13 November 2005 PET - World Health Organization Sarmiento; Dr. Enrique A. Tayag; Dr. Yoshihiro...

POCKET

TOOLEMERGENCY

2nd edition

Health Emergency

Management StaffDepart of HealthManila, Philippines

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F IL LO UR PE OA PT SS AA TL IBRU

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World HealthOrganization

Western Pacific Region

Emergency & Humanitarian ActionHealth Emergency

Management StaffDepart of HealthManila, Philippines

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F IL LO UR PE OA PT SS AA TL IBRU

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Acknowledgements ....................................................................iiiIntroduction ...............Abbreviations ............Roles and Responsibilities

Coordinating with Other Agencies Drafting the Health Disaster Management Plan

Rapid Health Assessment Critical Incident Management Pre-Hospital Activities ....Hospital Activities Prevention and Control of Communicable Diseases Nutrition Concerns ...Environmental Health ....Water Supply ..........Sanitation and Waste Management Vector and Vermin Control Epidemiology and Surveillance Psychosocial Care and Mental Health Management of Dead Bodies Forensic Science Concerns in Mass Fatalities Resource Management ...Risk Communication

Emergency Manager Deployment Checklist Rapid Health Assessment Forms Reference Values for Rapid Health Assessment and

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PREPARING FOR EMERGENCIES ..........................................5

RESPONDING TO EMERGENCIES .......................................16

APPENDICES ..........................................................................77

POCKET EMERGENCY TOOL

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iiC

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TS Contingency Planning Radio Procedures .........ConversionTable .........Websites ...................References ................Emergency Call Number Directory

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This pocket tool is a project of the Department of Health-Health Emergency Management Staff (DOH-HEMS), with support from the World Health Organization-Regional Office for the Western Pacific Region (WHO-WPRO).

The review and revision for this second edition was done through the efforts of Dr. Emmanuel S. Prudente, under the technical supervision of Dr. Arturo M. Pesigan of Emergency and Humanitarian Action (EHA) of the WHO-WPRO. Acknowledgement is also given to Dr. Carmencita A. Banatin, Dr. Marilyn V. Go, Dr. Teodoro J. Herbosa, Dr. Josephine H. Hipolito, Ms. Florinda V. Panlilio, Dr. Arnel Z. Rivera, Dr. Edgardo Sarmiento and Dr. Xiangdong Wang, who reviewed the text and provided valuable comments. Lay-out and cover design was done by Mr. Zando Escultura.

The first edition was through the efforts of the following individuals: Engr. Russell Abrams; Dr. Shigeki Asahi ; Dr. Carmencita A. Banatin ; Dr. Agnes B. Beñegas ; Mr. Miguel C. Enriquez ; Mrs. Guia P. Flores ; Dr. Raquel dR. Fortun ; Dr. Camilla A. Habacon ; Dr. Lourdes L. Ignacio ; Mrs. Elizabeth M. Joven; Dr. Susan P. Mercado; Dr. Daniel T. Morales; Dr. Jean-Marc Olivé; Dr. Hitoshi Oshitani; Dr. Arturo M. Pesigan; Dr. Manuel F. Quirino; Dr. Lilia M. Reyes; Dr. Arnel Z. Rivera; Dr. Edgardo Sarmiento; Dr. Enrique A. Tayag; Dr. Yoshihiro Takashima; Dr. Xiangdong Wang; Mrs. Zen Delica Willison; Mr. Robin Willison; and Dr. Ladislao N. Yuchongco, Jr.

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Human survival and health are the common objectives and measures of success of all humanitarian endeavors.

The goal of the Department of Health (DOH) through the Health Emergency Management Staff (HEMS) is to prevent or minimize the loss of lives during emergencies and disasters in collaboration with government, business and civil society groups. The main purpose of this pocket tool is to help guide and prepare health sector professionals in the field in the event that an emergency occurs. A compendium of recent DOH, WHO and other international agencies' guidelines, checklists and standards, this booklet provides essential pointers on how to carry out rapid health assessment, networking and coordination, planning, and other necessary tools especially in times of tragedies and adversities.

This pocket tool, however, neither provides nor claims to be the definite and only guideline to follow in emergencies. Thus, references to complementary documents and websites, where more detail can be found, are provided at the end of the booklet. Also, because every disaster is unique, some of the suggested procedures may need to be tailored to local conditions.

ndFurthermore, this pocket tool is an evolving text; this 2 edition was conceived from the lessons learned from the recent disasters that affected the country and the Western Pacific Region. Indeed, the success of this guide depends largely on the dynamics of its use and the tireless efforts of its users to improve it.

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CDC Centers for Disease Control and Prevention (USA)

CHD Center for Health DevelopmentCMR Crude Mortality RateDND Department of National DefenseDOH-HEMS Department of Health-Health Emergency

Management StaffDOTC Department of Transportation and Communication DPWH Department of Public Works and HighwaysDSWD Department of Social Welfare and DevelopmentEHA Emergency and Humanitarian UnitEMS Emergency Medical ServicesEOC Emergency Operations CenterEPI Expanded Program of ImmunizationER Emergency RoomLGU Local Government UnitMUAC Mid-Upper Arm CircumferenceNBI National Bureau of InvestigationNDCC National Disaster Coordinating CouncilNEHK New Emergency Health KitNGO Nongovernmental organizationNNC National Nutrition CouncilNPDEP Nutrition Preparedness in Disasters and

Emergencies PlanOpCen Operation CenterPHC Primary Health CarePNRC Philippine National Red CrossWHO-WPRO World Health Organization-Office for the Western

Pacific Region

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T.R.A.I.T. of a Health Emergency Manager/Coordinator

T ake the lead within the community in:

! health coordination and networking! rapid health assessment! disease control and prevention! epidemiologic and nutrition surveillance! epidemic preparedness! essential medicines management! physical and psychosocial rehabilitation! health risk communication! forensic concerns and management of mass casualties

R ecord and re-evaluate lessons learned to improve

preparedness in the future

A ssess and monitor health and nutrition needs so that they

are immediately dealt with

I mprove health sector reform and capacity building by

networking

T end and protect the practice of humanitarian access,

neutrality and protection of health systems in emergency situations

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Roles of Hospitals in Health Emergency Management

1. Observe all requirements and standards (hospital emergency plan, HEICS, Code Alert System, etc.) needed to respond to emergencies and disasters.

2. Ensure enhancement of their facilities to respond to the needs of the communities especially during emergencies.

3. Network with other hospitals in the area to optimize resources and coordinate transferring of victims to the appropriate facility.

4. Report all health emergencies to the Operation Center, and document all incidents responded.

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Steps in Preparing for Emergencies

1. Policy Formulation and Development! policy statement/implementing rules! guidelines, protocols, procedures! organizational structure! roles and functions! resource mobilization

2. Capability Building! training needs assessment! human resource development! training of trainers! database of experts! tabletop drills and exercises

3. Facilities Development! standardization/mprovement/upgrading of ER, ambulance,

Operation Center, hospitals! procurement of supplies, communications and equipment

4. Networking! organization of the health sector! coordination and planning! memorandum of agreement with stakeholders! networking activities

5. Disaster Planning! vulnerability and hazard assessment! all-hazards emergency operations plan! specialized planning for uncommon incidents (e.g. SARS,

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WMD)! communication plans! hospital preparedness and response plans

6. Public Information and Mass Media! advocacy activities! development of IEC's

7. Post-disaster Response Evaluation! monitoring and evaluation activities! postmortem evaluation

8. Systems Development! Logistics Management System! Management Information System! Communication System

9. Establishment of Emergency Operation Centers! Infrastructure, manpower, technology

10. Documentation and Research! publications! databanking! accomplishment reports! research studies! lessons learned

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Roles of Centers for Health Development in Emergency Management

1. Serve as the DOH Coordinating Body in their region

2. Manintain updated hazard and vulnerability assessment of their catchment areas

3. Observe all requirements and standards needed to respond to emergencies (Regional Emergency Plan)

4. Organize health sector in the region and provide mechanism for coordination and collaboration. Provide advice to the RDCC for health emergency concerns

5. Maintain operation center as regional repository of vents for the health sector. Identify an official spokesperson to answer concerns by the public and the media

6. Provide technical assistance and empower all LGUs in the area on health emergency management

7. Report to the Central DOH (HEMS) for all emergencies and disasters and any incident with the potential of becoming an emergency

8. Document all health emergency events and conduct researches to support policies and program development.

(Based on DOH Administrative Order 168, s.2004)

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At the Center for Health Development (CHD) level…

The following should be readily available

for reference and may be compiled in collaboration with other partners (government and non-government units). These information must be updated regularly:

Disaster profile of the regionPopulation size and distributionTopography and maps showing communication linesEpidemiologic profile of the regionLocation of health facilities and the services they provideLocation of potential evacuation areasLocation of stocks of food, medicine, health and water treatment and other sanitation supplies in government stores, commercial warehouses and international agencies and major NGOsKey people and organizations who would be responsible for/active in relief (contact phone numbers AND addresses)Individuals with special competencies and experience who may be mobilized on secondment from their institutions or as consultants in case of need (contact phone numbers AND addresses)A roster of regular resource persons ready to translate technical information materials into local dialect (i.e., traditional healers, indigenous health workers, barangay captain, etc.)

information

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The following should be readily available for use AT ALL TIMES:

1. Vehicles2. Communications equipment3. Back-up power supplies4. Computers, printers, facsimiles and photocopying machines5. Water testing sets6. Food supplements7. Temporary shelter capacities8. Funding requirements9. Personal protective equipment

resources

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Prepare internal arrangements within the DOH and with other public health related government entities, UN agencies, NGOs, and other institutions in the country whose expertise and/or services may be called upon during emergencies (DND, NDCC, DSWD, DPWH, DOTC, PNRC, etc.)

Steps in Establishing Good Working Relationships with Other Groups or Entities

1. Have a common goal.2. Designate a good and strong facilitator.3. Define the parameters of the project. Reach a consensus

on objectives, strategies and plans. 4. Discuss needs and lines of action. 5. Have operating guidelines. 6. Encourage member participation.7. Build trust among members. Fix issues early on.8. Maintain regular communication and correspondence

among members.9. Give priority to the whole group. Each agency is vital.10. Develop clear and attainable mission statements from the

beginning of the project.11. Enlist and maintain the support of top-level-management.12. Educate all members about the range of services each

agency can provide.13. Make partners aware of policies and protocols.14. Adopt responsibilities in the context of what was agreed

upon15. Adjust to changes. Be flexible and be open to possibilities,

unforeseen events and new opportunities.

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16. For members to attend, allow adequate incentive.17. Have a product or concrete result showing the team's effort

and share among members so that there is a sense of accomplishment. Celebrate.

Ps of Facilitation:

1. PURPOSE explains the overall aim of the session.! Have ground rules, a clear agenda, and desired

outcomes.

2. PRODUCT describes the session's deliverables in specific outputs.! Discuss needs and lines of action.! Reach a consensus on objectives, strategies, and plans.

3. PARTICIPANTS push the issues. Know their perspectives and concerns. A designated and experienced chairperson should practice facilitative behavior: listening, encouraging participation, not being defensive, asking open-ended questions, and optimistic but realistic

4. PROBABLE ISSUES give an idea of the potential

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Health coordination must start as soon as possible, it should be regular and frequent. At

the start of a crisis, changes are fast and many. To coordinate is to facilitate.

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roadblocks.! Sort issues by categories and types.! Approve the agenda before starting the meeting.

5. PROCESS is the detailed set of steps that will be taken to create the product.! Circulate information among partners.! Preliminary word clarification and definition, brainstorming,

rank order of issues according to importance to the group.! Have group memory by using flip charts or handouts.

Coordination is sharing information with other persons or organizations so they can work

together in harmony without friction or overlapping - based on regular communication

of relevant data.

The resulting consensus should be that everyone feels that he has been heard and that

everyone agrees and is willing to support the decision.

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Disaster Reaction Sequence:

! Surprise: Is it true? Has it really happened?! Lack of information: What is happening?! Events escalate: It's getting worse but I don't know ! the details?! Lack of control: I don't know therefore I cannot do.! Siege mentality: Why is this happening to us?! Panic: Will we ever recover from this?! Short term reaction: Get everyone away from me

Common Communication Concerns:

! “I don't have the correct facts.”! “I might upset other people with what I'll say.”! “There might be a better spokesperson.”! “There may be legal implications to what I say.”! “I might risk my reputation.”! “I might be asked something I cannot answer.”! “I might sound stupid.”

If you do not tell, information will be gathered elsewhere, leading to misinformation,

misunderstanding, and their consequences…

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You may follow the outline provided below; however, it is not meant to replace alternative outlines that you may deem more appropriate and useful.

I. BackgroundPresent the following:! geographic description ! disasters that have occurred ! gaps in response! hazard maps! vulnerabilities and risks

II. Goals and Objectives

III. Potential Problems Analysis

IV. Resource Analysis

V. Management Structurea. Explain the organization (an accompanying diagram is

essential)b. Specify command, control, lead organization and

coordination

VI. Roles and Responsibilities

VII. Strategies

VIII. Annexes (i.e., glossary, abbreviations, directory of contact persons)

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Steps in Responding to Emergencies

Immediate Response: 1. Assess the situation2. Contact key health personnel3. Develop initial health response objectives and establish an

action plan4. Establish communication and maintain close coordination

with the EOC5. Ensure that the site safety and health plan is established,

reviewed, and followed6. Establish communication with other key health and medical

organizations.7. Assign and deploy resources and assets to achieve

established initial health response objectives8. Address health-related requests for assistance and informa-

tion from other agencies, organizations and the public9. Initiate risk communications activities10.Document all response activities

Intermediate Response:1. Verify that health surveillance systems are operational2. Ensure that laboratories likely to be used during the response

are operational and verify their analytical capacity3. Ensure that the needs of special populations (e.g., children,

disabled persons, elderly, etc.) are being addressed4. Manage health-related volunteers and donations

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5. Update emergency risk communication messages6. Collect and analyze data that are becoming available through

health surveillance and laboratory systems7. Periodically assess health resource needs and acquire as

necessary

Extended Response: 1. Address psychosocial and mental health concerns2. Prepare for transition to extended operations or response

disengagement3. Address risks related to the environment4. Continue health surveillance/epidemiologic services5. Ensure that local health systems are preserved and access to

health care, including essential drugs and vaccines, is guaranteed

(Adapted from CDC's Public Health Emergency Response Guide.)

Hours 12-24

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The following should be made available for reference from the event.

Basically, the following key questions need to be answered:! Is there an emergency or not? (If so, indicate type, date,

time and place of emergency, magnitude and size of affected area and population)

! What is the main health problem? ! What health facilities or services have been or may be

affected?! What is the existing response capacity? (actions taken by

the local authorities, by DOH-HEMS)! What decisions need to be made?! What information is needed to make these decisions?

Situation Report Outline:

1. Executive Summary2. Main Issue

a. Nature of the emergency (causative and additional hazards, projected evolution)

b. Affected area (administrative division, access)c. Affected health facilitiesd. Affected population (sex/age breakdown)

3. Health Impacta. Direct impact: reasons for alert (3 main causes of

morbidity/mortality, CMR, under-5 mortality rate, acute malnutrition rate)

b. Other reasons for concern (e.g., trauma, reports/rumors of outbreak)

critical information requiredwithin 24 hours

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c. Indirect health impact (e.g., damage to critical infrastructures/lifelines)

d. Pre-emergency baseline morbidity and mortality (when available)

e. Projected evolution of health situation: main causes of concern if the emergency will be protracted

4. Vital Needs: current situationa. Waterb. Waste disposalc. Foodd. Shelter and environment on sitee. Fuel, electricity, and communicationf. Other vital needs (e.g., clothing and blankets)

5. Critical Constraintsa. Security: coordinate with the safety officer to identify

hazards or unsafe conditions associated with the incidentb. Transport and logisticsc. Social/political and geographical limitsd. Other constraints

6. Response Capacity: functioning resourcesa. Activities already underwayb. National protocols, contingency plansc. Operational support (command post, regional unit and

referral system, external assistance, state of communications)

d. Operational coordination (lead agencies, mechanisms, flow of information)

e. Strategic coordination (local/international relationships)7. Conclusions

a. Are the current levels of mortality and morbidity above-average for this area and this time of the year?

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b. Are the current levels of morbidity, mortality, nutrition, water, sanitation, shelter and health care acceptable by international standards?

c. Is a further increase in mortality expected in the next 2 weeks?

8. Recommendations for Immediate Actiona. What must be put in place as soon as possible to reduce

avoidable mortality and morbidity?b. Which activities must be implemented for this to happen?c. What are the risks to be monitored?d. How can they be monitored?e. Which inputs are needed to implement all these?f. Who will be doing what?

9. Emergency Contacts: local donor representatives, DOH counterparts and neighboring regional directors.

10.Annexes: include all detailed information that are relevant

*See appendix for sample of rapid health assessment form.

Be honest in the conclusions and practical in the recommendations. Recommendations that cannot be put into practice quickly are useless.

Prioritize the health problems (in terms of magnitude and severity and of feasibility of

response interventions).

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Steps as First Responders

a. Assume command (until a more senior personnel arrives) b. Assess the situation and advise the appropriate authorities

and agenciesc. Set perimeters! Identify and set perimeter (hot zone, warm zone, cold

zone)! Implement safety and security measures! Identify access and egress routes

d. Establish the initial medical command post e. Establish Safety Officerf. Establish Staging Officerg. Establish liaison with other services on siteh. Determine priorities and time constraintsi. Develop an incident plan in conjunction with members of the

Incident Management Teamj. Task response agencies and supporting servicesk. Coordinate resources and supportl. Monitor events and respond to changing circumstancesm. Report actions and activities to the appropriate agencies and

authorities

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Triaging

Objective:To quickly identify victims needing immediate stabilization or

transport and the level of care needed by these victims by assessing airway, breathing, and circulation (ABC's).

Color Tagging

Ideally, the following information should be contained in the patient's color tag:

a. patient's sequence numberb. name of patientc. injuries identifiedd. previous interventions given at the scene

1st priority: Life-threatening - needs to be treated within 1-3 hoursa. obstruction/damage to airwayb. breathing disturbance (RR =30/min or RR <10/min)c. circulation disturbance (HR =100/min or weak pulses)d. altered level of consciousnesse. external bleeding with CVS collapse

RED TAG

Triaging is done if there are more victims than health responders. Reverse triaging is done

during the Search and Rescue stage where the priority is to get as much people out of danger

with the least effort.

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YELLOW TAG

GREEN TAG

BLACK TAG

2nd priority: Urgent - needs to be treated within 4-6 hoursa. major burns: involving hands, feet or face (excluding

respiratory tract); complicated by major soft tissue traumab. spinal injuries; long bone or pelvic fracturesc. environmental injuries (heat/cold exposure)

3rd priority: Requires no treatment or can be delayeda. minor injuries not threatened by ABC instabilityb. minor fractures/soft tissue injuries/burnsc. injuries so severe that survival cannot be expected even

under the most ideal conditions; obviously mortal wounds where death is certain (such as head injuries or massive burns)

Last priority:a. death or moribund state

In emergency situations the most practical means of tagging may only be by color ribbons

or even pentel pens

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Color-Coded Alert Systems

The hospital alert status shall be declared either by the Secretary of Health, the HEMS Director, the Chief of Hospital or the HEMS Coordinator. The alert status shall continue to be in effect until cancelled by the Chief of Hospital or the HEMS Coordinator.

CODE WHITE

Alert Mode is called with any of the following conditions: ! a strong possibility of a military operation (e.g., coup

attempt) ! any planned mass action or demonstration within the area! forecasted typhoons, the path of which may affect the area! national or local elections or plebiscites! national holidays or celebrations (e.g., New Year's Eve,

Holy Week, etc.)! other conditions which may be declared as disasters by

the Chief of Hospital or other appropriate authority

There should be necessary preparations of the necessary equipment and even personnel. Aside from those who are on regular duty for the day, the following should be on-call anytime during his/her duty days: 1. surgeons2. orthopedic surgeons3. anesthesiologists4. internists5. O.R. nurses 6. ophthalmologists

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7. otorhinolaryngologistsnd8. 2 response team should be on call

9. EMS, nursing personnel and administrative personnel residing at the hospital dormitory shall be placed on on-call status for immediate mobilization

Partial/Selective Activation is proclaimed when 20-50 casualties (red tags) are expected. This may require the activation of the hospital network or at the judgment of the director or the HEMS coordinator, may only involve the hospital nearest the emergency site.

The following should respond once CODE BLUE is on:1. on-scene response team2. medical officer in charge of the emergency room 3. ALL orthopedic residents 4. medical officer in charge of the operating room5. surgical team on duty for the day

CODE BLUE

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The composition of the back-up and on-call teams would depend on the type and level of the hospital. The suggestions here are based on a general tertiary hospital. Each hospital can come up with its own team members. In some places like Metro Manila, there can also

be designated support hospitals (usually specialty hospitals). These specialty hospitals act as support to a receiving hospital (e.g., San Lazaro and Fabella Hospital supporting Jose

Reyes Memorial Medical Center).

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6. officer in charge of supplies at the CSR7. surgical team on duty the previous day8. ALL anesthesiology residents9. nursing supervisor on duty10.operating nurses living within or in the vicinity of the hospital 11.ENTIRE security workforce12.ALL third and fourth year residents13.ALL O.R. nurses14.institutional workers on duty

Full Activation is put into effect when more than 50 (red tag) casualties are momentarily anticipated, expected or suddenly brought to the hospital. The situation may require more than one hospital to respond by sending an on-scene team.

The following should respond once Code Red is on: 1. ALL persons enumerated under Code Blue2. ALL institutional workers3. ALL nursing attendants4. ALL nurses5. ALL medical interns and clinical clerks

CODE RED

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If there is a strong possibility that there would be a need to change the alert status from code white to blue to red, the Chief of Hospital is authorized to:1. Cancel all leaves of personnel and for them

to report to the hospital.2. Put back-up teams on standby within the

hospital for rapid deployment.3. Take other steps necessary to respond to

the emergency situation (e.g. cancel elective surgeries, etc.).

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Steps in Ensuring Communicable Disease Control in Emergencies

1. Conduct rapid health assessment (see previous section)2. Provide general prevention measures in coordination with

other sectors, including:! Food security, nutrition and food aid! Water and sanitation! Shelter

3. Provide community health education messages including information on how to prevent common communicable diseases and how to access relevant services! Encourage people to seek early care for fever, cough,

diarrhea, etc., (especially children, pregnant women and older people)

! Promote good hygienic practice! Ensure safe food preparation techniques! Ensure boiling or chlorination of water

4. Implement as indicated, specific prevention measures, such as mass measles vaccination campaign, Expanded Program on Immunization, and vector control.

5. Provide essential clinical services6. Provide basic laboratory facilities7. Set-up surveillance/early warning systems

a. Detect outbreaks earlyb. Report diseases of epidemic potential immediatelyc. Monitor disease trends

8. Control outbreaksa. Preparationb. Detectionc. Confirmation

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d. Investigatione. Control measuresf. Evaluation

Notes on Immunization

! A single suspected measles case is sufficient to prompt an immediate immunization response. Life-saving measles vaccine should be made available immediately targeting all infants and children 6-59 months of age. The suggested target age group may be expanded up to 15 years, if feasible, in areas where there is substantial crowding.

! Each visit to health care facilities should be seen as an opportunity to vaccinate for routine EPI regardless of the reason for the visit. Vaccination program activities should be included as part of basic emergency health care services.

! Mass vaccination against cholera and typhoid fever is not recommended. The most practical and effective strategy to prevent cholera and typhoid is to provide clean water in adequate quantities and adequate sanitation. Sufficient soap and hygiene education will further prevent the transmission of both diseases.

! Mass tetanus vaccination programs are not indicated. However, tetanus boosters may be indicated for previously vaccinated people who sustain open wounds or for other injured people depending on their tetanus immunization history.

! Mass vaccination for Hepatitis A is not recommended.

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Nutrition Preparedness

1. Planning: Every effort should be done to formulate an inter-sectoral and comprehensive plan (i.e., NNC's Nutrition Preparedness in Disasters and Emergencies Plan or NPDEP).

2. Nutritional Management: Is an institutional and multi-sectoral concern. It is equally the responsibility of the national government, local government and even non-government units. Disaster Coordinating Teams implement the NPDEP while involving the Municipal Nutrition Action Officer in the creation of Disaster Response Teams.

3. Adequate Nutrition: During emergencies, infants (<1y/o) and children (<5y/o) are the most vulnerable group. Interrupted breastfeeding and inappropriate complementary feeding will heighten the risk for malnutrition, illness and mortality.

4. Resource Generation and Mobilization: Maintain a stockpile of culturally acceptable food items that can be stored for a long period of time such as rice, canned goods, noodles, dried fish and canned/powdered milk. Intensify campaign on creating vegetable gardens in schools and backyards. Identify and coordinate with donor agencies and companies that can donate food during disasters.

5. Public Education: Promote the acceptability and utilization of donated foods ideal for disasters (i.e. compact food). Support the innovation of nutritionally dense ready-to-eat foods.

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6. Cultural and Indigenous Habits: Customs should be taken into consideration in food management.

7. Gate Keepers: Identification of local/tribal leaders are critical for nutrition education, supplementation, and resettlement feeding.

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! Following a major sudden disaster, some people may have no access to food and/or be unable to prepare food for a few days at least.

! In slow-onset crisis or in situations where the livelihood of the community is greatly undermined, particularly in areas where nutritional status was already poor, it will be important to monitor nutritional status and households' access to food, and to initiate remedial action (e.g. through supplementary feeding) if nutritional status is at risk.

! In extreme cases, nutritional rehabilitation through intensive, supervised therapeutic feeding (TF) may be required.

! Because the number of caregivers is reduced during emergencies and their ability to cope is diminished by physical and mental stress, strengthening caregiving capacity is an essential part of promoting good feeding practices for infants and young children.

! Healthy workers are essential. Aside from looking after the basic health and nutritional needs of the displaced population, health workers have to be debriefed to look after their personal health as well.

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Energy Requirements

For initial planning purposes:! Average daily energy requirement : 2,100 kcal/person/

day ! When the data are available, the planning figure should be

adjusted according to:! Physical activity level add 140 kcal for moderate activity,

350 kcal for heavy activity (e.g., during construction or land preparation works)

! Age/sex distribution when adult males make up more than 50% of the population, requirements are increased; when the population is exclusively women and children, requirements are reduced.

! Special needs of pregnant and lactating women a. Pregnant women? Need an additional 300 kcal/day? If malnourished, need another 500 kcal/day? Should receive iron and folate supplements

b. Lactating women? Need an additional 500 kcal/day? If malnourished, need another 500 kcal/day? Should receive sufficient fluids, taking into account

activity

Other nutritional requirements:! Protein: 10 to 12% of diet (i.e. 52 to 64 g)! Fat/oil: = 17% of diet (i.e. 50 g)! Micronutrients: a range of micronutrients (vitamins and

minerals) are required for survival and good health

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Ideal Foods for Disaster! Carbohydrate sources rice, root crops, bread, noodles ! Protein sources eggs, canned meat and fish, fresh meat and

fish, dried meat and fish, milk! Fat sources cooking oil, margarine! Vitamin and mineral sources fruits and vegetables! Others coffee and other beverages

* see appendix for examples of rations.

Nutritional Assessment

The most widely accepted practice is to assess malnutrition levels in children aged 6-59 months as a proxy for the population as a whole. Reports should always describe the probable causes of malnutrition, and nutritional edema should be reported separately.

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Two-stage cluster sampling is normally used: 30 clusters are selected, then 30 children

within each cluster.

Edema of both feet

Weight-for-Height*

MUAC

Body Mass Index

Mild Malnutrition

No

80-90%

(-1 to -2 SD)

12.5 to 13.5 cm

17 to <18.5

Moderate

Malnutrition

No

70-79%

(<-2 to -3 SD)

12.0 to 12.5 cm

16 to <17

Severe

Malnutrition

Yes

< 70%

(<-3 SD)

<12 cm

<16

Classification of Acute Malnutrition

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Age

6-11 months

1-5 years

Dose

100,000 IU

200,000 IU

*see appendix for length-for-weight/height-for-weight reference values**see appendix for decision framework for implementing feeding programs.

Feeding Recommendations

! Up to 6 months of age: Encourage mothers to exclusively breastfeed as often as the child wants, day and night, at least 8 times in 24 hours. Do not give any other fluid or food.

! 6 months to 12 months: Breastfeed as often as the child wants. In addition, give adequate servings of locally available complementary foods at least 3 times a day.

! 12 months to 2 years: Breastfeed as often as the child wants. Give adequate serving of locally available complementary food at least 5 times a day.

Give vitamin A if a child has severe malnutrition. Give one dose in your presence and give one dose to the mother to give it to

the child at home the next day.

There should be a continual search for malnourished children so that their condition

can be identified and treated before it becomes severe.

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! 2 years and older: Give three meals of family food per day. Also, give nutritious snacks, twice daily.

Notes on Breastfeeding

! Breastfeeding's multiple advantages are especially important during emergencies (i.e., protection from infection and its consequences, contraceptive effect, privileged nurturing moment important for both mother and child). Every effort should be made to identify ways to breastfeed infants whose mothers are absent or incapacitated. Every effort should be made to create and sustain an environment that encourages frequent breastfeeding for children under two years of age.

! A nutritionally adequate breast-milk substitute, fed by cup, should be available for infants who do not have access to breast milk. The use of infant-feeding bottles and artificial teats in emergency settings should be actively discouraged.

! Emergencies do not justify routine distribution of breast-milk substitutes. Formula feeding may increase the considerable risk of child morbidity and mortality.

! The nutritional status of breastfeeding women should be protected as an end in itself, and as a means of maintaining the adequate growth and development of their children.

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Minimum level of necessary services to be provided:1. Adequate shelter for displaced persons! Evacuees should be protected from the elements! Secure against violence! Provide allocations for privacy! Avoid overcrowding.! Floor area per person: 3.5 square meters! Fresh air ventilation per person per hour: 20-30 cubic

meters! Lighting: adequate (minimum is a 5-foot candle)! Ventilation: adequate (combined openings at least 10% of

floor area)2. Sufficient quantities of accessible drinking water 3. Facilities for excreta and liquid waste disposal4. Protection of food supplies against contamination5. Protection of individuals in affected population against vector-

borne diseases through vector control activities and through chemoprophylactic methods.

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Assessment

1. Assess water resources for human consumption to ascertain the availability of water (quantity and quality) in relation to the demand.

2. Estimate the demand, identify possible sources and assess the possibility of developing these resources.

3. Consult local people in the identification of water sources to be developed.

4. Tap the expertise of the local Sanitary Engineer in the assessment of the water resources and the conduct of sanitary survey.

5. Always consider seasonal factors in the assessment.

Organization1. Organize water allocations between the host community and

the evacuees to prevent overstraining water resources.2. Evaluate the technology used in the water supply system to

ensure that continuous and long-term operational needs are within reach of the community and the evacuees.

3. From the start, involve the evacuees in the maintenance and operation.

Provision of adequate amounts of drinking water is of utmost importance after disaster. It should first be made accessible to victims and relief workers and in essential locations, such

as hospitals and treatment centers. After drinking water is secured within stricken areas, making water available for domestic uses (such

as cleaning and washing) should be considered.

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4. Train evacuees without prior experience.5. Combine water control and treatment with improved personal

hygiene and environmental health practices.6. The design and construction of the water supply system must

be closely coordinated with evacuation camp planning and layout as supported by health promotion and sanitation.

7. Consider using pumps and other mechanical equipment attainable in the area where fuel and spare parts are available, and maintenance is not a complicated aspect. Technical breakdown should be quickly repaired.

8. Monitor both the organizational and technical aspects of the complete water supply system.

Immediate Action after a Disaster

1. Estimate water requirements and assess water supply possibilities.

2. Make an inventory of water sources and assess all sources in terms of their quality and yield.

3. Protect water sources from pollution. Provide water in good quantities and reasonable quality.

4. Improve access to supplies by developing water sources and a storage and distribution system to deliver sufficient amounts of safe water, including reserve.

5. Conduct regular sample collection and testing of water quality.

6. If possible, use water sources that do not need treatment. If there is a large number of evacuees, decontamination of water is necessary. Treat water according to the characteristics of the raw water.

7. Set up schedules for operation and maintenance.

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8. Maintain and update information on water resources obtained during needs assessment, planning, construction, operation and maintenance.

Intermediate Response

1. If the minimum amount of water cannot be made available from local sources, recommend transfer to another evacuation camp.

2. If storing the water in tanks is employed, the storage should be tested periodically.

3. Domestic hygiene and environmental health measures should be observed in order to protect the water between collection and use.

Organize a distribution system that prevents pollution of the source and ensures equity if water is insufficient.

Water Need

1. Minimum Demand (per person per day); calculate the following:a. 2 liters for drinkingb. 10 liters for food preparation and cookingc. 15 liters for bathingd. 15 liters for laundrye. 10 liters for sanitation and hygiene

2. Quality: To preserve public health, a large amount of reasonably safe water is preferred over a small amount of purified water.

3. Control: Bacteriological, biological, chemical, physical and

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radiological quality of water must be deemed safe.! There are no fecal coliforms per 100 ml at the point of

delivery.! People drink water from a protected or treated source in

preference to other readily available water sources,! Steps are taken to minimize post-delivery contamination.! No negative health effect is detected due to short-term use

of water contaminated by chemical (including carry-over of treatment chemicals) or radiological sources, and assessment shows no significant probability of such an effect.

4. Other Needs:a. Hospital and Clinics:! Out-Patient: 5 liters per patient per day! In-Patient: 40-60 liters per patient per day

b. Mass Feeding Centers: 20-30 liters per person per dayAnimals! Cow/Carabao: 30 liters per day! Pig: 1.5 liters per day! Goat: 1.5 liters per day! Poultry: 2 liters per day

5. Water Decontamination/Disinfectants:! Water Purifier: 2 tablets per person per day! HTH (high-test hypochlorite) Stock Solution: 1 liter/20

families/5 days! Shock Disinfection: 50-100 parts per million (ppm) of 60-

70% of available chlorine! Environmental Cleaner-Sanitizer

6. Drinking Water Container: one container of 10 liters per family7. Communal Water Storage Tank: 10 liters per person per day.

Volume of tank good for 2 days demand; half full in the

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evening; with free residual chlorine of 0.7 ppm.8. Shallow Well: for toilet flushing and cleaning9. Water Points:! Distance between Water Point and Users: 150 m (max.)! Minimum Number of Water Points: 1 tap per 250 users! Queuing time at a water source is no more than 15

minutes.! It takes no more than three minutes to fill a 20-liter

container.

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Assessment

Excreta Disposal1. What is the current defecation practice (including anal

cleansing)? If it is open defecation, is there a designated area?

2. Is the current defecation practice a threat to water supplies (surface or ground water) or living areas?

3. Are there any existing facilities? If so, are they used, are they sufficient and are they operating successfully? Can they be extended or adapted?

4. What is the ratio of domestic facilities to population?5. What is the maximum one-way walking distance for users?6. Are people prepared to use pit latrines, defecation fields,

trenches, etc.?7. What is the level of the groundwater table?8. Are soil conditions suitable for on-site excreta disposal?9. Do current excreta disposal arrangements encourage

vectors?10. Are there materials or water available for anal cleansing?

How do people normally dispose of these materials?11.How do women manage issues related to menstruation? Are

there appropriate materials available for this?

Drainage1. Is there a drainage problem (e.g. flooding of dwellings or

toilets, vector breeding sites, polluted water contaminating living areas or water supplies)?

2. Is the soil prone to water logging?3. Do people have the means to protect their dwellings and

toilets from local flooding?

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Solid Waste Management 1. Is solid waste a problem?2. How do people dispose of their waste? What type of how

much solid waste is produced?3. Can solid wastes be disposed of on-site, or does it need to be

collected and disposed of off-site?4. Are there health facilities and activities producing waste?

How are wastes being disposed of? Who is responsible?

Immediate Action

1. Localize defecation and prevent contamination of water supply.

2. Collect baseline data of the site and locate zones for sanitary facilities.

3. Develop appropriate systems for the disposal of excreta, refuse and wastewater.

4. Plan the number and location of sanitary facilities and services to be established and provided.

5. Establish sanitation teams for the construction and mainte-nance of facilities.

6. Set up services for vector and vermin control. 7. Set up services for management of dead bodies 8. Establish a monitoring and reporting system.9. Include environmental health as an integral part of health

promotion.

Excreta Facilities1. Communal Trench Latrine: for 50 persons, 1.2 m x 0.3 m x

0.6 m. Use only soil for cover.2. Pit Latrine: 1 seat for 20 persons, 1.2 m x 0.6 m x 0.6 m

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3. Ventilated Improved Pit: 1 seat for 20 persons, 0.8 m x 0.7 m x 3.0 m

4. Pour-Flush Water-Sealed Toilet: 1 seat for 20 persons.5. Others: “Antipolo,” Aqua Privy, Deep Pit Latrine, Reed Odorless

Earth Closet (ROEC), Chemical Toilet: 1 seat for 20 persons.6. Urinals: Urine Soakage, Four-Funnel Urinal7. Children's Feces: should be disposed of immediately and

hygienically8. Distance of Latrines:! From users: 250 m (max.)! From shelters: 30 m (min.)! From any water source: 25 m radial distance

Liquid Waste Facilities

1. Infiltration Trench, Grease Trap and Soakage Pit, Baffle Grease Trap, and Cold Water Grease Trap.

2. Locate not less than 25 meters radial distance from any source of water supply.

3. Protect from vermin harborage and breeding.4. There should be no standing wastewater around water points

or elsewhere in the settlement.5. Drainage: Run-in and run-off water management.6. Shelters, paths, water and sanitation facilities should not be

flooded or eroded by water.

Bottom of any latrine should be at least 1.5 meters above the water table. Drainage or

spillage from defecation systems must not run towards any surface water source or shallow

groundwater source

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Solid Waste Facilities

1. Storage:! 100-liters capacity per 10 families! Distance from users: 15 m (max.)! Bulk storage bin: centralized bin for temporary storage

before collection! No contaminated or dangerous health waste in living or

public spaces2. Collection: organize a camp refuse collection team3. Disposal:! Burial: Communal Open Pit, 1.2 m x 1.2 m x 1.8 m ! Cross Fire Trench Incinerator: for 20 families (2.4 m x 0.3

m x 0.3 m)! Barrel and Trench Incinerator, Bailleul Incinerator, Inclined

Plane Incinerator, Open Corrugated Iron Incinerator, Rock Pit Incinerator, Drying Pan Incinerator and Open Turf Incinerator: for 10 families

! Final disposal does not create health or environmental problems

Health-care Wastes

1. Be aware of the public health and occupational risks from health-care waste

a. Vaccination, notably for Hepatitis B should therefore be provided to waste handlers.b. All waste handlers should wear protective clothing. c. Hand-washing and disinfection are a must.

2. Minimize health-care waste3. Segregate:

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! To be done at point of generation using dedicated, colored and/or marked containers

! Separate wastes into three main categories:i. infectious sharps (collect sharps in puncture proof

containers with a lid that can be closed, mark with biohazard symbol)

ii. non-sharp infectious wastesiii. non-infectious wastes

! If no separation of wastes takes place, the whole mixed volume of health care waste needs to be considered as being infectious.

1. Dispose properly. Wastes to be buried and should not be incinerated:

a. used infectious plastic syringes and needlesb. other infectious PVC plastics such as tubing, catheters, IV setsc. anatomical wastes

All these should be buried in a sharps waste burial pit.

Dig a pit 1 to 2 meters wide and 2 to 5 meters deep. Line the bottom of the pit with clay or low permeable material. Construct an earth mound around the mouth to prevent to prevent water

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Non-infectious waste 80%

Pathological waste and infectious waste 15%

Sharps waste 1%

Chemical or pharmaceutical waste 3%

Pressurized cylinders, broken Less than 1% thermometers…

Approximate percentage of waste types per total waste in PHC centers

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from entering. Construct a fence around to prevent unauthorized entry. Alternately place layers of waste and 10 cm of lime and soil inside. When the pit is within about 50 cm of the ground surface, cover the waste with soil and permanently seal it with cement or embedded wire mesh.

Another method involves placing the sharps waste in hard containers such as metal drums and adding an immobilizing material such as bituminous sand, clay or cement mortar. The container or drum can be sealed and buried in a trench or transported to a local landfill.

(For other strategies, please see WHO (2004). Management of solid health-care waste at primary health-care centres: A decision-making guide. Geneva: World Health Organization.)

Security fence

50cm of soil cover

Cement orembeddedwire mesh

Earth mound to prevent surface

water from flowing into the pit

2 to 5m

1 to 2m

Soil or soil-lime layer

Bio-medical waste

Bottom clay layer

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Assessment

1. What are the vector-borne disease risks and how serious are these risks?

2. If vector-borne disease risks are high, do people at risk have access to individual protection?

3. Is it possible to make changes to the local environment (by drainage, excreta disposal, refuse disposal, etc.) to discour-age vector breeding?

4. Is it necessary to control vectors by chemical means? 5. What information and safety precautions need to be provided

to households?

Preventive Measures

a. Conduct vermin population density survey.b. Vulnerable populations are settled outside of the malar-

ial/dengue zone. In areas of known malaria risk: ! spraying of shelters with residual insecticide and/or

retreatment/distribution of insecticide-treated mosquito nets in areas where their use is well-known.

In areas endemic of dengue: ! water storage containers should be covered to prevent

them from becoming mosquito-breeding sites. Attempts should be made to eliminate pooled water which may be gathering amongst the debris.

c. Vector breeding or resting sites modified.d. Screening of living quarters.e. Rats, flies and other mechanical nuisance pests kept within

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acceptable levels.f. Intensive fly control is carried out in high-density settlements

when there is risk or presence of diarrhea outbreak.g. Removal of breeding and harborage places of vectors and

maintenance of sanitation. Garbage must be collected and appropriately disposed to discourage rodent vector breeding.

h. Larvi-trapping

Chemical Control

a. 1 sprayer for every 50 familiesb. 1 misting machine for every 50 familiesc. 1 fogging machine for every 500 familiesd. Fumigation for the camp, if needed (with proper precautions);

done under the supervision of an emergency Sanitary Engineer

e. Adulticides: for crawling and flying insectsf. Rodenticide: for rats and mice (under some conditions)g. Larviciding: introduction of local bioremediation microbes

Estimation of Vector Population

Mosquitoes: 1. Select several shelters in the camp.2. In the shelter, close all openings, windows, holes, etc.3. Spread a white sheet on the floor of the rooms.4. Spray the insecticide and wait 20 minutes until the insecticide

has killed the mosquitoes.5. Count the number of killed adult mosquitoes and record.6. The following can be determined:

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! The number of killed adult mosquitoes divided by the number of inspected shelters will give the average mosquito density per shelter.

! The number of killed adult mosquitoes divided by the number of persons occupying each shelter will give the average number of mosquitoes per person.

! The number of mosquitoes found with blood in the abdomen (red or black) divided by the number of person living in the shelter will give the average number of bites per person.

7. Send the collected mosquitoes to a laboratory for identifica-tion.

Flies:1. Count the average number of flies that land on a grill placed

where flies congregate during three 30-second periods.

(from: Lacarin, CJ and Reed RA (1999) Emergency Vector Control Using Chemicals, Water, Engineering and Development Center (WEDC), Loughborough.)

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Epidemiologic Methods of Emergency Management

Objectives:! Assess the urgent needs of human populations! Match available resources to needs! Prevent further adverse health effects! Monitor and evaluate program effectiveness! Improve contingency planning! Optimize each component of emergency management

Application:! Hazard mapping! Analysis of vulnerability! Assessment of the flexibility of the existing local system for

emergency! Assessment of needs and damages! Monitoring health problems! Implementation of disease-control strategies! Assessment of the use and distribution of health services! Etiological research on the cause of mortality and morbidity! Follow-up long-term impacts of health, etc.

Steps in Developing a Surveillance System After a Disaster

1. Establish objectives! Detect epidemics ! Monitor changes in the population? Numbers

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? Health status including nutritional conditions? Security? Access to food? Access to water? Shelter and sanitation? Access to health services

! Facilitate the management of relief

2. Develop Case Definitions (Request NEC)! Standard case definitions of health conditions simplify

reporting and analysis

3. Choose the Indicators! Indicators must:? Illustrate the status of the population ? (e.g., death rates)? Measure the effectiveness of relief ? (e.g., immunization coverage)

4. Determine Data Sources! Data can come from health-care facilities (“passive

surveillance”) and from surveys in the community (“active surveillance”)

! Involve those who provide health care! Health surveillance in an emergency requires input from

all sectors

“Case definitions” and “Indicators” need to be agreed upon by all those involved in the relief

operations.

53

5. Develop Data Collection Tools and Flows! Use pre-existing local formats and/or international

standards! Use formats that facilitate data entry (EpiInfo):! Utilize existing process flows

6. Field-Test and Conduct Training! Can these data produce the information required?! Training field workers will improve data facility and local

analysis

7. Develop and Test the Strategy of Data Analysis! Data analysis should cover:? Hazards and impact on the population's health? Quality and quantity of services provided? Impact of services on population's health? Relation between services provided to different groups

(evacuees and hosts)? Deployment and utilization of resources

! Major operations may require a central epidemiological unit

8: Develop Mechanisms for Disseminating Information (Risk Communication)! Who will receive the information?! For the information to be useful, it must be disseminated

widely and in a timely fashion:? Feedback will sustain data collection and the

performance of field workers? Health information is important for the activities of other

sectors

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! Sharing information is good coordination

9: Monitor and Assess Usefulness of the System! Is everybody reporting on time? Which data are missing?! Lack of information in areas or programs that have

problems! Is the system useful?! Is the information generated by the system being used for

decision making?! If not, readjust the system

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Steps in Promoting Psychosocial and Mental Health

1. Assess psychosocial and mental health concerns. Schedule consultative meetings with the provincial and municipal health workers in the affected area to:! Estimate the psychosocial problems experienced by the

people, guided by the classification of people at high risk ! Estimate available resources for mental health/social

services

* see appendix for Summary Table on Projecting Mental Health Assistance

2. Brief field officers in the areas of health and social welfare regarding issues of fear, grief, disorientation and need for active participation. Mobilize informal human resources in the community (e.g., Red Cross volunteers, religious and political leaders).

3. Conduct mostly social interventions that do not interfere with acute needs such as the organization of food, shelter, clothing, PHC services, and, if applicable, the control of communicable diseases.

The impact of a traumatic event is likely to be greatest in persons who had a pre-existing

mental health problem, a history of prior trauma, greater exposure to the disaster and its aftermath, and those who lack family and peer

support.

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4.Establish contact with PHC. ! Develop the availability of mental health care for a broad

range of problems through general health care and community-based mental health services.

! Manage urgent psychiatric complaints (i.e., dangerous-ness to self or others, psychoses, severe depression, mania, epilepsy) within PHC.

! Ensure availability of essential psychotropic medications at the PHC level. Many persons with urgent psychiatric complaints will have pre-existing psychiatric disorders and sudden discontinuation of medication needs to be avoided.

5. Start planning medium- and long-term development of community-based mental health services and social interventions needed during recovery and rehabilitation. This is vital since it is during this phase that survivors will be rebuilding their lives amidst the grief from the loss of loved ones, property, and livelihood.

6. If the acute phase is protracted, start training and supervising PHC workers and community workers (e.g., provision of appropriate psychotropic medication, 'psychological first aid', supportive counselling, working with families, suicide prevention, management of medically unexplained somatic complaints, substance use issues and referral).

As far as possible, manage acute distress without medication. It is also not advisable to

organize single session psychological debriefing to the general population as an early interven-

tion after exposure to trauma.

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7. Educate other humanitarian aid workers as well as community leaders (e.g., village heads, teachers, etc.) in core psychological care skills (e.g., 'psychological first aid', emotional support, providing information, sympathetic reassurance, recognition of core mental health problems) to raise awareness and commu-nity support and to refer persons to PHC when necessary.

8. Carefully educate the public on the difference between psychopathology and normal psychological distress, avoiding suggestions of wide-scale presence of psychopathology and avoiding jargon and idioms that carry stigma.

9. Facilitate creation of community-based self-help support groups. The focus of such self-help groups is typically problem sharing, brainstorming for solutions or more effective ways of coping (including traditional ways), generation of mutual emotional support and sometimes generation of community level initiatives.

10.Provide support to caregivers who, because of the exhaustion and enormity of the job, may experience "burn-out."

Interventions for Children Affected by Emergencies

1. Encourage parents, teachers, and other caregivers to understand and monitor child emotional reactions. Remember that children's reactions vary with age.

2. Help reduce effects by offering emotional support and security to the child.

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3. Facilitate recovery by modelling healthy coping strategies.

* See “Mental health and psychosocial care of children in disasters” (WHO, 2005) for further guidance.

Valuable social interventions include:

! Ensuring ongoing access to credible information on the emergency, on the availability of assistance, and on the location of relatives to enhance family reunion

! Establishing access to communication with absent relatives, if feasible

! Organizing family tracing for unaccompanied minors, the elderly and other vulnerable groups.

! Giving 'psychological first aid':? basic, non-intrusive pragmatic care with a focus on

listening but not forcing talk? assessing needs and ensuring basic physical needs are

met? providing or mobilizing company (preferably family or

significant others)? encouraging but not forcing social support? protecting from further harm

! Widely disseminating uncomplicated, empathic information on normal stress reactions and culturally appropriate relaxation techniques to the community at large

! Public education should focus primarily on normal reactions, because widespread suggestion of physical and mental disease may potentially lead to unintentional harm.

! The information should emphasize an expectation of hope, resilience and natural recovery.

! Promote community self-help activities- conceived and

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managed by communities themselves.! Discouraging unceremonious disposal of corpses. Facilitate

conditions for maintaining or re-establishing appropriate cultural practices, including grieving and burial rituals by relevant practitioners.

! Assuming the activity is safe:1. Encouraging activities that facilitate the inclusion of the

bereaved, orphans, widows, widowers, or those without their families into social networks

2. Encouraging the organization of normal recreational activities for children and encouraging starting schooling for children, even partially

3. Involving adults and adolescents in concrete, purposeful, common interest activities (e.g., assist in caring for the ill especially if people are cared for at home, construct-ing/organizing shelter)

! Strengthening the community's and the family's ability to take care of children and other vulnerable persons.

Specific Concerns for Victims of Attacks Involving Biochemical Weapons

Attacks involving biochemical weapons may induce significant mental and social effects.1. Exposure to any stressor is a risk factor for a range of long-

term social and mental problems (including anxiety and mood disorders as well as non-pathological trauma and grief reactions)

2. Physical exposure to agents may induce organic mental disorders

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3. Attacks are associated with experience of intense social and psychological distress, especially fear

4. Fear of biochemical attacks may be associated with epidemics of medically unexplained illness

5. Social problems may emerge after exposure to agents (e.g., population displacement; breakdown of community support systems; and social stigma associated with contagion or contamination)

! In case of quarantine or evacuation, enhance access to communication with absent relatives and friends.

! If appropriate and feasible, set-up telephone support systems to reduce isolation of people who are isolating themselves to reduce the chance of infection.

! Manage medically unexplained symptoms immediately to prevent potential chronicity of such symptoms.

! Public education campaigns may need to be organized to reduce social stigma and related social isolation of ex-patients and health workers who may be shunned because of undue public fear of contagion or contamination.

Psychosocial Concerns for Disaster Workers

Burnout or Disaster Fatigue:! state of extreme exhaustion or depletion, physically,

emotionally, mentally and socially! person feels worn-out and depleted of energy but feels that

he/she has not done enough

Signs of Burnout:! Low energy and exhaustion

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! Detachment and separation from one's self; increasing feeling of “non-feeling,” “deadness,” indifference and even skepticism

! Aloneness, feeling unappreciated and mistreated! Impatience, heightened irritability! Increasing anger, suspiciousness! Confusion, agitation, limiting ability to focus mind and

behavior! Depression, psychosomatic complaints! Denial that anything is wrong; “I don't care”

Management of Burnout! Rotation of work assignments to allow time away from the

daily routine of disaster work for those in the field ! Rest and recreation program for those in active duty! CISD sessions should be done regularly for those in the field! Superiors and the agency itself should provide for situations

to give credit, express appreciation and recognition of their disaster workers at regular intervals

! Provision of appropriate assistance for those who might require counseling and/or specialist psychiatric attention

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Historical research on group behavior has shown that contrary to common expectations,

public panic is uncommon. Disasters may leave some communities with increased social coherence. Community members often show great altruism and cooperation, and people

may experience great satisfaction from helping each other.

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Health Considerations in Cases of Mass Fatalities

Emphasize that, in general, the presence of exposed corpses poses no threat of epidemics. The corpse has a lower risk for contagion than an infected living person. The key to preventing disease is to improve sanitary conditions and to educate the public.If death resulted from trauma, bodies are quite unlikely to cause outbreaks of diseases. They may, however, transmit gastroenteritis or food poisoning syndrome to survivors if they contaminate streams, wells, or other water sources. Thus, any bodies (or dead animals) lying in water sources should be removed as soon as possible.

!

!

!

! The National Disaster Plan/Emergency Operations Committee should specify the institution that will coordinate all processes related to the management of dead bodies.

! The health sector should take the leading role in:1. Addressing concerns about the

supposed epidemiological risks posed by dead bodies

2. Providing medical assistance to family members of the victims.

! The work of handling, identifying, and disposing of dead bodies is based on forensic sciences and requires a multidisciplinary team. However, in the absence of medico-legal experts, the health officer may need to carry out these tasks to the best of his or her abilities.

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!

!

The risk posed by bodies buried by a landslide or mudslide is nonexistent.It should be noted that in areas where certain diseases are endemic, the disposal of bodies may become a priority. However, even in such cases the presence of dead bodies should not be considered an important public health risk.

Principal diseases that should be avoided by those responsible for managing corpses in order to prevent possible contagion:

1. streptococcal infection2. gastrointestinal infection (e.g., cholera, salmonellosis)3. Hepatitis B and C4. HIV

64

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Practical Approach to a Multiple Fatality Incident

1. Initial Concerns! Type of incident (natural hazards, e.g., flood, landslide,

earthquake, epidemics; human-generated, e.g., fire, land/sea/air transport crash, accidental or deliberate use of biochemical/radionuclear agents)

! Probable condition of remains (e.g. burnt, with severe trauma, decomposed, contaminated)

! Estimated number of fatalities! Location of incident! Local authority in-charge! Budget

2. Personnel ! Tap medico-legal officers from the NBI or PNP and local

government doctors.! Mobilize volunteers like medical and dental students or

specialists from the area.

Ideally a list of the people involved and their contact numbers should have been prepared beforehand.

3. Handling of the Bodies at the Scene! As much as possible document the location and position

of each body at the scene prior to removal.! Mark bodies/body parts to preserve their relationship to

one another.! Sketch and photograph for documentation.

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! Every effort must be taken to identify the bodies at the site where they are found. Tags should be attached to the bodies that provide the name (if known), approximate age, sex, and location of the body.

4. Evidence and Property! All items of property that are on the body should remain on it.! Other items associated with a body should be collected as

property and tagged with the body.! The location of loose items (e.g., proximity to which body)

should be documented prior to collection.

5. Removal and Transport of Remains! Before removing any body, body part or property, there

should be adequate documentation.! Care must be taken not to lose, contaminate or switch

such body, body parts or property to be removed and transported.

! Properly labeled separate bags must be used.! Be particularly careful of potential loss of teeth if they are

loose (e.g., badly burned or crushed remains); put a bag around the head.

! When adapting vehicles to transport dead bodies, it is advisable to use trucks or vans, preferably closed, with floors that are either waterproof or covered with plastic

! Using health service vehicles—specifically, ambu-lances—to transfer human remains from the site of the disaster is ill-advised.

Before anything else, observe and record first.

66

6. Temporary Mortuary Facility! Identify a place that can be converted into a makeshift

morgue (e.g., empty warehouse, covered basketball court).

! Basic requirements:? Security? Adequate lighting, ventilation, water supply? Examining tables? Instruments for examining the remains and documenta-

tion! Ideally, should consist of a reception, a viewing room, a

storage chamber for bodies not suitable for viewing and a room to store personal possessions and records.

7. Examination of Remains! Objectives of the postmortem examination:? Identification of the remains? Cause of death determination? Manner of death determination? Collection of forensic evidence

! In emergency situations, usually the critical need is to identify the victims.

! Identification through visual identification by the next-of-kin should be limited to bodies that are suitable for viewing (i.e., not decomposed, burnt or mangled) and should be subject to verification by other means.

! A more reliable system of identification entails an objective comparison of antemortem and postmortem information.

! Because of limited resources, not all bodies can undergo a full autopsy; priority may be given to certain remains (such


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as those of transport operators driver, pilot/ship captain and crew).

! A detailed examination of the external body is done; marks such as tattoos, scars, moles and deformities are searched.

! Fingerprints are obtained and dental charting is done.! Blood and other tissue/fluid samples are collected for

possible tests (e.g., histopathology, DNA analysis, toxicology).

! Property collected from each body (e.g., clothes, jewelry, wallets, IDs) must be described and inventoried.

8. Preservation of the Body! Remains are best stored refrigerated (e.g., in rented

refrigerated storage trucks) while awaiting examination.! After the postmortem examination, embalming can be

done.

9. Dealing with Claimants! Notify family members of the death or disappearance of

victims in a clear, orderly, and individualized manner.! Organize a separate area where the next-of-kin can be

systematically interviewed for data.! Useful antemortem information to get:

Name, age, sex, height, buildAppearance when last seenDistinguishing features (tattoos, scars, moles, deformities, etc.)Significant medical history

! Ask the next-of-kin to submit the following:Medical records including x-ray films


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Dental recordsClear photograph with teeth baredFingerprints on file

! Note that personal items that a person believed to be among the victims could have used (e.g., toothbrush, hairbrush, other items), could potentially contain reference fingerprints or DNA samples.

10.Death Certification and Release of Bodies! Properly identified victims shall be issued death certifi-

cates and the bodies released to the next-of-kin.! Maintain a record of how the bodies are disposed of

including information regarding the claimants' names, addresses and contact numbers.

! Bodies could remain unidentified in case of insufficient antemortem and postmortem data; these remains should be buried separately (not cremated!) and their postmortem records stored for future evaluation.

! Court proceedings could be initiated according to Philippine laws that would legally declare dead the unidentified and missing victims.

11.Disposal of Dead! Respond to the wishes of the family and provide all

possible assistance in final disposition of the body.! Burial is the preferred method of body disposal in

emergency situations unless there are cultural and religious observances that prohibit it. ? The location of graveyards should be agreed upon by

the community and attention should be given to ground conditions, proximity to groundwater drinking sources


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(which should be at least 50 m) and to the nearest habitat (500 m).

? Burial depth should be at least 1.5 m above the groundwater table, with at least 1 m of soil cover.

? If coffins are not available, corpses should be wrapped in plastic sheets to keep the remains separate from the soil.

? Burials in common graves and mass cremations are rarely warranted and should be avoided.

! Reject unceremonious and mass disposal of unidentified corpses. As a last resort, unidentified bodies should be placed in individual niches or trenches, which is a basic human right of the surviving family members.

12.Other concernsEnsure that there is a plan for the psychological and

physical care for the relief workers. Handling a large number of corpses can have an enormous impact on the health of the working team.

Give priority to the living over the dead: The priority is to treat survivors and re-establish the

health care system as soon as possible!


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The arrival of inappropriate relief donations can cause major logistic chaos.

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Supply Management General Guidelines:

! Only a single government official should be made responsi-ble for channeling requests to avoid duplication and confusion.

! Donors should be asked to provide large amounts of a few items to simplify and expedite transfers.

! Requests should indicate clearly the order of priority, amounts, and formulations (compatible with the size of the affected population).

! Do not request perishable products and vaccines unless refrigeration and special handling facilities are available.

Guidelines for Drug Donations

! Based on expressed needs of the affected population.! Sent only with prior consent of recipient.! Based on the list of essential drugs.! Obtained from a quality source with quality standards.! Formulation and efficacy of foreign donations should be

similar to those commonly used in the country.! Label should at least contain generic name, dosage forms,

strength, quantity in container, and expiry date.! After the arrival of foreign drug donations, the medicines must

have a remaining shelf life of at least 1 year.

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Donation Labeling and Donation Marking

— foodstuff

— clothing and household items

— medical supplies/equipment

1. Labeling:! Consignments of medicines branded green should

indicate expiry date and temperature controls.! English should be used on all labels.

2. Size and weight! Goods should be in a 25-50 kg container, manageable by

a single person.

3. Contents! Relief supplies must be packed by type in separate

containers.! Value of relief goods is lost if there is no color-coding.! Give advance notice to the health relief coordinator and

supply information about the package (e.g., name and contact number of donor, date, method of transport, details of contents, and other special requirements for handling).

RED

BLUE

GREEN

Upon arrival of the donations/ consignments, acknowledge their receipt. Call or write the

senders and thank them.

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Communication Objectives:

! Acknowledge the event with empathy.! Establish spokesperson credibility! Explain and inform the public, in simplest terms, about the

risk! Provide emergency courses of action (including how/where

to get more information)! Commit to partners and public to continued

communication.! Listen to feedback and correct misinformation.! Empower risk/benefit decision-making.

Steps in Communicating Risks

1. Verify situation! Get the facts.! Obtain information from additional sources to put the

event in perspective.! Review and critically judge all information. Determine

credibility.! Clarify information through subject matter experts.! Begin to identify staffing and resource needs to meet the

expected media and public interest.! Determine who should be notified of this potential

emergency.

2. Conduct notifications

3. Activate Crisis Plan! Ensure direct and frequent contact with the EOC

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! Determine what your organization is doing in response to the event.

! Determine what other agencies/organizations are doing.! Determine who is being affected by this crisis. What are

their perceptions? What do they want and need to know?

! Determine what the public should be doing.! Determine what's being said about the event. Is the

information accurate?

4. Organize assignments! Identify the spokesperson for this event.! Determine if subject matter experts are needed as

additional spokespersons.! Determine if the organization should continue to be a

source of information to the media about this emergency, or would some issues be more appropriately addressed by other government entities?

5. Prepare information and obtain approvals

6. Release information to media, public and partners through arranged channels! Provide only information that has been approved by the

appropriate managers. Don't speculate! Repeat the facts about the event! Describe the data collection and investigation process! Describe what your organization is doing about the

emergency.! Describe what other organizations are doing.! Explain what the public should be doing

74

! Describe how to obtain more information about the situation

7. Obtain feedback and conduct communication evaluation

8. Conduct public education

9. Monitor events

(Adapted from CDC (2002). Crisis and Emergency Risk Communication.)

Media Management

What makes a “good” spokesperson?! Media savvy/rapport! Versatility to be a statesman or a brawler! Consistent and continuous authority! Sufficient knowledge and information! Available anytime (24 hours/day, 7 days/week)

Stick to facts, and put them in context! There is no such thing as 'off-the-record'.

Everything you say and do can be reported. Be careful with what you say in the presence of journalists, even after a formal interview is finished and at social gatherings

! Never make disparaging or critical remarks about local authorities or international partners

! Do not mention weaknesses they might be all that is reported

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75

Spokespersons must be supported with

the following:! Information and facts! Resources and contacts! Equally competent alternate

What do the people want to know?! What has happened? (Incident and Scope)! Why did it happen? (Cause)! Who or what should be held responsible? (Blame)! What is being done about it? (Action)! What will prevent it from recurring? (Result)

Press Releases:! Titles and opening lines are the most important parts grab

attention and encourage awareness! Put key points in first paragraph! Text needs to be brief (max. A4)! Use language appropriate for the audience! Advocate for health in general! Share credit and visibility with partners

by authority

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APPENDICES


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This list contains basic supplies, materials, equipment needed in the field.

YES NO1. Did you receive your orders?2. Is/are the mission objective/s clear? 3. Did you inform your family?4. Do you have with you

a. Mission order? b. Identification card? c. Emergency call number directory?d. Mission area map?e. List of contact persons/numbers?f. Communication equipment?g. Cell phone? Mobile phone? h. Handheld radio & accessories?i. Pocket notebook & ball pen? j. Laptop computer?k. Transistor radio (with extra batteries)?l. Basic PPE (cap, mask, gloves)?m. Cash & reimbursement vouchers?n. Water canteen?o. Food provisions?p. First aid kit?q. Backpack with clothing & blanket?r. Flashlight/candles & matches?s. Portable tent (if available)?t. Mosquito repellent?u. Pocket knife?v. Digital camera?w. Pocket Emergency Tool?

78


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RAPID HEALTH ASSESSMENT(To be submitted within 24 hrs)

as of ____________________.

Nature of Event: ___________________________________________Date and Time of Occurrence: ________________________________Region: __________________________________________________

A. Magnitude of Event

B. Consequences

No. of Families &

No. of No. of No. of IndividualsMunicipality Families Individuals Evacuation in Evac'n

Province /City Affected Affected Centers Centers

TOTAL

Municipality /City No. of Death/s No. of Injured No. of Missing

TOTAL

79

C. Health Facilities Available in Affected Area

D. Lifelines Available in Affected Area

E. Status of Essential Drugs/Suppliers

Stock level good for ________________________________ (no. of cases/no. of days/weeks/month)

F. Actions Taken

\

G. Problems Encountered

Total No. No. of Functional No. of Non Functional RemarksHospitalsGov'tPrivateRHUOthers

Type Yes No RemarksCommunicationsElectric PowerWaterRoads/BridgesOthers

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80

H. Recommendations

Prepared by: ___________________Position: ______________________Office: ________________________Date: _________________________

HEMS FORM II

RAPID HEALTH ASSESSMENTFOR MASS CASUALTY INCIDENT

(To be submitted within 24 hrs)

A. Description of the Event

Nature of the Event: ________________________________Time of the Event: _________________________________Date of the Event: _________________________________Place of the Event: _________________________________

B. Number of persons affected

Death: __________________________________________Injured: __________________________________________

Treated on site: _________________________________Referred to hospital: _____________________________OPD: _________________________________________Admitted: ______________________________________

Missing: __________________________________________Total: ___________________________________________


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C. Actions Taken

D. Problems Encountered

E. Recommendations


* Please fill up Form A for the listing of cases.HEMS FORM III

RAPID HEALTH ASSESSMENTFOR OUTBREAKS

A. Description of the Event

Nature of the Event: _______________________________Time of the Event: _________________________________

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82

Date of the Event: _________________________________Place of the Event: ________________________________

B. Consequences

Population Exposed: _______________________________Number of Death/s: ________________________________Number of Cases: _________________________________

Admitted: _____________________________________OPD: _________________________________________

C. Actions Taken

D. Problems Encountered

E. Recommendations


* Please fill up Form A for the listing of cases.


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Nam

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(Injured, Died, M

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Estimating Population Size

Basic Needs


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Age Groups Average % in Population 0 — 4 years 12.45 — 9 years 11.710 — 14 years 10.515 — 19 years 9.520 — 59 years 48.6*Pregnant women 2.4

WaterQuantityQuality

SanitationLatrine

Waste disposal

SoapShelter

Individual requirementsCollective requirements

Household fuelWeight of firewood

20 L/person/day200 persons/water pointIn hospital settings more water per person is needed

Ideally one per family; minimum of one seat per 20 persons 6 to 50 meters from housing1 communal pit per 500 persons; size: 2 m x 5 m x 2 m250 g/per person/per month

24m /person

230m /personincluding shelter, sanitation, services, community activities, warehousing access

15 kg/household/daywith one economic stove per family, the needs may be reduced to 5 kg/stove/day

Average Requirements

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Emergency Food Requirements

Recommended ration person/day: 2,116 kcalTotal kg/person/month for alimentation: 16.4 kg

Examples of Rations for General Food Distribution(Providing 2100 kcal/person/day)

Micronutrients (e.g., iodine, Vit. A) are important.

Food kcal content g/person/month

Cereals 350/100 g 13.5Pulses 335/100 g 1.5Oil (vegetable) 885/100 g 0.8Sugar 400/100 g 0.6

- As available -

Continued on next page

Commodities

Meal with ricePulses

(i.e. peas, beans, mongo)

Oil/fat

Fortified cereal

Canned fish/meat

Sugar

Salt

Vegetables/fruits

Ration 1

(g)45050

25

-

-

20

5

Ration 2

(g)42060

30

-

30

20

5

Ration 3

(g)40060

25

50

-

15

5

Function

Main source of energy and proteinProvide protein and various micronutrients

Concentrated source of energy for palatability and the absorption of Vit. AProvides essential vitamins and minerals, and is useful as weaning foodNeeded for proteins and minerals (including iron)Needed for cultural habits, palatability, and home oral rehydrationProvides sodium, and is needed for home oral rehydrationValuable source of vitamins and minerals

86

Condiments/spicesApproximate food

value:Energy (kcalProtein (gFat (g)

21165141

20924538

21135843

Needed because of cultural habits and for palatability

Examples of rations continued

- As available -

Essential Primary Health Care (PHC) Activities

Essential PHC Activities

Vaccination

<5y/o clinic & growth monitoring

Antenatal clinicAssisted deliveriesOPD Consultation

Treatment & follow-up sessions

Tetanus toxoid

BCGDTP1-TT1DTP2-TT2Measles

Target

all children of 0-59 months

all pregnanciesall deliveries

1.5 per pregnancy

all new births0-1 yr0-1 yr9-12 months

Optimal Coverage of Target

100% of <5y/o per month

50% of pregnancies/month1/12 of total group per month1.5 per person/yr0.13 per person/month4 per outpatient consultation

30% per month

1/12 of total group per month1/12 of total group per month1/12 of total group per month1/12 of total group per month


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Hospital:Population ratio 1:150,000 to 300,000

Normal staffing:2 medical officers 1:500 or 1:100060-100 other staff CHWs

(or home visitors) or 1 person/day = 7 hoursHealth Information Teams of field work

Health Personnel Requirements

Health Workers Emergency requirements (e.g. refugee camp) for treatments, management and clerical duties: 60 staff x 10,000 population

Health Supplies Requirements

Essential drugs and medical equipment

Safe water

WHO Basic NEHK UnitWHO Supplementary NEHK Unit

Preparing 1 L of stock solution 1%

Using the stock solution

1 kit for 10,000 pop for 3 mos.1 kit for 10,000 pop for 3 mos.

calcium hypochlorite 70%: 15 g/L of waterbleaching powder 30%: 33 g/L of watersodium hypochlorite 5%: 250 ml/L of watersodium hypochlorite 10: 110 ml/L of water0.6 ml or 3 drops/liter of water60 ml/100 liters of water

Allow the chlorinated water to stand at least 30 minutes before using.


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Health Status

Daily Crude Mortality RateDaily Under-5 Mortality RateAcute Malnutrition (W/H or MUAC) in

Under-5Growth Faltering Rate in Under-5Low Weight at Birth (<2.5 kg)

More than

1 per 10,000 population2 per 10,000 children <5 y/o10% of children <5 y/o

30% of monitored children7% of live births

Cut-off Values for Emergency Warning


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NCHS/WHO normalized reference values for weight-for-length (49-84) and weight-for-height (85-110 cm) by sex.


Length Boys' weight (Kg) (cm) Median -1 SD -2 SD -3 SD -4 SD

90% 80% 70% 60%49 3.1 2.8 2.5 2.1 1.850 3.3 2.9 2.5 2.2 1.851 3.5 3.1 2.6 2.2 1.852 3.7 3.2 2.8 2.3 1.953 3.9 3.4 2.9 2.4 1.954 4.1 3.6 3.1 2.6 255 4.3 3.8 3.3 2.7 2.256 4.6 4 3.5 2.9 2.357 4.8 4.3 3.7 3.1 2.558 5.1 4.5 3.9 3.3 2.759 5.4 4.8 4.1 3.5 2.960 5.7 5 4.4 3.7 3.161 5.9 5.3 4.6 4 3.362 6.2 5.6 4.9 4.2 3.563 6.5 5.8 5.2 4.5 3.864 6.8 6.1 5.4 4.7 465 7.1 6.4 5.7 5 4.366 7.4 6.7 6 5.3 4.567 7.7 7 6.2 5.5 4.868 8 7.3 6.5 5.8 5.169 8.3 7.5 6.7 6 5.370 8.5 7.8 7 6.3 5.571 8.8 8.1 7.3 6.5 5.872 9.1 8.3 7.5 6.8 673 9.3 8.6 7.8 7 6.274 9.6 8.8 8 7.2 6.475 9.8 9 8.2 7.4 6.676 10 9.2 8.4 7.6 6.877 10.3 9.4 8.6 7.8 778 10.5 9.7 8.8 8 7.179 10.7 9.9 9 8.2 7.380 10.9 10.1 9.2 8.3 7.581 11.1 10.2 9.4 8.5 7.682 11.3 10.4 9.6 8.7 7.883 11.5 10.6 9.7 8.8 7.884 11.7 10.8 9.9 8.9 7.9

Boys


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Boys continued

Length Boys' weight (Kg) (cm) Median -1 SD -2 SD -3 SD -4 SD

90% 80% 70% 60%85 12.1 11 9.9 9 7.986 12.3 11.2 10.1 9 8.187 12.6 11.5 10.3 9.2 8.188 12.8 11.7 10/5 9.4 8.389 13 11.9 10.7 9.6 8.490 13.3 12.1 10.9 9.8 8.691 13.5 12.3 11.1 9.9 8.892 13.7 12.5 11.3 10.1 8.993 14 12.8 11.5 10.3 9.194 14.2 13 11.7 10.5 9,295 14.5 13.2 11.9 10.7 9,496 15.7 13.4 12.1 10.9 9.697 15 13.7 12.4 11 9.798 15.2 13.9 12.6 11.2 9.999 15.5 14.1 12.8 11.4 10.1100 15.7 14.4 13 11.6 10.3101 16 14.6 13.2 11.8 10.4102 16.3 14.9 13.4 12 10.6103 16.6 15.1 13.7 12.2 10.8104 16.9 15.4 13.9 12.4 11105 17.1 15.6 14.2 12.7 11.2106 17.4 15.9 14.4 12.9 11.4107 17.7 16.2 14.7 13.1 11.6108 18 16.5 14.9 13.4 11.8109 18.3 16.8 15.2 13.6 12110 18.7 17.1 15.4 13.8 12.2

Length Girls' weight (Kg) (cm) Median -1 SD -2 SD -3 SD -4 SD

90% 80% 70% 60%49 3.3 2.9 2.6 2.2 1.850 3.4 3 2.6 2.3 1.951 3.5 3.1 2.7 2.3 1.952 3.7 3.3 2.8 2.4 253 3.9 3.4 3 2.5 2.154 4.1 3.6 3.1 2.7 2.2

Girls



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90% 80% 70% 60%55 4.3 3.8 3.3 2.8 2.356 4.5 4 3.5 3 2.457 4.8 4.2 3.7 3.1 2.658 5 4.4 3.9 3.3 2.759 5.3 4.7 4.1 3.5 2.960 5.5 4.9 4.3 3.7 3.161 5.8 5.2 4.6 3.9 3.362 6.1 5.4 4.8 4.1 3.563 6.4 5.7 5 4.4 3.764 6.7 6 5.3 4.6 3.965 7 6.3 5.5 4.8 4.166 7.3 6.5 5.8 5.1 4.367 7.5 6.8 6 5.3 4.568 7.8 7.1 6.3 5.5 4.869 8.1 7.3 6.5 5.8 570 8.4 7.6 6.8 6 5.271 8.6 7.8 7 6.2 5.472 8.9 8.1 7.2 6.4 5.673 9.1 8.3 7.5 6.6 5.874 9.4 8.5 7.7 6.7 675 9.6 8.7 7.9 7 6.276 9.8 8.9 8.1 7.2 6.477 10 9.1 8.3 7.4 6.678 10.2 9.3 8.5 7.6 6.779 10.4 9.5 8.7 7.8 6.980 10.6 9.7 8.8 8 7.181 10.8 9.9 9 8.1 7.282 11 10.1 9.2 8.3 7.483 11.2 10.3 9.4 8.5 7.684 11.4 10.5 9.6 8.6 7.685 11.8 10.8 9.7 8.7 7.786 12 11 9.9 8.8 7.787 12.3 11.2 10.1 9 7.988 12.5 11.4 10.3 9.2 8.189 12.7 11.6 10.5 9.3 8.290 12.9 11.8 10.7 9.5 8.491 13.2 12 10.8 9.7 8.592 13.4 12.2 11 9.9 8.7


Girls continued


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90% 80% 70% 60%85 12.1 11 9.9 9 7.993 13.6 12.4 11.2 10 8.894 13.9 12.6 11.4 10.2 995 14.1 12.9 11.6 10.4 9.196 14.3 13.1 11.8 10.6 9.397 14.6 13.3 12 10.7 9.598 14.9 13.5 12.2 10.9 9.699 15.1 13.8 12.4 11.1 9.8100 15.4 14 12.7 11.3 9.9101 15.6 14.3 12.9 11.5 10.1102 15.9 14.5 13.1 11.7 10.3103 16.2 14.7 13.3 11.9 10.5104 16.5 15 13.5 12.1 10.6105 16.7 15.3 13.8 12.3 10.8106 17 15.5 14 12.5 11107 17.3 15.8 14.3 12.7 11.2108 17.6 16.1 14.5 13 11.4109 17.9 16.4 14.8 13.2 11.6110 18.2 16.6 15 13.4 11.9

Girls continued

1. Length is generally measured in children below 85 cm, and height in children 85 cm and above. Recumbent length is on average 0.5 cm greater than standing height; although the difference is of no importance to the individual child, a correction may be made by deducting 0.5 cm from all lengths above 84.9 cm if standing height cannot be measured.


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2. SD = standard deviation score (or Z-score). The relationship between the percentage of median value and the SD-core or Z-score varies with age and height, particularly in the first year of life, and beyond 5 years. Between 1 and 5 years median -1 SD and median -2 SD correspond to approximately 90% and 80% of median (weight-for-length, and weight-for-age), respectively. Beyond 5 years of age or 110 cm (or 100 cm in stunted children) this equivalence is not maintained; median 02 SD is much below 80% of media. Hence the use of “percentage-of-median” is not recommended, particularly in children of school age. Somewhere beyond 10 years or 137 cm, the adolescent growth spurt begins and the time of its onset is variable. The correct interpretation of weight-for-height data beyond this point is therefore difficult


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Decision Framework for Implementing Selective Feeding Programs

Findings

Serious situation:Malnutrition rate: = 15%or 10-14%, plus aggravating

factors

Alert/Risky situation:Malnutrition rate: 10-14% Or 5-9%, plus aggravating

factors

Unsatisfactory situation:Food availability at household level below 2100 kcal per person per dayAcceptable situation:Malnutrition rate: < 10% with no aggravating

factors

Actions Required

! 'Blanket' supplementary feeding for all members of vulnerable groups (especially children, pregnant and lactating women, adults showing signs of malnutrition)

! Therapeutic feeding programs for severely malnourished individuals

! Targeted supplementary feeding for individuals identified as malnourished in vulnerable groups (mildly to moderately malnourished children under 5 years, selected other children and adults)

! Therapeutic feeding programs for severely malnourished individuals

! Improve general rations until local food availability and access can be made adequate

! No need for population interventions! Attention for malnourished

individuals through regular community services


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1. Malnutrition rate: defined as the percentage of the child population (6 months to 5 years) who are below either the reference median weight-for-height minus 2 SD or 80% of reference weight-for height and/or with edema.

2. Aggravating factors: ! Food availability at household level less

than the mean energy requirement of 2100 kcal/person/day

! Crude mortality rate more than 1 per 10,000 per/day

! Epidemic of measles or whooping cough! High incidence of respiratory or

diarrheal diseases


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Description

Severe disorder (e.g., psychosis, severe depression, severely disabling form of anxiety disorders, etc.)Mild or moderate mental disorder(e.g., mild and moderate forms of depression and anxiety disorders including PTSD)

Moderate or severe psychological distress that does not meet criteria for disorder, that resolves over time ormild distress that does not resolve over timeMild psychological distress, that resolves over time

Before Disaster: 12 month

prevalence rates

2-3 %

10%

No estimate

No estimate

After Disaster: 12 month

prevalence rates

3-4%

20%(which over the years reduces to 15% through natural recovery without intervention)

30-50%(which over the years will reduce to an unknown extent)

20-40%(which over the years increase as people with severe problems recover)

Type of aid recommendations

Make mental health care available through general health services and in community mental health services1. Make mental health care available through general health services and in community mental health services2. Make social interventions and basic psychological support interventions available in the communityMake social interventions and basic psychological support interventions available in the community

No specific aid needed

Summary Table on Projecting Psychosocial/Mental Health Assistance

These rates vary with setting (e.g. sociocultural factors, previous and current disaster

exposure) and assessment method but give a very rough indication what WHO expects the

extent of morbidity and distress to be.


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Good communications are essential for management and security. Use the correct prowords and phonetic alphabet. Spell only important words.

Numerals should be transmitted digit by digit except round figures as hundreds and thousands. Repeat only important numbers.

Check your equipment regularly.

A — Alpha N — November

B — Bravo O — Oscar

C — Charlie P — Papa

D — Delta Q — Quebec

E — Echo R — Romeo

F — Foxtrot S — Sierra

G — Golf T — Tango

H — Hotel U — Uniform

I — India V — Victor

J — Juliet W — Whiskey

K — Kilo X — X-ray

L — Lima Y — Yankee

M — Mike Z — Zulu

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METRIC TO ENGLISH ENGLISH TO METRIC

Length

Surfaces

Volumes

Weights

To convert into Multiply by To convert into Multiply by

mm inches 0.03937 inches mm 25.4cm inches 0.3937 inches cm 2.54meters inches 39.37 inches meters 0.0254meters feet 3.281 feet meters 0.3048meters yards 1.0936 yards meters 0.9144km yards 1093.6 yards km 0.0009144km miles 0.6214 miles km 1.609

2 2cm sq. inches 0.155 sq. inches cm 6.4522 2m sq. feet 10.764 sq. feet m 0.09292 2m sq. yards 1.196 sq. yards m 0.8361

2 2km sq. miles 0.3861 sq. miles km 2.59hectares acres 2.471 acres hectares 0.4047

3 3cm cubic inches .06102 cubic inches cm 16.3873 3m cubic feet 35.314 cubic feet m 0.0283173 3m cubic yards 1.308 cubic yards m 0.76463 3m gallons (US) 264.2 gallons (US) m 0.003785

liters cubic inches 61.023 cubic inches liters 0.016387liters cubic feet 0.03531 cubic feet liters 28.317liters gallons (US) 0.2642 gallons (US) liters 3.785ml teaspoon 0.2 teaspoon ml 5.0ml tablespoon 0.067 tablespoon ml 15.0ml fluid ounces 0.033 fluid ounces ml 30.0liters cups 4.166 cups liters 0.24liters pints 2.128 pints liters 0.47liters quartz 1.053 quartz liters 0.95

grams grains 15.432 grains grams 0.0648grams ounces 0.03527 ounces grams 28.35kg ounces 35.27 ounces kg 0.02835kg pounds 2.2046 pounds kg 0.4536kg ton (US) 0.001102 ton (US) kg 907.44kg ton (long) 0.000984 ton (long) kg 1016.0metric ton pounds 2204.6 pounds metric ton 0.0004536metric ton ton (US) 1.1023 ton (US) metric ton 0.9072metric ton ton (long) 0.9842 ton (long) metric ton 1.0160


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TemperatureCentigrade to Fahrenheit: Multiply by 1.8 and add 32Fahrenheit to Centigrade: Subtract 32 and multiply by 0.555

Weight of water by volume (at 16.7°C or 62°F):1 liter = 1 kg 1 UK gallon = 10 pounds1 UK gallon = 1.2 US gallons 1 UK gallon = 4.54 liters1 US gallon = 0.8333 UK gallons 1 US gallon = 8.33 pounds1 US gallon = 3.79 liters 1 liter = 0.26 gallons1 cubic foot = 62.3 pounds

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NAME ADDRESSNational

Asian

WHO

Other UN Agencies

Department of Health-Philippines (DOH) http://www.doh.gov.phNational Disaster Coordinating Council (NDCC) http:/www.ndcc.gov.phPhil. Atmospheric, Geophysical and Astronomical http://www.pagasa.dost.gov.ph

Services Administration (PAGASA)Phil. Institute of Volcanology & Seismology http://www.phivolcs.dost.gov.ph

(PHIVOLCS)Phil. Nuclear Research Institute (PNRI) http://www.dost.gov.ph/pnriPhil. National Red Cross http://www.redcross.org.ph

Asian Disaster Preparedness Center (ADPC) http://www.adpc.ait.ac.thAsian Disaster Reduction Center (ADRC) http://www.adrc.or.jpAsian Disaster Reduction & Response Network http://www.adrrn.net

Emergency and Humanitarian Action (EHA) http://www.who.int/disastersRegional Office for the Western Pacific http://www.wpro.who.int/sites/eha

(WPRO)-EHAEuropean Region- Emergency Preparedness http://www.euro.who.int/emergencies

and Response ProgrammePan-American Health Organization http://www.paho.org/english/ped

(PAHO)- Disasters & Humanitarian AssistanceRegional Office for the South-East Asia (SEARO) http://w3.whosea.org/index.htmEssential Drugs and Medicines policy http://www.who.int/medicinesInjuries and Violence Prevention http://www.who.int/violence_injury_

preventionMental Health http://www.who.int/mental_healthNutrition http://www.who.int/nutReproductive Health http://www.who.int/reproductive_healthWater and Sanitation http://www.who.int/water_sanitation

_healthPAHO SUMA http://www.disaster.info.de

sastres.net/SUMACentro Regional de Informacion Sobre Desastres http://www.crid.or.cr/cridHealth Library for Disasters http://www.helid.desastres.net

UNAIDS http://www.unaids.orgUN Disaster Management Training Program http://www.undmtp.org

(UNDMTP)UN Environmental Programme http://www.unep.orgUN High Commissioner for Refugees (UNHCR) http://www.unhcr.chUN International Children's Educational Fund http://www.unicef.org

(UNICEF)



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NAME ADDRESS

Other International Organizations

UN International Strategy for Disaster Reduction http://www.unisdr.orgUN Population Fund http://www.unpfa.orgUN Office for the Coordination of Humanitarian http://ochaonline.un.org

Affairs (UN-OCHA)World Bank http://www.worldbank.orgWorld Food Programme http ://www.wfp.org

Emergency Management Australia (EMA) http://www.ema.gov.auFederal Emergency Management Agency http://www.fema.gov

(FEMA), USACenters for Disease Control & Prevention http://www.cdc.gov

(CDC), USAAgency for Toxic Substances and Disease Registry http://atsdr1.atsdr.cdc.gov:8080/

hazdat.htmlEM-DAT: Center for Epidemiology and Disaster http://www.cred.be/emdat/

(CRED) International Disaster DatabaseDatabases on Emergency Statistics and http://www.md.ucl.ac.be/entites/

Bibliographic References (CRED) esp/epid/missionInternational Directory of Emergency Centers http://www.oecd.org/dataoecd/

for Chemical Accidents (2000) 0/39/1933385.pdfWorld Meteorological Organization http://wmo.ch/web/www/reparts/

expert-ERA-0498.htmlAlertnet http://www.alertnet.orgDisaster Relief http://www.disasterrelief.orgInternational Committee of the Red Cross http://www.icrc.orgInternational Federation of Red Cross and Red http://www.ifrc.org

Crescent SocietiesMedecins Sans Frontiers http://www.msf.orgOne World http://www.oneworld.netOrganization for Economic Co-operation http://www.oecd.org

and Development Relief Web http://www.reliefweb.intRefugee Nutrition Information System http://acc.unsystem.org/scn/

publications/html/rnis.htmlReproductive Health for Refugee Consortium http://www.rhrc.org

(RHRC)Sphere Project http://www.sphereproject.orgAmerican College of Emergency Physicians (ACEP) http://www.acep.orgNatural Hazards Center at the University http://www.colorado.edu/hazards

of ColoradoCentral Investigation Agency (CIA) Factbook http://www.cia.gov/cia/publications/

factbook

Websites continued

WEBSITES


102

General1. WHO. Essentials for emergencies.2. WHO. (2003). Emergency response manual (provisional version).3. CDC. Public health emergency response guide for State, Local, and

Tribal Public Health Directors Version 1.0. Atlanta, Georgia: Centers for Disease Control and Prevention.

4. Sphere Project (2004). Humanitarian charter and minimum standards in disaster response. Geneva: The Sphere Project.

5. UP Open University/DOH/WPRO. Emergency Medical Services System Manual. Postgraduate Course in Health Emergency Management, Module 3: Public Health Issues in Emergencies. August 14-20, 1999.

6. UP Open University/DOH/WPRO. Emergency Medical Services System Manual. Postgraduate Course in Health Emergency Management, Module 5: Emergency Medical Services System. August 14-20, 1999.

Communicable Diseases1. WHO (2005). Communicable disease control in emergencies: A field

manual. Geneva: World Health Organization.2. WHO (2004). Technical note: Post-tsunami flooding and

communicable disease risk in affected Asian countries. Geneva: World Health Organization.

Nutrition1. WHO (2003). Guiding principles for feeding infants and young

children during emergencies. Geneva: World Health Organization.2. Joint UNICEF WHO ISP (2005). Recommendations on infant

feeding in emergencies. Jakarta, Indonesia January 7, 2005.

Environmental Health1. WHO (2004). Management of solid health-care waste at primary

health-care centres: A decision-making guide. Geneva: World Health Organization.


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2. WHO/SEARO. (2005) Planning Emergency Sanitation. Technical Notes in Emergencies, Technical Note No. 12. India: WHO/Regional Office for South Asia.

3. Lacarin, CJ and Reed RA (1999) Emergency Vector Control Using Chemicals, Water, Engineering and Development Center (WEDC), Loughborough.

Psychosocial Care and Mental Health1. WHO. (2003). Mental health in emergencies: psychological and

social aspects of health of populations exposed to extreme stressors. Geneva: World Health Organization.

2. WHO. (2005). Mental health and psychosocial care of children in disasters. Geneva: World Health Organization.

3. WHO. (2005). Mental health of populations exposed to biological and chemical weapons. Geneva: World Health Organization.

Management of Dead Bodies1. PAHO (2004). Management of dead bodies in disaster situations.

Washington DC: Pan American Health Organization.2. WHO/SEARO. (2005), Disposal of dead bodies in emergency

conditions. Technical Note No.8. India: WHO/Regional Office for South Asia.

Resource Managementnd1. WHO. (1999). Guidelines for drug donation 2 ed. Geneva: World

Health Organization.

Risk Communication1. CDC (2002). Crisis and emergency risk communication. Atlanta,

Georgia: Centers for Disease Control and Prevention.

REFERENC

ES


104

Organization Hotline Number/sAFR Reserve Command-Rescue and Emergency Medical Team 921-3746AFP-Office of the Surgeon General (AFP-OTSG) 911-6509

911-6001 loc. 6416Assoc. of Phil. Volunteer Fire Brigades, Inc. 522-2222Assoc. of Volunteer Fire Chiefs & Firefighters of the Phil., Inc. 160-16Bureau of Fire Protection (BFP) 928-8363EARNET Network 911-9009DOH-Dengue 723-2493DOH OPCEN 929-6919/929-6853

743-1937/741-7048Metro Manila Development Authority (MMDA)

Road Emergency Group 882-0851EARNET Network 136

National Disaster Coordinating Council (NDCC) 912-5668National Poison Control Control & Information Service 524-1078/404-0257

5218450 local 2311National Voluntary Blood Center 929-6274Office of Civil Defense (OCD) Operation Center 911-1406/912-2556Philippine Atmospheric, Geophysical and Astronomical 929-4570/927-1541

Services Administration (PAGASA) 928-2031/927-2877Philippine Coast Guard (PCG)

Action Center 527-3880/338-5634527-8481 loc 6134

Coast Guard Medical 301-9369Philippine General Hospital (PGH)

EARNET Network 523-5350521-8450 loc. 3166

Philippine Institute of Volcanology and Seismology (PHIVOLCS) 426-1468/927-1104Philippine Long Distance Telephone Company (PLDT) 171Philippine National Police (PNP) Patrol 117 117Philippine National Red Cross (PNRC)

EARNET Network 527-0864Disaster Management 527-8384 loc 133/134PNP Firearms and Explosives 724-8085Quezon City Rescue-Sagip Buhay

EARNET Network 928-4396


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CHD Coordinator Tel No./Cell No.CHD I Ms. Michelle Dumbrique (075) 515-6842

0928-2979687CHD II Dr. Baldomero Lasam (078) 844-6585

0927-3046479CHD III Dr. Nemesio Santos (045) 961-3802

0917-4586351CHD IV-A CALABARZON Dr. Noel Pasion (02) 913-0864

0920-2290001CHD IV-B MIMAROPA Dr. Aurora Enojado (02) 995-0827

020-9242841CHD V Dr. Juancho Gideon Torres (052) 483-0840 loc 513

0919-4704465CHD VI Mr. Jerry Porras, RN (033) 321-0607 loc 15

0919-5555194CHD VII Mr. Rennan Cimafranca, RN (032) 418-7629

0917-3248741CHD VIII Atty. Anabelle De Veyra, RN (053) 323-5025

0920-2587119CHD IX Dr. Marcos Redoble Jr. (062) 9911313

0919-3424124CHD X Dr. Marianne Trabajo (088) 350-4322

0918-4477173CHD XI Dr. Paolo Pantojan (082) 224-3011

0927-7798177CHD XII Mr. Leo Chiong, RN (064) 421-4583

0920-2031559CHD-Metro Manila Dr. Marilyn Go (02)535-1488

0920-2993329CHD-CAR Ms. Elnoria Bugnosen, RN (074) 444-5255

0918-3641876CHD-CARAGA Dr. Teodofreda Sarabosing (085) 342-5208 loc 102

0921-7650285CHD-ARMM Ms. Julie Villadolid (064) 421-6842

0919-8981919

Centers for Health Development.

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Hospitals

HOSPITALS Coordinator Tel No./Cell No.Metro Manila Hospital

Amang Rodriguez Medical Dr. Rommel Menguito (02) 942-5988Center 0920-9624967

Dr. Jose Fabella Memorial Dr. Romeo Bituin (02) 734-5561-65Hospital 0919-2045910

Dr. Jose N. Rodriguez Dr. Joseph Espinosa (02) 962-8209Memorial Hospital 0918-6973937

Dr. Jose R. Reyes Memorial Dr. Arthur Platon (02) 740-3785Medical Center 0919-5538588

East Avenue Medical Center Dr. Emmanuel Bueno (02) 921-64800917-8391240

Las Pinas General Hospital Dr. Rodrigo Hao (02)873-0556 loc 105& Satellite Trauma Center 0917-8255210

Lung Center of the Philippines Dr. David Geollegue (02) 924-6101 loc 333/4030927-4407329

National Center for Mental Dr. Romeo Sabado (02) 531-9001 loc 356Health 091 5-7444709

National Children's Hospital Ms. Celia Pangan, RN (02) 724-0656-590915-4406067

National Kidney & Transplant Ms. Ma. Belinda Evangelista (02) 924-3601 loc 3094Institute 0917-9514096

Philippine Children's Medical Dr. Maria Eva Jopson (02) 924-9158Center 0917-6454339

Philippine Heart Center Mr. Elmer Benedict Collong (02) 925-2401 loc 38300919-4175540

Philippine Orthopedic Center Mr. Willy Veloria (02) 711-23160928-2142979

Quirino Memorial Medical Dr. Roberto Dalmacion (02) 421-9289Center 0918-9121169

Research Institute for Tropical Dr. Renato Alegabres (02)V807-2628-32Medicine 0920-2452485

Rizal Medical Center Dr. Roel Tito Marcial (02) 671-97400918-9100589

San Lazaro Hospital Dr. Miguel Montes La'o (02)732-3776 loc 4280918-4230855

San Lorenzo Ruiz Women's Dr. Noel Valderrama (02) 294-4853Hospital 0916-4838300

Taguig-Pateros District Dr. Alexis Uy (02) 838-3485 loc 116Hospital 0919-6525470

Tondo Medical Center Dr. Arnel Rivera (02) 251-8420-23 loc 2340919-5905244



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Valenzuela General Hospital Ms. Aida Caudra (02) 294-6711 loc 1060920-8225384

Ilocos Training & Rehional Dr. Cesar Bernabe (072) 242-5543Medical Center, San 0919-2500155Fernando City, La Union

Mariano Marcos Memorial Dr. Jesus Tomas (077) 792-3144Hospital & Medical Center, 0919-8183679Batac, Ilocos Norte

Region I Medical Center, Dr. Dominador Manzano, Jr. (075) 523-4103Dagupan City 0919-8888067

Batanes General Hospital, Dr. Epifanio Pagalilauan 0321-6349448Basco, Batanes

Cagayan Valley Medical Center, Dr. Jaime Balubal (078) 844-0033-34Tuguegarao, Cagayan 0321-5803907

Veterans Regional Hospital, Dr. Joselito Gonzales, DMD (078) 805-3561 loc 132Rosario, Santiago City, 0919-6314981Isabela

Bataan General Hospital, Dr. Manuel Ponce (047) 237-3635Tenejero, Balanga City, 0920-5743077Bataan

Jose B. Lingad Memorial Dr. Alfonso Danac (045) 963-6845General Hospital, Dolores, 0917-5106373City of San Fernando

Paulino J. Garcia Memorial Dr. Huberto Lapuz (044) 463-9937Regional Medical Center, 0918-9173970Cabanatuan City

Batangas Regional Hospital, Dr. Ernesto Reyes (043) 723-0165Batangas City 0918-9250911

Bicol Medical Center, Dr. Rico Nebres (054) 472-5106Naga City 0920-9055649

Bicol Regional Training Dr. Jose Gabriel Penas (052) 483-0635& Teaching Hospital, 0919-3340542Legaspi City, Albay

Bicol Sanitarium, Cabusao, Dr. Edgardo Sarmiento (054) 451-2244Camarines Sur 0919-3210904

Corazon Locsin Montelibano Dr. Antonio Vasquez (034) 435-1591 loc 229Memorial Hospital, 0920-9277506Bacolod City

Don Jose Monfort Medical Ms. Jacobina Padojinog, RN (033) 361-2011Center, Barotac Nuevo, 0915-9671354Iloilo

Regional Hospital

Hospitals continued


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Western Visayas Medical Ms. Freida Sorongon, RN (033) 321-1797Center, Mandurriao, 0919-4316384Iloilo City

Gov. Celestino Gallares Dr. Edgar Pizarras (038) 411-3185Memorial Hospital, 0918-5047051Tagbilaran City

Vicente Sotto Memorial Dr. Joseph Al Alesna (032) 253-9891 loc 134Medical Center, Cebu City 0917-5469234

Eastern Visayas Regional Dr. Adelaida Asperin (053) 321-3129Medical Center, 0919-5540022Tacloban City

Margosatubig Regional Ms. Nona Galvez, RNHospital, Margosatubig, Zamboanga del Sur

Zamboanga City Medical Dr. George Rojo (062) 991-8523Center, Zamboanga City 0919-4970004

Amai Pakpak Medical Center, Engr. Emmanuel Cadut (063) 352-0070Marawi City, Lanao del Sur

Mayor Hilarion Ramiro Dr. Proceso Mintalar (088) 521-0022Regional Training & 0917-5803174Teaching Hospital, Mindog, Maningcol, Ozamis City

Northern Mindanao Medical Dr. Enrique Saab (08822) 726-362Center, Cagayan de 0917-4042987Oro City

Davao Medical Center, Dr. Ricardo Audan (082) 227-2731 loc 4116Davao City 0927-3455823

Davao Regional Hospital, Dr. Sergio Dalisay (084) 400-4416Apokon, Tagum City 0920-9219690

Cotabato Regional Medical Dr. Dimarin Dimatingkal (064) 421-2340 loc 303Center, Cotabato City 0917-7266737

Baguio General Hospital Dr. Manuel Quirino (074) 443-5678& Medical Center, 0920-9117224Baguio City

Luis Hora Memorial Regional Dr. Edgardo Bolombo 0919-4418559Hospital Abatan, Bauko, Mt. Province

Adela Serra Ty Memorial Dr. Amando Gen Barbadillo (086) 211-3700Medical Center, Tandag, 0918-5848214Surigao del Sur

Caraga Regional Hospital, Dr. Panfilo Jorge Tremedal (085) 341-2579Butuan City 0916-8283513

Hospitals continued


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