Tatd 2015 Suppl 1 by LookUs Scientific

ISSN 1304-7361

Turkish Journal of Emergency Medicine Türkiye Acil Tıp Dergisi VOLUME 15

SUPPLEMENT 1

YEAR 2015

Citation Abbreviation: Turk J Emerg Med

Special Edition of Turkish Journal of Emergency Medicine Türkiye Acil Tıp Dergisi Özel Sayısı “Basic Concepts of Disaster Medicine and Humanitarian Action for Emergency Physicians” “Acil Tıp Uzmanları İçin Afet Tıbbı ve İnsani Yardım Organizasyonlarında Temel Kavramlar”

@TurkJEmergMed

TurkJEmergMed

Issued by The Emergency Medicine Association of Turkey This Journal is indexed in Turkish Medical Index of TUBITAK-ULAKBIM, EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE and Turkiye Citation Index.

www.trjemergmed.com

Turkish Journal of Emergency Medicine SUPPLEMENT EDITORS Selim SUNER, M.D. The Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Division of Disaster Medicine and Emergency Preparednesse

Murat ERSEL, M.D. Ege University School of Medicine, Department of Emergency Medicine

EDITORS Suleyman TUREDI, M.D. Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine

Orhan CINAR, M.D. Gulhane Military Medical Academy (GMMA), Department of Emergency Medicine

Arzu DENIZBASI, M.D. Marmara University, Faculty of Medicine, Department of Emergency Medicine

ASSOCIATE EDITORS Seyran BOZKURT, M.D. Mersin University Faculty of Medicine, Department of Emergency Medicine Cem ERTAN, M.D. Izmir University Faculty of Medicine, Department of Emergency Medicine Nurettin Ozgur DOGAN, M.D. Kocaeli University, Faculty of Medicine, Department of Emergency Medicine Nese COLAK ORAY, M.D. Dokuz Eylul University Faculty of Medicine, Department of Emergency Medicine Mehmet Ali KARACA, M.D. Hacettepe University Faculty of Medicine, Department of Emergency Medicine Ozlem KOKSAL, M.D. Uludag University Faculty of Medicine, Department of Emergency Medicine Serkan SENER, M.D. Ac覺badem University, Faculty of Medicine, Department of Emergency Medicine Ibrahim TURKCUER, M.D. Pamukkale University, Faculty of Medicine, Department of Emergency Medicine

TECHNICAL REVIEW AND METHODOLOGY EDITOR Haldun AKOGLU, M.D.

Marmara University, Faculty of Medicine, Department of Emergency Medicine Issued by The Emergency Medicine Association of Turkey This Journal is indexed in Turkish Medical Index of TUBITAK-ULAKBIM, EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE and Turkiye Citation Index.

www.trjemergmed.com

Turkish Journal of Emergency Medicine SCIENTIFIC ADVISORY BOARD Jeffrey ARNOLD, M.D. Elizabeth DEVOS, M.D. Geijsel FEMKE, M.D. C. James HOLLIMAN, M.D. Monseireus KOEN, M.D. Mark LANGDORF, M.D. Frank LOVECCHIO, M.D. Matej MARINSEK, M.D. Resmiye ORAL, M.D. Pini RICARDO, M.D. Petrina ROBERTA, M.D. Brown RUTH, M.D. Lemoyne SABIN, M.D. Selim SUNER, M.D. Judith E. TINTINALLI, M.D.

FORMER EDITORS Rifat TOKYAY, M.D. (2001-2003) Hamit HANCI, M.D. (2003-2004) Oktay ERAY, M.D. (2004-2007) Sedat YANTURALI, M.D. (2006-2008) Cenker EKEN, M.D. (2007-2010, 2012) Ersin AKSAY, M.D. (2009-2011) Murat PEKDEMIR, M.D. (2010-2013)

Turkish Journal of Emergency Medicine ISSN 1304-7361

ISSUED BY THE EMERGENCY MEDICINE ASSOCIATION OF TURKEY

VOLUME 15 NUMBER Suppl. 1 OCTOBER 2015

OWNER YILDIRAY CETE, M.D. on behalf of the Emergency Medicine Association of Turkey

CORRESPONDENCE Turkiye Acil Tip Dernegi, Cankaya Mah., Cinnah Cad., No: 51/10 Cankaya, Ankara, Turkey Tel: +90 - 312 - 438 12 66 • Fax: +90 - 312 - 438 12 68 e-mail: bilgi@tatd.org.tr, editor@trjemergmed.org Published four times a year.

PUBLISHER

Printed on acid-free paper.

KARE YAYINCILIK | karepublishing Sogutlucesme Cad., No: 76/103, 34730 Kadikoy, İstanbul, Turkey Tel: +90 - 216 - 550 61 11 Fax: +90 - 216 - 550 61 12

Periodical

COORDINATION DESIGN PRESS DATE

English correction service by makaletercume.

Ali CANGUL Edibe COMAKTEKIN October 2015

This publication is printed on paper that meets the international standard ISO 9706: 1994. Free full-text articles in English are available at www.trjemergmed.com.

KARE @TurkJEmergMed

TurkJEmergMed

Turkish Journal of

Emergency Medicine Contents

OCTOBER SUPPLEMENT 1 2015

vii

Publishing with the Turk J Emerg Med

viii

Instructions for Authors

Foreword Suner S, Ersel M

xii

Önsöz Suner S, Ersel M

xiii

Acknowledgement

REVIEWS

History of Disaster Medicine Suner S

History and Principles of Humanitarian Action Rysaback-Smith H

Assessing and Planning Health Actions During a Crisis Suner S

Field Organization and Disaster Medical Assistance Teams Arzıman I

Communicable Diseases and Outbreak Control Ameli J

Water and Sanitation Standards in Humanitarian Action Ersel M

Food and Shelter Standards in Humanitarian Action Pothiawala S

Turkish Journal of

Emergency Medicine Publishing with the Turk J Emerg Med

1. The Turkish Journal of Emergency Medicine (Turk J Emerg Med) is published four times per year. The total number of original research articles is 15 per year and research articles (including original research, case studies, letters to the editor and reviews) constitute at least 50% of the published material. Every issue published will contain a minimum of 4 research articles. Apart from the research articles, Turk J Emerg Med also publishes articles in the categories of case studies, case series, visual diagnoses in emergency medicine, letters to the editor, brief reports, reviews and evidence based emergency medicine in consultation with the editorial board. Reviews are presented upon invitation from the editor. 2. All reviewer comments, signed copies of manuscripts and corrections will be kept in digital format in the journal archives for a minimum period of 5 years. 3. The submitted manuscripts are first reviewed by the journal’s editor who determines whether the manuscript deserves further evaluation or not. For submissions that are granted further evaluation, the editor assigns the manuscript to one of the assistant editors. The editor and the assistant editor then forwards the manuscript to two reviewers or one reviewer and a member of the scientific board for evaluation. If both the editor and the assistant editor determines the manuscript is not scientifically valuable or not an original work, or if it does not relate to emergency medicine or does not address the journal’s target audience, then they reject the manuscript directly without forwarding it to the reviewers. 4. The goal of the Turk J Emerg Med is to notify the authors with the acceptance of their submission for peer review within 14 days, peer review period of 21 days and final evaluation and notification of 28 days from the receipt of the manuscript. The authors are given 10 days for minor revisions and 20 days for major revisions. The final page layout is provided to the authors

within 30 days of the acceptance of the manuscript for publication, for final review and proof. 5. The assistant editor may consult the research methodology editor to clarify any problems in the statistical design and evaluation of the study during the peer review process. Even if such consultation is not sought during the review process, it can be implemented upon request of the editor in chief prior to the final acceptance of the manuscript. 6. All manuscripts containing material written in English will be evaluated by the language editor before the manuscripts are considered for publication. 7. Manuscripts submitted to the Turk J Emerg Med are expected to conform with the Helsinki Declaration and meet the common requirements of the biomedical journals. 8. Articles are listed on the content page and are published in appropriate sections (original research, case report, review, etc.). 9. The journal is printed on acid-free paper. 10. Advertisements are not allowed within articles. 11. The editor(s) of the Turk J Emerg Med are elected by the Board of the Emergency Medicine Association of Turkey once a year in January. The Turk J Emerg Med board consists of editor(s), assistant editors, a research methodology editor and a language editor. 12. All material published in the Turk J Emerg Med are the property of the Emergency Medicine Association of Turkey. This material may not be referred without citation nor may it be copied in any format. Authors are responsible for all statements made in their articles.

Editors of the Turk J Emerg Med Assoc. Prof. Dr. Suleyman TUREDI Assoc. Prof. Dr. Orhan CINAR Prof. Dr. Arzu DENIZBASI

Turkish Journal of

Emergency Medicine Instructions for Authors SUBMITTING MANUSCRIPTS Turk J Emerg Med accepts online manuscript submission. Users should visit journalâ&#x20AC;&#x2122;s web site and create an account before submitting their manuscripts. Resources for Authors page includes manuscript writing guidelines, drafts, templates and many useful examples for different manuscript types, as well as ethical standards that you should follow. You may want to check the sections on Reporting Statistics and Preparing Figures in the Resources for Authors page before sending your manuscript for peer-review.

REQUIRED FILETYPES AND MINIMUM SUBMISSION REQUIREMENTS Before submission via electronic submission system, a number of separate MS Word (.doc) and Adobe (.pdf) files should be prepared with the following formatting properties. No submissions will be accepted without a Cover Letter and a Title Page. 1. Cover Letter: A Cover Letter file should be included in all types of Manuscript submissions. On the Cover Letter, the author(s) should present the Title, Manuscript Type and Manuscript Category of the submission, and whether the submitted work had previously been presented in a scientific meeting. The Cover Letter should contain a statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration by Turkish Journal of Emergency Medicine. In addition, the Full Name of the Corresponding Author and his/her Contact Information including the Address, Phone number and E-mail Address should be provided at the bottom of the Cover Letter. The Cover Letter should be signed by corresponding author, scanned and submitted in .jpg or .pdf format with other manuscript files. The order of a Cover Letter should be as follows: a. Title, Manuscript Type b. Statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration c. Corresponding Author(s) Full Name, contact information including address, phone, and e-mail address d. Signature of the Corresponding Author 2. Title Page: A Title Page file should be included in all types of Manuscript submissions. Please prepare your title page as a separate electronic file, including the following elements: a. Title of the manuscript Generally nondeclarative, not a question, begins with main concept if possible, and without causal language, eg, "effect of," unless the study is an RCT b. Author(s) List, please list their full names and up to 2 academic degrees per author; do not include honorary affiliations, such as fellow status in an organization. c. Affiliation(s) of each author, including department or division, institution, city, state, country. d. Corresponding Author(s) Full Name, contact information including address, phone, and e-mail address e. Funding or other financial support should be acknowledged. f. Conflict of interest statement: A conflict of interest statement should be provided in bottom of the Title Page. Please list of all potential conflicts of interest for each author, in accordance with ICMJE Recommendations. In case of no conflicts of interests, please provide a statement such as: "Conflicts of Interest: None declared". g. We will assume that you will not make reprints available unless you specify otherwise. 3. Abstracts: On the Abstracts Page, the author(s) should present Abstract and Keywords (at least three) in this order. Keywords must be chosen carefully from MeSH Database (http://www.ncbi.nlm.nih.gov/mesh) websites. Number of Words and Structure requirements of Abstracts regarding to different Manuscript Types are listed below the Instructions for each Manuscript Type. 4. Main Text: A Main Text file should be included in all types of Manuscript submissions. This file should include Title, Abstracts Page, Main Text of your manuscript, and the References Section combined into a single electronic file. Tables can be included in this file as separate pages after References section, or may be uploaded separately as you prefer. Structure of the Main Text differs between Manuscripts types. Please refer to the Instructions for each Manuscript Type. a. This combined file with the sections of Abstracts, Keywords, Main Text, References with/without Tables should be a blinded version of the original manuscript. The names of the authors', and any identifying information including the academic titles, institutions and addresses must be omitted. Apart from the stage of the manuscript evaluation process, manuscripts submitted with any information pertaining to the author(s) will be rejected as soon as it is noticed. 5. Tables: Tables summarizing the data should be clearly formatted without using any templates. Data presented in the tables should not be included in its entirety in the text.

should be uploaded in MS Word (.doc) format and the electronic file should be named accordingly (Tables_xxx_vx.doc; see below). Tables should not be uploaded as pdf, jpeg or else. e. Arrange tables so that the primary comparisons of interest are horizontal, leftto-right (the standard reading order). Provide the N for each column or row and marginal totals where appropriate. 6. Figures: If the manuscript includes Figures then each Figure should be uploaded as a separate file in all types of Manuscript submissions. The information contained in the figure/image should not be repeated in its entirety, however reference to the figure/ image must be referred in the text. a. Technical reqirements i. Figure legends should be appear on a separate page after the References section. ii. During submission, all figures must be uploaded in a separate file from the text file and should be named accordingly (Figure1_xxx; Figure2_xxx; see below section: Electronic Filenames). iii. No legends or titles should be included in the Figures. iv. Pictures should be saved in JPEG, EPS or TIF format. v. Please submit photographs and figures with a resolution of at least 300 dots per inch. Figures are easiest for us to process if submitted in TIFF or EPS format. b. Content requirements i. We prefer graphics that show the distribution of data (eg, scatterplots, 1-way plots, box plots) to those showing summaries of data (eg, pie charts, bar graphs of means). Pie charts generally should not be used for research results. ii. If the data collected are paired (eg, pre and post, or 2 different measures on the same subject), then choose a graphical format that conveys the inherent pairing of the data. If data are paired, they should be displayed as such iii. Avoid background gridlines and other formatting that do not convey information (eg, superfluous use of 3-dimensional formatting, background shadings). Graphs should not be 3-D unless the data are. iv. Omit internal horizontal and vertical rules. v. If measurements are discrete, display as discrete points rather than a continuous line. vi. 95% CIs should be provided whenever appropriate (rather than SE) vii. For graphs, axes should begin at zero; if they do not, a break should be shown in the axis viii. Odds ratios should be displayed on a logarithmic scale ix. Survival curves should include number at risk below x axis x. Please check the references in the Resources for Authors page for many useful examples and guidelines for figure creation. c. Ethical requirements i. The owner and/or subject of the photograph must sign the Patient Consent Form, regardless of identifying material which can be found at Forms, Templates and Examples page under Resources Menu. ii. Figures should not be reproduced from other sources without permission 7. Statements, permissions, and signatures: a. Author Contribution Form: Designated authors should meet all four criteria for authorship in theICMJE Recommendations. All authors, and all contributors (including medical writers and editors), should specify their individual contributions and should complete a standard form, which is available at Forms, Templates and Examples page under Resources Menu. b. Conflict of Interest Form: A conflict of interest exists when professional judgment concerning a primary interest (such as patientsâ&#x20AC;&#x2122; welfare or validity of research) may be influenced by a secondary interest (such as financial gain). Financial relationships are easily identifiable, but conflicts can also occur because of personal relationships or rivalries, academic competition, or intellectual beliefs. A conflict can be actual or potential, and full disclosure to The Editor is the safest course. Failure to disclose conflicts might lead to publication of an Erratum or even to retraction. All submissions to Turk J Emerg Med must include disclosure of all relationships that could be viewed as presenting a potential or actual conflict of interest. All authors are required to provide a Conflict of Interest Statement and should complete a standard form, which is available at Forms, Templates and Examples page under Resources Menu. c. Patient Consent Form: Publication of any personal information about an identifiable living patient requires the explicit consent of the patient or guardian We expect authors to use a standard patient consent form which is available at Forms, Templates and Examples page under Resources Menu. d. Copyright Transfer Form: All authors are required to provide a Copyright transfer from with complete a standard form, which is available at Forms, Templates and Examples page under Resources Menu.

a. Tables must be numbered consecutively. b. Each Table must be referred to in the text. c. Number and Title of each Table should be written at the top of each page before MANUSCRIPT FORMATTING the Table. d. Tables can be included in Main text file as separate pages after References section, Manuscript format must be in accordance with the ICMJE-Recommendations for the or may be uploaded separately as you prefer. If you prefer a separate file, Tables Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals

Turkish Journal of

Emergency Medicine Instructions for Authors (updated in August 2013). Papers that do not comply with the format of the Journal will be experimental animal trials, or any other clinical or experimental studies. Maximum 8 authors, returned to the author for correction without further review. Therefore, to avoid loss of time 4000 words (including references, tables, and figure legends), 30 references, 6 tables and/or and work, authors must carefully review the submission rules. figures. Submission of research articles should include below mentioned pages, sections and Manuscript structure should be complient with the guidelines of WAME . Please check this files as defined above in required filetypes section: guideline and Resources for Authors page for more information if you are not sure how to write a manuscript. Extensive number of resources, drafts, templates and articles are provided for you so you can create an excellent manuscript. General Format 1. General Style: a. The manuscript should be typed in a Microsoft Word™ file, single-column format, double-spaced with 2.5 cm margins on each side, text should be justified on both the right and left margins of the page in Times New Roman, 12pt. b. Main text should include page numbers at the right bottom and consecutive line numbers. c. Every effort should be made to avoid medical jargon. 2. For the Blind Initial Review: The names of the authors', and any identifying information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected. 3. Use of English: Proper use of English terminology and grammar should be employed. 4. Statistical Analysis: All studies should be analyzed in consultation with those experienced in statistical analysis. 5. Units of Measure: Measurements should be reported using the metric system according to the International System of Units (SI). Laboratory values should be presented with normal limits. Consult the SI Unit Conversion Guide, New England Journal of Medicine Books, 1992. Please check Resources for Authors page for more information. 6. Drugs: Generic names for drugs should be used. Doses and routes for the drugs should be stated. When a drug, product, hardware, or software mentioned within the main text product information, including the name of the product, producer of the product, city of the company and the country of the company should be provided in parenthesis in the following format: “Discovery St PET/CT scanner (General Electric, Milwaukee, WI, USA)” 7. Abbreviations: We discourage the use of any but the most necessary of abbreviations. They may be a convenience for an author but are generally an impediment to easy comprehension for the reader. All abbreviations in the text must be defined the first time they are used (both in the abstract and the main text), and the abbreviations should be displayed in parentheses after the definition. Abbreviations should be limited to those defined in the AMA Manual of Style, current edition. Authors should avoid abbreviations in the title and abstract and limit their use in the main text. 8. Decimal points or commas: Decimal numbers should be separated from the integers with points. Commas should not be used in decimals throughout the manuscript. 9. Use of percentages: Percent sign should be located after the percentages. 10. References: References should be numbered consecutively in the order in which they are first mentioned in the text, and should be formatted in AMA style (3 authors then "et al"). Avoid referencing abstracts, or citing a "personal communication" unless it provides essential information not available from a public source. Examples of Referencing are as follows: i. Article: Raftery KA, Smith-Coggins R, Chen AHM. Gender-associated differences in emergency department pain management. Ann Emerg Med. 1995;26:414-21. ii. Book: Callaham ML. Current Practice of Emergency Medicine. 2nd ed. St. Luis, MO:Mosby;1991. iii. Book Chapter: Mengert TJ, Eisenberg MS. Prehospital and emergency medicine thrombolytic therapy. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY:McGraw-Hill;1996:337-343. iv. Courses and Lectures (unpublished): Sokolove PE, Needlesticks and high-risk exposure. Course lecture presented at: American College of Emergency Physicians, Scientific Assembly, October 12, 1998, San Diego, CA. v. Internet: Fingland MJ. ACEP opposes the House GOP managed care bill. American College of Emergency Physicians. Web site. Available at: http://www.acep.org/ press/pi980724.htm. Accessed August 26,1999. vi. Personal Communication: Use of personal communications should be avoided. If necessary, the person's name, academic title, and the month and year of the communication should be included in the reference. A letter of permission from the person referred to should accompany the manuscript. vii. Please check Resources for Authors page for more information.

MANUSCRIPT TYPES AND SPECIFIC FORMATTING GUIDELINES Identification of article type is the first step of manuscript submission because article type dictates the guidelines that should be used, including formatting and word limits of the manuscript. The main categories are outlined below: Research Article: Original studies of basic or clinical investigations in emergency medicine. These articles can include randomized controlled trials, observational (cohort, case-control or cross-sectional) studies, destructive studies, diagnostic accuracy studies, systematic reviews and meta-analyses, nonrandomized behavioral and public health intervention trials,

1. Abstracts Page: Both English and Turkish (if relevant) abstracts are required. Abstracts should not exceed 250 words and should be structured with the following subheadings: Objectives, Material and Methods (with design), Results, and Conclusion (case control study, cross sectional study, cohort study, randomized controlled trial, diagnostic accuracy study, meta-analysis and systemic review, animal experimentation, non-randomized study in behavioral sciences and public health, etc.). In your results emphasize the magnitude of findings over test statistics, ideally including the size of effect and its confidence intervals for the principal outcomes. 2. Main Text: The main text should be structured with the following subheadings: Introduction, Material and Methods, Results, Discussion, Acknowledgments, References, Tables, and Figure Legends.

a. Introduction: A three-paragraph structure should be used. Background information on study subject (1st paragraph), context and the implications of the study (2nd paragraph) and the hypotheses and the goals of the study (3rd paragraph). Background: Describe the circumstances or historical context that set the stage and led you to investigate the issue. Context: Describe why your investigation is consequential. What are its potential implications? How does it relate to issues raised in the first paragraph? Why is this specific investigation the next logical step? Goals of the study: Clearly state the specific research objective or hypothesis and your primary outcome measure. b. Material and Methods: The method section, is one of the most important sections in original research articles, and should contain sufficient detail. The investigation method, study sample, analyses performed, commercial statistical programs used, details of measurement and evaluation (e.g.: make and model of biochemical test devices and kits) should all be clearly stated. The names of local ethics committee or other approving bodies should be provided in Methods section for prospective studies. The Methods section should be organized with logical and sequential subheadings. The optimal subheading choices will vary with the analysis, but the following examples applicable to most clinical research: i. Study design and setting: Describe the study design using standard terms, and describe the study setting in a fashion that conveys characteristics that could affect the external validity (generalizability) of the findings. ii. Sample size estimation: Describe how you performed the sample size estimation, which tests and assumptions were used, and which sample size estimation software was used (if relevant). iii. Selection of Participants: Describe how participants were identified, screened, and enrolled. Remember to consider all participants including patients, providers, and outcome assessors, as appropriate. There should be a list of the inclusion and exclusion criterion with descriptions. In survey studies, information concerning who implemented the survey and how it was performed should be specified. iv. Interventions: Describe any interventions in sufficient detail to permit replication. Describe any blinding of subjects, providers, outcome assessors, or data analysts. Describe methods for determining whether the intervention was actually received. v. Methods and Measurements: Discuss how and when measurements were made. Discuss the precision and reliability of the measurements. How were spurious or missing measurements handled? Discuss who collected the data and how they collected it. Discuss how data were entered, checked, and processed. vi. Outcomes: Describe the study's primary and secondary outcome measures, and if needed explain why they were chosen to address the study objective. When possible, use outcomes that have been previously validated, or provide evidence of your own efforts to validate the measure. Emphasize patientcentered outcomes (eg, pain, days off from work, death) over intermediate outcomes (eg, change in forced expiratory volume, change in asthma score). vii. Power of the study: Provide the achieved power of the study according to the primary outcome that you used to calculate the sample size. viii. Analysis: Detail the primary analysis and specify any software that was used, including the name of the software and the company that produces it. Provide references for any non-routine analytic methods. If appropriate, detail sensitivity analyses that explore how results change when assumptions about the investigation are modified. c. Results: The demographic properties of the study population, the main and secondary results of the hypothesis testing must be provided. Commenting on the results and discussing the literature findings should be avoided in this section. Present as much data as possible at the level of the unit of analysis, graphically if possible. Emphasize the magnitude of findings over test statistics, ideally using size of effect and associated confidence intervals for each outcome. d. Discussion: The main and secondary results of the study should briefly presented and compared with similar findings in the literature. Providing intensive background information should be avoided in this section. Consider only those

Turkish Journal of

Emergency Medicine

Instructions for Authors published articles directly relevant to interpreting your results and placing them in context. Do not stress statistical significance over clinical importance. Avoid extrapolation to populations or conditions that you have not explicitly studied in your investigation. Avoid claims about cost or economic benefit unless a formal cost-effectiveness analysis was presented in the Methods and Results sections. Do not suggest "more research is needed" without stating what the specific next step is. Optionally, you may include a paragraph "In retrospect, . . ." to candidly discuss what you would do differently if given the opportunity to repeat the study, so others can learn from your experience. e. Limitations: The limitations of the study should be mentioned in a separate paragraph subtitled as the "Limitations" in the end of the discussion. Explicitly discuss the limitations of your study, including threats to the internal and external validity of your results. When possible, examine the magnitude and direction of each bias and how it might affect the interpretation of results. f. Conclusion: A clear conclusion should be made in the light of the results of the study. The potential effects of the results of the study on the current clinical applications should be stated in a single sentence. Inferences that are not supported by the study results should be avoided. g. Acknowledgments: h. References: References section should be in a separate page. i. Figure Legends: Figure Legends should be included in the Main Text in a separate page and this page should be the at the end of the Main text file. 3. Tables: At the end of the Main Text file as separate pages or as a separate file.

tables and/or figures. The authors should also submit copies of the articles proposed as supporting evidence. Visual Diagnosis: These are short case reviews with interesting and educative visual material. Visual Diagnosis is to be presented in two parts. In the first part, the case is summarized and the image is presented. In the second part, the diagnosis is provided in the heading, followed by a discussion of the management of the case and the specifications of the images. Maximum 2 authors, 500 words (including references), 5 references, 2 figures. No tables are allowed. There is no need for an abstract. Letter to the Editor: Opinions, comments and suggestions made concerning articles published in Turkish Journal of Emergency Medicine or other journals. Letters should contain a maximum of 1,000 words and 5 references are allowed for these single author submissions. No abstract is required.

GUIDELINES FOR SPECIFIC RESEARCH STUDY DESIGNS Randomized controlled trials (RCTs) RCTs must be reported in accordance with the CONSORT statement, summarized as follows: 1. Title includes the phrase "randomized controlled trial" 2. Clear depiction of the three elements of randomization: sequence generation, allocation, and concealment 3. Clear description of which outcome assessments were and were not blinded 4. A figure summarizing participant flow through the trial 5. Protocol deviations described, and whether analysis is intention to treat 6. Outcomes each reported with size of effect and associated confidence intervals.

4. Figures: Should not be included in the Main text file and should be uploaded as separate files as with the properties describes above in required filetypes section: Chart reviews 5. Ethics or Review Board Approval: If your manuscript involves original research, Least methodological elements that Turkish Journal of Emergency Medicine seek in you will be asked to verify approval or exemption by an institutional review or ethics retrospective research are as follows: board. Turkish Journal of Emergency Medicine will be unable to further consider 1. Trained and monitored abstractors use explicit protocols, precisely defined variables, manuscripts without approval or formal exemption. (The only exceptions are for and standardized abstraction instruments. analyses of third party anonymized databases which already have pre-existing IRB 2. Authors clearly describe how missing, conflicting, and/or ambiguous chart elements approval or exemption.) were coded. 6. Compliance with manuscript writing guidelines: If your manuscript involves 3. Interrater agreement assessed by having a sample of charts reviewed independently original research, you will be asked to verify compliance with guidelines for each by two or more abstractors. corresponding study design. Please check Resources for Authors page for checklists 4. When possible, abstractors are blinded to the study hypothesis and/or study group and relevant documents. assignment, particularly for chart elements that are not wholly objective. Case Reports: Brief descriptions of clinical cases or the complications that are Observational studies seldom encountered in emergency medicine practice and have an educational value. We prefer observational studies to be compliant with the latest STROBE guidelines. Consideration will be given to articles presenting clinical conditions, clinical manifestations or complications previously undocumented in the existing literature and unreported side Studies on diagnostic tests of adverse effects of the known treatment regimens or scientific findings that may trigger Weprefer studies on diagnostic tests to be compliant with the latest STARD guidelines. further research on the topic. Abstracts of case reports should mainly include information Clinical Decision Rules about the case, should not exceed 150 words, must be on a separate page and should be unstructured. The main text of Case Series should be structured with the following Weprefer clinical decision rules performed and reported in compliance with Green: subheadings: Introduction, Case Presentations, Discussion and References. Maximum Methodologic standards for interpreting clinical decision rules in emergency medicine: 5 authors, 1500 words (including references, tables, and figure legends), 15 references, 2014 update. 2 tables and/or figures. Case reports should be compatible with The CARE Guidelines: Meta-analyses Consensus-based Clinical Case Reporting Guideline which can be found on the Resources Meta-analyses of therapeutic trials should be compliant with the PRISM-P 2015 guidelines, for Authors Page. while meta-analyses of observational studies should be compliant with the MOOSE Case Series: Brief descriptions of clinical cases or the complications that are seldom guidelines. encountered in emergency medicine practice and have educational value. Abstracts POLICY FOR THE REPORTING OF METHODOLOGY AND STATISTICS should not exceed 250 words and be unstructured as case reports. Maximum 6 authors, 2500 words (including references, tables, and figure legends), 15 references, 3 tables Reporting Size of Effect and Its Confidence Intervals and/or figures. The main text of Case Series should be structured with the following Turkish Journal of Emergency Medicine strongly prefers that each comparative study outcome be reported with an estimated size of effect and its confidence intervals. Such subheadings: Introduction, Case Presentations, Discussion and References. reporting is advocated by the CONSORT statement, and lets readers to understand the Brief Report: Original reports of preliminary data and findings or studies with small approximate power and clinical importance of the observed magnitude of effect. numbers demonstrating the need for further investigation. Abstracts should not exceed 250 words and structured as research articles. Limitations include: maximum 6 authors, An example for the un-preferred type of reporting without size of effect: 4000 words (including references, tables, and figure legends), 15 references, 4 tables 1. A successful outcome was noticed in 98% of patients given Drug X versus 88% of and/or figures. Besides these constraints, all the formatting, approval, ethics and writing patient given Drug Y. guidelines of research articles also applies to brief reports. 2. In categorization of EF, the agreement (Weighted Kappa) between EPs and the Concept: Clinical or non-clinical articles related to the field of emergency medicine and cardiologist was 0.861 and 0.876, respectively. detailing improvements to emergency medicine practice. Abstracts should not exceed 3. For men, the average CWT on the right 5th intercostal space at the mid-axillary line 250 words with free structure. Maximum 3 authors, 4000 words (including references, was 32.7 mm and for women it was 39.3 mm (p=0.04)â&#x20AC;Ś tables, and figure legends), 15 references, 3 tables and/or figures. Examples for the preferred type of reporting with size of effect and confidence intervals: Review Article: Comprehensive articles reviewing national and international literature 1. A successful outcome was noticed in 98% of patients given Drug X versus 88% of related to current emergency medicine practice. Generally Turkish Journal of Emergency patients given Drug Y (difference 10%, 95%CI -2%, 17%). Medicine publishes only invited review articles. Other authors should contact the editor 2. In categorization of EF, the agreement (Weighted Kappa) between EPs and the prior to submission of review articles. Maximum 2 authors, 4000 words (including cardiologist was 0.861 (SE: 0.045, 95% CI: 0.773, 0.948) and 0.876 (SE:0.042, 95% CI: references, tables, and figure legends). There is no limit to the number of references. 0.793, 0.959), respectively. Evidence-Based Emergency Medicine: Articles seeking to detail clinical and medical practices should present a clinical scenario followed by the research question(s), followed by a selection of the best available evidence, analysis of the evidence and the application of the evidence. Abstracts should not exceed 250 words with free structure. Maximum of 4 authors, 4000 words (including references, tables, and figure legends), 15 references, 3

3. For men, the average CWT on the right 5th intercostal space at the mid-axillary line was 32.7 mm (SD 13.9; 95% CI: 30.3, 35.1) and for women it was 39.3 mm (SD 15.9; 95% CI: 32.4, 46.1). The average CWT on the right 5th intercostal space at the mid-axillary line was significantly higher in women than in men (p=0.04)

FOREWORD

here is consensus that the frequency and intensity of natural disasters are on the rise. With the increasing world population, particularly in coastal areas, the human impact of these events is multiplied. Concurrently, the number of displaced populations and those living in refugee camps are at levels never seen before in history. There is record number of organizations providing medical and logistical humanitarian assistance for these people. While the impulse of helping fellow people in need is inherently human1, given the complexities of providing humanitarian aid, specialized training and careful coordination and organization is essential to effectively manage any response. In this special edition of the journal the authors will discuss the history of disaster medicine and humanitarian aid, as well as particular topics related to the organization of care in disasters and humanitarian operations such as issues related to matching resources to need. While the scope of this special issue is limited, the manuscripts cover a broad overview while providing specific content which can be a used as starting point for health care providers who are interested in this topic. We would like to acknowledge the BIARI program at the Watson Institute at Brown University and the grant funding provided to support this effort. 1- “But really, they did it because every human being has a basic instinct to help each other out. It might not seem that way sometimes, but it’s true. If a hiker gets lost in the mountains, people will coordinate a search. If a train crashes, people will line up to give blood. If an earthquake levels a city, people all over the world will send emergency supplies. This is so fundamentally human that it’s found in every culture without exception. Yes, there are assholes who just don’t care, but they’re massively outnumbered by the people who do. And because of that, I had billions of people on my side.” Excerpt From: Weir, Andy. “The Martian.” Broadway Books, 2014.

Selim SUNER & Murat ERSEL Department of Emergency Medicine, Division of Disaster Medicine and Emergency Preparedness The Warren Alpert Medical School of Brown University & Ege University School of Medicine, Department of Emergency Medicine

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ÖNSÖZ

iç şüphesiz dünyanın en güzel coğrafyalarından birinde kurulmuş Türkiye maalesef bu güne kadar pek çok afet yaşamıştır. Afetlere karşı mücadele ve hazırlıklı olabilmek için öncelikle afet bilincinin oluşturulması gereklidir. Hem toplumda afet bilincinin geliştirilmesi hem de sağlık personelinin bilgi ve donanımın arttırılması konusunda Türkiye Acil Tıp Derneği özellikle Afet Komisyonu tarafından verilen Hastane Afet Planı Eğitimleri, İzmir İl Sağlık Müdürlüğü ile ortak gerçekleştirilen Afet Tıbbı Eğitimleri ve benzeri bir çok eğitim ve panel ile acil sağlık hizmetlerinde görev yapan tüm sağlık personeli ve elbette halkımız için çok önemli adımlar atmıştır. Türkiye Acil Tıp Derneği’nin (TATD) yaptığı çalışmalar ve eğitimler ülkemizde sağlık hizmetlerinde afetle mücadele ve müdahale yapılanmasının oluşturulmasında önemli bir zemin ve kaynak hazırlamıştır.

Diğer yandan ülkemizin özellikle Ortadoğu komşuları Suriye ve Irak’ta ortaya çıkan iç karışıklıklar nedeni ile çok sayıda mültecinin akınına uğraması, acil sağlık çalışanlarının kitlesel göç hareketleri veya afetler nedeni ile organize edilmesi gereken insani yardım organizasyonları konusunda bilgi birikimini arttırmak günümüzde oldukça önemli hale gelmiştir. Bu özel sayı ile hem acil tıp uzmanlarına hem de diğer sağlık çalışanlarına hem afet oragnizasyonlarının temel prensiplerini hem de afet veya kitlesel göç hareketleri nedeni ile gerekli olacak insani yardım organizasyonlarında afetzede veya mültecilerin ihtiyacı olacak temel unsurları güncel standartlar ışığında sunmak istedik. Bu özel sayının basımı Brown Üniversitesi Uluslararası Gelişmiş Araştırmalar Enstitüsü – Brown’s University International Advanced Research Institutes (BIARI) - Watson Enstitüsü’nün sağladığı burs desteği ile gerçekleştirilmiştir. Bu özel sayıya katkılarını sunan Brown Üniversitesi öğretim üye ve elemanlarına, BIARI 2014 mezunlarına ve TATD Yönetim Kurulu Başkanı Dr. Yıldıray Çete’ye en derin şükranlarımızı sunarız. Prof. Dr. Selim SUNER ve Doç. Dr. Murat ERSEL Özel Sayı Editörleri Brown Üniversitesi Warren Alpert Tıp Fakültesi Acil Tıp Anabilim Dalı & Ege Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı

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ACKNOWLEDGEMENT

This special edition “Basic Concepts of Disaster Medicine and Humanitarian Action for Emergency Physicians” of Turkish Journal of Emergency Medicine is published with the support of the grant of Brown University’s International Advanced Research Institutes (BIARI) - Watson Institute.

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REVIEW

History of Disaster Medicine Selim SUNER Department of Emergency Medicine, Division of Disaster Medicine and Emergency Preparedness, The Warren Alpert Medical School of Brown University, USA

SUMMARY Erik Noji, mentioned, tongue in cheek, Noah as the first disaster manager during a lecture in 2005. The canonical description of “The Genesis Flood” does describe Noah as a master planner and executer of an evacuation of biblical proportions. After gaining knowledge of a potential catastrophic disaster he planned and executed an evacuation to mitigate the effects of the “Genesis Flood” by building the Ark and organizing a mass exodus. He had to plan for food, water, shelter, medical care, waste disposal and other needs of all the evacuees. Throughout history, management of large disasters was conducted by the military. Indeed, the military still plays a large role in disaster response in many countries, particularly if the response is overseas and prolonged. The histories of emergency preparedness, disaster management and disaster medicine have coevolved and are inextricably intertwined. While disaster management in one form or another existed as long as people started living together in communities, the development of disaster medicine took off with the emergence of modern medicine. Similar to disaster management, disaster medicine also has roots in military organizations. Keywords: History; disaster; medicine.

It is perhaps as difficult to trace a history of Disaster Medicine as it is to define “disaster”. Following the theory of historical genealogy promulgated by Foucault, disaster medicine has multiple origins and a history of parallel development rather than a linear chronology.[1] Erik Noji, mentioned, tongue in cheek, Noah as the first disaster manager during a lecture in 2005.[2] The canonical description of “The Genesis Flood” does describe Noah as a master planner and executer of an evacuation of biblical proportions. After gaining knowledge of a potential catastrophic disaster he planned and executed an evacuation to mitigate the effects of the “Genesis Flood” by building the Ark and organizing a mass exodus. He had to plan for food, water, shelter, medical care, waste disposal and other needs of all the evacuees. Similar stories are present in the mythology of many cultures. In more recent

history, some inhabitants of Pompeii evacuated outside the city, when they noticed warning signs of an impending disaster, in the days prior to the massive eruption of Mount Vesuvius. Historical records are few, but one can surmise that these evacuations could have been organized by forward thinking “disaster managers”.[3] Throughout history, management of large disasters was conducted by the military. Indeed, the military still plays a large role in disaster response in many countries, particularly if the response is overseas and prolonged. Currently, there are civilian or governmental organizations, separate from military establishments, which conduct disaster response and medical care in most nations. Many of these organizations have sprouted from military roots. Correspondence: Selim SUNER, M.D. 55 Claverick Street, Providence, RI 02903, USA e-mail: ssuner@brown.edu

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Social scientists trace the modern history, in the western world, of disaster medicine to the works of Heinrich Zangger, on civilian mine explosions in the early 20th century.[4] While many developments in military medicine informed medical care during disasters, with Zangger and others who started investigating epidemiology and care during specific disasters, a body of literature started to emerge defining a separate specialty.

Table 1. Milestones in the development of Disaster Medicine in the United States 1803 Congressional Fire Disaster Relief Legislation 1964 Great Alaskan Earthquake 1974 Disaster Relief Act 1977 Natural Earthquake Hazard Reduction Program 1979 Formation of FEMA

The histories of emergency preparedness, disaster management and disaster medicine have coevolved and are inextricably intertwined. While disaster management in one form or another existed as long as people started living together in communities, the development of disaster medicine took off with the emergence of modern medicine. Similar to disaster management, disaster medicine also has roots in military organizations.[5-9]

1980 Civilian Military Contingency Hospital system

The development of triage in the 1790’s, by Baron Dominique Jean Larrey, Surgeon in Chief to Napoleon’s Imperial Guard10, rapid evacuation and field surgical care which started in WWII and was further refined in the Vietnam and Korean wars are important links in development of Disaster Medicine. In fact, the aerial view of the mobile army surgical hospital unit depicted in the opening credits of the US TV series M*A*S*H11, closely resembles the layout of disaster medical assistance teams (DMAT) during current deployments. Large pandemics such as the 1918 influenza epidemic, the cold war with civil defense programs, ever increasing human impact of natural disasters (particularly earthquakes and hurricanes in the United States), development and use of chemical, biological, radiological, nuclear and explosive (CBRNE) agents and the evolution of humanitarian assistance are all interwoven into the fabric of disaster medicine.

2001 September 11 attacks and the Homeland Security

There are certain tipping points in the development of disaster medicine in the United States, some of which are discussed (Table 1). The Defense Against Weapons of Mass Destruction Act of 1996 (created by senators Nunn, Lugar and Domenici) which established first responder training for weapons of mass destruction (WMD) was an important turning point in disaster medicine after the use of Sarin by terrorists in the Tokyo subway system in 1995. The bombing of the Murrah federal building, killing and wounding scores including children, in the same year by a lone terrorist in the United States was another catalyst for this legislation. This program was the first to establish the education of the principles of medical care specific to WMD to large-scale, non-military audiences. These topics are widely covered in current textbooks on Disaster Medicine. Funding for these programs and the rapid promulgation of information particular to managing casualties from WMD events led to an increase in highly trained

1980 Mount St. Helens Volcanic Eruption 1984 NDMS 1985 DMATs 1989 Hurricane Hugo and Loma Prieta Earthquake 1990 Stafford Act 1992 Federal Response Plan 1996 The Defense Against Weapons of Mass Destruction Act

Act of 2002

2005 Hurricane Katrina

medical personnel with an in interest in disaster medicine. With the Congressional Fire Disaster Relief legislation of 1803, the United States federal government provided federal aid to New Hampshire after a series of fires devastated the town of Portsmouth, setting a president, which informed future disaster assistance programs. As the population of the United States grew into tighter urban communities and disasters affected larger numbers of people, the need was born for consolidation of programs, which led to the formation of the Federal Emergency Management Agency (FEMA) with President Carter’s executive order 12127 in 1974.[12] Although the Civilian Military Contingency Hospital System was in place, the National Disaster Medical System (NDMS) was formed in 1984 with the cooperation of the departments of Health and Human Services, Defense, Federal Emergency Management Agency (FEMA) and the Department of Veterans Affairs, with the anticipated need for large numbers of beds outside of the assets held by the military and Veterans Affairs (VA) systems to accommodate casualties from wars. The system relied on civilian cooperation from the private sector, medical community and State governments. The initial Disaster Medical Assistance Teams (DMAT) were formed to receive casualties of war which were transported to the US and distribute them to the network of NDMS hospital beds.[13,14] These team members trained on military aircraft using equipment and supplies from military surplus stores. Many teams were based on military instillations and trained closely with military personnel. DMAT’s consisted of civilian volunteers with medi-

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History of Disaster Medicine

cal training and support personnel who were entered into federal temporary employment only during deployment and large training missions. DMAT team members were initially supported by a sponsoring private sector agency (a hospital in many cases). Many DMAT teams formed 501(c) (3) tax-exempt non-profit organizations in order to procure and maintain funding. There was variable governmental support depending on federal budgets, which ebbed and flowed yearly with the political landscape. Owing to a lack of large number of war casualties, the roles and responsibilities of DMAT’s evolved. In the late 1980’s, DMAT’s were used to care for patients after natural disasters. After the terrorist attacks in Tokyo, utilizing Sarin, a weapon of mass destruction, training and focus of DMAT’s expanded to include care of patients following large terrorist attacks as well as natural disasters. The shifting preparedness focus also led to formation of specialized teams within NDMS. Disaster Medical Assistance Team specializing in weapons of mass destruction (DMAT-WMD), Disaster Mortuary Assistance Teams (DMORT), National Veterinary Assistance Teams (NVAT), International Medical Surgical Response Team (IMSURT) are teams formed as the expanded structure and role of NDMS matured.[13] The goal of maintaining a nimble and robust response capability and 72-hour self-sufficiency with a part-time work-force continues to be challenge. Although criticism of cost effectiveness and timeliness of some responses have been levied and leadership structure and decision making questioned, with a presence during multiple disasters world-wide (including major landmark incidents such as the September 11, 2001 attacks, Hurricane Katrina and the earthquake in Haiti) NDMS teams have cared for hundreds of thousands of patients and assisted states and nations with health-care needs. NDMS and DMATs are not the only systems for disaster response in the United States. There are local organizations and city and state assets devoted to response as well. Since disasters are always local events and historically federal response has been slow to reach affected areas, capabilities to respond and manage disasters at a community level is essential. The Joint Commission requires hospitals to be prepared with 72 hours of in-house capabilities. Many States have DMAT-like teams and equipment and supply stockpiles. Larger cities and counties also have capabilities, which have been developed from various funding resources such as the Metropolitan Medical Strike Teams.[15] With a diverse array of response and surge programs and personnel the challenge is in the coordination and synchronized management of assets. This role often rests upon municipal or state health departments or emergency management agencies. Even with advanced management

techniques and the incident command system along with emergency operation centers, utilizing the latest technology including redundant communication systems, advanced weather forecasting and computerized geographic information systems, there is room for improvement in coordinating assets, particularly after large scale disasters. In the past 150 years there have only been 10 disasters in the United States, where the death toll exceeded 1000 persons. Increasing urbanization world-wide and the shift of populations to coastal areas, coupled with the anticipated rise in severe weather related events secondary to climate change, there will undoubtedly be an increase in the human impact of large scale disasters in the decades to come. Increasingly, assets for disaster response in the United States have been utilized overseas. This trend will likely continue. However, there are limitations to overcome if such aid is to be effective. First, deployment must be swift and rapid. The greatest need for emergency care is in the immediate aftermath of the incident. In most disasters, the demand persists but diminishes exponentially. One exception to this may be prolonged events such as epidemics and outbreaks. The challenge of a quick disaster response is evident even in the United States but more so when trying to reach remote areas and mired in international bureaucracy and red tape. With improvements in communication technology and advancements in transportation this hurdle is not insurmountable. There may be a role in utilizing existing transportation systems and capitalizing on the established efficiencies of military transportation. This requires extensive and detailed arrangements, which have to be completed and exercised prior to a real event. Second, there must be a designated agency with authorities and capabilities to coordinate the response. Given that local governments are often disrupted or otherwise occupied, an overarching agency such as the World Health Organization can be assigned this task. However, extensive international agreements must be made a priori and sufficient resources allocated to the WHO or similar agency in order to accomplish this task. It may even be possible to create an international taskforce, much like the United Nations peace keeping force, to rapidly deploy to disasters. All the political “t”s must be crossed and the financial “i”s dotted for this to materialize. As future disasters cause increasing human suffering, the political will to create advanced response systems will materialize. We have seen with the recent Ebola epidemic in western Africa that ineffective response in one part of the world can have rippling effects throughout the world. We are at an age where there are sufficient technological developments to mitigate the health effects of disasters worldwide.

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References 1. Foucault M. Nietzsche, genealogy, history. In: Bouchard DF, editor. Language, Counter-Memory, Practice: Selected Essays and Interviews. Cornell University Press, Ithaca, NY, 1977. p. 139e164. 2. Erik Noji John C Cutler Annual Lecture, Pittsburgh PA, September 29, 2005. 3. http://www.mpm.edu/research-collections/artifacts/grecoroman-medical-equipment-reproductions/pompeii-andgreco-roman-m, Accessed 2-26-2015. 4. Stehrenberger CS, Goltermann S. Disaster medicine: Genealogy of a concept. Social Science&Medicine 120(2014) 317324. 5. Gaydos JC, Luz GA. Military participation in emergency humanitarian assistance. Disasters 1994;18:48-57. 6. http://www.usace.army.mil/About/History/HistoricalVignettes/ReliefandRecovery/047AlaskaEarthquake.aspx, Accessed 5/27/2015 7. http://www.usace.army.mil/About/History/HistoricalVignettes/ReliefandRecovery/036DisasterRecovery.aspx, Accessed 5/27/2015 8. http://libpress.colorado.edu/?p=2497, Accessed 5/27/2015

9. Dara SI, Ashton RW, Farmer JC, Carlton PK Jr. Worldwide disaster medical response: an historical perspective. Crit Care Med 2005;33(1 Suppl):S2-6. 10. Iain Robertson‐Steel Emerg Med J 2006;23:154–5. 11. 20th Century Fox Television for CBS, 1972-1983, starring Alan Alda. 12. https://www.fema.gov/about-agency, Accessed 5-19-2015. 13. The Key Role of NDMS in Disaster Response. Kevin Yeskey M.D. Deputy Assistant Secretary, Director, Office of Preparedness and Emergency Operations U.S. Department of Health and Human Services Committee on Homeland Security and Governmental Affairs Subcommittee on State, Local, and Private Sector Preparedness and integration United States Senate, July 22, 2010. http://www.hhs.gov/asl/testify/2010/07/ t20100722a.html, Accessed May 22, 2015. 14. Franco C, Toner E, Waldhorn R, Inglesby TV, O’Toole T. The national disaster medical system: past, present, and suggestions for the future Biosecur Bioterror. 2007;5:319-25. 15. Herihy T. An Evaluation of the First Metropolitan Medical Strike Team. Strategic Management of Change. An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program. April, 1998. http://www.usfa.fema.gov/pdf/efop/efo28255.pdf, Accessed 5/27/2015.

REVIEW

History and Principles of Humanitarian Action Heather RYSABACK-SMITH Brown University, Department of Emergency Medicine, USA

SUMMARY Humanitarian aid has been present in some form throughout human history, yet the modern concept of humanitarian aid has only truly emerged since the later half of the 20th century. Through a complex progression of world events and largely brought about in response to armed conflict, modern humanitarian aid is provided by a multitude of organizations and actors. The purpose of this chapter is to provide a brief overview of the history of humanitarian action, a review of the principles of humanitarian aid and an overview of the major documents which delineate those principles. Keywords: Humanitarian aid; human rights.

Broadly defined, the act of providing material assistance to people in need has existed throughout human history, often in the form of food or material aid provided during famine, drought or natural disaster. Yet the modern concept and system of humanitarian aid as we know it; the impartial, independent and neutral provision of aid to those in immediate danger; has only existed since the mid part of the 20th century. Although a system of international aid first originated after World War I with the Treaty of Versallies, a broadly accepted definition and key principles of humanitarian aid have only become part of conventional wisdom since the 1990s.[1] The underpinning philosophies contributing to humanitarian action are diverse. Multiple religious beliefs such as the concept of Christian charity prevalent in the West and the Islamic tradition of Zakat are reflected, as are ethical concepts of appropriate wartime conduct.[1] Issues surrounding treatment of soldiers and civilians during conflict that has had perhaps the greatest impact on the organization of humanitarian aid into the systems we see today; the horrors of war have led to many of the principles relevant to huma-

nitarian aid. The empires of Greece and Rome were among the first to record principles that outlined acceptable conduct in wartim[1]; likewise in â&#x20AC;&#x153;The Art of Warâ&#x20AC;? Chinese general Sun Tzu alludes to appropriate conduct during wartime.[2] In more modern times the various Geneva conventions represent a modern consensus on appropriate treatment of civilians, wounded soldiers and prisoners during conflict. During the Black Death Pandemic of the Middle Ages, public health boards were created to handle isolation, quarantine and disposal of bodies and represent the very beginnings of what might be called disaster medicine.[1] Modern technologic advances in weaponry, transportation and communication in the late 1800s enabled not only destruction of human life and property on a never before seen scale; but also the communication of those events to the world at large.[1] This communication and transportation infrastructure also allowed the potential for timely organization and provision of aid for the first time in history. While today humanitarian aid is often thought of as response to natural and manmade disasters such as hurricanes, earthquakes and typhoons, it was once almost exclusively Correspondence: Heather RYSABACK-SMITH, M.D. 32 George St, Warwick, RI, 02888, USA e-mail: hrybasacksmith@lifespan.org

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related to military conflict. The concept of appropriate treatment of wounded soldiers was put forth by Swiss activist Henry Dunant in “A Memory of Solferino” proposing a permanent relief agency to provide aid to wounded soldiers and civilians during battle.[3] This book prompted the creation of the Red Cross in 1863; one of the first true international aid organizations.[4] The Red Cross received a formal mandate at the first Geneva Convention in 1864 to provide neutral and impartial assistance to civilian and military victims of conflict under the organization of national Red Cross Committees.[4] The very beginnings of international monetary aid can likewise be traced to the late 1800s with the Northern Chinese Famine of 1876-1879, which prompted one of the first formal international relief funds.[5] After World War I, the Treaty of Versailles established the League of Nations, which would become the United Nations (UN); the first permanent international organization tasked with protecting vulnerable populations and maintaining peace.[1] In 1945, the UN ratified the Universal Declaration of Human Rights, for the first time establishing an international precedent for international intervention during both civil and international conflict.[6] At the same time, multiple UN organizations such as UNICEF, the WHO and UNHCR (formerly IRO) were established. Post WWII there was a sudden and unprecedented growth of non-governmental organizations (NGOs), with over 200 organizations established in the 4 years immediately following.[1,7] Aid began to become more global with increasing advances in transportation and communication, and began to shift from Europe to the less developed parts of the world. The term “third world,” was initially used to describe countries not aligned with North Atlantic Trade Organization (first world) or the Soviet Block (second world).[9] It contained many of the poorly developed new, post-colonial governments in Africa, Latin America and Asia and thus over time became collectively used to describe those underdeveloped and impoverished countries.[9] In the post-cold war humanitarian aid began to be focused on those co-called third world countries as the ideas of development and underdevelopment began to take hold in modern society.[1,7] As NGOs proliferated, so did advertising campaigns with images of starving children, largely African; these images became the dominant Western idea of humanitarian aid which tend to persist to this day.[1] There are many controversies surrounding the modern provision of aid, which are beyond the scope of this chapter; however the modern era can be largely characterized by a shift in thinking from short term aid provision and mitigation of suffering to development, largely provided by so-called developed countries. The rapid growth of NGOs and aid or-

ganizations has been attributed to many causes, including increased need in the post-colonial era, the proliferation of both natural and manmade disasters and an increasingly integrated global system. However, it is important to note that this also points to a potential shift in political and governmental interest and funding, with as-needed provision of assistance preferred over long term and complex developmental strategy.[7] The face of humanitarian aid today is complex, with hundreds if not thousands of NGOs and other organizations from many countries providing a variety of aid and development efforts. Today, both armed conflict and natural disasters affect an ever increasing number of people. Between 1980 and 2004, and estimated two million people were killed and five billion affected by approximately 7,000 natural disasters with staggering economic and social costs.[9] Around the clock media outlets provide to the general public extensive coverage of many of these natural disasters and conflicts, and internet and social media provide easy communication, organization and fundraising. This proliferation has led to both positive and negative developments in aid provision and will likely continue to greatly impact the delivery of aid far into the future. There are four basic principles that govern humanitarian aid: Humanity, neutrality, impartiality and independence. These principles were formally established by the UN General Assembly in 1991 (humanity, impartiality and neutrality) and 2004 (independence)[10,11] and reiterated by the ICRC.[12] Humanity refers to the provision of aid to all who are in need, wherever the need exists, with the purpose to protect and respect all human beings. Neutrality is the responsibility of aid organizations not to choose sides in conflict or to favor a particular political, religious or ideological bent. Impartiality demands aid be given based on need alone and based on any other distinctions including gender, race, nationality, ethnicity, class, political party or religious belief. Finally, independence refers to the requirement that aid organizations are autonomous from any political or military objectives or with those goals in mind.[13] Several well accepted international documents elucidate and expound upon these principles. The UN Code of Conduct, signed by more than 492 aid organizations, provides a set of common standards for organizations involved in the provision of aid and a commitment to the four principles.[13] The code establishes humanitarian assistance as a right to be provided to citizens of all countries, regardless of race, creed or nationality; without political agenda and with the preservation of the recipient’s dignity and respect for the recipient’s culture.[14] It also delineates the need for transparency, capacity building and long-term planning for rebuil-

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ding and prevention of future disasters[14]; in this way it presents a framework for aid which is both present and forward thinking. The Sphere Handbook was written to develop a set of “minimum standards” for international relief to be adopted by NGOs, government and donor agencies. It was first published as a draft in 1998, and since has gone through several iterations with a cadre of international agencies and impartial observers.[15] The Sphere handbook was devised by the Sphere project, a group of international NGOs who came together with intentions to improve the effectiveness of humanitarian aid and encourage accountability of aid orgnaizations (Gostelow). Underpining humanitarian action are several major principles of humanitarian law, specifically the rules set out by the Geneva conventions of 1949. While not directly addressing aid organizations, they provide some justification for the provision of relief to civilians and wounded military and impose upon the ratifying countries the obligation to allow assistance to be provided.[7] They also insist upon the provision of aid to be impartial, humanitarian and without favoring one particular side of the conflict, thus strengthening the principles of neutrality and impartiality.[7] Today, aid workers face an increasingly complex environment fraught with controversy, political battles and multiple international organizations. This is but a brief introduction to some of the history and principles of humanitarian aid. As conflicts and disasters become more frequent and increasingly geopolitical, adherence to the basic four principles becomes ever more important. To alleviate suffering and mitigate the effects of disasters such always remain at the forefront of provision of aid.

References 1. Davey E, Borton J, M Foley. A history of the humanitarian system, Western origins and foundations. HPG Working Paper. London: Overseas Development Institute; 2013. http://www. odi.org/publications/7535-global-history-humanitarian-action 2. Sun T. The art of war. Orange Publishing, 2013. 3. Jean-Henry D. A memory of Solferino. Geneva, Switzerland:

International Committee of the Red Cross, 1986. 4. ICRC. Discover the ICRC, 2007. Available at: http://www.icrc. org/eng/resources/documents/publication/p0790.htm. Accessed June 1, 2015. 5. China Famine Relief Fund Shanghai Committee. The great famine: report of the committee of the Chine famine relief fund. Shanghai: American Presbyterian Mission Press; 1879. Available at: https://openlibrary.org/books/OL25495777M/ The_great_famine Accessed May 22, 2015. 6. Marks S. Health and human rights: basic international documents. Cambridge, USA: Harvard University Press; 2006. 7. Mackintosh K. The principles of humanitarian action in international humanitarian law, HPG Report 5. Published March 2000. Available at: http://www.odi.org/uk/hpg/publications, Accessed May 20, 2015. 8. Tomlinson BR. What was the third world. Journal of Contemporary History 2003;307-321. 9. Strömberg, D. Natural disasters, economic development, and humanitarian aid. Journal of Economic Perspectives. 2007:21:199-222. 10. United Nations. Strengthening of the coordination of humanitarian emergency assistance of the United Nations. UN resolution 46/182. Available at: http://www.un.org/documents/ga/res/46/a46r182.htm, Published December 1991. Accessed May 16, 2015. 11. United Nations. Strengthening of the coordination of humanitarian emergency assistance of the United Nations. UN resolution 58/114. Published February 2004. Accessed online May 16, 2015. 12. ICRC. Resolutions of the 26th International Conference of the Red Cross and Red Crescent, 01-01-1996. Available at: http:// www.icrc.org/eng/resources/documents/report/57jmry.htm Accessed May 15, 2015. 13. OCHA. Humanitarian principles. Available at: http://www. unocha.org/about-us/publications. Accessed May 10, 2015. 14. ICRC. Code of conduct, 1994. Available at: http://www.ifrc. org/en/publications-and-reports/code-of-conduct/ Accessed May 15, 2015. 15. The Sphere Project. Humanitarian charter and minimum standards in disaster response. Oxford, UK: Oxfam Publishing; 2004. 16. Gostelow L. The Sphere Project: the implications of making humanitarian principles and codes work. Disasters 1999;23:316-325.

REVIEW

Assessing and Planning Health Actions During a Crisis Selim SUNER Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, USA

SUMMARY Initial stage of a disaster is managed with existing resources. The following stages of disaster response often involve assistance from outside of the disaster zone. This may consist of mutual aid from neighboring communities for small-scale incidents but in major disasters, the response is from federal or international agencies or often both. Rapid needs assessment after an incident is a collaborative effort between responding agencies and local emergency preparedness and health authorities. Ideally, a team from responding agencies with intimate knowledge and experience regarding the capabilities and assets of the responding entity along with local authorities, with decision making capacity, who have knowledge of the community, the limitations of the responding agencies and can obtain near real-time information about the incident and subject matter experts (engineering, medical, law enforcement, etc.) comprise the needs assessment team. Keywords: Crisis; health action; disaster planning.

The initial hours following a disaster are almost always chaotic. Crises arising during this period are managed by resources immediately available in the community. Community preparedness allows for a rehearsed response and may mitigate some of the unforeseen complications in management of the crisis. The current recommendations for hospitals suggest an internal 72-hour reserve for medications, supplies and personnel needs in order to respond to disasters without outside support. Recommendations also specify a plan to increase capacity rapidly (surge) and have a plan to utilize alternate sites for patient care if facilities are damaged or overwhelmed during a disaster.[1] This initial stage of the disaster is managed with existing resources. The following stages of disaster response often involve assistance from outside of the disaster zone. This may consist of mutual aid from neighboring communities for small-scale incidents but in major disasters, the response is from federal or international agencies or often both. There

is no well-established universal paradigm for coordinating this response.[2] In many instances, the local authority involved in receiving aid is charged with coordination and it is during the chaotic initial response that a needs assessment must be carried out. However, this can be challenging since local authorities are often overwhelmed with response and cannot allocate appropriate resources to properly asses needs and request proper aid. It is essential to complete a thorough, comprehensive, accurate and rapid needs assessment to properly match the requirements of a community after a disaster to the available resources.[3] From relatively small events that effect a community profoundly, such as the Station nightclub fire in Rhode Island, which resulted in a mass casualty burn incident[4] to large movements of internally or externally displaced populations, seen in refugee crises after conflict,[5-6] analysis of Correspondence: Selim SUNER, M.D. 55 Claverick Street Providence, RI 02903, USA. e-mail: ssuner@brown.edu

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needs and resources must be completed prior to a response and continually reassessed. The nature of the incident weather it is a natural disaster like the devastating tsunami in the Indian Ocean in 2004 or a man-made event related to terrorism such as the destruction of the World Trade Center in NYC in 2001,[7] can determine the specific detailed content of the needs assessment, but a standard comprehensive analysis utilizing predefined variables and checklists is required for each event.[8] Rapid needs assessment after an incident is a collaborative effort between responding agencies and local emergency preparedness and health authorities. Ideally, a team from responding agencies with intimate knowledge and experience regarding the capabilities and assets of the responding entity along with local authorities, with decision making capacity, who have knowledge of the community, the limitations of the responding agencies and can obtain near real-time information about the incident and subject matter experts (engineering, medical, law enforcement, etc.) comprise the needs assessment team. Even prior to arriving on the scene, the team may be able to gather essential information. Sources of information may be from news outlets, radio or phone communications, sources on the worldwide-web, satellite images, or even classified information in certain cases. The team should utilize checklists, triage, survey and other tools to systematically review the impact of the disaster on the community akin to a hazard and vulnerability analysis. The team should have access to ground and air transportation and any resources, which could aid in a complete assessment, such as street cameras, access to health care facilities, etc. While priority should be given to medical system assessment, initially, shelter, food and water assessment should also be performed simultaneously by subject matter experts. Often, each large aid organization and different branches of federal agencies will perform a needs assessment separately. While in some cases, this is appropriate due to the vastly different types of services provided by different agencies, coordination and information sharing should be conducted. If a unified incident command system is utilized the joint incident command center can facilitate this function. While assessment if initial health needs should be a rapid assessment to facilitate initial movement of health care teams into the disaster site, periodic reassessment is necessary to optimize resources. Also, after the initial broad assessment, follow-up appraisals may be necessary to identify specific niche needs such as evolving infectious disease outbreaks, need for mass vaccination or specialty needs such as â&#x20AC;&#x153;burn nursesâ&#x20AC;? as in the Station Night Club Fire incident in RI. These follow-on assessments may utilize data collection or survey methods and may take longer to complete.[9] An example

of a needs assessment leading to a focused response was during the Station nightclub fire in Rhode Island. Following the incident all emergency departments were involved in the acute care of patients, which were transported from the scene. The acute phase of the response was over in 8 hours. However, the trauma and burn center, Rhode Island Hospital had admitted many of the patients with large surface area burns. A rapids needs analysis conducted revealed the requirement specialty burn nurses to augment the nursing staff at Rhode Island Hospital. The National Disaster Medical System was able to deploy these specific assets to assist the hospital staff rather than activating an entire Disaster Medical Assistance Team (DMAT). Some of the assessment categories include: Environmental and building assessment Egress and access assessment Communications assessment Safety issues for responders Cultural issues for responders Responder needs (water, food, shelter, safety, specialty items such as hard hats, respirators, etc.) Current impact on local health care structure (can it provide day to day basic health maintenance needs?), Impact on local health care workers (are they able to go to work?) Support structures Vulnerable populations are often those, which suffer the most in the wake of a disaster. Children, the elderly, those who are bed-bound or with limited mobility, suffering from chronic debilitating illness and the mentally ill are some examples of the most vulnerable in the aftermath of a disaster. A thorough assessment must take into consideration the special needs of this population such as mobility requirements, accessibility, reliance on electrical power (respirators, LVAD, refrigeration for insulin), dialysis, daily wound care (diabetic ulcers, burn care, etc.).[10-11] While emergency healthcare is at the forefront of response considerations, often the lack ongoing daily preventative care and health maintenance provided by community and primary care organizations can lead to down-stream health crises. For example, during the widespread structural devastation seen after hurricane Katrina, many primary care offices were closed, health records destroyed and pharmacies inaccessible for a prolonged period. Many patients who relied on ongoing health maintenance, particularly for diabetes, cardiovascular disorders and hypertension were unable access their healthcare provider, get refills on their medications or even fill their prescriptions. This lead to increase use of emergency

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care facilities, set up by responding agencies, which were geared for acute care. These facilities were ill-prepared, equipped and staffed to manage chronic care issues. Over the past decade there has been increasing experimental use of advanced technology in disaster medicine. These technologies may be utilized in the assessment after disasters. Utilizing existing sources of large data deposits, such as real-time surveillance systems and hospital electronic medical records, illness and injury patterns in a community after a disaster can be discerned. Other technologies such as drones, which have been utilized to aid in search and rescue operations can also be used for birds-eye viewing.[12] and mass electronic communication schemes utilizing texting or social media may aid in the initial and follow-up needs assessments. Coupled with advanced mathematical modeling and use of global information systems (GIS) may lead to a more thorough and systematic appraisal.[13-15]

References 1. Waeckerle JF1. Disaster planning and response. N Engl J Med 1991;324:815–21. 2. Friedman E. Coping with calamity. How well does health care disaster planning work? JAMA 1994;272:1875–9. 3. Lillibridge SR, Noji EK, Burkle FM Jr. Disaster assessment: the emergency health evaluation of a population affected by a disaster. Ann Emerg Med 1993;22:1715–20. 4. Gutman D, Biffl WL, Suner S, Cioffi WG. The station nightclub fire and disaster preparedness in Rhode Island. Med Health R I 2003;86:344–6. 5. Margoluis RA, Franklin RR, Bertrend WF, Sellers TA. Rapid post-disaster community needs assessment: a case study of guatemala after the civil strife of 1979-1983. Disasters 1989;13:287–99. 6. Daley WR, Karpati A, Sheik M. Needs assessment of the dis-

placed population following the August 1999 earthquake in Turkey. Disasters 2001;25:67–75. 7. Suner S. On-site medical care during the September 11th WTC terrorist attack rescue and recovery effort and the National Disaster Medical System (NDMS). Med Health R I 2003;86:354–6. 8. Guha-Sapir D. Rapid assessment of health needs in mass emergencies: review of current concepts and methods. World Health Stat Q 1991;44:171–81. 9. Centers for Disease Control and Prevention (CDC). Assessment of health-related needs after Hurricanes Katrina and Rita-Orleans and Jefferson Parishes, New Orleans area, Louisiana, October 17-22, 2005. MMWR Morb Mortal Wkly Rep 2006;55:38–41. 10. Dyer CB, Regev M, Burnett J, Festa N, Cloyd B. SWiFT: a rapid triage tool for vulnerable older adults in disaster situations. Disaster Med Public Health Prep 2008;2 Suppl 1:45–50. 11. Coker AL, Hanks JS, Eggleston KS, Risser J, Tee PG, Chronister KJ, et al. Social and mental health needs assessment of Katrina evacuees. Disaster Manag Response 2006;4:88–94. 12. Tatham P. An Investigation into the Suitability of the use of Unmanned Aerial Vehicle Systems (UAVS) to Support the Initial Needs Assessment Process in Rapid Onset Humanitarian Disasters. International Journal of Risk Assessment and Management 2009;13:60–5. 13. Hlady WG, Quenemoen LE, Armenia-Cope RR, Hurt KJ, Malilay J, Noji EK, et al. Use of a modified cluster sampling method to perform rapid needs assessment after Hurricane Andrew. Ann Emerg Med 1994;23:719–25. 14. Anker M. Epidemiological and statistical methods for rapid health assessment: introduction. World Health Stat Q 1991;44:94–7. 15. Waring S, Zakos-Feliberti A, Wood R, Stone M, Padgett P, Arafat R. The utility of geographic information systems (GIS) in rapid epidemiological assessments following weather-related disasters: methodological issues based on the Tropical Storm Allison Experience. Int J Hyg Environ Health 2005;208:109–16.

REVIEW

Field Organization and Disaster Medical Assistance Teams Ibrahim ARZIMAN Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara, Turkey

SUMMARY Disasters cause an acute deterioration in all stages of life. An area affected by the disaster in which the normal activities of life are disrupted is described as a “Field” in disaster terminology. Although it is not easy to define the borders of this zone, the area where there is normally functioning society is accepted as the boundary. Disaster management is the responsibility of the local government. However, in many large disaster responses many non-governmental and international organizations play a role. A Disaster Medical Team is a trained, mobile, self-contained, self-sufficient, multidisciplinary medical team that can act in the acute phase of a sudden-onset disaster (48 to 72 hours after its occurrence) to provide medical treatment in the affected area. The medical team can include physicians, nurses, paramedics and EMTS, technicians, personnel to manage logistics, security and others. Various models of Disaster Medical Teams can be observed around the world. There is paucity of evidence based literature regarding DMTs. There is a need for epidemiological studies with rigorous designs and sampling. In this section of the special edition of the journal, field organizations in health management during disasters will be summarized, with emphasis on preparedness and response phases, and disaster medical teams will be discussed. Keywords: Field organization; disaster; medical team; DMAT.

Introduction Disasters cause an acute deterioration in all stages of life. The effects of disaster on the community and the scope of these effects may be explained by Maslow’s Hierarchy of Basic Human Needs.[1] In the pyramid of Maslow’s Hierarchy of Needs, the first and the basic steps consist of physiological and security needs (figure 1).[2] Although disasters with a large magnitude damage all levels of this pyramid, the fear and chaos experienced at the community level mostly are caused by the damage at the first step. Disaster management can be described as a systematic method to strengthen the pyramid or to provide resiliance before a disaster occurs. When the disaster strikes these principles also dictate how

to rebuild the pyramid. Health Management covers the first step of the Maslow’s Pyramid and is one of the most important responses in the early phases of a disaster incident. At the same time, disaster management should include various factors other than health concerns which require an equal emphasis. An area affected by the disaster in which the normal activities of life are disrupted is described as a “Field” in disaster terminology. Although it is not easy to define the borders of this zone, the area where there is normally functioning society is accepted as the boundary. In this section of the special edition of the journal, field organization in health management during disasters will be summarized, with emphasis on preparedness and response phases.

Correspondence: İbrahim Arzıman, M.D. Gulhane Military Medical Academy Department of Emergency Medicine, Ankara, Turkey. e-mail: ibrahimarz@hotmail.com

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Disaster management is the responsibility of the local government. However, in many large disaster responses many non-governmental and international organizations play a role.[3] Some organizations involved in disaster management and humanitarian assistance are listed in table 1.[3,5] The Incident Command System (ICS), first established in the 1970s in the U.S., for firefighters in the forest service and later adapted for all disaster and emergency situations, provides tenants of response organization.[6,7] ICS consists of effective command and control, safety, information processing and public information, liaison and operation elements (figure 2). Many intervention consisting of health concerns include planning, logistics and finance. The system is based on the principle that, a single command, a single action manager, a single unit manager and a single individual for a single job must exist with a limited and manageable scope of control.[8] Preparation for Field Response Preparation for the field response is in essence a risk management process and it should begin with risk analysis. High-risk emergencies and disasters and the health effects that will be caused by these events should be determined beforehand. These can be used to create a solid database to determine the steps that should be taken. During any disaster the initial response to help affected people come from bystanders and community citizens rather than professionals or rescue organizations. For this reason basic skills in search, rescue and first aid skills should be instilled in the general population akin to civil defense programs

taught in schools during the cold war in the United States. Currently, fire drills and most recently, active shooter drills which have become ubiquitous in schools could be adapted to include basics of staying alive and helping neighbors in need during mass casualty events. These programs could be customized using a hazard and vulnerability analysis of the community. The main objective of health services in disasters is to save lives and maintain the health of the community. A continuous service flow should be created beginning from the disaster scene to final treatment centers. In the early phase after a large disaster there is often a shortage of both search and rescue activities and medical services. These difficulties are can be mitigated by creating mobile medical units outside the disaster zone, equipped with rapid response capabilities and combining basic search-rescue skills with effective emergency medical services. These units are generally known as Disaster Medical Teams (DMT) and they will be discussed further in this manuscript. [DMAT is a specific team in the US and does not perform search and rescue, only medical treatment] In the organization of field response, deciding the responsibilities of personnel and establishing job descriptions are the initial steps to take. It should be very clear who will do what, when and how. In this context, it should be very clear who the incident manager is, who will provide the security and traffic flow, who will be liaison and coordinate the units, and who will collect information, process and provide feedback. During the pre-disaster phase, the locations for a

Command

Safety

Information

Liasion

Planning

Logistic

Figure 1. Incident command system.

Finance

Operations

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morality creativity spontaneity problem solving lack of prejudice acceptance of facts

Self-actualization

Esteem Love/Belonging

Safety Physiological

self-esteem confidence, achievement, respect of other, respect by other friendship, family, sexual intimacy security of body, of employment, of resources, of morality, of the family, of health, of property breathing, food, water, sex, sleep, homeostasis, excretion

Figure 2. The pyramid of Maslowâ&#x20AC;&#x2122;s Hierarchy of Needs.

command center with alternative, collecting points for the disaster management personnel and casualty collecting points for injured and non-injured people, collecting points for dead bodies, temporary treatment points should be established and communication and coordination methods between these areas established. For the command centers, an area resistant to the effects of the disaster and fully endowed with communication equipment should be chosen and alternative area identified for backup.[9] During the September 11, 2001 attacks in New York City, the initial command post along with many rescue vehicles were decimated by the collapsing buildings and a backup plan was rapidly established. A safe location with easy access to the disaster zone, should be chosen as collecting points. Casualty collecting points are a priority. These locations should be easily accessible to land and aerial vehicles (and marine vehicles if the location is amenable). Stadiums, parks and, airports (if coordinated and organized) are the preferred places for creating collecting points since easy access is built into these locations. Ice skating rinks, and cold storage facilities may be suitable alternatives as collecting points for the deceased. Proper organization of casualty collecting points is essential for rapid flow of wounded. Secure and controlled entry and exit, secondary triage following the entry point, treatment

areas segregated by triage levels and transportation areas for evacuation should be deliniated.[10] Mobile healthcare facilities may be integrated, next to or near existing health care facilities (even if they are non-functional). Preferably dead bodies should be collected in a separate location. Field organization for post disaster phase: In the early post disaster phase, a rapid needs assessment survey of the disaster area must be completed and the emergency action plan must be implemented. In disasters with a small magnitude, adequate information can be gathered from the teams that first respond, but in large disasters that affect an extended area like earthquakes, the magnitude of the disaster and its health effects can be determined more accurately from the air. The number of probable casualties and wounded, and the number of operational healthcare facilities and their current staffing, should be determined rapidly. Safety is one of the important issues in this early phase. The disaster zone should be encircled in a security belt and all the traffic flow in and out of the area tightly controlled. An effective communication network is one of the key points of a successful disaster management plan.[11] In disasters that affect a large area it is appropriate to divide the area based on the placement of casualty collecting points. Medical management should begin with secondary

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Table 1. Demographic and clinical characteristics of patients 1.

Action Against Hunger

2. ALERTNET 3.

The Andean Committee for Disaster Prevention and Assistance (CAPRADE)

CARE International

The Caribbean Disaster and Emergency Response Agency (CDERA)

Center for Disaster and Humanitarian Assistance Medicine (CDHAM)

El Centro de Coordinacion para la Prevencion de los Desastres NAturales en America Central (CEPREDENAC)

Center for Research on the Epidemiology of Disasters (CRED)

El Centro Regional de Informacion sobre Desastres (CRID)

10. Doctors without Boarders/ Medecins Sans Frontieres 11. The Disaster and Emergency Management Authority (AFAD) 12. Florida International University (FIU) 13. Global Center for Disaster Management and Humanitarian Action (Global-CDMHA) 14. The Humanitarian Practice Network (HPN) 15. InterAction 16. International Federation of the Red Cross and Red Crescent Societies (IFRC) 17. The Integrated Regional Information Networks (IRIN) 18. Organization of American States (OAS) 19. Office for the Coordination of Humanitarian Affairs (OCHA) 20. The Office of U.S. Foreign Disaster Assistance (OFDA) 21. ONEWORLD.NET 22. Oxfam International 23. Pan American Health Organization (PAHO) 24. ReliefWeb 25. The Sphere Project 26. United Nations Development Programme (UNDP) 27. United Nations High Commissioner for Refugees (UNHCR) 28. United Nations International Children’s Emergency Fund (UNICEF) 29. University of Wisconsin – Disaster Management Center (UW-DMC) 30. World Food Programme (WFP) 31. World Vision International

triage at the entry point (primary triage is conducted at the scene). The START triage methodology is an accepted mode in field triage. Patients should be channeled to the treatment areas according to their triage levels. During the treatment phase, patients’ need of surgery or other specialized treatment options requiring evacuation should be taken into consideration. When transporting patients for care, the current capacities of the healthcare facility in the area should be determined. The priority of patient transportation should be based on triage level and hospital capacity. In the initial hours after a disaster, transportation of patients with non-lethal trauma should be delayed. This can be more effectively accomplished if there are properly equipped and trained teams consisting of healthcare provi-

ders who can respond from the hospital to the scene. In the post disaster phase, receiving outside assistance can be considered as the second step for the field organization. Integration of outside resources into the response can be challenging. Entry to the disaster zone should be controlled and if possible medical relief resources should be managed by a single authority. The uncontrolled flow of personnel and haphazard relief supplies in the disaster zone can be at worst hazardous and often a waste of vital resources. At this stage, the performance and morale of the personnel working in the disaster zone should be evaluated and any sign of burn-out or stress should be addressed accordingly.

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The long term goal for healthcare services is to recreate the infrastructure including public health services, providing psychological and psychiatric support, providing health services for chronic patients who need frequent follow up. These are all efforts for recovery of a normal healthcare system. Healthcare services should be coordinated with other services during a disaster situation. Before and during the recovery phase, acute medical emergencies should be managed effectively while the basic needs of the individuals such as water, food, clothing, shelter and security should be maintained. Field operations during CBRN-E incidents: CBRN-E incidents have specific management considerations in disaster management. These incidents cause a disproportionately high psychological impact and even a small suspicion can trigger a massive wave of fear and panic in the community. Rumors of a chemical attack during the initial days of the rescue operation in NYC on 9-11-2001 caused a level of panic among responders and irrational operational adjustments. In order to manage these incidents properly, well trained professionals using special protective and detection equipment, unique medications, rarely used in day to day patient care, special decontamination units and regimented safety protocols are needed. Maintaining teams and equipment is expensive requiring extensive financial and organizational recourses. For this reason, a community-wide risk analysis is required to determine the number of personnel and equipment required to respond CBRN-E incidents, and the distribution of these teams. Ideally CBRN-E incidents should be managed mostly at the incident zone by determining hot, warm and cold zones according to risk levels and provide proper decontamination and initial treatment in these zones and transport only patients who have been decontaminated. In reality, patients still reach destination hospital without initial decontamination and treatment either by self-transporting or due to lack of rapid response teams to properly manage care (the flooding of emergency departments with contaminated patients after the Tokyo Sarin attacks in the mid 1990â&#x20AC;&#x2122;s is a good example of this phenomenon). Disaster response plans should be constantly revised and refined by repeated exercises and real world experiences. Disaster Medical Teams (DMTs) In 2013, approximately 100 million people were affected by disasters, and for the last decade this figure was 2 billion.[12] The majority of affected people were living in countries of medium and low income.[12] Even within developed countries, large scale disasters will occur. In large disasters, the preparedness most countries will be unable to meet the de-

mands of numbers of injured patients. There may be request for disaster medical and humanitarian aid following such disasters, which will require rapid mobilization of national and international resources.[13-17] A DMT is a trained, mobile, self-contained, self-sufficient, multidisciplinary medical team that can act in the acute phase of a sudden-onset disaster (48 to 72 hours after its occurrence) to provide medical treatment in the affected area.[18-20] The medical team can include physicians, nurses, paramedics and EMTS, technicians, personnel to manage logistics, security and others.[21] Various models of DMTS can be observed around the world. Some are detailed below: 1. USA The National Disaster Medical System (NDMS) is a federally coordinated system within the US Department of Health and Human Services that serves the Federal response by providing disaster medical care to the US and more recently with responses to the Bam Earthquake in Iran and the Earthquake in Haiti, to the world. NDMS can provide medical response to disaster area in the form of personnel, teams, supplies, and equipment, patient movement from a disaster site to unaffected areas, and definitive medical care at participating hospitals in unaffected areas.[22] NDMS Response Teams are Disaster Medical Assistance Teams (DMAT), Disaster Mortuary Operational Response Teams (DMORT), International Medical Surgical Response Team (IMSURT), and National Veterinary Response Team (NVRT).[23] A DMAT is a 35-member team of physicians, nurses, emergency medical technicians, pharmacists, and support personnel.[24] DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours, and the members are activated for two weeks on average.[18] There are currently 80 DMATs in the United States.[25] DMATs are principally a community resource available to support local, regional, and State requirements. However, as a national resource they can be federalized. DMAT personnel carry appropriate certifications and licensure. DMAT personnel may be paid while serving as intermittent federal employees and have the protection of the Federal Tort Claims Act.[18] 2. Canada The Disaster Assistance Response Team (DART) is a 200-Canadian Armed Forces (CAF) member military organization that can be deployed internationally in response to situati-

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ons ranging from natural disasters to complex humanitarian emergencies. DART was created by the Canadian government in 1996.[26,27] The DART can provide assistance for up to 40 days. Interestingly, the DART is not designed to provide first response services, such as search and rescue or emergency trauma care. They serve three critical needs in emergencies: 1. Water purification 2. Primary medical care 3. Engineering assistance.[27] The primary responsibilities of the DART are stabilizing the primary effects of the disaster, preventing sudden onset of the secondary effects of the disaster, and providing a time buffer for humanitarian aid organizations to deploy to the devastated area and preparing to deliver long-term recovery programs.[27] DART is composed of 6 main elements: 1. DART Headquarters (about 45 CAF members) 2. DART Company Headquarters (about 10 CAF members) 3. Engineer Troop (about 40 CAF members): 4. Medical Platoon (about 45 CAF members) 5. Logistics Platoon (about 20 CAF members) 6. Defence and Security Platoon (about 45 CAF members).[27] 3. Japan Japanese DMATs (J-DMATs) are different from US-DMATs, because the natures of disasters that can occur in these two countries are different. Earthquakes are the most common natural disasters in Japan while weather-related disasters are the more common in the United States.[20,21] J-DMATs are established in 2005 under the control of the Ministry of Health, Labor and Welfare. There were more than 700 DMATs in Japan in March 2010.[28] As of 2010, there are 4557 registered J-DMAT personnel, with734 separate J-DMATs in 393 medical facilities across the country.[20] The J-DMATs are smaller than US-DMATs, with 5-6 personnel; 1 or 2 medical doctors, 2 or 3 nurses, and 1 or 2 logisticians. J-DMATs are self-sufficient for 72 hours.[20] The activities of J-DMAT are medical data collection and communication in devastated areas, the 3Ts (triage, treatment, transport), providing medical support to hospitals, supporting staging care units, in-flight treatment of victims being evacuated, and supervision of emergency medical technicians.[20] It is estimated that Japanese DMATs have prevented up to 500 deaths following the Great East Japan Earthquake.[28,29] Unlike US-DMATs, J-DMATs do not participate in international missions, Japan supports international missions with medical teams dispatched by Japan Disaster Relief (JDR) that

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operates under Japan International Cooperation Agency (JICA).[20] 4. Israel Israel uses a model that is based on military personnel with civilian reservists.[30] They have the ability to integrate civilian and military agencies at all levels.[31] This model is a good example of civil-military cooperation and integration. This strategic, flexible approach may be more difficult to implement in other countries.[30,32] 5. Turkey After the 1999 Earthquakes, the government in Turkey reorganized the disaster and emergency management organization. Within the scope of Health Organization in Disasters Project, National Medical Rescue Teams (NMRT) were established in 2004 under the ministry of health.[33] A NMRT is a 5 person healthcare team with at least one doctor. Based on different local risks, NMRTs are may include mountain rescue teams, water rescue teams, CBRN teams, air rescue and/or evacuation teams. The Ministry of Health determines which teams will be established in which cities based on need and risk assessment. NMRTs also participates in international response missions.[34] Turkey is divided into 21 NMRT regions, and there are currently 4909 NMRT members in 81 cities, and approximately 6000 NMRT volunteers.[33] Consideration about DMTs Frequently there are delays in mobilizing DMTs, with most not arriving for 3 days or more after the event.[30] Most of the immediate care is provided by local personnel. Teams with sufficient flexibility to deploy rapidly would greatly enhance effectiveness. For an efficient response, limited resources must match the needs. This makes rapid needs assessment an essential component of initial response. To prevent delays in the deployment process pre-arranged agreements, transportation solutions and for international response, customs procedures should be determined before deployment. Sufficiently agile and multidisciplinary DMTs with appropriate training and predefined strategies management will most effective.[35] Due to the increasing complexity of humanitarian operations, a new multi-disciplinary approach for training and skills development is required.[36] There is a need for training of all members in use of basic equipment like communication gear, tents, shelters and water purification systems.[37] Lectures, simulated training in primary care and radiological emergencies should be included in the DMT training curriculae.[28] Peller et al. emphasized the importance

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of context in developing an evidence base for competency training in disaster response and management.[38] Timely topics like hospital evacuation, preparations to receive DMATs at damaged hospitals, coordination when DMAT activities are prolonged, safety management and communication when helicopters were on board have been added to the revised Japanese DMAT training program after the Great East Japan Earthquake.[39] A study of Australian DMT members showed that there should be more emphasis on the education and training, and leadership training has been considered as essential for DMT commanders.[40] DMATs must be self-sufficient for a minimum period of 72 hours.[37] The teams should bring their own equipment, pharmaceuticals, food, water and shelter. All members of the team should be able to use basic equipment. Logistics, funding, insurance issues should be addressed before deployment. Each organization should develop its own logistics capacity.[37] Communication, command control structure and information sharing are essential elements for DMTs. Also proper communication, both language and cultural, with the local population is essential particularly in international deployments. Using bilingual staff, offering language training and the use of interpreters can be viable solutions (30). Cultural factors and sensitivity should be taken into consideration. The selection of the members of the team will add to the success of the DMAT. Skill is not the only criteria to be chosen as a member of the team, teamwork and the ability of successfully carrying out the work required in the field are also desirable.[13,41] Personal characteristics such as experience and availability, personality, motivation, physical health, teamwork should be taken into consideration.[30] The members should be in good physical and mental health.[13,42,43] Stress management training and pre-deployment briefings are needed for all members as well as routine screening by a trained professional during deployment. Immunizations, of team members should to be current and reflect the geography of the response.[13,44] Sufficient stocks of personal medications, special issues like chemoprophylaxis against malaria and PEP for HIV are also suggested.[44,45] The other pre deployment health considerations are sunscreen, vector control, security of food and water.[13] Travel health consultation should be completed for deployments involving tropical locales or areas with specific health concerns before deployment are needed for DMT members.[44] Fatigue, morale management and sanitation are main factors that affect personal comfort, hygiene and health during deployment.[30]

Debriefing and follow up should occur at regular intervals during and after deployment. Along formal debriefings, psychological debriefings and medical examinations are needed.[13] 24% of the Turkish Red Crescent Disaster Relief team suffered from post-traumatic stress disorder after Asian tsunami deployment.[46] Leggat et al. emphasized that organizations should ensure that potential DMT members have a rigorous selection process, medical, dental and psychological screening, appropriate training, adequate security, health and safety intelligence for the area of support, adequate briefing and debriefing, travel health advice, access to medical care and welfare in the field, and an exit strategy and aeromedical evacuation. [17]

In conclusion, there is paucity of evidence based literature regarding DMTs. Most of the articles are descriptive. There is a need for epidemiological studies with rigorous designs and sampling. Cost-effectiveness of DMTs should be discussed. Each disaster is different, and the priorities and the needs will change. Lack of non-medical necessities such as drinking water, sanitation, food, shelter may be more pressing than healthcare needs in certain incidents. As the need for disaster relief work grows, evidence-based standardization becomes essential. International rules, standards and laws are needed for international missions. Improved guidelines for response, and global coordination with teams should be developed.

References 1. Donahue DA, Cunnion SO, Balaban CD, Sochats K. The all needs approach to emergency response. The Journal of the NPS Center for Homeland Defense and Security. Available at: https://www.hsaj.org/articles/204 (Accessed 30.05.2015). 2. Available at: http://commons.wikimedia.org/wiki/ File:Maslowâ&#x20AC;&#x2122;s_Hierarchy_of_Needs.svg (Accessed 30.05.2015). 3. Mothershead JL. Local disaster response. In: Ciontone GR, Darling RG, Anderson PD, Auf Der Heide E, Jacoby I, Noji E, Suner S. Disaster medicine. 3rd edition. PA, USA. ElsevierMosby; 2006. p. 84-90. 4. Available at: http://www.hsc.usf.edu/nocms/publichealth/ cdmha/toolkit_dm/Organizations_English.pdf (Accessed 30.05.2015). 5. Available at: https://www.afad.gov.tr/EN/Index.aspx (Accessed 30.05.2015). 6. Bradt DA. Site management of health issues in the 2001 World Trade Center disaster. Acad Emerg Med 2003;10:65060. 7. Briggs SM, Disaster management teams. Curr Opin Crit Care 2005;11:585-9. 8. Disaster management: In Prehospital Trauma Life Support, Prehospital Trauma Life Support Committee of The National

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Association of Emergency Medical Technicians in cooperation with the Committee on Trauma of the American College for Surgeons, Military. 8th edition. Chapter 19, p. 487-509. 9. Incident command center. Available at: http://www.downstate.edu/emergency_medicine/pdf/KCHCSection02.pdf (Accessed 30.05.2015). 10. Casualty Collection Point (CCP) Field Treatment Site. Available at: http://www.smgov.net/departments/oem/sems/operations/casualty-collection-point-field-treatment-site.pdf (Accessed 30.05.2015). 11. Nicolai B, Winer C, Keyuan J. Command Center for Disaster Management Communication System Data Warehouse Focus Area: Resource Allocation. Available at: http://webs.purduecal.edu/techgrad/files/2010/10/Directed_Project_Proposal_Mark_Kapocius_Spring-11.pdf (Accessed 30.05.2015). 12. Matsha-Carpentier, Naylor D. World Disasters Report 2014 International Federation of Red Cross and Red Crescent Societies. p. 220-2 Available at: https://www.ifrc.org/Global/ Documents/Secretariat/201410/WDR%202014.pdf. 13. Aitken P, Leggat P, Robertson A, Harley H, Speare R, Leclercq M. Pre- and post-deployment health support provided to Australian disaster medical assistance team members: results of a national survey. Travel Med Infect Dis 2009;7:305-11. 14. Rosenfeld JV, Fitzgerald M, Kossmann T, Pearce A, Joseph A, Tan G, Gardner M, Shapira S. Is the Australian hospital system adequately prepared for terrorism? Med J Aust 2005;183:56770. 15. Russbach R. International Assistance Operations in Disaster Situations. Prehosp Disast Med 1990;5:247-9. 16. Dara SI, Ashton RW, Farmer JC, Carlton PK Jr. Worldwide disaster medical response: an historical perspective. Crit Care Med 2005;33(1 Suppl):S2-6. 17. Leggat PA, Aitken P. Ensuring the health and safety of civilian disaster medical assistance teams. Travel Med Infect Dis 2007;5:324-6. 18. Available at: http://www.phe.gov/Preparedness/responders/ ndms/teams/Pages/dmat.aspx (Accessed 30.05.2015). 19. Kondo H, Koido Y, Morino K, Homma M, Otomo Y, Yamamoto Y, Henmi H. Establishing disaster medical assistance teams in Japan. Prehosp Disaster Med 2009;24:556-64. 20. Fuse A, Yokota H. An analysis of Japan Disaster Medical Assistance Team (J-DMAT) deployments in comparison with those of J-DMAT’s counterpart in the United States (US-DMAT). J Nippon Med Sch 2010;77:318-24. 21. Mace SE, Jones JT, Bern AI. An analysis of Disaster Medical Assistance Team (DMAT) deployments in the United States. Prehosp Emerg Care 2007;11:30-5. 22. Available at: http://www.phe.gov/Preparedness/responders/ ndms/Pages/default.aspx (Accessed 30.05.2015). 23. Available at: http://www.phe.gov/Preparedness/responders/ ndms/teams/Pages/default.aspx (Accessed 30.05.2015). 24. Sklar DP, Richards M, Shah M, Roth P. Responding to disasters: academic medical centers’ responsibilities and opportunities. Acad Med 2007;82:797-800. 25. Stopford BM. The National Disaster Medical System--America’s medical readiness force. Disaster Manag Response

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2005;3:53-6. 26. McCurdy I. DART: disaster assistance response team. IAEM Bull 1999;16:19-20. 27. Available at: http://www.forces.gc.ca/en/operations-abroadrecurring/dart.page (Accessed 30.05.2015) 28. Ushizawa H, Foxwell AR, Bice S, Matsui T, Ueki Y, Tosaka N, Shoko T, Aiboshi J, Otomo Y. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveill Response J 2013;4:51-5. 29. Japanese Association for Disaster Medicine. Lessons learnt from Great Hanshin-Awaji Earthquake-preventable death. DMAT standart text. Tokyo, Health Publishing Co., 2011, 8-10. 30. Anton Breinl Centre for Public Health and Tropical Medicine, James Cook University, Health Protection Group. Disaster Medical Assistance Teams: A Literature Review 2006, Available at: http://www.public.health.wa.gov.au/cproot/347/2/ disaster%20medical%20assistance%20teams%20literature%20review%202006.pdf (Accessed 30.05.2015). 31. Benin-Goren O, Blumenfeld A. Internalization of medical protocols during medical responses to conventional and unconventional mass-casualty incidents. Prehosp Disast Med 2005;20;85-6. 32. Bar-Dayan Y, Leiba A, Beard P, Mankuta D, Engelhart D, Beer Y, Lynn M, Weiss Y, Martonovits G, Benedek P, Goldberg A. A multidisciplinary field hospital as a substitute for medical hospital care in the aftermath of an earthquake: the experience of the Israeli Defense Forces Field Hospital in Duzce, Turkey, 1999. Prehosp Disaster Med 2005;20:103-6. 33. Available at: http://www.umke.org/umke-nedir-s3.html (Accessed 30.05.2015). 34. Afetlerde sağlık hizmetleri birimi ve ulusal medikal kurtarma ekiplerinin görevleri ve çalışma esaslarına dair yönerge. 2010. 35. Aitken P, Leggat P, Harley H, Speare R, Leclercq M. Human resources issues and Australian Disaster Medical Assistance Teams: results of a national survey of team members. Emerg Health Threats J 2012;5. 36. Elsharkawi H, Sandbladh H, Aloudat T, Girardau A, Tjoflat I, Brunnström C. Preparing humanitarian workers for disaster response: a Red Cross/Red Crescent field training model. Humanitarian Exchange Magazine 2010 March, issue 46. 37. Aitken P, Leggat P, Harley H, Speare R, Leclercq M. Logistic support provided to Australian disaster medical assistance teams: results of a national survey of team members. Emerg Health Threats J 2012;5. 38. Peller J, Schwartz B, Kitto S. Nonclinical core competencies and effects of interprofessional teamwork in disaster and emergency response training and practice: a pilot study. Disaster Med Public Health Prep 2013;7:395-402. 39. Anan H, Akasaka O, Kondo H, Nakayama S, Morino K, Homma M, Koido Y, Otomo Y. Experience from the Great East Japan Earthquake Response as the Basis for Revising the Japanese Disaster Medical Assistance Team (DMAT) Training Program. Disaster Med Public Health Prep 2014;8:477-84. 40. Aitken P, Leggat PA, Robertson AG, Harley H, Speare R, Leclercq MG. Education and training of Australian disaster medical assistance team members: results of a national survey. Prehosp Disaster Med 2011;26:41-8.

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41. Holland J, Wooster P. International rescue team: selection and training. Crisis Resp J 2004;1:51–4. 42. Palmer I. Psychological aspects of providing medical humanitarian aid. BMJ 2005;331:152–4. 43. Cruz-Vega F, Sun C, Brink B, Bugslag R, Gonzalez Del Castillo B, Hastings P.et al, 5th Asia-Pacific conference on disaster medicine. Theme 6: multidisciplinary team interaction: Summary and action plan. Prehosp Disast Med 2001;16:39-41.

44. Birch M, Miller S. Humanitarian assistance: Standards, skills, training and experience. BMJ 2005;330:1199–201. 45. Abrams T. The feasibility of prehospital medical response teams for foreign disaster assistance. Prehosp Disast Med 1990;5:241-6. 46. Armagan E, Engindeniz Z, Devay AO, Erdur B, Ozcakir A. Frequency of post-traumatic stress disorder among relief workers after the tsunami in Asia: do rescuers become victims?. Prehosp Disast Med 2006;21:168–72.

REVIEW

Communicable Diseases and Outbreak Control Jonathan AMELI Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, USA

SUMMARY Infectious disease during an emergency condition can raise the death rate 60 times in comparison to other causes including trauma. An epidemic, or outbreak, can occur when several aspects of the agent (pathogen), population (hosts), and the environment create an ideal situation for spread. Overcrowding, poor regional design and hygiene due to poverty, dirty drinking water, rapid climate changes, and natural disasters, can lead to conditions that allow easier transmission of disease. Once it has been established that an emergency condition exists, there must be a prompt and thorough response for communicable disease control. A camp should be created, and the disease managed rapidly. The overall goals are rapid assessment, prevention, surveillance, outbreak control, and disease management. Keywords: Communicable disease; outbreak control; disaster; prevention; surveillance.

Introduction

Emergency Department Precautions

Infectious or communicable disease can be defined as an illness caused by another living agent, or its products, that can be spread from one person to another.[1] An emergency condition can be defined as a state of disarray that has occurred during or after a regional conflict, or a natural disaster (i.e.: flood, earthquake, hurricane, drought).

The emergency department (ED) is the front line response system in many developed countries, and can act as the primary entry method for several communicable diseases. Prevention of transmission is paramount in keeping the ED a safe environment and limiting spread.

Infectious disease during an emergency condition can raise the death rate 60 times in comparison to other causes including trauma.[2] Greater than 40% of deaths in emergency conditions occur secondary to diarrheal illness with 80% of those involving children less than 2 years of age.[3] Of note, there is no dependable performance assessment tool in improving communicable disease surveillance in regards to outbreaks of infectious disease although the Centers for Disease Control (CDC) has proposed viable mechanisms for public health in general.[1]

Hand hygiene prevents harboring transient flora (including Staphylococcus aureus, Clostridium difficile among others) by reduction of bacterial counts. The recommendation is to use alcohol-based materials such as foam with an alcohol by volume of 60-70%, or if suspected C. difficile, hand washing with vigorous physical manipulation to reduce the amount of spores of pathogens.[4] This must be coupled with Standard Precautions, which involves the use of barriers such as gloves, gowns, masks, and eye wear, in order to prevent infection of the healthcare worker.[4] Other safeguards such as airborne droplet, regular droplet, and contact precautions are necessary to prevent spread of unique vectors. Airborne particles are small (less than or

Correspondence: Jonathan AMELI, M.D. Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI 02912. e-mail: jrzameli@gmail.com

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doi: 10.5505/1304.7361.2015.19970

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equal to 5 micrometers), and remain in the air for several hours. Measles and Tuberculosis (TB) among others are transmitted via airborne particles. N95 mask or powered air-purifying respirators are required.[4,5] Isolation rooms that have high ventilation (several changes in the air system per hour), and negative pressure should also be used.[4,6] Large particle droplet transmission occurs with vectors such as Haemophilus influenzae, Group A Streptococcus, and Bordetella pertussis among many others.[4] Patients suspected of meningitis or a respiratory infection that does not qualify under airborne should wear a surgical mask, in addition to the provider, and this is usually sufficient to prevent major spread. If able, a separate room or at least an area blocked by curtains is preferred.[5] Contact precautions are used for pathogens infecting mucosal or skin surfaces such as S. aureus, Methicillin Resistant S. Aureus (MRSA), or C. Difficile. Use of protective gowns and gloves is usually sufficient unless suspicion of a higher level of precautions exists.[5] Vaccinating health care personnel against pathogens including, but not limited to, Hepatitis B, Measles, Mumps, Rubella, Pertussis, Varicella, and Seasonal Influenza, is highly efficient in decreasing the risk of transmission of many infectious diseases.[7] This is not a replacement for standard precautions, airborne, droplet, contact precautions, or hand hygiene, but is another measure of safety to undertake.[4] Communicable Disease Control An epidemic, or outbreak, can occur when several aspects of the agent (pathogen), population (hosts), and the environment create an ideal situation for spread. Infectious agents are plentiful, mutate rapidly, and can become resistant to drugs if not destroyed completely. Low vaccination rates, poor nutrition, age (young and elderly), and immunosuppression all contribute to infectious risk. Overcrowding, poor regional design and hygiene due to poverty, dirty drinking water, rapid climate changes, and natural disasters, can lead to conditions that allow easier transmission of disease.[3] Once it has been established that an emergency condition exists, there must be a prompt and thorough response for communicable disease control. A camp should be created, and the disease managed rapidly. The overall goals are rapid assessment, prevention, surveillance, outbreak control, and disease management. For more detailed information on the logistics of communicable disease control, please view the World Health Organization (WHO) field manual.[8] Rapid Assessment “Rapid assessment” involves identification of the main dise-

ase, and obtaining detailed information about the host country in less than four days. First, compose the team. This will include public health experts in addition to experts in other fields such as sanitation, nutrition, and statistics. Second, assign tasks, and communicate thoroughly with the host country. Third, prepare a systematic method for data collection alongside statisticians. Data should focus on security, mapping the site, morbidity, mortality, demography, food availability, nutritional status, water, and sanitation among many other topics. Additionally, coordinate a visual inspection of the area prior to arrival, and interview key leaders of the area. This data should be clear, concise, goal-oriented, standardized, timely, and widely distributed to the team and all involved organizations. This will help guarantee appropriate funding, and communication with the host country. Prevention “Prevention” involves shelter, site planning, cleanliness, vaccination, vector control, and education. First, shelter and site planning, involves creating an environment that will avoid packing together individuals tightly as well as avoiding areas with high vector transmission, poor water supply, low security, poor vegetation and soil, and low ability for access (ie: close enough to a major center, but not so far as to make travel impossible). Second, cleanliness covers many aspects of what has already been discussed in the emergency room setting. Of note, full biohazard precautions should be taken with viral hemorrhagic fevers such as Ebola (to be discussed below). Water must be available for up to seven liters per person per day (in the most extreme situations), and it must be clean. This can rise up to 20 liters per person per day if taking into account bathing as well as cooking. Diseases spread in contaminated water are plentiful, and their evasion is of utmost importance in emergency conditions. Biological quality (less than 10 fecal coliforms per 100 ml of water) is important. Chlorine can be used to disinfect water. Chemical quality is of less importance than biological quality. Waste disposal is important.[8,9] Areas for excretion should not be near water sources, and they should be maintained with detail for sanitation. Pits to dispose of the contents should be created. Solid waste should be buried and/or burned. Liquid waste (ie: bathing) should be diverted into either storm water drains, or if in a dry area, to an isolated, separate pond, for disposal at a later time. Medical waste could be incinerated, preferably near the camp itself, making sure the contents do not travel to other dwellings. Otherwise, they should be buried after being sealed in a metal container.

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Disposing of the dead involves burial to at least 1 meter below earth. In most cases, the bodies should be wrapped in a body bag. Full biohazard precautions should be undertaken for diseases such as Ebola during burial. The clothing and other contact items of the deceased should be burned. With cholera, and other diarrheal illnesses, the bodies should be disinfected with 2% chlorine solution. Controlling vectors such as mosquitos (Malaria, Dengue, others) is essential to reduce specific disease transmission. For mosquitos, chemical environmental control, and use of mosquito nets treated with insecticide and repellent sprays are crucial. For Malaria, prophylactic drugs can be used. Environmental sanitation is important for Filariasis to prevent breeding of the Culex spp. mosquitos. For other vectors such as flies, mites, lice, and fleas, hygiene, insecticide and repellants are key factors in prevention of disease. Food supply for poor, underdeveloped nations is crucial in preventing disease. A person with malnutrition will be immunosuppressed and more likely to contract disease as well as less likely to survive the physical toll of any infectious disease. In addition, as with water, sanitation of food is key, and undercooked foods can lead to disease. A powerful vaccination campaign is imperative for prevention. Globally, vaccines against Measles, Meningococcal Meningitis and Yellow Fever are the most important to public health. Cholera vaccines can also be used. Measles requires 96% coverage for herd immunity to be established, and so with an outbreak of any disease, if the affected population is vaccinated <90% for measles, then prioritizing measles vaccination is necessary. Additionally, prioritize measles vaccines based on age, specifically, between 6 months and 14 years of age. Epidemic Meningitis can occur in crowded conditions, and is most commonly caused by Neisseria meningitidis. The vaccines for several serogroups of this pathogen last about 5 years (2 years in children), and it is 90% effective in those older than 2 years old. Children aged 2-10 years old are the most at risk. Yellow fever is only deadly in 5%, but the vaccination is effective in 95%, and lasts 10 years or more. The viral disease is transmitted by mosquitos and can have high morbidity when concurrent with other disease outbreak. It should not be given to symptomatic HIV-infected persons. The vaccine has a significant side-effect profile (fever, headache, myalgia) as compared to other vaccines. Oral cholera vaccines are available for those travelling to endemic areas as well as to people involved in emergency conditions. 2 doses of the oral cholera vaccine can be up to

65% effective for up to 5 years according to the most recent research.[10] Surveillance “Surveillance and early warning systems” should be set up in emergency conditions. This involves watching diseases on a continuum, finding trends, and reporting outbreaks earlier rather than later. This is a data collection phase, similar to the rapid assessment phase, but on a larger scale, and primarily involves interpretation of the data collected in order to create an efficient and effective public health response to the threat. Outbreak Control In summary, “outbreak control” involves “preparation, detection, confirmation, response, and evaluation.” Epidemics can be defined as outbreaks and vice versa according to the WHO. The first step of “preparation” covers much of what we have already discussed: setting up camp with isolation wards, gathering stockpiles of treatment supplies (medicines, vaccinations, tools), and collecting competent healthcare workers as well as a laboratory. Next, “detection” involves the development of an early warning system for epidemics such as acute watery diarrhea, measles, and others using laboratory confirmation, or clinical diagnosis as well as epidemiology to assess if the statistical analysis of the cases meets outbreak standards. “Response” involves confirming the diagnosis, formulating a hypothesis for the source, pathogen, and method of transmission, writing an investigation report, and ultimately, controlling the event by treatment, but moreover, prevention specific to the disease. Lastly, “evaluation” involves changing public health policies as needed, writing an outbreak report, and assessing the previous steps in detail in terms of success and appropriateness. Notable Communicable Diseases This section describes key features in bulletpoint form regarding a small selection of notable communicable diseases worldwide. Due to the enormous amount of information on this subject, several significant diseases will not be discussed such as meningitis, and pneumonia. Most of the information presented is adapted from the “Control of Communicable Diseases Manual” 20th Edition edited by Dr. Heymann. Please consult this manual for in-depth information, and a more exhaustive list.[10] Cholera • Significant epidemics with Vibrio cholerae subgroups: O1 and O139. • Bacterial infection of bowels. • Clinical: sudden onset, profuse, clear diarrhea. If untrea-

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ted, can lead to acidosis, hypovolemic shock, and renal failure in addition to other end-organ damage. • Associated with natural disasters, overcrowding, poor hygiene, and soiled water supply. • Diagnosis: stool culture, or microscopic examination of stool for “shooting stars.” o During epidemics, cholera should be presumed after the first batch of confirmed cases, by history and exam alone, and money should not be spent confirming every case of cholera thereafter. • Incubation: 2-3 days. • Transmission: consumption of water, or food contaminated with feces of infected persons. • Vaccinations: as discussed in previous section. • Management: o Strict isolation is not important although hygiene and handwashing is crucial. o Rehydration is key. Less severe cases can be managed with oral rehydration solution (ORS) alone. Moderate to severe cases must be managed with intravenous fluid. o In severe cases, doxycycline, or other antibiotics, can be used.

• Reservoir: unclear, but proposed to be forest (or cave for Marburg) fruit bats. • Incubation: 5-15 days. • Transmission: Person to person. Direct contact with infected blood, urine, vomit, diarrhea, semen (Ebola virus has been isolated in semen for up to 61 days), organs, and virtually any secretions. Care must be taken during funerals because the virus will still be active in a deceased person. Highest risk exists in late stages of illness. It has not been documented if the virus is transmitted via airborne routes. • No approved vaccine exists yet. • Management: o Strict isolation of patients, their secretions, and their deceased body, at the highest level of biohazard precautions. Laboratory tests and contact in general should be kept at a minimum. Only essential interaction with patient should occur until the virus has been cleared from their body. Disinfect all equipment and patient secretions with 0.5% sodium hypochlorite solution, or 0.5% phenol with detergent as well as the use of incineration, or autoclave. o No approved anti-viral treatment exists yet. o Supportive care.

Ebola and Marburg (Viral Hemorrhagic Fever)

Hantavirus

• Acute viral (negative stranded RNA viruses: Filoviridae) illness.

• Zoonotic disease.

• Clinical: fever, malaise, myalgia, headache, sore throat, diarrhea, vomiting, non-specific rash.

• Two different syndromes.

• Severe or fatal progression is possible (32-88% for Ebola, 22-90% for Marburg): hemorrhagic diathesis and shock. • Diagnosis: multiple methods available via blood or tissue samples (PCR, ELISA, immunohistochemistry, detection of IgM or rising IgG). o Labs: lymphopenia, thrombocytopenia, transaminitis, creatinine elevation, uremia. o A recent article describes an evidence-based method to diagnose Ebola infection without relying fully on laboratory tests (in a highly endemic area of West Africa). The 6 items that were shown to be predictive of a positive laboratory confirmation of Ebola: “sick contacts, diarrhea, loss of appetite, muscle pains, difficulty swallowing, and absence of abdominal pain.” This can help avoid nosocomial spread of the disease, minimizing unnecessary contact with infected bodily fluids by healthcare providers.[11] • Largest outbreak to date in 2014: Guinea, Liberia, Sierra Leone, Nigeria, and Senegal with almost 4,000 confirmed or suspected cases as well as almost 2,000 deaths (as of 08/31/2014).

• Bunyaviridae virus. o Shared features: fever prodrome, thrombocytopenia, and leukocytosis. o Hemorrhagic Fever with Renal Syndrome (HFRS): fever for 3-7 days then severe back or abdominal pain, hypotension/shock, oliguria/renal failure, diuresis, then a long protracted convalescence phase if the patient survives. o Hantavirus Pulmonary Syndrome (HPS): pulmonary edema/respiratory distress and shock. More fatal than HFRS. • Diagnosis: IgG and IgM in serum. Virus usually not detectable. • Reservoir: rodents. • Incubation: 2-4 weeks. Faster for HPS (2 weeks). • Transmission: aerosol from rodent excrement most likely. • Prevention: rodent control, disinfect rodent infested areas, vaccine (only available for Hantaan and Seoul viruses). • Treatment: supportive care. Dialysis for HFRS. Ribvarin in some early cases. Avoid supplementing too much fluids with HPS. Respiratory ICU level of care for HPS.

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Hepatitis

o Requires co-infection with Hepatitis B.

• Viral.

o More severe form of Hepatitis B.

o Several types: A, B, C, D, E. o Clinical findings: abdominal pain, nausea, anorexia, fevers progressing to jaundice, transaminitis. • Hepatitis A (Picornaviridae, +RNA virus): o Acute only. Not chronic. o Spreads rapidly in emergency conditions. o Can last 1 year in a minority of cases. o Low fatality rate. o Incubation: 30 days average o Transmission: Fecal-oral route. o Prevention: sanitation, hygiene, water supply, vaccine if in epidemic area, immunoglobulin in special cases. o Management: supportive. • Hepatitis B (Hepadnavirus, dsDNA virus); o Acute infection, but can progress to chronic. Can result in hepatocellular carcinoma, cirrhosis. o Diagnosis: analysis of antigens and antibodies to different components of the virus in the serum. o 2 billion persons infected globally by WHO estimates. o Incubation: 2-3 months. o Transmission: bodily fluid exposure, and even up to 7 days outside of human reservoirs on objects. o Prevention: vaccine, blood bank control. o Treatment: supportive. In some cases, although high cost, anti-viral medications can be given. • Hepatitis C (Hepacivirus, of the Flaviviridae, enveloped RNA virus): o 75% become chronic infections. 20% of these will develop cirrhosis over 20 years. Some will develop hepatocellular carcinoma. o Diagnosis: analysis of antigens and antibodies to HCV. o 150 million people are chronically infected with HCV according to WHO. o Incubation: 6-9 weeks average. o Transmission: parenteral (at-risk populations: drug abusers sharing needles, those receiving blood products frequently, hemodialysis patients) o Prevention: no vaccine. Blood bank control. Needle exchange. o Management: supportive. Anti-viral medications can clear the infection in some cases. • Hepatitis D (delta antigen of Hepatitis B)

• Hepatitis E (Hepeviridae, single-stranded RNA virus) o Similar to Hepatitis A, but shorter course. o High mortality in pregnant women. o Co-infection indicates higher infectivity of Hepatitis B in adults. HIV/AIDS • Acquired Immune Deficiency Syndrome (AIDS) results from chronic infection with Human Immunodeficiency Virus (HIV). • Multiple infections result from AIDS including severe pneumonia, diarrhea, and many others. • Retrovirus. • Flu-like illness within the first several weeks of infection, followed by several years of dormancy, followed by AIDS with a sharp decline in CD4 cells in untreated patients. • Diagnosis: detection of antibodies and/or antigens. Viral load also useful. • 35 million persons living with infection of HIV worldwide with 70% living in Sub-Saharan Africa. • Transmission: blood primarily, and other bodily fluids (penile-vaginal, penile-anal, dirty needle, mother to infant during pregnancy, transfusion). Risk increases with higher viral loads. • If latent TB and HIV, 6-8 times higher chance of progressing to active TB. • Prevention: education regarding safe needle use, safe sex, pregnancy and HIV. Post-exposure prophylaxis. Blood bank control. • Management: Three-drug antiretroviral regimen is recommended lifelong. Prophylactic medications based on CD4 counts. Antibiotic treatments for specific infections (ie: TB). Influenza • Acute viral illness primarily of the upper respiratory tract. • Symptoms: fever, myalgia, dry cough, headache, sore throat. In children, gastrointestinal symptoms may be present as well. • Complication: Lower respiratory tract extension. Superimposed bacterial pneumonia (Streptococcus pneumoniae, or S. aureus with large proportion being MRSA). • 90% of deaths are in elderly. Children under 2 years old at high risk as well. Some strains of Influenza can cause severe disease in healthy, young people. • Current types of Influenza that are included in seasonal vaccine: subtypes of Influenza A (H1N1 and H3N2), and

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Influenza B. o Antigenic drift requires a biannual review to change the vaccine. o Antigenic shift is more disastrous to public health, and can result in a pandemic.

• Management: anti-malarial antibiotics and supportive care. Drug resistance is an issue. Refer to most appropriate and up to date management. Promptly treat P. falciparum. Measles

• Diagnosis: history and physical as well as RT-PCR via upper respiratory swab (most commonly nasopharyngeal).

• Acute viral disease.

• Incubation: 2 days.

• Clinical: Prodrome of fever.

• Measles virus (Morbillivirus of Paramyxoviridae).

• Transmission: droplet, and contact.

o Cough, coryza, conjunctivitis, and Koplik spots.

• Prevention: Education, and vaccination.

o Rash on day 3-7. Spreads from head to rest of body.

• Management: isolation of patient, and early administration of neuraminidase inhibitors (within 48 hours of symptom onset) for those at high risk (immunosuppressed, elderly), supportive care. Malaria • Protozoan parasites: Plasmodium falciparum, P. vivax, ovale, and malariae. • Acute febrile disease: cyclic fevers with almost any symptom present from cough to abdominal pain to headaches. • P. falciparum malaria o Severe. Often fatal if not treated. o Unique, differentiating factors: decreased sensorium, seizures, respiratory distress, shock. • Other causes of malaria o Usually not fatal, but patients are often significantly ill. o Cyclic fevers can occur up to 4 years due to parasite living in liver if untreated. • Diagnosis: o WHO recommendation: every suspected case should be tested. o Microscopy: visualize parasites directly on blood smear.

• Complications: bacterial superinfections (pneumonia, otitis media, and others). • Diagnosis: IgM and IgG (greater than 4 fold rise) detection, PCR. o Labs: leukopenia. Vitamin A levels are often low. • Incubation: 14 days. • Transmission: airborne droplet, upper respiratory secretions. • Prevention: vaccine is highly effective. Measles epidemics declined in the 1990s, but even with 90% immunization coverage, there can be significant outbreaks during an emergency condition. This is even more apparent when measles immunization coverage is low such as in Ethiopia, and Afghanistan.[3] • Management: isolation, vitamin A supplementation, primarily supportive. SARS, MERS • Coronaviruses (CoV). o Enveloped single stranded positive RNA • SARS (Severe Acute Respiratory Syndrome), SARS-CoV: o Viral pneumonia with bilateral infiltrates reminiscent of Acute Respiratory Distress Syndrome (ARDS).

o RDT (rapid diagnostic test), PCR assays.

o 30% required ICU level of care. Rapid progression to respiratory failure after day 10.

o Serologic tests are not recommended because they cannot detect active infection.

o November 2002 was the first case, and the outbreak, around Southern China, lasted until 2004.

• 660 thousand deaths reported in 2010, mostly in Africa. • Incubation: 2 weeks for P. falciparum, and slightly longer for the others. • Transmission: bite of female Anopheles mosquito, which usually feeds at night, infects a human, which in turn, infects other mosquitos that feed on the human, which can then infect humans once again. • Prevention: previously mentioned in vector control above.

o Diagnosis: PCR is available for sputum, urine and stool, but is not fully reliable. Since 2004, there has not been any documented SARS-CoV infection so testing is not available in most places. o Reservoir: likely the Himalayan masked palm civet (Paguma larvata). o Incubation: 5 days. o Transmission: person to person via contact and respiratory secretions.

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o Management: treat for pneumonia until proven otherwise. • Fully isolate with contact and airborne precautions if SARS-CoV is suspected to have reemerged. • MERS (Middle East Respiratory Syndrome), MERS-CoV: o 2012 emergence in Saudi Arabia. o Viral pneumonia. o Clinical: Fever, and cough. Severe respiratory distress requiring intubation. More recently, milder cases have been diagnosed, but mortality is 40% in severe cases, especially in patients with comorbidities such as heart disease, and immunosuppression. o Diagnosis: sputum samples and serum should be tested via rapid real-time PCR. Test all suspected cases (significant respiratory symptoms in patients that have traveled to, or reside in, the middle east). o Reservoir: unknown. Possibly bats, or dromedary camels. o Incubation: unknown, estimated at 2-14 days. o Transmission: unknown, but likely similar to SARSCoV. o Prevention: Use N95 respirator, and maximum contact/airborne precautions, when treating, and in particular, intubating, a patient suspected of MERS-CoV. No vaccine available. o Management: • Fully isolate with contact and airborne precautions. • Antibiotics for pneumonia until proven otherwise. • No antiviral treatment exists. • Supportive care. Tuberculosis • Mycobacterium tuberculosis. • Latent and Active (pulmonary and extrapulmonary) forms. • Clinical: cough, fevers, weight loss. • Fibrosis of lungs in advanced disease. • Diagnosis of active TB: traditional is obtaining at least 2 sputum specimens showing acid-fast bacilli (AFB). More recently is using the Xpert MTB/RIF molecular test. Chest x-ray can show cavitations in the upper lobes. • In 2011, there were 1.4 million deaths from TB despite a slow decline in the global incidence since the early 2000s.[12] • Multi drug-resistant (MDR) and extensively drug-resistant (XDR-TB) are major threats.[12]

• Incubation: not readily known. HIV and immunosuppression causes a more rapid progression from latent to active TB. • Transmission: airborne droplet nuclei, respiratory secretions. • Prevention: no reliable vaccine available. Education is paramount. Treatment of latent TB. • Management: o Strict airborne isolation. o Prompt treatment with antibiotics based on the most up to date recommendations. o Supportive care.

References 1. Babaie J, Ardalan A, Vatandoost H, Goya MM, Akbarisari A. Performance assessment of communicable disease surveillance in disasters: a systematic review. PLoS Curr 2015;7. 2. Connolly MA, Heymann DL. Deadly comrades: war and infectious diseases. Lancet 2002;360 Suppl:23–4. 3. Abdallah S. Control of communicable diseases. Public Health Guide for Emergencies, The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies. 2nd edition. 2008. 4. Liang SY, Theodoro DL, Schuur JD, Marschall J. Infection prevention in the emergency department. Ann Emerg Med 2014;64:299–313. 5. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007;35(10 Suppl 2):65–164. 6. Behrman AJ, Shofer FS. Tuberculosis exposure and control in an urban emergency department. Ann Emerg Med 1998;31:370–5. 7. Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60:1–45. 8. Connolly MA. Communicable disease control in emergencies: A field manual. WHO World Health Organization 2005. 9. Harvey PA, Reed RA. Planning environmental sanitation programmes in emergencies. Disasters 2005;29:129–51. 10. Heymann DL. Control of communicable diseases. 20th edition, APHA. Offficial Report of the American Public Health Association 2015. 11. Levine AC, Shetty PP, Burbach R, Cheemalapati S, GlavisBloom J, Wiskel T, et al. Derivation and Internal Validation of the Ebola Prediction Score for Risk Stratification of Patients With Suspected Ebola Virus Disease. Ann Emerg Med 2015;66:285–293. 12. Christian KA, Ijaz K, Dowell SF, Chow CC, Chitale RA, Bresee JS, et al. What we are watching-five top global infectious disease threats, 2012: a perspective from CDC’s Global Disease Detection Operations Center. Emerg Health Threats J 2013;6:20632.

REVIEW

Water and Sanitation Standards in Humanitarian Action Murat ERSEL Ege University School of Medicine, Department of Emergency Medicine, Izmir, Turkey

SUMMARY The right to water and sanitation is an inextricable human right. Water and sanitation are critical determinants for survival in the initial stages of a disaster. An adequate amount of safe water is necessary to prevent death from dehydration, to reduce the risk of water-related disease and to provide for consumption, cooking and personal and domestic hygienic requirements. The main objective of WASH - (Water supply, Sanitation and Hygenie promotion) programmes in disasters is to reduce the transmission of faeco-oral diseases and exposure to disease-bearing vectors through the promotion of: good hygiene practices, the provision of safe drinking water, the reduction of environmental health risks, the conditions that allow people to a healthy life with dignity, comfort and security. Keywords: Water; sanitation; disasters; humanitarian response; hygenie promotion; drainage; vector control; waste disposition.

Comprehensive research on water, sanitation and hygiene promotion issues among refugee populations is challenging. Hurdles related to these studies include security restrictions, complex operational conditions, scarce resources, understaffing or high staff turn-over, the difficulty of undertaking thorough measurements during emergency situations and the fact that refugee camps are often forcibly located in isolated locations.[1] There are many examples in recent history which highlight the importance of water and sanitation standards in humanitarian actions, such as the humanitarian crises following the Sudanese Civil war in 1998[2] or Haiti earthquake in 2010.[3] The right to water and sanitation is an inextricable human right.[4] This right is recognised in international legal instruments and provides for sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic uses and accessible sanitation facilities. An adequate amount of safe water is necessary to prevent death from

dehydration, to reduce the risk of water-related disease and to provide for consumption, cooking and personal and domestic hygienic requirements.[5] During the past decade the humanitarian response community has initiated a number of interagency initiatives to improve accountability, quality and performance in humanitarian action. Four of the most widely known initiatives are the Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP), Humanitarian Accountability Partnership (HAP), and People In Aid and the Sphere Project. Representatives of the agencies promulgating these initiatives started meeting on a regular basis in 2003 in order to collaborate on common issues and harmonise activities where possible.[6] Water and sanitation are critical determinants for survival in the initial stages of a disaster. People affected by disasters are generally more susceptible to illness and death from disease, which to a large extent are related to inadequate sa-

Correspondence: Murat ERSEL, M.D. Ege University School of Medicine, Department of Emergency Medicine, Izmir, Turkey. e-mail: murat.ersel@ege.edu.tr

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doi: 10.5505/1304.7361.2015.48753

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nitation, inadequate water supplies and inability to maintain adequate hygiene.[5] The main objective of WASH - (Water supply,Sanitation and Hygenie promotion) programmes in disasters is to reduce the transmission of faeco-oral diseases and exposure to disease-bearing vectors through the promotion of: - good hygiene practices - the provision of safe drinking water - the reduction of environmental health risks - the conditions that allow people to a healthy life with dignity, comfort and security.[6] Simply providing sufficient water and sanitation facilities will not alone, ensure optimal use and achieve the desired impact on public health. In order to reach the maximum benefit from a response, it is imperative that disaster-affected people have the necessary information, knowledge and understanding to prevent water and sanitation-related diseases and to iclude them in the design and maintenance of facilities. Provision of sufficient clean water (for which minimum agreed standards exist),[5] adequate sanitation for excreta disposal, and management of medical and other solid waste can reduce diarrhoeal disease, typhoid fever, vector-borne disease, and scabies.[7] Despite efforts for maintaing water and sanitaiton standarts, failures occur due to cultural habits (not boiling the river water) or toilet behaviors (not using soap after after latrine use). Therefore in order to achieve the goal of sufficient water and sanitation standards, health providers also should monitor sanitation and water use activities of the population and focus on bridging the gap between what people know about water, sanitation and hygiene and their actual practices.[8] The Minimum Standards for Water supply, sanitation and hygiene promotion (WASH) The WASH (Water supply, sanitation and hygiene promotion) program aims to promote better personal and enviromental hygenie in order to protect health, with protecting the envoriment, promoting health and facilitate access to resources. An effective WASH programme relies on an exchange of information between the agency and the disaster-affected population in order to identify key hygiene problems and culturally appropriate solutions. Hygiene promotion is vital to a successful WASH intervention. The focus on hygiene promotion is both general and specific. In general terms, hygiene promotion is integral to all of the sections and is reflected in the indicators for water supply, excreta disposal,

vector control, solid waste management and drainage.[9] 2. Hygenie Promotion Hygenie promotion is a necessary component of WASH programs in diasters. Hygenie promotion allows people to learn how to prevent and/or mitigate related diseases. Hygiene promotion enables a planned and systematic paradigm to let people learn how to prevent and/or mitigate water, sanitation and hygiene-related diseases. The major element in this program is the promulgation of knowledge, participation and utilization of resources among the affected population. Men and women of all ages should be made aware of key public health risks. Hygiene promotions ensure that people make the best use of the water, sanitation and hygieneenabling facilities. There are three key factors to promote these messages: 1. a mutual sharing of information and knowledge, 2. the mobilisation of affected communities, 3. the provision of essential materials and facilities. Information is disseminated via previously identified spesific social, cultural or religious groups and using appropriate channels of mass communication. Also, interactive hygiene communication methods are utilized wherever feasible in order to ensure ongoing dialogue and discussions among those affected.[10] There are several main tenant of hygenie promotion Teaching the community to wash their hands after defecation, after cleaning a childâ&#x20AC;&#x2122;s bottom, and before eating and preparing food. Caretakers of children should be taught using demonstrative techniques the safe disposal of childrenâ&#x20AC;&#x2122;s faeces and about key behaviours and misconceptions about hygiene promotion activities. Representatives from all user groups should to be involved in planning, training, implementation, monitoring and evaluation of hygiene promotion. That involvement of all groups may facilitate information flow between humanitarian actors and the affected population so that misconceptions where identified, are addressed. In the early stages of a disaster the use of mass media for hygenie promotion may increase its impact on the targeted population. Information should be disseminated using different channels and by targeting different at-risk groups especially those who are illiterate, have communication difficulties and those who do not have access to traditionaldevices to accesss media such as radio or television or internet.[10] The planning of hygiene promotion must be culturally app-

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ropriate and may offer useful opportunities for affected people to monitor their own hygiene improvements. The use of outreach workers or home visitors provides an interactive way to access large numbers of people. In a camp setting, there should be two hygiene promoters per 1,000 members of the affected population. For an effective hygenie promotion activity, all men, women and children of all ages should receive information regarding the priority hygiene items. A basic minimum hygiene items pack consists of water containers (buckets), bathing and laundry soaps, and menstrual hygiene materials. Every housing unit requires two 10â&#x20AC;&#x201C;20 litre capacity water containers, one for transportation and one for storage. Soap for bathing (250 mg) and a laundry (200 mg) and additionaly acceptable menstrual hygenie materials for women should be distributed regulary every month. Members of the community should be trained regarding safe and effective use of hygenie items if these are unfamiliar.. Use and satisfaction with distributed hygenie material should be monitored regularly after distribution and necessary adjustments made after receiving feedback.[11] The affected population may need additional items which are not included in basic hygenie packets such as blankets etc. depending on environmental conditions. Also people with specific needs (e.g. incontinence or severe diarrhoea may require increased quantities of personal hygiene items such as soap). Those who are confined to bed may need additional items, such as bed pans. According to socio-cultural practices, hygenie packages may include tootbrushes, toothpaste, shampoo, razors, combs, nail clippers and diappers. To ensure timely distribution of the hygenie items the cooperation and agreement of the affected population is essential.[11] The components of the aid package should be vetted with community leaders and each item reviewed for need based on envorment and cultural acceptance prior to mass dissemination. 3. Water Supply and Treatment of Drinking-Water in Emergency Situations Water is essential for life, health and human dignity. In extreme situations having Access to clean water for meeting basic needs has a critical importance. Many times poor hygenie due to insufficient water or consumption of contaminated water is the main reason for spraed of infection. In a disaster, the main priority is to provide safe and equitable access to an adequate amount of water for drinking, cooking and personal and domestic hygiene even if it is of intermediate quality.[12] Therefore location of public water points should be planned sufficiently close to households to enable use of the minimum water requirement. Water consumption data should be also obtained directly from community sources or household surveys. Data col-

lected using these methods will be more effective than the measurement of water pumped into the pipeline. According to Sphere Standarts, minimal water intake need for a victims survival is 2.5-3 /lt/day and varies with the climate and individual physiology. Total quantity should also include water for basic hygenie practices (2-6 litres per day) and basic cooking needs (3-6 litres per day) bringing the total requirement to 7.5-15 litres per day. This amount is >20 litres according UNHCR standards. (R2) The proximity and sustainability of sufficient quantity of water should be considered. When selecting water sources groundwater and/or gravity-flow supplies from springs are preferable, as they require less treatment and no pumping.[12] According to Sphere Standards accesibility to water should be limited to 8 hours/day in order to prevent overuse and misuse of the water sources. Approximate flow rates according to guidelines are as follows; 250 people per tap based on a flow of 7.5 litres/minute, 500 people per hand pump based on a flow of 17 litres/minute and 400 people per single-user open well based on a flow of 12.5 litres/minute. All community members should have equitable access to water points regardless of gender or ethnicity. Also, water distribution and pumping times should be planned in consultation with the users including women and minorities. The maximum distance from any household to the nearest water point should be 500 metres and maximum queueing time at a water source 30 minutes.[12] Water Quality and Emergency Treatment of Drinking Water Water quality is important to ensure the safety of effected peoples health. Water should be at a sufficient quality to be drunk and used for cooking and also suitable to use for hygenic purposes. When use of a centrally operated water treatment system is not possible, point-of-use water treatment (PoUWT) at the household level can be an alternative. Drinking water supplies need to be treated during and after an emergency to make them safe. Treatment at the point of use is generally quicker and less expensive, but it can be more difficult to manage than a centeralized system. Only water used for drinking and preparing food needs to be treated.[13,14] Some pretreatment methods for obtaining potable water are aeration, settlement, filtration and disenfection. Aeration will remove volatile substances such as hydrogen sulphide and methane which affect taste and odour; reduce the carbon dioxide content of the water; and facilitates sedimentation and filtration of iron and manganese by oxidation. One simple method at the household scale is to rapidely

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shake a water container and leave it standing for 30 minutes. This methods allows the suspended solids and some pathogens (such as Guinea worm - dracunculiasis) to settle the bottom of the container.[13] By filtration contamination will be removed by physically blocking particles. Membrane, sand and ceramic filters are using for filtration. Disinfection methods are boiling, solar disinfection and chemical disinfection. For chemical disinfection chlorine is commonly used in tablet, liquid and powder forms, chlorine will kill most viruses and bacteria however some species of protozoa (notably cryptosporidium) are resistant to chlorine. Free chlorine residual in disinfected water should be 0.2-0.5 mg per litres and in the case of specific diarrheal epidemic, residual chlorine level should not be less than 1mg per liter. There should be no fecal coliforms at the water distribution unit.[1,14] Using surveys, possible contamination at the water resources or problems at the transport points can be detected. If any fecal coliforms are present, the water should be treated. Water can be contaminated after delivery to the households, therefore it should be routinely sampled and tested at the point of use. A residual disinfectant such as chlorine should be used to treat water contaminated at the point-of-use. Community mapping is a particularly effective way of identifying where the public health risks are. WHO recommends the use of its water safety plan (WSP), which is a holistic approach covering hazard identification and risk assessment, an improvement/upgrade plan, monitoring of control measures and management procedures, including the development of supporting programs.[14,15] Planners should be aware about the risk for potential chemical or radiological contamination risks. When there is sufficient conern, these risks need to be rapidly assessed and addressed with local authorities. Although taste is not in and of itself a direct health problem, if the safe water supply does not taste good, users may drink from unsafe sources and put their health at risk. To avoid this, hygiene promotion activities are needed to ensure that only safe supplies are used.[14] 4. Waste Disposal A safe disposal process creates the first barrier to excretarelated disease. It is a major priority in most disaster events and should be addressed with as much speed and effort as the provision of a safe water supply. The main standard of excreta disposal is to maintain the living environment in general and specifically the habitat, food production areas,

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public centres and surroundings of drinking water sources free from human fecal contamination. After a disaster, demarcation and cordoning off defecation areas, and building communal toilets should be completed as soon as possible. Every member of the community should use these services and for people who do not traditionally use toilets, it is necessary to conduct a concerted hygiene promotion campaign. In urban disasters where there could be damage to existing sewage systems, installing portable toilets or use of septic and/or containment tanks that can be regularly desludged may be required.[16] This occured after Hurricane Katrina in Coastal Mississippi and caused delayes in re-opening hospitals and clinics. Disaster affected populations need to have adequate, appropriate and acceptable toilet facilities. Those facilites should be sufficiently close to their dwellings, and should allow rapid, safe and secure access at all times, day and night. All excreta containment measures, i.e. trench latrines, pit latrines and soak-away pits, should be at least 30 metres away from any groundwater source. Pits should be at least 1.5 metres above the groundwater table. These distances should be increased for fissured rocks and limestone. In flooded environments toilets or septic tanks have to built in elevated areas in order to prevent a spillage. The distance from dwellings should be no more than 50 metres.[17] Childrenâ&#x20AC;&#x2122;s faeces need a particular attention, because children have excretarelated infections more frequently and they may not have developed antibodies to infections.[16] Toilets must have safe access, and there has to be a provision of privacy in line with the cultural norms of the users. Toilets should be kept clean and should be havean adequate supply water or other solutions for hand washing. Containers for disposal of womenâ&#x20AC;&#x2122;s hygiene materials should be provided. There should be provision for desludging, transport and appropriate disposal during long-termoperations. Maximum number of people for use of each toilet is 20. The use of the toilets should be arranged by household or by sex. Special toilets may need to be constructed for children, older people and persons with disabilities. The type of sanitation facility adopted depends on the phase of the diasaster and preferences of the intended users, existing infrastructure, local soil characteristics, construction materials and according to the availability of water.[17] Different excreta disposal types for different phases of a disaster response are listed in the table below. For the first days of a disaster, a demarcated defecation area should be specified. Trench latrines are suitable for use up to two months, also simple pit latrines can be used. For middle term and long term use ventilated improved pit (VIP) latrines, ecological sanitation (Ecosan) systems with urine diversion and sep-

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tic tanks are suitable. Public toilets have to be provided in a ratio 3:1 (women:men) and where possible urinals should be provided. Households should be responsible for cleaning and maintanence of shared toilets. People living with chronic illnesses need easy access to a toilet as they frequently suffer from chronic diarrhoea and reduced mobility. Water and clenasing material ( toilet paper or another material) should also be provided.[17] 5. Vector Control Vector- borne diseases are a major health risk following disasters and during refugee crises. Musquitos are responsible for transmission of disease, particularly malaria, which is a leading cause of morbidty and mortality. Musquitos are also vectors for yellow fever, dengue and haemorrhagic fever. Biting flies, bedbugs and fleas can transmit diseases such as murine typhus, scabies and plague. Also non-biting or synathropic flies (house fly, blow fly, flesh fly etc.) play a mojor role in the transmission of diarrheal disseases. Ticks transmit relapsing or hemorrhagic fever, lyme disease, babesiosis and anaplasma; body lice transmit typhus and relapsing fever. Rats and mice are host for vectors eg. fleas, which may transmit Lassa fever, plague among other infections, and they transmit leptospirosis, Hanta vir端s and salmonellosis.[18] Vector-borne diseases can be prevented by measures which prevent the spread of vectors. Decisions about vector control interventions should be based on an assessment of potential disease risk. Factors such as immunity status of affected population (e.g. refugees, internally displaced people (IDPs) - movement from a non-endemic to an endemic area is a common cause of epidemics). Pathogen type, number of vectors, species and increase exposure to the vectors (proximity or pattern of the settlement etc.) influence risk.[18] One of the key issues in vector-borne disease control is site selection and provision of shelter. To reduce the exposure risk of the affected population to the vectors is a key determinant in diease prevention. With regard to malaria control, for example, camps should be located 1-2 kilometres upwind from large breeding sites, such as swamps or lakes. Often the benefits of locating camps near clean water sources makes his decision challanging. Other initiatives for controlling vectro-borne diseases are maintaining a safe water supply, proper excreta disposal, solid waste management and drainage, provision of health services (including community mobilisation and health promotion), use of chemical agents for vector control, family and individual protection including the use of mosquito netting, and effective protection of food stores. Vector control programs should aim to reduce vector population density, reduce human-vector contact and reduce vector breeding sites.[19]

The impact of vector control programs are measured by monitoring vector-borne disease incidence rates and parasite counts. Specific environmental engineering measures can be taken to reduce the opportunities for vector breeding. These include the proper disposal of human and animal excreta, proper disposal of refuse in order to reduce the number of flies and rodents, drainage of standing water, and clearing unwanted vegetation cover around open canals and ponds to control mosquitoes and ticks. If these interventions are not sufficient to reduce vector breeding localised chemical control measures or individual protection measures may be needed (eg. spraying affected spaces to reduce the number of the flies). Local experts may have specific knowledge regarding local disease patterns, breeding sites and seasonal changes in vector number at the disaster site.[19] Enviromental mosquito control aims to eleminate three main mosquitos breeding sites. These species are responsible for transmission of filariasis (Culex&Anopheles), malaria (Anopheles) and yellow fever and dengue (Aedes). Examples of environmental mosquito control include adequate drainage, functional VIP (ventilated improved pit) latrines, keeping lids on squatting holes of pit latrines and on water containers, and keeping wells covered and/or treating them with a larvicide (e.g. for areas where dengue fever is endemic).[19] Individual vector protection involves timely provision of protection measures such as insectiside-trested materials, tents, curatins, beting nets. Especially insecticide impregnated bed netting is effective for protection not only for musquitos but also body and head lice, fleas, ticks, cockroaches and bedbugs. Long-sleeved clothing, household fumigants, burning coils, aerosol sprays can be used against mosquitoes. Personal hygiene and regular washing of clothes and bedding are the most effective protection against body lice. Mass laundering, and chemical personal treatment are alternative vector protection methods.[20] 6. Solid Waste Management and Drainage Inadequate solid waste management can cause public health risks of the affected population. These risks can arise from the breeding of flies and rodents and pollution of the surface or groundwater sources. Solid waste disposal should be implemented in close consultation and coordination with the affected population. All households should have easy access to refuse containers, at least a 100 litre refuse container should be available per 10 households, those containers should be emptied twice a week at minimum. However the waste should be removed

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from the living envoriment daily. Communal refuse pits should be located no more than 100 metres from households. All medical waste should be isolated and disposed of separately in properly engineered pits or safe containers in health facilities. If waste is to be buried on-site in either household or communal pits, it should be covered daily with a layer of soil to prevent attracting flies and rodents. Care should be taken to prevent contamination of the groundwater by material leacing from waste pits.[21] During the recent Ebola epidemic in Western Africa, many Ebola Treatment units utilized a incineartion facility at each camp to manage contaminated solid waste. 7. Drainage Pooling surface water may cause health risks by contamination of clean water supplies, vectro breeding, damage to toilets and dwellings and also drowning. Water pools may come from household wastewater, leaking toilets, rain or rising floodwaters. A proper drainage plan is essential to protect the community from health risks and maintain habitable settlements. The plan should address stormwater drainage through site planning and wastewater disposal using small-scale, on-site drainage Appropriate drainage facilities have to be built to keep dwelling areas free of pooling water. All water distribution points and hand washing facilities should have an effective drainage system to prevent pooling. The drainage system should be desined to protect shelters, paths and all water sanitation facilities from flooding and water erosion.[22] Conclusion Water is indispensable for human life and is a priority for survival. Following disasters and during humanitarian relief activities providing safe supplies of water to the affected people is a major challenge. Hygiene and sanitation standards should be implemented into the daily activities of a community as soon as possible in order to protect the population from disease and outbreaks. WHO and Sphere Project have published standards for water and sanitation in humanitarian actions which can guide healthcare workers and other providers bringing humanitarain assistance for an effective response.

References 1. Cronin AA, Shrestha D, Cornier N, Abdalla F, Ezard N, Aramburu C. A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators – the need for integrated service provision. Journal of Water and Health 2008;6:1-13.

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2. Griekspoor A, Collins S. Raising standards in emergency relief: how useful are Sphere minimum standards for humanitarian assistance? BMJ 2001;323:740–2. 3. Schuller M, Levey T. Kabrit ki gen twòp mèt: understanding gaps in WASH services in Haiti’s IDP camps. Disasters 2014;38(S1):S1-S24. 4. The Right to Water (articles 11 and 12 of the International Covenant on Economic, Social and Cultural Rights), CESCR, General Comment 15, 26 November 2002. UN Doc. E/C.12/2002/11. Committee on Economic, Social and Cultural Rights. https://www1.umn.edu/humanrts/gencomm/escgencom15.htm 5. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Minimum standards in Water Supply, Sanitation and Hygiene Promotion, The Sphere Project 2011. p. 83-7. 6. http://en.wikipedia.org/wiki/Humanitarian_aid 7. Connolly MA, Gayer M, Ryan MJ, Salama P, Spiegel P, Heymann DL. Communicable diseases in complex emergencies: impact and challenges. Lancet 2004;364:1974-83. 8. Atuyambe LM, Ediau M, Orach CG, Musenero M, Bazeyo W. Land slide disaster in eastern Uganda: rapid assessment of water, sanitation and hygiene situation in Bulucheke camp, Bududa district. Environmental Health 2011;10:38. 9. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response. The minimum standards. Water supply, sanitation and hygiene promotion (WASH), The Sphere Project 2011. p. 88-90. 10. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Hygiene promotion standard 1: Hygiene promotion implementation, The Sphere Project 2011, p.91-93 11. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Hygiene promotion standard 1: Hygiene promotion implementation, The Sphere Project 2011, p.94-96 12. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Water supply standard 1: Access and water quantity, The Sphere Project 2011, p.9799 13. WHO WDEC. Technical notes on drinking-water, sanitation and hygiene in emergencies.Updated:July2013 http://www. who.int/water_sanitation_health/publications/2011/WHO_ TN_05_Emergency_treatment_of_drinking_water_at_the_ point_of_use.pdf 14. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Water supply standard 2: Water quality, The Sphere Project 2011, p.100-103 15. WHO - Water Safety Plan: The Guidelines : a framework for safe drinking water p.22-36 http://www.who.int/water_sanitation_health/dwq/gdwq3_2.pdf 16. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Excreta disposal standard 1: Environment free from human faeces, The Sphere Project 2011, p.105-107 17. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Excreta disposal stan-

Ersel M

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dard 2: Appropriate and adequate toilet facilities, The Sphere Project 2011. p.107-10. 18. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Vector Control, The Sphere Project 2011. p. 111. 19. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Vector control standard 2: Physical, environmental and chemical protection measures, The Sphere Project 2011. p. 113-6.

20. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Vector control standard 1: Individual and family protection, The Sphere Project 2011. p. 111-3. 21. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, Solid waste management, The Sphere Project 2011. p. 117-20. 22. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, 7. Drainage, The Sphere Project 2011. p. 121-3.

REVIEW

Food and Shelter Standards in Humanitarian Action Sohil POTHIAWALA Department of Emergency Medicine, Singapore General Hospital, Singapore

SUMMARY The number of disasters, both natural as well as man-made, has been increasing in frequency in the recent years. This leads to short as well as long-term effects on food security and shelter, requiring humanitarian assistance. This article aims to identify the principles and standards that are applicable to food and shelter related aid that needs to be provided by the co-operation of the local government as well as the relevant supporting organizations. Also, food and shelter security during a disaster response is achieved through better preparedness. The level of preparedness must include risk assessment, contingency planning, stockpiling of equipment and supplies, emergency services and stand-by arrangements, communications, information management and coordination arrangements between various agencies involved. Discussing these issues would contribute to a better understanding of the implications of the right to adequate food and shelter, which in complex humanitarian emergencies, is one of the key necessities of the affected population. Keywords: Disaster; food; shelter; humanitarian emergency.

Introduction The number of disasters has been growing in the recent years. Traditionally, we try to distinguish disasters as “natural” and “man-made”. Increasingly, every contemporary humanitarian crisis is caused by a combination of factors. Most of these disasters have negative short-term as well as longterm effects on food security and shelter, requiring humanitarian assistance.[1] Nepal has been overwhelmed by the recent massive earthquakes in April and May 2015. The earthquakes are expected to have significant implications for food security and agricultural-based livelihoods, and have also destroyed more than 130,000 houses and damaged more than 85,850 residences. Hence, access to food, maintenance of an adequate nutritional status and proving shelter to the displaced population are critical determinants of people’s survival during the time of a disaster.

This article aims to identify the principles and standards that are applicable to food and shelter related aid which will be provided by the co-operation of relevant institutions (local government, international support organizations, NGOs, donor governments, etc.). Thus, discussing these issues would contribute to a better understanding of the implications of the right to adequate food and shelter, which in complex humanitarian emergencies is one of the key necessities of the affected population. Protection Principles The principles of impartiality and non-discrimination apply in emergency situations and humanitarian action.[2,3] Most humanitarian agencies explicitly apply the principle of nondiscrimination in their relief programs. For example, the Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief states that

Correspondence: Sohil POTHIAWALA, M.D. Singapore General Hospital, Department of Emergency Medicine, Singapore. e-mail: drsohilpothiawala@yahoo.com

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doi: 10.5505/1304.7361.2015.98360

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“aid is given regardless of the race, creed or nationality of the recipients and without adverse distinction of any kind”, and that “aid priorities are calculated on the basis of need alone”. Commitment Five of the World Food Summit Plan of Action commits States to “Endeavour to prevent and be prepared for natural disasters and man-made emergencies and to meet transitory and emergency food requirements in ways that encourage recovery, rehabilitation, development and a capacity to satisfy future needs”. Similarly, everyone has the right to adequate housing which includes the right to live in security, peace and dignity, as well as protection from forced eviction and the right to restitution. Vulnerabilities of the disaster affected population The food-related aid has to be distributed only on the basis of need, regardless of any other factors. Certain specific groups need to be given special consideration is the assessment of their needs and delivery of aid. This group includes the more vulnerable members of the society like children, the elderly, persons with disabilities, expectant and nursing mothers, refugees and Internally Displaced People (IDP). The international humanitarian law, article 70(1) states that “in the distribution of relief consignments, priority shall be given to those persons, such as children, expectant mothers, maternity cases and nursing mothers, who, under the Fourth Convention or under this Protocol, are to be accorded privileged treatment or special protection”.[4,5] Different cultural aspects including certain religious taboos should also always be respected. However, dietary preferences and habits not amounting to taboos may have to be temporarily put aside in order to ensure freedom from hunger and the right to life. Standards for Food Security and Nutrition In general, food needs that arise from sudden-impact disasters eg. Earthquake, floods, etc are urgent but temporary, whereas in slow-impact disasters like droughts, civil wars, etc, food needs develop gradually and tend to last longer [6]. Disasters can make pre-existing inequalities worse. Although the affected state is the main duty-bearers to ensure appropriate management of the food and shelter crisis followed by long-term rehabilitation, humanitarian agencies working alongside the local government also have a responsibility to work with the disaster-affected population in a way that is consistent with the rights. Food security during a disaster response is achieved through better preparedness. The level of preparedness must inc-

lude risk assessment, contingency planning, stockpiling of equipment and supplies, emergency services and stand-by arrangements, communications, information management and coordination arrangements between various agencies involved. The Sphere handbook states that food security exists “when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life”.[7]This definition involves the three crucial elements that form the basis of food security: availability, access and utilization. There are two characteristic phases of an emergency response, the first phase at the onset and during the early stages of an emergency and a second phase, when the situation is stabilized. During the first phase of acute crisis, the initial energy need is determined based on the available information. To launch an immediate response, multi-sector initial rapid assessments may be sufficient. The quick supply of food saves lives and a standard food ration is provided to the population. People needing additional nutritional requirements (eg, malnourished children, pregnant and breast-feeding mothers, etc) may require and additional ration of food over and above the standard basic ration. Community participation is a key element during this phase. When the situation is stabilized, the initial figures are then revised based on the circumstances and information available once the food management and monitoring systems are established. Specific standards developed within the Sphere Project may give an indication of practical implementation of food security. a. Assessment Food security Standard 1: Where people are at increased risk of food insecurity, assessments are conducted using accepted methods to understand the type, degree and extent of food insecurity, to identify those most affected and to define the most appropriate response.[8] Various quantitative and qualitative tools can be used to monitor the needs (eg joint food assessment missions, vulnerability analysis and mapping [VAM], household food economy assessments). Also, support for people’s coping strategies, resilience and recovery capacities is essential. This assessment along with the study of the coping mechanism of the population would help achieve food security as well as achieve self-reliance. Therefore, while focusing on urgent

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and immediate needs, aid programs should also consider longer-term concerns.

population-wide interventions and individual treatment by providing supplementary feeding.

Food security standard 2: Where people are at increased risk of under nutrition, assessments

Minimum Standards in Food Security

are conducted using internationally accepted methods to understand the type, degree and extent of under nutrition and identify those most affected, those most at risk and the appropriate response.[9] It is important to identify groups with the greatest nutritional support needs and the underlying factors that affect the nutritional status. The decision making should analyze this and then develop a framework to appropriately respond to the needs, bearing in mind the capacity to respond. b. Infant and young child feeding Suboptimal infant and young child feeding practices increase vulnerability of this group to under nutrition, disease and death. The risks are heightened in disasters which makes them increasingly vulnerable in the emergency phase.. Standard 1: Safe and appropriate infant and young child feeding for the population is protected through implementation of key policy guidance and strong coordination.[10] Optimal feeding practices that maximize survival and reduce morbidity in children under 24 months are early initiation of exclusive breastfeeding, exclusive breastfeeding for 6 months, continued breastfeeding to 24 months or beyond, and introduction of adequate, appropriate and safe complementary foods at 6 months. Standard 2: Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that minimizes risks and optimizes nutrition, health and survival outcomes.[11] This can be achieved through giving priority to pregnant and breastfeeding women to access food, cash and/or vouchers. It is also important to incorporate other supportive interventions like integrated skilled breastfeeding counseling, additional nutritional support and linkage to food security programs to ensure access to adequate food. c. Management of acute malnutrition and micronutrient deficiencies Acute malnutrition and micronutrient deficiencies are associated with an increased risk of morbidity and mortality for affected individuals. Micronutrient deficiencies are difficult to identify and when known to be prevalent in the population, it may be assumed that this could be exacerbated by the disaster. These deficiencies should be tackled using

While meeting immediate needs and preserving productive assets will be the priority at the onset of a crisis, responses must always be planned with the longer term in mind, including an awareness of the impact of a degraded environment and its restoration. The “general nutritional support standard 1: nutrient supply” of the Minimum Standards in Nutrition reads: “people’s nutrient needs are met”. General food rations should contain at least 2000 kilocalories of energy per person per day (more in the cold climate) as well as the minimum daily allowances of protein, fat and micronutrients recommended by the United Nations.[12,13] The key indicators include standards in terms of intake of vitamins and other nutrient substances, absence of scurvy, pellagra or beri-beri, access to breast milk or recognized substitutes for infants under six months and overall low levels of malnutrition. The “requirement standard” for food aid reads: “the food basket and rations are designed to bridge the gap between the affected population’s requirements and their own food sources”. The Sphere Project’s food quality and safety standards should also be mentioned. General nutritional support standard 2 of the Minimum Standards in Nutrition reads: “food that is distributed is of sufficient quality and is safely handed so as to be fit for human consumption”. The key indicators include the absence of outbreaks of food-borne diseases caused by distributed food, the absence of complaints from the recipients, the existence of appropriate quality checks, etc. General nutritional support standard 3 states: “foods that are provided are appropriate and acceptable to the population”. The key indicators are consultation with people regarding the acceptability and appropriateness of the foods being distributed; no conflict with the religious or cultural traditions of population, the staple food distributed is familiar to the population, etc. General nutritional support standard 4 states: “food is stored, prepared and consumed in a safe and appropriate manner, both at the household and community level”. In addition, the resource management standard for food aid includes key indicators concerning food aid storage (“storage is safe and clean”, “food commodities are inspected and unfit commodities are certified and disposed of in accordance with standard procedures”, etc.). The disaster-affected population in need of food security should receive assistance that meets their primary needs, prevents erosion of their assets, reduces vulnerability and

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promotes their dignity. Distribution of food, cash or vouchers or a combination of these is the most common initial response to acute food insecurity. Other types of response that need to be considered early are food subsidies, temporary fee waivers, employment programs, productive support to livelihoods, destocking, fodder provision and the priority to re-establish normal market arrangements. The purpose would be to promote local agricultural development, strengthen regional and local markets and enhance the longer-term food security of affected country. Various agencies should take into account what others are doing to ensure that the combined response and services provided are complementary The environmental impact of food security All natural and man-made disasters involve a certain degree of environmental impact, which includes but is not limited to degradation of natural resources such as forests, soil, water biodiversity in general. Environmental degradation may in turn negatively affect health and social conditions of the local population. Humanitarian operations can also have a negative impact on the environment, depending on the kind of aid that is provided, which may include forest degradation (due to the gathering of fuel wood for cooking purposes), air pollution (due to the burning of cooking fuel), waste (discarded food packaging etc.) and the introduction of pests. Thus, the responses should build the capacity of people to manage natural resources and help the environment from further degradation. Shelter - a basic necessity during disaster

planned camps can be used to accommodate affected populations who are unable or unwilling to return to the site of their original dwelling and for whom hosting by other families is not an option. Minimum Standards in Shelter and Settlement The “Shelter and settlement standard 1: Strategic planning” states that appropriate strategies to provide shelter contribute to the security, safety and health of the affected population.[14] The non-displaced disaster-affected population should be assisted on the site of their original location with temporary shelter, or with resources for the repair or construction of existing houses or build new structures. Assistance could be provided in the form of provision of appropriate construction materials, tools and fixings, cash or vouchers, technical guidance and training or a combination of these. The provision of building materials and policies relating to housing construction should appropriately enable the expression of cultural identity and diversity of the population. Displaced populations who are unable to return to their original homes may arrange shelter with host families; settle as individual households or in groups of households within existing settlements. Alternatively, they may need to be temporarily accommodated in camps or in suitable large public buildings used as collective centres or school buildings. Often, people prefer to stay with other family members or people with whom they share historical, religious or cultural, and they should be assisted to do so.

Shelter is a critical determinant for survival of the affected population in the initial stages of a disaster. It is essential to provide security, personal safety, protection from the climate and to prevent disease outbreaks. It is also important for individual human dignity and to enable affected population to recover from the impact of disaster. Eventually, the appropriate response will also be determined by the ability of the displaced population to return to the site of their original dwelling and start the recovery process.

The “Shelter and settlement standard 2: Settlement planning” aims to enable the safe and secure use of accommodation and essential services by the affected population being accommodated in temporary communal settlements.[15] This includes safe, secure and equitable access to essential services like water, sanitation, energy for cooking, communal cooking facilities, heating and lighting, healthcare, solid waste disposal, schools, places of worship, meeting points, recreational areas including child-friendly spaces and space for livestock accommodation.

An initial needs assessment is essential to identify the shelter and settlement needs of the affected population, vulnerabilities and capacities and availability of various opportunities to aid recovery. As the shelter, settlement and non-food item standards and actions are implemented, a vulnerability and capacity analysis should be performed as it helps to ensure that the response effort supports those who have a right to assistance in a non-discriminatory manner and who need it most. The disaster-affected population, especially vulnerable people with specific needs, along with the relevant authorities, should be involved in any such assessment temporary

The “Shelter and settlement standard 3: Covered living space” defines the adequate housing that ensures sufficient covered living space providing protection from the climate, fresh air and ensuring privacy and safety from structural hazards and disease vectors.[16] A covered floor area in excess of 3.5 m2 per person is often required, with the minimum 2 meters floor-to-ceiling height at the highest point also being a key factor. Shelter solutions should encompass a range of climatic extremes and within the house, there should be materials to screen personal and household space which would aid in the provision of adequate personal privacy.

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General Shelter standard 4 “Construction” provides for use of local safe building practices, materials, expertise and capacities and also maximizes the involvement of the affected population and local livelihood opportunities.[17] Use of local skills and resources should be maximized. It is useful to involve the affected population, local building professionals and the relevant authorities in developing the appropriate safe building practices, provision of materials, labor, technical assistance and regulatory approval for the procurement and construction administration practices. Environmental impact is mentioned in the Shelter and settlement standard 5 and it states that shelter and the construction materials and building techniques used should minimize adverse impact on the local natural environment.[18] Efforts should be made to retain trees and other vegetation where possible, to increase water retention, minimize soil erosion and provide shade. Such management will enable us to meet the ongoing and future needs of the disaster-affected population. There are also minimum standards for the Non-food items and the “standard 1: Individual, general household and shelter support items” mentions that the affected population must have sufficient items to ensure their health, safety and well-being.[19] Arrangements should be done to meet the needs using familiar, locally sourced products. There should be a plan for orderly, transparent and equitable distribution of all non-food items with plans to replenish them for the population displaced for an extended period of time. The “standard 2: Clothing and bedding” states that the disaster-affected population should have provisions for sufficient clothing, blankets and bedding to ensure their personal comfort, dignity, health and well-being of the affected population is preserved.[20] The minimum standards of “Cooking and eating utensils” are mentioned in Standard 3 and the affected population should have access to culturally appropriate items for preparing and storing food.[21] The utensils should be made of foodgrade plastic or stainless steel. The “non-food items standard 4: Stoves, fuel and lighting” states provisions for the disaster-affected population to have access to a safe, fuel-efficient stove and an accessible supply of fuel or domestic energy, or to communal cooking facilities.[22] Each household also should have access to appropriate means of providing sustainable artificial lighting or alternatives to ensure personal safety. “Tools and fixings” standards are laid out in standard 5 and they identify and meet the tools and fixing needs for the safe construction of shelters, carrying out essential maintenance

and provide training for use of tools and debris removal.[23] Last but not the least, shelter and the non-food item responses by the government and supporting agencies should support existing coping strategies and also promote selfsufficiency to those who are affected by the disaster. Where public buildings, particularly schools, have been used as temporary communal accommodation, the planned and managed safe relocation of the sheltered population should be undertaken as soon as possible to allow for normal activities to resume. Any response should minimize the long term adverse impact on the natural environment, while at the same time, maximize opportunities for the affected population to maintain or re-establish activities of daily living. Conclusion In the past two decades, much progress has been made among the major relief agencies in standardizing approaches while dealing with disasters and complex emergencies. Food and shelter aid decisions need to be based on the minimum standard requirements discussed in this article as well as in the Sphere Project handbook in detail. They also need to be systematically evaluated repeatedly, not only for the content, but also based on their impact and effectiveness in real life situations. These activities need the inclusion and enhanced co-operation between the local government and the various non-government agencies when such emergencies occur.

References 1. Maxwell D. Food Security and its implications for political stability: A humanitarian perspective. Presented at the High level expert forum on addressing food insecurity in protracted crises, Rome 2012. 2. For a definition of impartiality, see International Committee of the Red Cross, Commentary on the Additional Protocols of 8 June 1977 to the Geneva Conventions of 12 August 1949, Geneva-Dordrecht, 1987, paragraphs 2800 - 2802; and Fundamental Principles of the International Red Cross and Red Crescent Movement, Principle of Impartiality. 3. Human Rights Committee, General Comment 18, Non-discrimination, 10 November 1989, paragraphs 7 and 13. 4. International Humanitarian Law, article 70(1) of Additional Protocol I. 5. Article 23(1) of the Fourth Geneva Convention. 6. Fisher D. Fast Food: Regulating emergency food aid in sudden-impact disasters. Vanderbilt J Transnational Law. 2007;40:1127-53. 7. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 145. 8. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project

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2011. p. 150. 9. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 154. 10. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 159. 11. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 160. 12. UN Adm. Comm. Coord. Sub-Comm. Nutr. 1995. Rep. Workshop Improvement Nutr. Refug. Displaced people in Africa, Machakos, Kenya, Dec 5-7. Geneva, Switz: UN. 13. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and regugee situations. Annu. Rev. Public Health 1997;18:283-312. 14. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 249. 15. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 254. 16. The Sphere Project, Humanitarian charter and minimum

standards in humanitarian response, The Sphere Project 2011. p. 258. 17. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 262. 18. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 265. 19. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 269. 20. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 271. 21. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 273. 22. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 274. 23. The Sphere Project, Humanitarian charter and minimum standards in humanitarian response, The Sphere Project 2011. p. 276.