
Exercise

Drills

Table Top
Exercise

LEVEL OF PREPARATION

284 AN OVERVIEW OF DISASTER LIFE SUPPORT IN DISASTER MANAGEMENT

 16.9 Summary

Training Type of Time for

Duration Frequency Cost
Name Exercise preparation

Tabletop 3 times a At least 4

Discussion 0.5-1 day Low
Exercise year weeks

Operational
1-2 times a At least 2
Drills on specific 3-5 hours Medium
year months
objective

Functional At least 6
Operational 1 day Once a year High
Exercise months

Full-Scale Massive Up to 3 Once every At least 12

Very High
Exercise Operational days 3 years months

Bibliography

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CC BY-NCSA 3.0 IGO.

Guidelines for Developing Emergency Simulations and Drills Washington, D.C.: PAHO,
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European Centre for Disease Prevention and Control. Handbook on simulation exercises
in EU public health settings – How to develop simulation exercises within the framework
of public health response to communicable diseases. Stockholm: ECDC; 2014.

After Action Reviews and Simulation Exercises under the International Health Regulations
2005 M&E Framework (IHR MEF). Geneva: World Health Organization; 2018 (WHO/
WHE/CPI/2018.48). Licence: CC BY-NC-SA 3.0 IGO.

The Words into Action (WiA) guidelines © UNDRR 2020

THE ASEAN Regional Disaster Emergency Response Simulation Exercise (ARDEX),

September 2015 AHA Centre

285
 APPRECIATION AND ACKNOWLEDGEMENT

• Dr Sakinah Binti Alwi • Dr Dharwin Nair A/l Chandran

• Datuk Dr Mohmed Alwi Bin Haji Abdul Rahman • Dr Belinder Kaur A/p Baldev Singh
• Dr Jonathan Yeap Han Hsiung • Dr Thamil Vaanan A/lr Rajendran
• Dr Lee Tuan Cheong • Dr Simon Raj A/l Yanegamani
• Dr Thayaharan A/l Subramaniam • Dr Wan Aznita Binti Wan Abdullah
• Dr Ahmad Fadzil Bin Sujak • Dr Mohd Muzakkir Bin Zul Wizaratain
• Dr Nor Khatijah Binti Ahmad • Dr Rafiqah Binti Azhar
• Dr Faridah Binti Jaafar Dr Mohd • Dr Najwa Binti Azhar
• Dr Alfiah Anas Bin Mohd Hashim • Dr Mohd Amirul Ashraf Bin Mohd Almizat
• Dr Hazlina Binti Mohd Noh • Dr Siti Hajar Binti Riduan
• Dr Noriani Binti Daud • Dr Muhammad Fikri Bin Fahruddin
• Dr Zaliza Binti Sinwan • Dr Mohd Hamdi Bin Razali
• Dr Siva A/l Perumal • Dr Syakirah Binti Azami
• Dr Sharifah Naieman Binti Syed Mansor • Dr Nur Sabrina Binti Badarussamin
• Dr Noredelina Binti Mohd Noor • Dr Manimegala A/p Karunakaran
• Dr Ab Halim Sanib • Dr Muhammad Asyaari Bin Hambali
• Dr Mohd Amin Mokhtar • Dr Shahrizan Majid Bin Allapitchai
• Dr Nurul Huda Ahmad • Dr Nur Syahira A’tiqah Binti Amran
• Dr Khairul Izwan Hashim • Dr Muhammad Ariff Bin Abd Hafidz
• Dr Syed Jamal Fikri Bin Syed Yusoff • Dr Tuan Muhammad Hafiz Bin Tuan Ab Hamid
• Dr Chong Woon Wee • Dr Ibtisam Binti Yusoff
• Dr Nabil Muhamaad Bin Al Kuddoos • Dr Amirah Binti Razali
• Dr Kasturi A/p Sivan • Dr Nurul Nabilla Binti Sabri
• Dr Vijaykumar Silvaraja • Dr Nur Farahin Binti Hussain
• Dr Pak Jun Wee • Dr Abdul Aziz Bin Abdul Rahim
• Dr Ian Tey Zhe Yuan • Dr Lydia Binti Mohamad Rashid
• Dr Sherwynd Voon Vui Leong • Dr Hanim Zafirah Binti Burhan
• Dr Harris Bin Kassim • Dr Neeshanthi A/p Sundareson
• Dr Vijayindran A/l Purushothman • Dr Kirrainya Nair A/p Chandru
• Dr Muhammad Noorul Azman Bin Noorul Ameen • Dr Law Zhen Theng
• Dr Syed Muhammad Hafiz Bin Syed Hassan • Ppp Rohimin Bin Che Soh
• Dr Valliamah A/p Suppiah • Ppp Mohd Zureehan Zakaria
• Dr Mursyidah Bin Mansor • Matron Nor Hayati Abdul Hamid
• Dr Nurul Liyana Binti Osman • Kj Nor Asikin Sanusi
• Dr Farah Nurwahida Binti Shahrin • Kj Ridawati Abdullah
• Dr Muhammad Suhaimi Bin Othman • Kj Ruzlina Binti Abdul Rasit
• Dr Mohd Zawawi Bin Md Hamzah • Kj Azni Laili Binti Zainin
• Dr Noor Hafizah Binti Ab Rahman • Ppp Che Mohd Shahiran Bin Che Omar
• Dr Wang Wee Chert • Ppp Azero Bin Azami
• Dr Shireen Ng Wei Yin • Ppp B. Husin
• Dr Shazleena Azla Binti Ismail • Ppp Che Mohd Khairul Fahmi Bin Che Ismail
• Dr Lishaliney A/p Uthrapathy • Ppp Azrul Sham Bin Adam
• Dr Devinia Nevidya A/p Rayappan • Ppp Ganesan A/l Muragasu
• Dr Sharifah Maisarah Binti Syed Othman • Ppp Mohd Shahrin Bin Yusoh
• Dr Surendraraja A/l Yuvarajah • Jt Norfatihah Binti Md Noor
• Dr Chor Yun Hung • Jt Nurul Farahana Bin Hanafi
• Dr Abdul Azim Bin Abd Rahim • Jt Noaini Binti Yusof
• Dr Jagathesvary A/p Rajakurunathar • Ppw Amir Firdaus Bin Mohd Ridzuan
• Dr Muhammad Haikal Bin Mohd Nasir • Ppw Amir Firdaus Bin Mohd Ridzuan
• Dr Chor Yun Hung • Sandra Babo A/l Appalasamy
• Dr Muhammad Syazwan Shah Bin Mohd Shihabuddin • Nurul Akma Jahya Azim
• Dr Muhammad Haniff Abdullah