By: Dr Seyed Mohsen Zahraei National EPI Manager Center for Communicable Disease Control

1. دوره آموزشی ملی مدیریت بهداشت بلایا و کاهش خطر بیماریهای واگیر پس از بلایای طبیعی: پاسخ بهداشت عمومی By: Dr Seyed Mohsen Zahraei National EPI Manager Center for Communicable Disease Control

2. Disaster Health Management & Risk Reduction Training Course (DHMR) • برنامه درسی DHMR که توسط همکاری مشترک بین دانشکده بهداشت و انستیتو ملی تحقیقات بهداشت از دانشگاه علوم پزشکی تهران است و از طریق کمک مالی انجمن بین المللی و ملی بهداشت و مشاوره فنی سازمان بهداشت جهانی در 15-30 اکتبر 2008 ایجاد شد. DHMR-6 Course is organized by: • دوره DHMR-6 توسط سازمانهای زیر برگزار گردید: • دانشگاه تهران علوم پزشکی • گروه بهداشت عمومی فاجعه در دانشکده بهداشت عمومی • وزارت بهداشت در شرایط اضطراری و حوادث در موسسه ملی تحقیقات بهداشت • وزارت بهداشت، درمان و آموزش پزشکی، I.R.Iran • مرکز مدیریت اضطراری حوادث و فوریتها

3. اهداف یادگیری • به منظور ارائه یک نمای کلی از مسائل مربوط به آمادگی و پاسخ اضطراری امدادگران بهداشتی • برای درک بهتر عوامل زمینه ای در شیوع بیماری های واگیر با عوارض بالا • برای بررسی ویژگی بیماری های که بزرگترین نگرانی در بلایا است

4. M Kokic, IFRC/RCS

5. بیماریهای واگیر در بلایا کلید به حداقل رساندن مرگ و میر آمادگی کافی واکنش هماهنگ شده ، سریع بهبود مستمر

6. بیماریهای واگیر دربلایا • مداخله به موقع و تلاش برای هماهنگی با نیاز به بررسی مستمر در ماموریت های آمادگی محلی و ملی در سطح بین المللی • تا حد زیادی توسط دولت در حال انجام است، و آموزش سازمان خصوصی و دانشگاهی و برنامه های آموزشی را تسهیل می کند.

7. عوامل مطلوب برای شیوع بیماری • شروع آن با تاثیر سریع و گسترده • منابع آبدر معرض خطر • جابجایی تعداد زیادی از مردم • پناه موقت در شرایط نامناسب با تراکم جمعیت بالا • بهداشت عمومی نامناسب • به خطر افتادن مدیریت زباله

8. عوامل مطلوب برای شیوع بیماری • کمبود بالقوه ی مواد غذایی • سوء تغذیه • درصد سطح ایمنی • شیوع بیماری موجود در جمعیت قبل از وقوع فاجعه • به خطر افتادن زیرساختها • کاهش منابع • بالا رفتن حساسیت جمعیت

9. اپیدمیولوژی و نظارت • ایجاد سیستم نظارت در بیماریها در اسرع وقت • شناسایی منابع کلیدی • پزشکان محلی، پرستاران، کارکنان بهداشت • عملکرد بیمارستان / درمانگاه • آیا تجهیزات پزشکی فورا در دسترس است • دسترسی به قربانیان • جاده ها، آبراه ها، ارتباطات راه دور، و غیره

10. اپیدمیولوژی و نظارت • کسب اطلاعات اپیدمیولوژیک قبل از تاثیرعوارض • پایه فرکانس و توزیع بیماری (انتظار) (بروز، شیوع، و مرگ و میر) • خطرات شناخته شده • پوشش ایمن سازی • سطح آگاهی / آموزش و پرورش در جامعه

11. Health Surveillance • The objective is not to assess what has already happened (injuries, death, etc) • but to monitor changes and provide an early warning of what MAY happen in the future.

13. Water-borne Diseases - Diarrhea • Diarrhea can be a major contributor to overall morbidity and mortality in a disaster due to: • large scale disruption of infrastructure • compromised water quality • poor sanitation • massive displacement of population into temporary crowded shelters • common sources of food and water subject to cross contamination

14. Water-borne Diseases - Diarrhea • Cholera • spreads rapidly; high mortality across all age groups • major global threat and epidemic threat is constant in developing countries throughout the year • rapid recognition and response imperative during acute post-disaster phase to prevent epidemic • emergence of antibiotic-resistant strains of Vibrio cholera complicate efforts in some regions and should be considered in preparedness planning

15. Water-borne Diseases - Diarrhea • Dysentery • Bacillary dysentery caused by Shigella • Fecal-oral transmission from contaminated food/water • Suspect if bloody diarrhea present • particular concern (along with cholera) due to ease of transmission, rapid spread in crowded conditions, and immediate life-threatening conditions • guidelines on managing outbreak available from WHO (http://w3.whosea.org)

16. Acute Respiratory Infections • Increased risk for pneumonia: • overcrowding • susceptibility • malnourishment • poor ventilation in temporary shelters • Many acute infections involve upper respiratory system; mild and self-limiting • Lower respiratory infections (bronchitis, pneumonia) are generally more severe and require hospitalization

17. Acute Respiratory Infections • Account for up to 20% of all deaths in children less than 5 years of age, with majority due to pneumonia (WHO) • May account for a major portion of overall morbidity depending on: • Region affected • Characteristics of displaced population and temporary dwellings • Early recognition and management are keys to avoiding an outbreak

18. Measles • Few outbreaks associated with natural disasters although possibility remains high • Outbreaks prevented through • effective early warning system • rapid response to suspicious reports • availability of vaccine

19. Measles • Mt Pinatubo eruption (Philippines) 1991 • measles accounted for 25% morbidity and 22% of mortality among 100,000 people displaced • attributed to very low immunization coverage and cultural barriers of indigenous tribe that represented majority of displaced population • Therefore, threat of measles epidemic remains high following natural disasters

20. Tetanus • Due to collapsing structures and falling debris • Earthquakes and tsunamis inflicts numerous crash injuries, fractures, and serious wounds • Tetanus expected when immunization coverage is low or non-existent • Injured and non-immunized should receive: • prompt surgical and medical care of contaminated open wound • tetanus immunization and/or immunoglobulin depending on vaccination history and seriousness of the wound infection

21. Vector-Borne Diseases • Risk usually higher following disasters (hurricane [typhoon] flood, or tsunami) • Higher risk due to increase in number and range of vector habitats • Initially flushed out mosquito breeding sites return shortly after waters begin to recede

22. Vector-Borne Diseases • Factors favoring outbreaks: • changing dynamics of vector • displacement of large numbers of people in temporary crowded shelters • Lag time of up to 8 weeks before onset

23. Vector-Borne Diseases: Malaria • associated with serious public health emergencies with little warning • likelihood of epidemic high when: • disaster in malaria-endemic area • public health infrastructure is disrupted • highly vulnerable population exists • usually 4-8 weeks after initial impact • several weeks duration before peak

24. Vector-Borne Diseases: Malaria • Effective control possible in early stages if timely response in implementing control measures • Morbidity and mortality reduced with early diagnosis and treatment • If diagnosis delayed, treatment based solely on clinical history without demonstration of parasites • important considerations for planning • emergence of anti-malarial resistance • increased transmission potential due to expanding range of vector habitats

25. Vector-Borne Diseases: Malaria • vectors exclusively Anopheles - breed in stagnant fresh or brackish water • transmission efficiency dependent on • species of mosquito • preferred breeding habits • prevalence of parasite • in endemic areas disruptions may change otherwise poor breeding conditions into favorable ones

26. Water-borne Diseases: Summary

27. Vector-borne Diseases: Summary

28. Direct Contact Diseases: Summary

29. Summary • Immediate concern is rapid detection and response to address existing health needs and prevent epidemics • Factors that also play key roles in controlling communicable diseases in disaster setting:

30. Summary • Emergency response aimed to mitigate adverse health effects requires: • Multidisciplinary approach employing a broad range of expertise • Identification and attention to those in need of immediate threat • Multidisciplinary effort forms framework for recovery • Requires ongoing preparedness planning, education, and training efforts

31. Infectious Disease Risks From Dead Bodies Following Disasters Dr Seyed Mohsen Zahraei National EPI Manager Center for Disease Control

32. Introduction • Respect of the dead is a value deeply ingrained in all cultures and religions. • Rituals and practices may differ according to time, religion, or place: Burial before sunset for Muslims; Funeral after one night of prayer for Jews; Before three days for Christians; The use of the white shroud in Oriental culture; The use of the coffin in most of the Western world.

33. Natural disasters cause large numbers of deaths in a short period of time, placing overwhelming stress on individuals and society and presenting health officials with an uncommon challenge of handling large numbers of cadavers.

34. According to the International Red Cross and Red Crescent, in the ten-year period of 1993 through 2002, 531000 persons were killed by natural disasters, including earthquakes and floods. • More than 26000 persons died in Bam-December 2003 • Around 150000 deaths in tsunami of Indonesia -December 2004

35. In most of sudden disasters-especially earthquakes- precipitous mass burial, incineration, or collective disposal of cadavers have been carried out under public and political pressure.

38. Why should a health agency take a firm position against expedite burial of victims? • Mass burial has very serious health consequences: - Identification of the body and the normal process of grieving are essential for prompt individual recovery from severe stress caused by sudden natural disasters and personal losses.

39. 2. The second reason is that officials and the mass media justify expeditious measures for burial by the presumed risk that those bodies exposed to the environment would pose to public health. • Most of the visible measures, such as superficial incineration or dusting with lime or “disinfectants” are unlikely to be of any effectiveness and their value is only in the eyes of public.

40. 3. The commonly held belief that human and animal corpses pose a public health threat has resulted in confusion among authorities and the general public and led to incorrect prioritization and use of scarce resources in crisis situations, and these errors often have caused more deaths and illnesses than caused by the disaster itself.

41. Remember that: • Dead bodies are the result of an epidemic and not the cause of the epidemic. • In natural disasters deaths occur mainly from trauma as a direct result of the type of disaster. • After death, body temperature drops quickly and the most resistant bacteria and viruses die quickly. this makes it extremely difficult for microorganisms to transfer from dead bodies to vectors, and from vectors to human populations.

42. Animal Corpses • Massive animal deaths in cases of natural disasters are not a health hazard for humans. • Zoonotic diseases from animal corpses may be occur in endemic areas for those diseases. • The microorganisms of greatest concern are Cryptosporidia, Campylobacter and Listeria, but only when the bodies are in the water.

43. Bacterial Infections Tuberculosis Streptococcal infections Gastrointestinal infections Meningitis and Septicemia due to Meningococcus Viral Infections Gastrointestinal infections Creutzfeldt-Jakob disease Hepatitis B Hepatitis C HIV infection Hemorrhagic fever Infectious Risk of Human Corpses

44. Risk to the public • The risk to the public is negligible because they do not touch dead bodies • There is the potential risk of drinking water supplies contaminated by fecal material released from dead bodies

45. Risk to body handlers • Individuals handling human remains have a small risk through contact with blood and feces from the following: * Hepatitis B and C * HIV * Tuberculosis * Diarrheal disease • Due to work in hazardous environment, they may be at risk of injury and tetanus.

46. Safety precautions for body handlers • Use gloves and boots • Wash hands with soap and water after handling bodies and before eating • Avoid wiping face or mouth with hands • Wash and disinfect all equipment, cloths, and vehicles used for transportation of bodies • Face masks are unnecessary, but should be provided if requested to avoid anxiety • Hepatitis B vaccination

47. Recommendations for burial • The water table should be at least 2.5m deep in order to allow a traditional grave depth of 1.8m, with a 0.7m unsaturated zone. • To protect water supplies, distances of at least 30m from springs or watercourses and 250m from any well, borehole, or any source of drinking water have been suggested.

48. Thank you for your attention

49. Epidemiology and Surveillance • Establish and distribute protocols • laboratory procedures • case definitions • case management • frequency and method of reporting • thresholds for every disease with epidemic potential above which a response must be initiated (epidemic threshold)

50. Epidemiology and Surveillance • Rapid health assessments • conducted as soon as possible • purpose - assess immediate impact/health needs • critical to directing timely decisions and planning • rely on pre-impact information • demographic, geographical, environmental, health facilities and services, transportation routes, security • information from key informants • visual inspection of the affected area