Journal of Health Management Special Edition Vol II December 2015

JOURNAL OF HEALTH MANAGEMENT
SPECIAL EDITION VOL II: DECEMBER 2015
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 1

ADVISOR
Dr. Shahnaz Binti Murad

Deputy Director General of Health
(Research and Technical Support)
EDITOR IN-CHIEF
Dr. Nor Izzah Binti Hj Ahmad Shauki

Director, Institute of Health Management
MD (USM), MCommHealth (H&HM) (UKM)
EDITORIAL BOARD
Dr. Nor Filzatun Binti Borhan

MD (USM), MPH (UM)
Datin Dr. Noriah Bidin
MBBS (DOW), MPH (UM)
Dr. Nor Haniza binti Zakaria
MD (AIR LANGGA UNIVERSITY)
MANAGING EDITOR
Dr. Pangie anak Bakit

Dr. Munirah Ismail
Minson Majimbun
Siti Zubaidah Ahmad
Mohd Idris Omar
Nooreyzan Manangin
2 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

Table of Content
Rapid Assessment Of Floods In Kelantan: Information For Action 5
Saraswathi BR1, Fadzilah K2, Rosemawati A2

1Penang State Health Department
2Office of Deputy Director General of Health (Public Health)
Post Flood Delivery Of Humanitarian Assistance To 13

The Orang Asli Settlements In Gua Musang, Kelantan
Alzamani Mi, Siti MY, Mohd Khairi AL, Hani HH, Syed Hazran SM,
Abu HAA Emergency Department, Hospital Kuala Lumpur
Bugs In The Water: A Review Of Effects Of Floods 20

Among Rescue Workers, Healthcare Workers And Flood Victims
Eswaran K
Clinical Research Center, Hospital Duchess of Kent
Institute For Health Management - Transit Center For 38

Flood Disaster 2015; Psychosocial Impact On Volunteers
Munirah I, Norhidayah MD
Institute For Health Management
Lessons From The Remediation Of A Flood-Damaged Health Clinic 49
Alzamani MI, Malathy R, Hafiz SM, Abu HAA Emergency Department,

Hospital Kuala Lumpur
Post Deployment Activities And Challenges In Crisis 62

Preparedness Response Center Institute For Health Management

M Fairuz AR, Pangie B, Krishan O, Noriah B, N Filzatun B, N Izzah AR
Institute For Health Management
Managing Child Flood Victim by Psychological 75

Engagement: A Pilot Project
Alzamani MI, Mona KG, Nurul LR, Hafiz SM, Ahmad IKB, Abu HAA
Emergency Department, Hospital Kuala Lumpur
Public Health Challenges During Flood Disaster: Managing 86

Food Poisoning Outbreak In Pusat Pemindahan MRSM
Pasir Salak Perak Tengah District January 2015
Nor Samsiah AR, Ariza AR

Perak State Health Department

JOURNAL OF HEALTH MANAGEMENT
SPECIAL EDITION VOL II: DECEMBER 2015
4
1
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015
Rapid Assessment of Floods in Kelantan: Information for Action
Saraswathi BR1, Fadzilah K2, Rosemawati A2
1Penang State Health Department
2Office of Deputy Director General of Health (Public Health)
Abstract
In December 2014, Kelantan faced unprecedented flooding which damaged infrastructure, disrupted services
and caused mass destruction. The response mechanisms in place for such an event failed. The epidemiology
intelligence team was called in to carry out an assessment to determine functionality of the health centres,
identify potential threats and take immediate measures where possible. We assembled in teams at the
office of the Director General of Health and targeted eight affected districts affected. After collection of
information on functioning routes to the areas, we arrived at the field where we appraised the evidence
through direct observation, focus group discussion, key informant interviews and street interviews. We took
steps where possible to mitigate the risks identified on site. All evidence and information gathered form our
teams were channelled back to the National Coordination committee through social media application in
real time. This information was then transformed into action by the relevant departments and committees.
The basis for any action taken in times of disaster must be a good assessment of the situation on the field.
This is to target the response according to the need.
Key words: floods, information, disaster
Introduction
Kelantan, located on the north-east coast of peninsula flooding that occurs during this period; however
Malaysia has a tropical climate and experiences the magnitude of this years flooding caused these
intermittent rain throughout the year. The North- systems to fail, resulting in a displaced population
East monsoon that prevails from November to without emergency relief such as food, clean
January brings heavy rain to this region annually. clothing, clean water and access to medical aid.
Often, during this period low-lying regions get Many parts of the interior of the state and clinics were
flooded. But climate change, can result in extremes cut off, communication lines were down, and roads
that may present in the form of floods, landslides and were submerged and inaccessible. Information was
flash floods. In December, 2014, an unprecedented sketchy. The State Crisis Preparedness and Response
amount of rainfall caused massive flooding in the centre (CPRC) was in operation but to escape the
state of Kelantan. The areas affected first were floods that affected the State Health Department,
those in the coastal, riverine and low-lying areas. they had to move their operation centre several
But with the concomitant high tides larger areas times. Health staff throughout the state was limited
were affected and the destruction that followed as they dealt with their own situations: many were
came about in two waves. The first wave occurred affected by the floods with their homes submerged
on the 17th December 2014 followed by another or destroyed. Some were unable to get to work,
wave on 25th December 2014. and there was no information from the state of
Response mechanisms are in place for the annual some staff.

On 29th December, the Deputy Director General staff from other department at the
of Public Health Malaysia issued a directive to the evacuation centres and the evacuees
Epidemiology Intelligence Malaysia (EIP Malaysia) b. Focus groups we met with CPRC
teams to deploy to the affected areas to carry out staff and the evacuees to identify
an assessment of health infrastructure and services. problems and to better understand
The objectives were to determine operational their needs
capacity of the health services, identify potential c. Rapid assessment surveys using
threats, take immediate measures where possible to street interviews
avert further risk and to recommend interventions d. Direct observation; we observed the
that may alter the course and influence the outcome procedures going on at the CPRC, at
of potential health threats. the health centres, at the evacuation

centres and also on the street where
Methodology possible, to assist us in the rapid
A very quick risk assessment was carried out as we assessment of the situation
were given four days on the field including travel In each of the stages, there was transparency and
time. There were several stages in the process of sharing of information. We informed the stakeholders
carrying out the risk assessment. of all our findings daily. We were in contact with
1. Stage of Preparation: teams were identified all the other teams carrying out risk assessment in
and assembled. We were equipped to be the state through the social application telegram
self-sufficient, with a four-wheeled drive where we uploaded photographs and provided daily
and stocked with sufficient dry rations and feedback to the EIP Director and the Deputy DG
water for our personal use. In anticipation of Health in real time. They then channelled the
of what may be needed, we stocked up on relevant information to the flood central coordinating
disinfection, spray can for disinfection, as committee at CPRC, Ministry of Health.
well as with sufficient petrol. Satellite phones were used to communicate in
2. Collection of event information and areas where the telephone lines were down. The
literature search: we learnt through the phones were also used for us to log in every day
media and websites the current local to the office of the DG of Health to confirm our
situation specifically about accessibility. whereabouts and safety.
The CPRC Ministry of Health data updated
us with a list of affected district health
Results
We started travel on the 30th December, 2014 after
clinics and with maps of the area.
deciding on our modus operandi. We left for the
3. Extraction and appraisal of the evidence:
field on the afternoon of the same day. On 2nd
This was done on site by the various teams.
January, all the teams headed back to the Office of
We used qualitative methods that are
the Deputy DG of Health to consolidate and present
survey information and direct observation.
the findings to the National Coordination Committee
We collected data identified from:
(NCC) on the 4th January, 2015.
a. Key information interviews this was
carried out by interviewing health Preparation and collection of information
personnel from the clinics, operations The fully equipped teams met at the office of the
room staff at the district CPRC, Director of the Epidemiology Intelligence Programme
Malaysia to determine which districts to go to, the 8 that were affected by the flooding.
most appropriate routes based on the current road
Evidence appraisal
situation and the data required from each of the
From the 8 districts we assessed the extent of
teams. We started a group on social media using
damage. The findings are summarised as in Table
the telegram application to communicate with each
1 and Table 2. All information was relayed to the
other. We were also provided with satellite phones.
EIP Director who then relayed it to the National
Our orders were to report daily on our findings: this
Coordination Committee for action. All our findings
was also to ensure our safety.
were accompanied by photographs.
There are 10 districts in Kelantan and we targeted
Table 1: Summary of Health facility and evacuation centres visited
District Health facility visited Evacuation centre (EC) Date of

and communities visited assessment
Kota Baru 1. Kota Baru Health Office
2. Flood district operations centre
3. KK Badang - 31.12.14
4. KK Kijang 01.01.15
5. K1M Seri Cemerlang
Tumpat 1. Tumpat Health Office 1. SK Pasir Pekan 31.12.14
2. KD Pasir Pekan 2. Mukim Sungai Pinang 01.01.15
Jeli 1. Jeli Health Office 1. SK Kuala Balah
2. KK Kuala Balah 2. SK Bukit Jering 31.12.14
3. KK Kubor Datu 3. SK Lubok Bongor
4. KK Lubok Bongor
Tanah 1. Tanah Merah District
Merah Health Office 1. Kusial Baru EC
2. KKIA Tanah Merah 2. EC Gobek 01.01.15
3. KK Gual Ipoh
4. KD Kulim
Gua Musang 1. Gua Musang Health Office 1. SMK Tengku Indra Putra 1 (TIP 1)
2. CPRC Gua Musang district 2. SMK Tengku Indra Putra 2 (TIP 2) 31.12.14
3. KK Bandar Gua Musang 3. Bertam Baru 01.01.15
4. KK Aring 4. Community at Kesedar region
5. KK Bertam Baru 5. Community at Gua Musang
6. KK Chiku
Kuala Krai 1. KK Dabong
2. KK Laloh
3. KK Manik Urai 31.12.14
4. KD Keroh
5. KD Kuala Nal
6. KD Kemubu
Pasir Mas 1. Rantau Panjang Health Clinic
2. KK Tendong 1. Gelang Mas EC 31.12.14
3. KD Lati 01.01.15
4. KK Bandar Pasir Mas
Machang 1. KD Kerilla 01.01.15

Table 2: Summary of findings, recommendations and actions taken
Scope Summary of Findings Our recommendation Action taken by

central committee
CPRC 1. In some districts the 1. CPRC to be located 1. Sourcing of gen sets by

management CPRC was affected preferably within the National Coordinating
and disease and they had to the state health Committee
surveillance move to safer ground department. However 2. Deployment of staff from
as well. Since lines where this was other states to CPRC to
were down and some also flooded, we decide where they would
clinics totally cut recommended a be most needed and
off information was location where the staff sent there.
sketchy. can easily access it.
2. The districts were 2. Water and electricity
just organising their needs to be available so
disease surveillance. gen sets to be provided
In some areas there to CPRC to function
were no maps. effectively.
3. Assistance in running
the CPRC especially
in districts where the
staff were already
overwhelmed.
Communication There was no alternative Satellite phones to be kept This issue is being considered
communication line in centrally and to be used in for long term planning.
areas where there was disasters.
no power nor telephone
line.
Transport Most of the vehicles were Deploy more vehicles to When staff from others
saved during the floods. the area. districts were deployed to
However there was a the State, they were asked
desperate need for more to come with their own
vehicles as they were transport and driver. This was
needed to transport staff coordinated at the Institute
to and fro from affected for Health Management.
areas. The vehicles were Transport was also sourced
also used to go into and sent to the districts for
villages carrying medical their own use.
supplies for the affected
community.
Electricity Power supply affected To supply gen sets to The National coordinating
in all districts and clinics. committee sourced for gen
many clinics and health sets and had them sent to
facilities without power. affected areas.
Water Most water supplies cut To carry out chlorination The engineering division was
as pipe lines were either of all tube wells and GFS given the task to ensure that
destroyed or submerged. source of water supply. extensive comprehensive
Many parts of Kelantan chlorination was carried out
also depends on gravity according to the specification
feed system (GFS). as set by Ministry of Health
guidelines to prevent
disease.

central committee
Human Many health facilities 1. Deploy more staff from 1.

Staff were deployed
Resource with insufficient staff and other states. from other states and
those who were there 2. The health officer of there was continuous
were tired. Some were some badly affected replacement of staff
working continuously in districts to be replaced when the batch returned
spite of their own homes temporarily so that they to original state
being affected. may rest. 2.
Three Public Health
Physicians were
immediately sent to serve
2 weeks each at the
districts of Gua Musang,
Pasir Mas and Tumpat
respectively.
Medical 1. Disinfection was 1. Suggest providing 1. The medical supplies

supplies and done using very bigger spray cans. were totally coordinated
stockpiles small spray cans 2. Send in more supplies by the central
which was labour of medicines committee through
intensive. the pharmaceutical
2. A lot of drugs and services and this was
medical supplies continuously sent.
were destroyed in 2. Hospitals from other
the floods as not all states also sent medical
were saved. supplies when their staff
went down to the region.
Personal 1. There were To supply PPE and boots to 1. Masks and boots were
Protective insufficient masks the staff in the field. mobilised to the state
Equipment for staff working in immediately.
the flood areas. 2. All volunteers and staff
2. Staff were not working in flood prone
wearing boots in area ordered to bring
spite of risk of their rubber boots and
leptospirosis and to wear them.
other infection.
Affected clinics Some were a total loss 1. Total loss clinics to 1. Engineering divisions
while others were a be replaced or to find sent to follow up on the
partial loss. Partial loss alternate sites where findings and reassess
meant that the clinic the staff can function the clinics to make sure
would be able to function with setting up of that they are able to
after cleaning. temporary tents. function as soon as they
2. Partial loss clinics to are found to be safe.
start with available 2. Identify areas where
equipment after cleaning. tents could be placed
3. Assistance in cleaning and used as temporary
clinics.
3. Central committee
coordinate with the
Ministry of Education to
assist in cleaning the
affected health facility.

central committee
Flood SOP and flood plans do To review the flood Simulation exercises are
Management not take into account management plan to being considered.
Plan severe flooding which take into account major
would not only affect disasters.
infrastructure, but
would affect staffing and
communication.
Evacuation 1. In addition to the We requested for hygiene All needs were channelled to
centres gazetted evacuation kits for the evacuees at the the respective departments
centres, there are EC that has none or limited and units. The kits as
many non-gazetted water supply. requested were prepared
centres, some and distributed.
located on hillsides
and some even
in vehicles by the
roadside.
2. Toilets in most of the
EC are clogged due
to very high usage
and insufficient
water.
There were some measures taken by the team of the most damaging natural disasters occurred in
when they visited the districts. Disinfection was Asia in 2014. In the same year about 35 percent of
carried out at evacuation centres that we visited. all global economic losses were the result of flooding
We focused on the toilets and the drains as water - the highest rate since 2010i. The top three perils
was needed to mix the disinfectant and water was were floods, tropical cyclones and severe weather
in short supply. We also distributed hand sanitizers and these contributed for 72% of all economic
to the clinic staff. In addition, health promotion losses. Floods were overall the costliest peril.
materials were handed out: these covered food
The Kelantan floods in December 2014 also affected
and water borne disease, leptospirosis and general
other states in the county and continued into 2015.
cleanliness and precautions necessary to prevent
It hit Malaysia from 15th December 2014 to 3rd
disease during floods. In some areas, where the
January, 2015. Johore, Kedah, Negeri Sembilan,
clinics were totally gone, we were able to advice
Pahang, Perak, Perlis, Sabah, Sarawak, Selangor and
where temporary static clinics could be set up after
Terengganu were also affected. By 20th December
discussion with the local staff.
2014, most of the rivers in Kelantan Pahang, Perak
Discussion and Terengganu had reached dangerous levels.
Natural disasters are a more common occurrence Twenty one people died in the floods. The state
in tandem with global climatic change. The Annual of Kelantan had the most number of evacuees
Global Climate and Catastrophe Report published 20,468. As the heavy rains continued, the situation
by Impact categorizes each event by economic loss worsened and most of the roads in Kelantan were
and insured loss and it is stated there that eight inaccessible.

Our task covered the health centres and we found was improved to prevent disease outbreaks and
that the health centres were affected these to ensure prompt response to any disease threat.
included the Klinik Desa. Hospitals were more Immediately following the floods and in anticipation
resilient as they were a bigger institution and they of outbreaks of leptospirosis and melioidosis, a
have gen sets of their own but this is not true in directive was sent out to the whole country for
health centres. Many of the health centres were states to report daily, cases of melioidosis as this
located close to the riverine areas and near the was not a disease listed that carried mandatory
banks. This may be chosen to facilitate river travel notificationii. Leptospirosis and other food and
in predominantly rural Kelantan but this came with water borne diseases were monitored daily though
its associated risk. The Ministry of Health should the e-notifikasi system of the Ministry of Health
consider relocating such health facilities to higher where all diseases are registered on line.
ground. With the current change in climate, seasonal
Conclusion
flooding is eminent. Hospitals were therefore able
The unprecedented floods that took place in
to provide the public with immediate medical
Kelantan caught the Health services off guard. In
treatment. Health centres that were affected used
spite of lack of information, the EIP team played a
mobile vans and temporary shelters to provide
major role in the early period to assess the extent of
immediate basic medical care.
the damage and disruption of services and provide
The success of our actions is the speed with which feedback to the National Coordination Committee.
we return to the non-emergency system. This is Their early information assisted in formulating the
a challenging task taking into consideration the action taken by the central coordinating committee
level of destruction that occurred here. We aimed to help mitigate the effects on health.
to prevent excessive mortality and morbidity and
strengthen overall capacity to manage with limited Recommendations
resources. This is seen in the data from the Ministry The floods in Kelantan at the end of 2014 and
of Health where in tangent with our efforts there early 2015 were unprecedented and a severe
were no outbreaks of typhoid, leptospirosis, test of our services. To be better prepared in the
melioidosis or any other outbreaks associated with future we recommend that the state develop an
the floods, recorded. info blast system to alert the districts of potential
disasters and also to update them so that they
Every need that we presented from our findings was
can prepare accordingly. Evacuation facilities need
discussed at the central committee and action was
to be identified in advance and supplied with
taken to meet the needs after assessing feasibility.
the necessary items such as blankets and other
Three Public Health Physicians were sent to critical
necessities. Medical supply should also be kept on
districts to assist and replace tired staff for between
standby especially towards the end of the year as
4 to 6 weeks. This enabled the district health officers
the floods are a recurrent event. On a long term
to have much needed rest and tend to their own
basis, we suggest that future health facilities be
families who were affected by the floods. It also
built away from riverine and low-lying areas.
helped to boost the morale of the doctors involved
Disaster management is the way forward for us.
as we worked together in this disaster as a team.
To achieve this we recommend that disaster
The disease surveillance and response system

epidemiology and disaster management to be Limitations
included in the training of young doctors especially As time was essential, we relied in part on expert
in the Masters of Public Health courses. Simulation knowledge from key informants, who were usually
exercises to encompass this would also assist in the medical and health staff from the state or
preparing our staff to handle such events. community leaders. At the EC we held focus group
Our public health response team that carried out discussions with the evacuees and community
this assessment faced challenges in getting into the leaders. Where possible we attempted to concur
area and carrying out our own assessment: in the with our observations. Some clinics were still
long term we suggest developing a mobile public inaccessible at the time of our visit.
health response team with a vehicle such as a bus

Acknowledgment
or a truck suitably equipped so that we can function
We would like to acknowledge the Director General
out of that vehicle.
of Health, Malaysia for permission to publish the
article.
References
1. Aon Benfield (2014). Annual Global Climate 2. Law of Malaysia (2013). Act 342. Prevention
and Catastrophe Report, Impact Forecasting. and Control of Infectious Disease Act 1988.
(cited : 19 May 2015). Available from:
http://thoughtleadership.aonbenfield.com/
Documents/20150113_ab_i
f_annual_climate_catastrophe_report.pdf.

Post-Flood Delivery of Humanitarian Assistance to the Orang Asli Settlements
in Gua Musang, Kelantan
Alzamani MI, Siti MY, Mohd Khairi AL, Hani HH, Syed Hazran SM, Abu HAA
Abstract
Introduction: Major floods affected Kelantan towards the end of December 2014. Among the worst hit
areas were Kuala Krai and Gua Musang. There were a number of aboriginal settlements there that were
hard hit and almost forgotten.
Materials & Methods: To assist the aborigines who were badly affected by the floods, we collaborated
with the Society for the Orang Asli, the Department of Orang Asli Affairs (JHEOA) and the National Welfare
Foundation (YKN). We provided a mobile medical team comprising two Emergency Physicians, one medical
officer, three housemen, a health attendant and a driver. We worked with YKN and they provide water
filtration units, wellness kits and bedding worth RM126,000.
Results: The team used four-wheel drive vehicles to gain access to the aboriginal settlement areas. The
team set up mobile clinics at Kampung Pasir Linggi in Kuala Krai and Pos Tohoi in Kuala Betis. We observed
that the victims at these villages lost nearly all their belongings. They did not have access to medical servi
ces due to their location and lack transport to the nearest health center. We served a total of 476 aborigines.
The common illnesses included upper respiratory tract infections, acute gastroenteritis and dyspepsia.
Conclusion: A natural disaster caused a breakdown in basic amenities. Aborigines located deep in the
jungle should not be neglected. Resources need to be deployed to the victims location. Mobile clinics were
the best way to provide the required medical care in this situation. Collaboration between multiple agencies
ensured good logistical support in the provision of medical care for the aborigines.
Introduction
Massive floods affected the Malaysian east coast catastrophic floods. The worst affected was the
from 15th December 2014- 3rd January 2015. indigenous community in Kelantan involving a total
One of the worst hit areas affecting the aborigines of 7,995 people from 67 villages, especially those
was the inland area of Gua Musang. There were in Gua Musang. The Orang Asli Affairs Department
a number of aboriginal settlements there and they (JAKOA) had spent more than RM2 million on food
were hard hit and almost forgotten. Some 42,000 and basic necessities for the indigenous communities
indigenous people from 261 villages throughout affected by the floods. We describe our relief work
the country were reportedly affected in these in the Gua Musang Orang Asli settlements.

Photo1: Team members in convoy for the humanitarian assistance
Main Objectives
The main aims of this mission were to provide medical and a driver was formed. The team was joined by
services and to supply basic needs, including items another 37 volunteers in a convoy of 12 four-wheel
for personal hygiene, household items, cleaning drive vehicles and a lorry and supplied water filters,
supplies and school supplies, water purifiers, beds, bedding and wellness kits worth RM126,000 to the
bedding and blankets to the villagers who had lost indigenous community in Gua Musang, Kelantan.
nearly all their belongings in the floods. The mission took 2 days from 30th-31st January
2015 and involved mainly Kampung Pasir Linggi in
Materials and Methods
Kuala Betis and Pos Tohoi in Gua Musang, Kelantan.
The project was carried out from 30th-31st January
2015 at Kampung Kuala Linggi in Kuala Betis and Results
Pos Tohoi in the district of Gua Musang. It was a The journey A convoy of 12 four-wheel drives and
collaboration between the Emergency Department a truck made their way by the East Coast Highway
of Hospital Kuala Lumpur, the National Welfare to Gua Musang, Kelantan. From Gua Musang, the
Foundation and the Department of Orang Asli Affairs convoy made its way to Kampung Pasir Linggi
and the Pahang Association for Orang Asli Concerns at Kuala Betis. The obstacles encountered were
(POAPP). The mobile medical team from the minimal as the flood had subsided considerably.
Emergency Department of Hospital Kuala Lumpur The village was damaged and furniture could be
(HKL) comprising two Emergency Physicians, one seen hanging from trees and clothes were found on
medical officer, three housemen, a health attendant electrical cables, marking the level of floods.
Photo 2: On the way to Kuala Betis via off-road access

Mobile Medical Service Operations at assistant assisted with drugs dispensing. A total
Kampung Pasir Linggi, Kuala Betis number of 94 patients were treated there. After
Kuala Betis has two settlements. Upon arrival, we serving this community, the team moved uphill to
observed that the houses had been damaged and another settlement (about 5 minutes drive away)
furniture could be seen hanging from trees. The and set up a clinic behind the four-wheeled drive
villagers had minimal clothing and the children vehicles and treated another 80 patients. The main
walked barefooted. A mobile clinic was set up under illnesses include upper respiratory tract infections,
a tent. A triageur performed both registration and acute gastroenteritis and dyspepsia. In total we
triaging. 4 doctors provided medical examination treated 174 patients in Kuala Betis. The distribution
simultaneously while a fifth doctor and a health of illnesses is illustrated in Figure 1.
Photo 3: Medical Team operating under a tent

Figure 1: The distribution of illnesses for the
patients treated at Kuala Betis
The total population here was about 300 people. The distribution of cases included Upper Respiratory Tract
Infection (URTI) 83.9 % (146), Acute Dyspepsia 2.9% (5), Acute Gastroenteritis (AGE) 2.9 % (5), Fungal
Infection 2.9% (5) and Herpes Zoster 0.5% (1). The distribution of donated items worth RM 78,000 was
done by the National Welfare Foundation at Kuala Betis. This included 10 water purification units of 20 litres
capacity, bedding and family wellness kits.
Figure 2: The distribution of illnesses for the patients treated at Pos Tohoi

302 patients treated at Pos Tohoi. The distribution of cases included 63.2% (191)
Upper Respiratory Tract Infection (URTI) 78.8% (238), Acute Dyspepsia 8.3% (25)
, Acute Gastroenteritis (AGE) 6.6% (20) , Fungal 6.0% (18) and Goitre 0.03% (1).
Table 1: Distribution of Cases Managed at both Kuala Betis and Tohoi
Location URTI Acute AGE Herpes Fungal Goitre Total

Dyspepsia Zoster
Kuala Betis 148 5 5 1 5 0 174

(85.1%) (2.9%) (2.9%) (0.5%) (2.9%) (0.0%)
Tohoi 238 25 20 0 18 1 302

(78.8%) (8.3%) (6.6%) (0.0%) (6.0%) (0.03%)
Total 476
Discussion
During the major floods, the access to the Orang they stay far inland and shy away from developed
Asli areas was cut off completely. For two days, areas. Buajaroen (2013) described volunteer work
they stayed on a hill and had limited food. In by nurses to care for those affected and assist in
the future, areas isolated by the floods should be re-establishing a functioning health care system
referred to the military or similar agencies with the following a flood in 2010. The author found that
vehicles appropriate for such emergencies. Gupta the concept and principle of health care services
et al (2012) described the damage and dysfunction management were community based and involved
of a civil hospital of Leh in the Ladakh region of home care and field hospital services. A community-
North India following flash floods. In this disaster, based approach such as the mobile teams placed
search and rescue operations were launched by the within the community as we had done proved to be
Indian Army immediately after the disaster. Mass beneficial for the Orang Asli.
casualty management was handled by the army The Orang Asli community, like any other aboriginal
doctors while relief work was mounted by the army community are a passive lot and only require
and civil administration. The authors found that basic needs for their livelihood. They rarely seek
disaster preparedness was critical, particularly in help in most situations and will do all they can
natural disasters. The Armys immediate search, to survive. Nevertheless, the National Orang Asli
rescue, and relief operations and mass casualty Affairs Department (JAKOA) - the authority in-
management effectively and efficiently mitigated charge of this community checks on them and
the impact of the flash floods, and restored normal organizes help. Despite having experienced
life rapidly. mulitiple disaster events in the past, they do not
Post-flood volunteer work must be community display the attitude of seeking help and could
based with field orientation. More often than not, easily be forgotten. In reality, they could be in dire
access to health centres may not be possible. circumstances. Stimpson et al (2008) described
Existing health centres too, may not be functional. how the frequency of exposure to a flood was
This is more so for the Orang Asli community as associated with the probability of seeking help from

agencies that provide disaster-related services. The community and individual recovery. Such planning
authors discovered that the probability of seeking would be of great effectiveness if employed among
disaster relief services increased with the number the Orang Asli community.
of flood experiences. Racial/ethnic minorities, rural Network centrality is essential for faster recovery
residents, economically challenged individuals, and of all Orang Asli settlements. The Orang Asli Affairs
people with low levels of perceived social support Department do have the date of populations at
may be more likely than people without these settlements. Nevertheless, the establishment of
characteristics to seek services. Nevertheless, this an operations center would facilitate all assistance
was not the case in the Orang Asli community. to all affected areas. Moore et al (2003) described
The level and pattern of community development the Mozambique floods in 2000. Mozambique then
affect its capacity to respond to flooding. The Orang suffered its worst flooding in almost 50 years.
Asli community obviously has a limited resilience in Coordination of disaster assistance was critical for
the face of flood disaster. They are also situated effective humanitarian aid operations, but limited
too far from relief centers that can be counted for attention had been directed toward evaluating
assistance. Buckland and Rahman (1999) examined the system-wide structure of inter-organisational
the relationship between community preparedness coordination during humanitarian operations. In
and response to natural disaster and their level and our experience, we noted there were other groups
pattern of community development by investigating participating in humanitarian assistance as well.
preparation and response to the 1997 Red River One group was stranded when their vehicles could
Flood by three rural communities in Manitoba, not exit the area they had served. Therefore, a
Canada. The hypothesis was supported in that central information network to ensure no overlap
the level and pattern of community development occurs would be good for this situation.
affect community capacity to respond to flooding.
Structural factors also affect residential location or
Communities characterised by higher levels of
relocation. The relocation of Orang Asli was limited
physical, human and social capital were better
to nearby hilly areas during floods. Patients mobility
prepared and more effective responders to the
was also limited being located in the jungle.
flood. The Orang Asli who remain unsophisticated
Chan (1995) described the strong influence of
had a low capacity to respond and thus needed
structural factors in peoples persistent occupation
assistance.
of floodplains. Thus, despite a high level of flood
The recovery of the Orang Asli needs to be facilitated. hazard awareness, a high level of pessimism and
They were under-resourced and rather backward a high level of expectation of future floods, poorer
being aborigines. Rowlands (2013) described individuals seldom attempt to leave for more
Australias broad disaster recovery planning and advantageous locations but remain instead trapped
management approach, adopting a social and in their present locations by structural factors
community recovery perspective. Strengths-based, such as poverty, low residential and occupational
solution-focused approaches to intervention, and a mobility, low educational attainment, traditional
sound understanding of community development land inheritance, government aid, and government
principles, were essential to facilitating community disaster preparedness, relief and rehabilitation
recovery. He illustrated the full spectrum of planning, programmes. These forces exerted a strong
immediate psychosocial response, and longer term
influence upon individuals and largely control
their choice of residential location in response to disaster. This should be considered in all recovery
flood hazards, thereby reinforcing the persistent efforts such as rebuilding their homes and others
occupation of floodplains. On the other hand, in the future.
structural factors such as landlessness, rural-urban Conclusion
migration, floodplain encroachment and squatting Co-operation between governmental and non-
were highly influential in leading people to move. governmental organizations facilitated the
However, even for those who moved, structural efficient delivery of humanitarian assistance to the
factors largely confined their choice of residential aborigines. Local authority involvement ensured
location to urban floodplains. The same was noted safe journey through the interior and acceptance by
among the Orang Asli community in that they affected aborigines. The main illnesses in the Orang
stayed put at their settlement areas and would not Asli victims were upper respiratory tract infection,
move to relief centres. acute gastroenteritis and dyspepsia in post-
Soliman et al (1998) designed a survey to elicit flood phase. We recommend a multi-organization
workers perceptions of providing crisis outreach approach in the delivery of humanitarian assistance
services to survivors of the 1993 flood in Illinois. to the Orang Asli community in the future.
Their findings highlighted the benefits of recruiting Acknowledgment
local workers in disaster relief work. The positive We would like to acknowledge the Director General
outcomes of the experience included both personal of Health, Malaysia for permission to publish the
and professional growth. The benefit of recruiting article. We also would like to thank the National
local workers in disaster relief work was seen as Welfare Foundation (YKN), the Pahang Association
Orang Asli could be recruited in the recovery phase for Orang Asli Concerns (POAPP) and the Orang Asli
to rebuild homes and provide transport in this Affairs Department (JAKOA) for their contributions.
References
1. Stimpson, J.P., Wilson, F.A., Jeffries, S.K. 4. Gupta, P., Khanna, A., Majumdar S. (2012).
(2008). Seeking help for disaster services after Disaster management in flash floods in leh
a flood. Disaster Med Public Health Prep, 2(3), (ladakh): a case study. Indian J Community
139-141. Med, 37(3), 185-190.
2. Buckland, J., Rahman, M. (1999). Community- 5. Buajaroen, H. (2013). Management of health

based disaster management during the 1997 care services for flood victims: the case of the
Red River Flood in Canada. Disasters, 23(2), shelter at Nakhon Pathom Rajabhat University
174-191. Central Thailand. Australas Emerg Nurs J,
16(3), 116-122.
3. Rowlands, A. (2013). Disaster recovery
management in Australia and the contribution 6. Moore, S., Eng, E., Daniel, M. (2003).
of social work. J Soc Work Disabil Rehabil, International NGOs and the role of network
12(1-2), 19-38. centrality in humanitarian aid operations: a
case study of coordination during the 2000
Mozambique floods. Disasters, 27(4), 305-
318.

7. Soliman, H.H., Lingle, S.E., Raymond, A. 9. Kendall, E., Del, Fabbro, L., Ehrlich, C., Rixon, K.
(1998). Perceptions of indigenous workers (2011). Rebuilding community: considerations
following participation in a disaster relief for policy makers in the wake of the 2011
project. Community Ment Health J, 34(6), 557- Queensland floods. Aust Health Rev, 35(4),
568. 520-522.
8. Chan, N.W. (1995). Choice and constraints 10. Blum, N., Fee, E. (2008). The Sungari River
in floodplain occupation: the influence of flood and the Jewish community in Harbin,
structural factors on residential location in China. Am J Public Health, 98(5), 823.
Peninsular Malaysia. Disasters, 19(4), 287-
307.

Bugs in the water: A review of effects of floods among Rescue Workers,
Healthcare Workers and Flood Victims
Eswaran K
Clinical Research Center, Duchess of Kent Hospital
Abstract
Introduction: Several Malaysian states were inundated due to floods which occurred in December 2014. This
review article focuses on the bioecological characteristics of several waterborne or water-related pathogens
and the susceptibility of humans which may be associated with communicable disease transmission among
Rescue Workers (RWs) and Healthcare Workers (HCWs) who are mobilised during disaster management.
Methodology: Research articles pertaining to common waterborne diseases due to extreme water events
were searched electronically and profiled according to latitude. Diseases which are more endemic in tropics
and subtropics were evaluated.
Results: Ecological, climatic factors and human activities cause pathogens to proliferate before floods and
disseminate during and after floods. The increased concentration of these pathogens in the environment
and animal reservoir around human habitation are risk factors for disease outbreaks. Improving RWs
and HCWs competencies to take immediate and appropriate measures after floods will reduce the risk of
waterborne disease outbreaks.
Conclusion: The bioecological properties of pathogens in Malaysia may need to be studied further to
understand the interactions between these factors. The applicability of appropriate frameworks such as
cross-cutting competencies and surveillance systems utilized in other countries can be adapted to suit the
needs of the Malaysian population.
Keywords: pathogen, bioecological, waterborne, flood, worker
Introduction on waterborne diseases and water-related diseases

Communicable disease outbreaks following the which occur during and after extreme water events
wake of natural disasters have a deleterious effect such as storms and floods. Diseases and disease
on disaster victims. Rescue Workers (RWs) and outbreaks are evaluated in terms of bio-ecological
Healthcare Workers (HCWs) involved in disaster aspects of pathogens and susceptibility factors
management are not exempt from the health of populations. Characteristics of pathogens and
hazards of these diseases1-3. RWs respond to ecological aspects of environment drivers during
remove victims from the dangers of a disaster and floods which could adversely affect RWs and HCWs
comprise military, police, fire, rescue services and are also analysed.
emergency medical services personnel4. Healthcare The main objective of this review article is to
Workers (HCWs) are mobilised to areas which describe common waterborne and water-related
are affected by disaster to provide medical and pathogens which affect RWs and HCWs. The
psychological aid to disaster victims. secondary objective is to illustrate the correlation
During extreme water events such as floods, between bioecological factors, susceptibility factors
outbreaks due to waterborne diseases and vector- and measures that need to be taken to reduce
borne diseases are common. This article will focus disease outbreaks during and after floods.

Methodology are bacteria. The second most common pathogen
A literature search for this article was carried out reported is virus (27.6%) while the third most
using the following using search terms: (floods common is protozoa (25.1%). Fungal outbreaks
OR natural disasters) AND (waterborne diseases are least frequently reported (0.6%) (5). The
OR water-related diseases OR infectious diseases hosts, mode of transmission and clinical features
OR bacteria OR protozoa OR virus OR fungus OR of the diseases are summarised in Table 1. Figure 1
pathogen OR cholera OR gastroenteritis OR typhoid illustrates the pathogens profiled in Malaysia while
OR melioidosis OR leptospirosis OR cryptosporidiosis Figure 2 illustrates the pathogens profiled at the
OR giardiasis OR Hepatitis E OR aspergillosis) AND tropics and subtropics.
(healthcare workers OR rescue workers). Bacterial
The following databases were searched: PubMed 1. Cholera
Central, (http://www.ncbi.nlm.nih.gov/pmc/), Bio Vibrio cholera is a small, curve-shaped gram
Med Central (http://www.biomedcentral.com/), negative rod bacilli with a single polar flagellum5.
Emerging Infectious Disease (http://wwwnc.cdc. It is a facultative anaerobe which possesses
gov/eid/), Morbidity and Mortality Weekly Report fermentative and respiratory metabolism5. To date,
(http://www.cdc.gov/mmwr/), Centres for Disease three strains of Vibrio cholera namely classical, E1
Control and Prevention (http://www.cdc.gov/) and Tor and O139 have been identified5-6. The first six
WHO website (http://www.who.int/en/). cholera pandemics were caused by classical strains.
Information from relevant research articles were V. cholera O1 E1 Tor coexisted with O139 strain
analysed an correlated. Common waterborne during the 7th cholera pandemic. Both E1 Tor and
diseases and water relateddiseases which are O139 strains have been implicated in extensive
related to outbreaks following floods and storms outbreaks in the Indian subcontinent. E1Tor strains
from countries that are situated in tropical and were also responsible for the 2000 and 2009
subtropical latitudes were gathered. Pathogen outbreak in Kelantan, Malaysia7.
bioecological characteristics including environmental Cholera is severe in people who have not previously
factors, zoonotic hosts, mode of transmission, been vaccinated or infected. People who consume
clinical features and complications resulting from antacids or are of the O blood group are more
infection were collated. These bio-ecological factors susceptible to this infection5. Ingestion of minimum
were correlated with several outbreak mitigation amount of V. cholera cells is adequate to produce
measures, surveillance frameworks and surveillance symptoms. The disease is more severe among
systems which are currently applied or undergoing patients who ingest high number of organisms5.
evaluation in countries such as United States, The mortality rate of this infection is 50%
Canada, Thailand, Pacific Island Countries (PICs) without the institution of treatment5. Depending
and Australia. on the level of dehydration, orally administered
rehydration salt will suffice for mild dehydration
Results
while moderate to severe level of dehydration
Bacteria constitute the most common causal
requires vigorous administration of intravenous
pathogens associated with disease outbreaks
fluid5. The administration of antibiotics serves as
reported. 46.7% of the causal pathogens for
an adjunct and reduces the duration of diarrhoea7.
waterborne outbreaks due to extreme water events
The indiscriminate prescription of antibiotics causes

cholera strains to develop resistance to antibiotics7. ranges between 10 and 15%8. Patients who have
The proliferation of V. cholera in brackish water been treated with antibiotics have been known to
is associated with seasonal variation and micro- have a higher incidence of relapse as compared to
level environmental factors such as temperature, patients who have not been treated with antibiotics8.
salinity, aquatic reservoirs and the presence of Pregnant women constitute a particularly vulnerable
vibriophage6. The suitable salinity ranges from group in that 70% may suffer miscarriage if
0.25 to 3.0 % while temperatures higher than complications are not treated8. In addition,
5C assist in maintaining the pathogen in the individuals with low educational level are more
environment6. Heavy blooms of aquatic reservoirs vulnerable to the disease9. Sharing food with people
such as zooplankton and phytoplankton which act suffering from salmonellosis, poor hand washing
as vectors for this pathogen enhances the risks of and consumption of raw vegetables are among the
cholera epidemics. Zooplankton and phytoplankton risk factors for contracting salmonellosis9. A Fijian
blooms occur as the temperature of water and study suggested that sharing Kava, a local beverage
precipitation increase5-7. When the environmental could have contributed to typhoid outbreaks among
conditions are not suitable for bacterial proliferation, indigenous Fijians during the months following
the bacteria enters a dormant stage for an extended Cyclone Tomas which affected all four divisions of
period of time. The rise in sea surface temperature the republic in March 201010.
enhances zooplankton bloom. This results in an Salmonellae is also known to survive for weeks if the
explosion of the zooplankton population during humidity, temperature and pH of the soil or water is
dry seasons6. As the sea surface height increases favourable5. Sewage, agricultural waste and storm
during the monsoonal season, the bacteria runoff contribute to the increased concentration of
harboured by the zooplankton are washed from this pathogen5. Untreated sewage effluent which
coastal waters into inland waters6.In addition, it flows into coastal areas will contaminate shellfish
has been hypothesised that low concentrations of which concentrate this bacteria in their water
vibriophages after monsoonal seasons play a role filtration process5.
in increasing the risk of cholera epidemics6. Hence, 4. Melioidosis
the risk of cholera epidemic increases as a result of This disease is caused by Burkholderia pseudomallei,
increased availability of aquatic reservoir in coastal a gram negative bacillus which is a free living
water during extreme water events such as floods. soil saprophyte3,8. The incidence rate (IR) varies
2. Salmonellosis between states in Malaysia and is between 6.1 and
Salmonellosis is caused by a facultative gram 16.35 per 100 000 population per year in Pahang
negative bacterium5,8. Salmonella enterica serovar and Kedah respectively.
Typhi ( S. typhi ) causes enteric or typhoid fever Treatment of melioidosis consists of intravenous
while S.paratyphi causes paratyphoid fever8. Both administration of ceftazidime, meropenam or
S. typhi and S. paratyphi are pathogenic to humans. imipenam for a period of two weeks followed by
Diseases such as melioidosis and scrub typhus can sulfamethoxole / trimethroprim and doxycycline
mimic the symptoms of enteric fever . The organism
8 for three months8. Treatment compliance may be
can be isolated in cultures of blood, stool, urine, affected by the long course of treatment. There
sputum, bone marrow and identified via serology . 8 is a possibility that this pathogen establishes
The case-fatality rate (CFR) due to complications its virulence by developing in vivo resistance to

recommended standard antibiotics11. haemoptysis13. The CFR can be as high as 47%
The case fatality rate (CFR) among patients in when haemoptysis occur13. Prompt diagnosis of the
Kedah according to a hospital-based Melioidosis disease reduces the risk associated with morbidity
Registry set up in 2005 was 33.811. A significantly and mortality. Rapid-test kits such as the Leptospira
higher CFR (70%) due to melioidosis was observed Serology Kit (Bio-Rad Marnes-la Coquette) and the
among RWs and rescuers from the village who PanBio IGM ELISA were used during a leptospirosis
assisted in a rescue operation in Lubuk Yu, Pahang .3 outbreak in the Philippines after the floods13. The
The possible reasons for this were due to delayed availability of these kits in a nearby hospital resulted
identification of the outbreak and co-infection with in timely management of patients13. Climatic factors
Leptospirosis3. such as torrential rain and increased precipitation
Vulnerable occupational groups comprise farmers, prior to torrential rain have been strongly associated
fishermen and people who work in the forest3,11. with outbreaks12.
Diabetes mellitus is a major risk factor which Hence a heavy downpour in the beginning of search
increases the mortality and morbidity of patients11. and rescue operations in Lubuk Yu could have
Alcoholism, as observed in Northern Territory, caused seepage of the bacteria from surrounding
Australia is another risk factor11. The environmental soil into the river3. Increased human activity such
drivers for the proliferation of this pathogen are as littering during and before the operation and
precipitation, periods of high rainfall and soil dilapidated stalls may have attracted rodents3.
erosion containing B. pseudomallei into water Protozoal
banks3,12. Aerosolization of dust particles containing 1. Cryptosporidiosis
the pathogen has also been linked to disease Cryptos poridium parvum is a zoonotic waterborne
outbreaks12. protozoan parasite5,8. This pathogen has a low
5. Leptospirosis infectious dose16.
Leptospirosis is caused by a pathogenic spiral Chlorination does not eliminate the oocyst
bacteria that belongs to the genus Leptospira completely. The oocyst can be eliminated in
3. The prevalence of this infection in Malaysia is drinking-water by boiling it12.
12.6%3. Approximately half of Leptospirosis cases 2. Giardiasis
are attributed to occupational exposure. The The disease caused by this flagellate enteric
vulnerable occupational groups are agricultural protozoa is the most commonly reported intestinal
workers, poultry farmers, sewage workers and parasitic infestation in the world14. The main reason
military personal3. Young and male patients are for its high global endemicity is due to the highly
also more vulnerable to the disease while being old infectious nature of the Giardia cyst and its ability to
increases the chances of mortality . Recreational
3,13 remain infectious for many months regardless of the
activities such as water sports in contaminated favourability of the environment14. The prevalence
water increases the chances of contracting the of giardiasis in Malaysia is 11.6 %14. The infection
disease3. rate is higher in Peninsular Malaysia (13.6%) than
Humans are the incidental host of this pathogen via in Sabah (5.8%) and Sarawak (2%)14. The Dusun
contact with rodent urinecontaminated water3. Fatal tribe was found to have experienced significantly
leptospirosis due to Weils disease is characterised higher prevalence rates of this enteric protozoa
by signs and symptoms of jaundice, anuria and than the Murut and Bajau tribes14.

It is interesting to note that the indigenous people 3) A constructed wetland which was built as a field
of Sabah who consumed piped water have a higher research site.
prevalence of giardiasis than people who drank The tidal wetland was initially an estuary. Landscape
water from streams14. This was in contrast with the conversion from estuary to accommodate agricultural
indigenous population in East Malaysia where the and livestock operations caused degradation of the
prevalence of giardiasis was lower in populations wetlands. Subsequently, water salinity in these
that consumed piped water . Treated water from
14 areas become brackish or hypersaline. Other than
water plants showed no contamination with these salinity, changes in water quality parameters such
protozoa and the contamination process was as dissolved oxygen, total dissolved solids and
postulated to occur after the treatment process. water temperature are significantly associated
One reason pointed out was the contamination of with changes in both protozoal concentrations16.
uncovered water tanks which are commonly used The prevalence of the Cryptosporidium oocyst and
by the natives in Sabah to store piped water . 14 Giardi a cyst in the dairy wetland was significantly
Vulnerable populations were identified as those higher than in the other two wetlands. Sampling
with a low level of education, those who stayed in revealed that the prevalence of both protozoa was
houses without latrines and those whose lifestyles highest at sites nearest to the dairy farm and lowest
included unhygienic practices such as not boiling further downstream16. Concentrations of both
water, not washing hands after playing with animals, protozoa were significantly higher after rainfall16.
indiscriminate garbage disposal, barefootedness The probability of detecting Crytosporidium
and indiscriminate defecation14. IgA deficiency and oocyst and Giardia cysts was 45 and 1510 times,
malnutrition are predisposing factors that underlie respectively, more likely during wet season than
chronic infection8. during dry season16.
Environmental factors related to Cryptosporidiosis A Malaysian-Thailand study, on the other hand,
and Giardiasis outbreak As environmental factors theorised that heavy rain washed away the protozoa
of both cryptosporidiosis and giardiasis are and contamination of rivers by these protozoa was
usually associated together in most studies, these low as a result of dilution15. High precipitation has
pathogens will be discussed under the same context also been identified as a cause of cryptosporidiosis
in this article. and giardiasis outbreaks14,16.
In Malaysia, water beds which contain high Virus
concentration of C. parvum are recreational lakes 1. Hepatitis E
and rivers . High C. parvum concentration in
15 Hepatitis E virus (HEV) is a single stranded RNA,
these water beds have also been observed in other caliciviradae8. The spectrum of the disease ranges
countries. A study in California, USA compared between subclinical, acute, chronic and fulminant
microbial concentration in three types of wetlands16: hepatitis17.
Fulminant hepatitis is characterised by a sudden
1) Tidal wetland that receives water runoffs from onset of symptoms of liver failure18. Treatment for
urban and agricultural areas and drains into a acute infection is by providing supportive care8.
nearby bay. Individuals with high susceptibility to infection
2) A diary wetland which receives runoffs from include women who are on oral contraceptives,
cattle farms haemodialysis patients and patients with pre-

existing liver cirrhosis8. The death rate due to 1. Aspergillosis
fulminant hepatitis in pregnant women can exceed Aspergillus fumigatus accounts for the most number
20% . 8 of filamentous fungi that cause infection1. There are
The 4 genotypes of this virus are G1, G2, G3 and G4, fungal species such as Neosartorya hiratsukae that
all of which have been known to affect humans . 19 are closely related to A. fumigatus which have been
Genotypes G1 and G2 were only identified from known to cause localised and invasive infections21.
humans19. G3 and G4 have displayed zoonotic The mode of entry of this pathogenic fungus is via
transmission19. The animal reservoir for genotypes aspiration of debris-laden water or contaminated
3 and 4 include swine, deer, mongoose, rabbits water due to drowning or near-drowning incidents1.
and cattle19. Porcine related infections have been Aspiration pneumonia caused by fungi, bacteria
linked to the consumption of raw porcine meat . 19 or both pathogen have been commonly known as
The overflow of sewage into the drinking water Tsunami Lung1. Immuno-competence does not
supply during the 1955-1956 floods in Delhi, India eliminate the mortality risk, as previously healthy
lead to the first confirmed outbreak of Hepatitis individuals who have nearly drowned in tsunami
E . Another outbreak that occurred in the 2005
18 related incident have succumbed to pneumonia
Pakistan earthquake was linked to poor sanitary secondary to A. fumigatus and multi organ
and hygienic conditions due to unavailability of a disseminated aspergillosis1.
clean water supply after the earthquake20. A high propensity for misdiagnosis leads to cases
Fungal where fungal infection are misdiagnosed as upper
Fungal infection has become an increasingly respiratory tract infections (URTI)1. This could
common disease among evacuees and rescue lead to administration of medications which may
workers in the recent years due to global hydro- not cure the disease. For example, an outbreak
meteorological changes . The resulting clinical
1 of fungal infection was missed during a fungal
outcome of fungal infection could range from an outbreak which occurred following an earthquake in
uncomplicated infection by Tenia corporis 2 to a California in 19941. Another reason for the delayed
life threatening condition such as aspergillosis1. diagnosis of aspergillosis in the aftermath of the
The major factor linked to infection during flooding 2011 earthquake and tsunami in Japan was due to
is environmental disruption of fungal spores. The delayed transportation of patients who would have
warmer average global temperature has caused required treatment in secondary or tertiary health
expansion of some species of fungus to countries facilities. In addition, investigative samples could
with different latitude .
1 not be transported to nearby medical laboratories
because public roads were inundated by flood water
after the catastrophe1.

Table 1: The host, mode of transmission, clinical features and complications associated with waterborne
and water-related disease transmission after extreme water events. The references for the pathogens are
stated for each pathogen.
Pathogen Hosts Mode of transmission Clinical features and

complication
1 Vibrio cholera5 1. Zooplan 1. Shellfish consumption 1. Acute and intense diarrhoea

kton 2. Hypovolemic symptoms
2. Phytopla 2. Contact with 3. Circulatory collapse
nkton contaminated water
3. Contaminated surface water
usage or consumption
2 S. typhi and Various 1. Oro-faecal 1. Myalgia

S. paratyphi 5,8,9 species of 2. Contaminated food and 2. Diaphoresis
reptiles and water 3. Headache
birds 3. Contaminated shellfish 4. Anorexia
consumption 5. Vertigo
3 Burkholderia 1. Sheep 1. Entry via breaks in skin 1. Soft tissue abscess

Pseudomallei 8,1 1 2. Horse 2. Aerosolization of 2. Osteomyelitis
4. Swine contaminated dust particles 3. Septic arthritis
5. Rodent 3. Goat 4. Liver and splenic abscess
6. Monkey 5. Brain abscess
7. Marsupial 6. Subacute pneumonia
7. Fulminant pneumonia
4 Leptospira Rodent 1. Break in skin and mucous 1. Fever, myalgia, tea coloured
spp.
3.13 membrane urine, jaundice
2. Contact with contaminated 2. Weils disease
water 3. Disseminated Intravascular
Coagulation symptoms
4. Haemolytic Uremic
Syndrome symptoms
5. Thrombotic Thrombocyto
penic Purpura symptoms
6. Vasculitis
5 Cryptosporidium 1. Cattle 1. Contaminated water 1. Diarrhoea

parvum 5,8 2. Oyster consumption 2. Nausea
2. Oro-faecal 3. Vomiting
4. Abdominal cramps
5. Dehydration
6. Mild fever
6 Giardia Cattle 1. Contaminated water or 1. Fever with chills

spp. 5,14,16
food consumption 2. Nausea
2. Oro-faecal 3. Vomiting
3. Oro-anal 4. Abdominal pain
4. Contact with infected animals 5. Weight loss

Pathogen Hosts Mode of transmission Clinical features and
complication
7 Hepatitis E 17-19 1. Swine 1. Oro-faecal 1. Flu-like symptoms

2. Deer 2. Contact with infected rodents 2. Chills
3. Mongoose 3. Fatigue
4. Rabbits 4. Nausea
5. Cattle 5. Vomiting
6. Rodent 6. Right hypochondria pain
7. Jaundice
8. Dark urine
8 Aspergillus Aspiration of debris- laden water 1. Pneumonia

fumigatus1 2. Multi-organ dissemination
symptoms
3. Meningitis
Figure 1: Pathogens profiled in Malaysia: Vibrio cholera (1), Burkholderia pseudomallei (2), Leptospira
spp. (3), Cryptosporidium parvum (4), Giardia spp. (5)

28
37
Figure 2: Pathogens profiled at the tropics and subtropics: Vibrio cholera (1), S. typhi and S. paratyphi (2),
Burkhoderia pseudomallei (3), Leptospira spp. (4), Cryptosporidium parvum (5), Giardia spp. (6), Hepatitis E
(7), Aspergillus fumigatus (8).
JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

Measures To Reduce Disease Outbreaks
Disaster management affects the physical and mental health of RWs and HCWs. Mitigation in this review,
has been divided into 2 phases, pre-disaster and post-disaster phases. These measures are outlined in Table
2.
Table 2: Measures to reduce disease outbreaks following extreme water events such as floods. The
references for mitigation for both phases are stated next to each measure.
Mitigation During Pre- Details

Disaster Phase
1 Develop conceptual l Develop frameworks to identify potential hazards and take

frameworks and cross- rapid measures to avoid disease outbreaks.
cutting competencies22 l Emphasis on multidisciplinary approach.
2 Identification of l Identify determinants such as healthcare capacity.

determinants including l Training of RWs to initiate response effectively and efficiently.
healthcare capacity to l Improve coordination between NGOs, civil society, military
respond to disaster23 services, HCWs and RWs.
l Training HCWs who are often mobilised to disaster areas on
specific diseases which frequently occur after floods.
3 Evaluation of risk factors l Evaluation of socioeconomic changes, dysfunctional public

which obstruct prevention health system, clean water supply disruption, sewage
and control program20 disposal during and after floods during policy-making for
disaster management.
l Reducing vulnerability of RWs and HCWs to communicable
diseases.
4 Pre-positioning and l Emergency Kits containing suitable medications and rapid

distributing Emergency tests according to factors including population characteristics
Kits24 produced and distributed to shelters.

Mitigation During Post- Details
Disaster Phase
1 Suitable shelter l Identify geographical areas with clean water supply, sanita-
establishment by utilising tion facilities and transport.
GIS mapping25 l Innovation and use of portable clean water devices to clean
and utilise natural water sources.
2 Vaccination campaigns25 l Immediate tetanus vaccination for RWs, HCWs and victims
injured during disaster.
l Consider vaccinating populations where certain waterborne
diseases are endemic.
3 Improvement in transport l Device systems to transport investigational samples to

of investigational samples nearby functioning healthcare facilities and laboratories.
and medications 13,25 l Improve transport of medications from healthcare facilities to
shelters.
4 Use of appropriate Faecal l Utilise parameters from FIBs and faecal coliforms to predict
Indicator Bacteria (FIB) risk of disease outbreaks
and faecal coliform5,16
Discussion
Hydro-meteorological events such as floods flooding caused by vector-borne diseases were
have increased in frequency due to climate not emphasized. This review article focused
changes, changing patterns of precipitation on waterborne and water-related diseases.
and an increase in the sea level1. Global Moreover some evidence from this study may
warming and the El-Nino effect has enhanced not represent the entire Malaysian population
proliferation of hosts that harbour pathogens. because studies regarding diseases such as
It has also contributed to emerging and re- giardiasis were gathered from indigenous
emerging infections that are affected by Malaysian communities.
climatic changes .6
There are similarities and differences with
regards to environmental factors, vulnerable
The strength of this article is that examples of populations and hosts which affect transmission
various pathogen including bacteria, protozoa, of disease to humans. For example, increased
virus and fungi were assessed in terms of precipitation before periods of heavy rainfall
environmental factors, host, vulnerable is a common environmental factor associated
population and mode of transmission. Several with leptospirosis, melioidosis, cholera and
measures which could be taken before and cryptosporidiosis outbreaks.
after disasters were also discussed. This study The experimental infection of R. norvegicus
has several limitations. Outbreaks due to rats by HEV human strain isolated from humans

resulted in replication of HEV human strain immunosuppressed individuals are more
in the R. norvegicus rats17. This replicated susceptible to leptospirosis, meliodiosis and
strain was detected in the faeces and serum HEV infection.
of the infected rodent suggesting possibility
of transmission of this replicated virus among In the pre-disaster phase, measures to
humans17. In addition, rodents such as the develop the competencies of HCWs and RWs
Asian Musk shrew which originally inhabited are imperative. Contrary to the popular belief,
the Indian subcontinent have been recently handling human corpses does not pose a
found in South East Asia19. high risk of disease transmission among RWs.
However, PPE is still recommended as stated in
Hence, there remains a high possibility that fact sheets which were developed for disaster
pathogens may be harboured by pests such victim identification (DVI) teams, to reduce
as rodents which live within close proximity disease transmission through contact with
of human dwellings17,19. Epidemics following liquid waste from dead bodies27. PPE including
changes in the environmental factors such disposable gowns, latex gloves, respirators and
as flooding can potentially cause HEV surgical masks were supplied to disaster victim
epidemics because rodents harbouring HEV identification
may contaminate water and food with their
excretions. (DVI) teams in Thailand after the 2004
Tsunami catastrophe27. NISOH certified N-95
With regards to melioidosis, the prevalence (N95) masks were recommended to public
of alcoholism in Malaysia is lower than health officials and the victims of the 2005 New
Australia. However, there may be regional Orleans hurricane28. A qualitative review of
differences of alcoholism in Malaysia. Suffice participants who were involved in mould clean-
to say, alcoholism is more prominent in several up activities revealed the respirator was worn
states in Malaysia. Alcohol consumption is upside down by 22% of the respondents while
highest in Kuala Lumpur (20.3%) followed 21% of the respondents used only one strap28.
by Sarawak (19.7%) and Sabah(18.4%)26. In The limited protection offered by a poorly
addition, traditional alcohol beverages such as placed mask enhances disease transmission
montoku and tapai is commonly consumed because unfiltered air is introduced through the
by the indigenous communities in Sabah and gaps in the respirators28. Training in wearing
Sarawak26. PPE usage must be done before disasters. The
morbidity and mortality due to leptospirosis
The high rate of fatality among RWs in Lubuk and melioidosis outbreaks among RWs can
Yu, Pahang was caused by a co-infection be reduced by training HCWs to identify these
of leptospirosis and melioidiosis. This co- infections22.
infection is possible because both organism
thrive in similar environments and are driven With regards to protozoa, chemical parameters
to proliferate under similar conditions3. such as ammonia, nitrate and nitrite are
Although individual susceptibility varies, associated with changes in Giardia cyst and
Cryptosporidium oocyst concentration29. A high from FIB and faecal coliform. Co-morbidity
concentration of ammonia could be linked to and social determinants of health such as
the usage of fertilizers in agricultural activities29. educational level, socioeconomic status and
the living conditions are factors which affects
Hence, chemical and water quality parameters a populations susceptibility to diseases14. For
are factors associated with the level of example, a group of indigenous people in
contamination of Cryptosporidium oocyst and Peninsular Malaysia prefer to drink unboiled
Giardia cyst in rivers15,16,29. In addition, recent water rather than boiled water because they
rainfall plays a significant role in altering the say it tastes better30. As a result, 28.6% of the
concentration of both protozoa in rivers16,29. This studied population utilized untreated water
shows that changes in the above mentioned from wells, rain and rivers30.
factors could be related to Cryptosporidium and
Giardia outbreaks following continuous rainfall Lastly, it would be relevant to ascertain the
which may result in floods. Further research incubation period (IP) of various pathogens as
is required to assess the relationship between this may inform surveillance for diseases which
these factors. may require measures such as Syndromic
Surveillance (SS)31. As such, a multidisciplinary
Suitable Faecal Indicator Bacteria (FIB) and approach should not only be emphasized
faecal coliform can be used to assess the among HCWs and RWs but a collaborative
probability of disease outbreaks5. FIB levels initiative between professionals from
could be monitored to predict protozoa levels various departments should be encouraged.
in wetlands. FIB also offers an easier and Collaboration between professionals from the
cheaper method to predict the concentration Environmental Health Department, The Bureau
of pathogens in rivers and streams16. The of Meteorology and tertiary education facilities
public health importance of this finding is would benefit prevention of disease outbreaks
that it would be essential to predict the immensely. Disease outbreak frameworks or
chances of an outbreak among RWs, HCWs models can be developed with the collaborative
and disaster victims after a recent downpour effort of various relevant departments. An
or a prolonged period of rain which may example of a disease outbreak model is
cause floods by utilising parameters derived illustrated in Figure 3.

should be encouraged. Collaboration outbreak model is illustrated in Figure 3.
Figure 3: Example of framework or model of a water-related or waterborne disease illustrating the inter-
Figure 3: Example
play between of framework
bio-ecological or model
factors, of a water-related
vulnerability or waterborne
factors and measures disease
to reduce an illustrating
outbreak.
the interplay between bio-ecological factors, vulnerability factors and measures to reduce an
Conclusion
outbreak.
The results of this study show that a close to reduce the risk of disease transmission.
relationship exists between pathogens, the The coexistence of pathogens in a similar
susceptibility of the human host, animal reservoir environment will pose an additional challenge
42
and environmental factors when extreme water and should be taken into consideration. This
events such as floods occur. Hence, measures could be done by identifying animal reservoirs,
or frameworks can be designed taking these analysing agricultural activities, recent
factors into consideration. The identification of deforestation and environmental changes which
silent carrier or chronic carrier of pathogens occur before extreme water events. Disaster
and vulnerable groups among HCWs or management strategies are complicated by
RWs can potentially reduce transmission of pathogens which have mutated. These new
diseases during floods. In addition, identifying pathogens identified by their serotypes are
vulnerable populations among disaster victims resistant to conventional drugs. New animal
would also reduce the risk of disease outbreaks reservoirs of these mutated serotypes are being
and transmissions. identified. Outbreaks secondary to emerging
and remerging diseases will be common in
Poor planning of flood mitigation strategy and future.
an unstructured surveillance system could
undermine the ability of RWs and HCWs to Evidence pertaining to the competencies of
recognise and take preventive measures RWs and HCWs which have been collated show
that improvements can be made to reduce the Competing interests
morbidity and mortality among RWs and HCWs The author declares that he does not have any
due to disease outbreaks. There is a need to competing interest.
study the vulnerability factors of the Malaysian
Acknowledgement
population as the applicability of frameworks and
I would like to acknowledge the Director
surveillance systems has to suit environmental,
General of Health, Malaysia for permission
climatic and serotypes of pathogens which are
to publish this article. I also would like to
commonly found in Malaysia and surrounding
thank the Director of Hospital Duchess of
regions. In future, climatic changes due to El-
Kent, Sandakan, Sabah for supporting the
Nino and unscrupulous human activities will
publication and presentation of this article. A
increase the frequency and intensity of extreme
special thanks to my parents and friends for
water events such as tropical cyclones, storms
their encouragement.
and floods.
References
1. Benedict, K., Benjamin, J.P. (2014). 4. Collins English Dictionary. Rescue
Invasive fungal infection after natural worker. (Cited: 10 April 2014). Available
disasters. Emerging Infectious Diseases, from http://www.collinsdictionary.com/
20, 349-355. dictionary/english/rescue-worker.
2. Centers of Disease Control and Prevention. 5. Cabral JPS (2010). Water Microbiology,
Infectious Disease and Dermatological Bacterial Pathogen and Water.
Conditions in Evacuees and Rescue International Journal of Environmental
Workers after Hurricane Katrina-Multiple Research and Public Health, 7, 3657-
States, August - September, 2005 (2005). 3703.
(cited : 7 April 2015). Available from

http://www.cdc.gov/mmwr. 6. Michael, E., Feldacker C., Islam, M.S., Ali,
M. (2008). Seasonality of Cholera from
3. Sapian, M., Khairi, M.T., How, S.H., 1974 to 2005. International Journal of
Rajalingam, R., Sahhir, K., Norazah, A. Health Geographics, 7 (31), 1-13.
(2012). Outbreak of Melioidosis and

Leptospirosis co-infection following a
rescue operation. Medical Journal of
Malaysia, 67 (3), 293-297.

7. Ang, G.Y., Choo, Y.Y., Kamarudin, B., 12. Chen, M.J., Lin, C.Y., Wu, Y.T., Wu, P.C.,
Husni, T.E., Hussin, A., Hani, M.H. et al. Lung, S.C., Su, H.J. (2012). Effects of
(2010). Molecular evidence of Cholera extreme precipitation to the distribution
Outbreak Caused by a Toxigenic Vibrio of infectious diseases in Taiwan, 1994-
cholera E1 Tor Variant Strain in Kelantan, 2008. Plos One, 7 (6), 1-7.
Malaysia. Journal of Clinical Microbiology,
48 (11), 3963-3969. 13. Amilasan, A.T., Ujjie, M., Suzuki, M.,
Salva, E., Maria, C.P., Koizumi, N.
8. Gideon Informatics (2010). Infectious (2012). Outbreaks of Leptospirosis after
diseases of Haiti. California, United States. flood, The Philippines, 2009. Emerging
Infectious Diseases, 18 (1), 91-93.
9. Sutiono, A.B., Qiantori, A., Ohta, T. (2010).
Characteristics and risk factors for typhoid 14. Choy, S.W., Mekhlafi, H.M., Mahdy,
fever after the tsunami, earthquake and M.A.K., Nasr, N.N., Sulaiman, M., Lim,
under normal conditions in Indonesia. Y.A., Surin, J. (2014). Prevalence and
BMC Research Notes, 3 (106), 1-9. associated risk factors of Giardia infection
among Indigenous Communities in Rural
10. Scobie, H.M., Nilles, E., Kama, M., Cool, Malaysia. Scientific Reports, 1-9.
J.L., Mintz, E., Kathleen, A. et al (2014).
Impact of a targeted typhoid Vaccination 15. Kumar, T., Onichandran, S., Lim, Y.A.L.,
Campaign Following Cyclone Tomas, Sawangjaron, N., IthoiInit, Andiappan, H.
Republic of Fiji. American Journal of et al. (2014).
Tropical Medicine and Hygiene, 90 (6), Comparative study on Waterborne
1031-1038. Parasites between Malaysia and Thailand:
A new insight. American Journal of
11. Hassan, M.R., Pani, S.P., Peng, N.P., Tropical Medicine and Hygiene, 90 (4),
Voralu, K., Vijayalakshmi, Mahenderkar, R. 682-689.
(2010). Incidence, risk factors and clinical
epidemiology of melioidosis: a complex
socio-ecological emerging infectious
disease in the Alor Setar region of Kedah,
Malaysia. BMC Infectious Disease, 10
(32), 1-8.

16. Hogan, N.J., Daniels, M.E., Watson, 21. Guarro, J., Kallas, E.G., Godoy, P., Karenina,
F.G., Conrad, P.A., Oates, S.C., Miller, A., Gene, Josepa. (2002). Cerebral
M.A. et al. (2012). Longitudinal Poisson Aspergillosis caused by Neosartorya
Regression to evaluate the epidemiology hiratsukae, Brazil . Emerging Infectious
of Cryptosporidium, Giardia and Fecal Diseases. 8 (9), 989-991.
Indicator Bacteria in Coastal California
Wetlands. Applied and Environmental 22. Hsu, E.B., Thomas, T.L., Bass, E.C.,
Microbiology, 78 (10), 3606-3613. Whyne, D., Kelen, G., Green, G.B. (2006).
Healthcare worker competencies for
17. Lack, B.J., Volk, K., Ronald, A. (2012). disaster training. 6 (19), 1-9.
Hepatitis E Virus Genotype 3 in Wild
Rats, United States. Emerging Infectious 23. Rumsey, M, Fletcher, SM, Thiessen,
Disease, 8 (18), 1268-1273. J, Gero, A, Kuruppu N, Daly, J. et al.
(2014). A qualitative examination of
18. Cowie, B.J., Adamopolous, J., Carter, health workforce needs during climate
K., Kelly, H. (2005) Hepatitis E Infection change disaster response in Pacific Island
Victoria, Australia. Emerging Infectious Countries. Human Resources for Health,
Disease, 11(3), 482-484. 12 (9), 1-11.
19. Guan, D., Li, W., Su, J. (2013). Asian Musk 24. World Health Organization. (2011). The
Shrew as a reservoir for rat Hepatitis Interagency Emergency Health Kit 2011.
E Virus, China. Emerging Infectious Medicines and Medical devices for 10000
Disease, 19 (8), 1341-1342. people for approximately three month.
20. Baqir, M., Sobani, Z.A., Bhamani, A., 25. Jafari, N., Shahsanai, A., Memarzadeh,
Bham, N.S., Abid, S., Farook, J. (2012). M., Loghmani, A. (2011). Prevention of
Infectious diseases in the aftermath of communicable disease after disaster: A
monsoon flooding in Pakistan. Asian review. Journal of Research in Medical
Pacific Journal of Tropical Biomedicine, 2 Sciences, 16 (7), 956-962.
(1), 76-79.

26. The Star Online. Sabah is 3rd highest 30. Anuar, S.T., Ghani, M.K.A., Azreen,
in alcohol consumption (2013) (cited S.N., Salleh, F.M., Moktar, N. (2013).
: 30 May 2015). Available from Blastocystis Infection in Malaysia:
h tt p : / / w w w. t h e s t a r. c o m . my / N e w s / Evidence of waterborne and human-to
Nation/2013/05/11/Sabah-is-3rd-highest- human transmissions among the Proto-
in-alcohol-consumption/ Malay, Negrito and Senoi tribes of Orang
Asli. Parasites and Vectors, 6(40), 1-12.
27. MMWR. (2005). Health concerns associated
with disaster victim identification after 31. Berger, M., Shiau, R., Weintraub, J.M.
tsunami- Thailand, December 26, 2004 to (2006). Review of syndromic surveillance:
March 31, 2005. 54(14), 349-352. implications for waterborne disease
detection. Journal of Epidemiology and
28. Cummings, K.J., Ganser, J.C., Riggs, M.A., Community Health, 60(6), 543-50.
Edwards, N., Kreiss K. (2007). Respirator
donning in Post-Hurricane New Orleans.
13 (5), 700-706.
29. Onichandran, S, Kumar, T, Salibay, CC,

Dungca, JZ, Tabo, HA, Tabo, N et al.
(2014) Waterborne parasites: a current
status from the Philippines. Parasites and
Vectors. 7(244), 1-8.

Institute For Health Management - Transit Center For Flood Disaster 2015;
Psychosocial Impact On Volunteers
Munirah I, Norhidayah MD
Institute for Health Management
Abstract
The Institute for Health Management (IHM) was appointed as a transit center for health
worker volunteers handling logistics, lodging, Psycholosocial First Aid (PFA) and post-
deployment debriefing. The first group of volunteers was deployed on 28th December 2014
and after 19 days in operation, 224 volunteers returned to IHM. Returnees were given a
debriefing session with counsellors, psychosocial assessment and a clinical examination.
Psychosocial assessment of the volunteers was measured by the Depression, Anxiety and
Stress Scale (DASS). The majority of volunteers were aged between 20-30 years (n=141,
62.9%) and worked as nurses (n=144, 64.3%). More than half the volunteers were female
(n=144, 64.3%) and 80 (35.7%) were male. Most volunteers (197) were deployed to Kelantan
in view of the severity of the flood over there. 135 volunteers spent 11-15 days in the disaster
affected area, 78 volunteers spent 6-10 days and the rest spent less than 5 days. From the
psychosocial assessment (DASS), 12 volunteers were identified with abnormal emotional
states in at least two of the emotional states. Among these, there were 8 nurses, 2 assistant
medical officers, 1 assistant engineer and 1 IT officer. Most of them had spent 10 or more
days as volunteers. Volunteers are exposed to traumatic events in the disaster setting and
these may act as stressors. If left unrecognized or untreated this may lead to mental health
disease such as Post Traumatic Stress Disorder (PTSD). Awareness of volunteers wellbeing
and their psychosocial state should be included in the preparedness for handling disasters.
Keyword: volunteers, psychosocial impact, post-deployment, DASS
Introduction thereafter. The scale and severity of the

The northeast monsoon brought heavy flood impacted many aspects of life, such
rains especially to the east coast of as health, education, security, social issues
Malaysia causing its worst flood in decades. and economy.
Floods in Kedah, Perak, Selangor, Pahang,
Johor, Terengganu and Kelantan saw The Ministry of Health (MOH) has assigned
displaced victims within a day and the its Crisis Preparedness Response Centre
continuous rise in the number of evacuees (CPRC) as the main coordinating agency for
48
flood updates, flood related disease Methodology
outbreak information, medical relief team The Crisis Preparedness Centre Response
deployment, machinery/power supply IHM was activated on the 28th December
support as well as other disaster public 2014 as the transit centre for MOH and
health related issues. The flood caused non-MOH volunteers. IHM handled the
major damage to MOH infrastructure and logistic arrangements ie. transport and
would have disrupted healthcare services. accommodation, as well as psychosocial
Apart from rescue and relief missions, MOH first aid prior to departure and upon return
focused on ensuring sustainability of health from the flood affected site.
services to affected patients and flood
victims. Samples were taken from the volunteer
registry, where 224 MOH volunteers who
The Institute for Health Management (IHM) had returned from flood-affected areas
was appointed as a transit center for MOH such as Kuala Krai, Gua Musang, Kota
volunteers tasked with managing the Bahru, Tanah Merah, Bentong, Jerantut,
logistics, lodging, PFA and also post- Kuantan and Temerloh.
deployment debriefing of these volunteers. Upon their return to IHM, the volunteers
Our centre (IHM), deployed the first group were debriefed by counsellors and
of MOH volunteers on 28th December 2014. subjected to psychosocial assessment and
Over 19 days (28th December 2014 to 16th clinical examination. The tool used for
January 2015), 494 of volunteers departed psychosocial assessment of the volunteers
for flood areas with 224 volunteers was the Depression, Anxiety and Stress
returning to IHM while the rest (270) Scale (DASS).
returned directly to their respective state or
center DASS functions to assess the severity of the
core symptoms of Depression, Anxiety and
Upon return, all the volunteers were given Stress. High DASS scores alert the clinician
a debriefing by counsellors and a clinical to explore the psychosocial status of the
examination in IHM. This was conducted to subject further. The scale should meet the
screen for acute clinical illness and need of both researchers and clinicians to
psychosocial red flags resulting from their measure the current psychosocial state and
stay in the flood affected area. its change over time (Agency for Clinical
Innovation, 2010).

49
DASS has a shorter (21 items) and a longer version. Use of the shorter version requires that
the final score for each emotional state (Depression, Anxiety and Stress) be multiplied by 2
(x2) (Agency for Clinical Innovation, 2010).
Table 1: DASS Severity Ratings

Severity Depression Anxiety Stress
Normal 0-9 0-7 0-14
Mild 10-13 8-9 15-18
Moderate 14-20 10-14 19-25
Severe 21-27 15-19 26-33
Extremely Severe 28 20 34
Source: Agency for Clinical Innovation, (2010). A Guide to the Depression, Anxiety and
Stress Scale (DASS) (http://www2.psy.unsw.edu.au/groups/dass/ accessed on 6 February
2015)
Results
The majority of volunteers were aged between 20-30 years and were therefore junior in
service. 52 volunteers were aged between 31 to 40 years and 23 volunteers were in their
forties. Staff aged between 51 to 60 years old comprised the smallest number participating as
volunteers (Figure 1).
160
141
140
Number of Volunteers (n)
120
100
80
60 52
40
23
20 7
0
20-30 31-40 41-50 51-60
Age Group (years)
Figure 1: Age group of volunteers
224 volunteers completed the post-deployment assessment at the IHM transit center. Most
volunteers were female, 144, 64.3%, and the rest were male 80, 35.7%. Majority of the
volunteers were nurses i.e. 144 or 64.2%, 17 were medical officers and 4 specialists. There
were 8 psychologists to provide psychological support. 10 of the volunteers were drivers
employed to provide transportation in the disaster area (Table 2).

50
Table 2: Numbers of volunteers for each professions
No Profession No. Of Volunteers

1 Nurse 144
2 Medical Officer 17
3 Driver 10
4 Assisstant Medical Officer (AMO) 10
5 Pembantu Perawatan Kesihatan (PPK) 6
6 Pembantu Pegawai Kesihatan Persekitaran (PPKP) 6
7 Engineer 7
8 Psychologist 8
9 Pharmacist 4
10 It Officer 2
11 Pembantu Kesihatan Awam (PKA) 4
12 Pembantu Rendah Awam (PRA) 1
13 Medical Specialist 2
14 Social Worker 1
15 Public Health Specialist 2
Total 224
Most volunteers were deployed to Kelantan, given the severity of the flood there. 197
volunteers were placed in affected areas such as Kuala Krai, Manek Urai, Gua Musang, Tanah
Merah, HUSM and other remote areas of Kelantan. 27 volunteers were deployed to Pahang to
assist the flood victims and the staff of the District Health Office, Bentong (Figure 2).
27, 12%
197, 88%
Kelantan Pahang
Figure 2: Volunteers deployment location
When the CPRC was activated, MOH appealed to its staff for volunteers to assist MOH facilities
and mobile health services units in affected areas. Most of the volunteers deployed to the
flood affected areas within the first 24 hours of the disaster spent between 11 to 15 days as
volunteers. In the early stages of the MOH response to the flood disaster, volunteers were
51
given a two-week deployment in the assigned flooded area. However, in the second week of
the operation and from volunteer feedback, the duration was shortened to one week taking
into consideration their physical and mental exhaustion. 78 of volunteers spent 6 to 10 days
in the affected area and 11 volunteers spent less than 5 days (Figure 3).
160
140 135
120
Number of Volunteers (n)
100
78
80
60
40
20 11
0
0 to 5 Days 6 to 10 Days 11 to 15 Days
Days Spent Volunteering
Figure 3: Number of days spent at disaster affected area
All returning volunteers underwent basic demonstrated symptoms of severe

medical screening and DASS assessment to emotional disturbance, he or she was
screen for any medical condition or referred to a psychiatrist. There were eight
psychosocial disturbance. Of the 224 nurses, two assistant medical officers, one
volunteers, 12 volunteers showed assistant engineer and one IT officer who
abnormal ratings in at least two of the showed mild to extremely severe emotional
emotional states. Respondents with at least states after returning from the flood
two abnormal emotional states would be affected area. Most of them had spent 10
followed-up by counsellors. If a volunteer or more days as volunteers (Table 3).

52
Table3:3:Volunteers
Table Volunteers(case)
(case) with
with at least
at least twotwo abnormal
abnormal scores
scores on DASS
on DASS assessment
assessment
NoNo
OfOf Days
Days Flood DASSDASS
Spent In The Flood
No Occupation Spent In The Affected
No Occupation Flood Affected Stress Anxiety
Anxiety Depression
Flood Area Stress Depression
Affected
Affected Area Area
Area
1.
1. Nurse
Nurse 1515 Kelantan
Kelantan MildMild Mild Mild Normal
Normal
2.
2. Nurse
Nurse 1515 Kelantan
Kelantan MildMild Mild Mild Normal
Normal
3.
3. Nurse
Nurse 1515 Kelantan Moderate
Kelantan Moderate Severe
Severe Severe
Severe
4.
4. Assistant
Assistant 1515 Kelantan Extremely
Kelantan ExtremelyExtremely
ExtremelyModerate
Moderate
Medical
MedicalOfficer
Officer Severe
Severe SevereSevere
5.
5. Information
Information 1515 Kelantan
Kelantan Severe
Severe Moderate
Moderate Moderate
Moderate
Technology
Technology
Officer
Officer
6. Nurse 14 Kelantan Mild Moderate Normal
6. Nurse 14 Kelantan Mild Moderate Normal
7. Nurse 14 Kelantan Mild Moderate Mild
7. Nurse 14 Kelantan Mild Moderate Mild
8. Nurse 14 Kelantan Moderate Severe Severe
8. Nurse
9.
Nurse 10
14 Kelantan
Kelantan
ModerateModerate
Mild
Severe Normal
Severe
9. Nurse
10. Nurse 1010 Kelantan
Pahang Mild
Normal Moderate
Moderate MildNormal
10. Assistant
11. Nurse 1010 Pahang
Pahang Moderate Mild Mild
Normal Moderate
Normal
11. Medical
Assistant
Officer 10 Pahang Normal Moderate Mild
Medical Officer
12. Assistant 4 Kelantan Normal Moderate Mild
12. Engineer
Assistant 4 Kelantan Normal Moderate Mild
Engineer
Discussion recovery. With regard to the Ministry of
Discussion
Malaysia experienced several traumatic recovery.
Health, With regard
establishing a Crisis to the Ministry of
Preparedness
Malaysia
events experienced
in 2014 from air several
crashes traumatic
to the Health,Centre
Response establishing a Crisis
was very Preparedness
important in
events
worst in 2014
floods. Whilstfrom air crashes
air crashes to the
may be rare ResponsetheCentre
coordinating was very
management important
of a crisis or in
worst
in floods.floods
Malaysia, Whilstare
air acrashes mayevent
recurring be rare coordinating
disaster thefrom
especially management
a public of a crisis or
health
in Malaysia,
due floods are
to the North-East a recurring
Monsoon event
that brings disaster especially from a public health
perspective.
adue
heavy rainNorth-East
to the especially Monsoon
to the east
thatcoast
brings perspective.
states.
a heavyThat
rainthe recent floods
especially to thewere
east the
coast Often, when a disaster strikes, the main
worst
states.experienced for sometime
That the recent floods may
werebethe focus is centered
Often, when aondisaster
the victims welfare
strikes, the main
due to experienced
worst other exacerbating factors such
for sometime mayas be andfocus
the efforts made to on
is centered easethe
their recovery
victims welfare
the loss of the water reservoir because of process. Until recently, very little emphasis
due to other exacerbating factors such as and the efforts made to ease their recovery
increasing deforestation and the was placed on the wellbeing of the
the loss of the water reservoir because of process. Until recently, very little emphasis
swallowing of rivers because or volunteers. Few studies have been
increasing deforestation and the was placed on the wellbeing of the
sedimentation and rubbish accumulation. conducted to examine this aspect of the
swallowing of rivers because or volunteers. Few studies have been
situation even though volunteers play a
sedimentation and rubbish accumulation. conducted to examine this aspect of the
Malaysia needs to strengthen its response crucial role in any disaster response.
situation even though volunteers play a
to major disasters such as the recent floods
Malaysia needs to strengthen its response crucial role in any disaster response.
to enable a prompt and smooth delivery of Individuals exposed to stressful events in a
to majorevacuation,
rescue, disasters such as the
service recent and
continuity floods disaster setting may develop an adverse
to enable a prompt and smooth delivery of Individuals exposed to stressful events in a
53
rescue, evacuation, service continuity and disaster setting may develop an adverse
53
psychological state after dealing with experience of or witnessing a life-
difficult and stressful conditions that threatening event such as military combat,
predispose them to clinical disorders such natural disasters, terrorist incidents,
as panic disorder, major depression and serious accidents, or sexual assault (U.S
substance addiction (Polusny & Follette, Department of Veterans Affairs). The
1995; Duncan et al., 1996; Green et al., severity and duration of traumatic events
2000). The volunteers deployed to a or exposure are important risk factors in
disaster-affected area undertake gruelling developing PTSD (The National Alliance on
tasks to assist victims. The MOH volunteers Mental Illness).
also come from various professional
backgrounds in that they include medical In the feedback received from the
officers, clinical specialists, nurses, volunteers, most of them reported being
assistant medical officers, counsellors, unclear on their task when they reached
drivers, engineers, social workers as well as the flood area. Most nurses assumed they
IT officers. While the volunteers with a were relieving a colleague who had been
medical background, may be used to on from duty for more than 48 hours rather
handling victims with illnesses, running the than to help with the cleaning the hospitals
mobile health service and MOH facilities, or health clinics. The miscommunication
some volunteers may not have any worked between and mistaken expectations of the
in a disaster setting previously. volunteers contributed to the confusion
with regard to their tasks and being
Armagan et al. (2006) studied the unprepared also may act as a of the
contribution of factors such as gender, age, stressor (Paton, 1994). In his study, Paton
professional experience and/or prior (1994) also described role that confusion
experience of traumatic events to the was more prominent in professionals than
prevalence of PTSD among the Aceh in volunteers. However, Dyregrov (1996)
tsunami volunteers. The study found no reported that role confusion or uncertainty
differences between most factors but was more common among volunteers.
identified that the PTSD symptoms were
more serious in volunteers with less The majority of volunteers scored normal
experience. Perrin et al. (2007) reported in DASS and only 12 individuals required
volunteers from professions that are not some follow up with regard to their
usually prepared for disaster were more psychosocial states. Studies on this topic
likely to develop PTSD. PTSD is a traumatic however did not mention timing of
psychological event following the subsequent assessment/screening, but the
54

practice in MOH is that re-assessment is showed persistence of symptoms up to 1
done 2 weeks post deployment. The year. It is natural after a dangerous event
authors recommend further studies to to have some of these symptoms. Some
follow up the volunteers and assess their serious symptoms such as Acute Stress
psychosocial status especially at the time Disorder (ASD) may go away after a few
PTSD is likely to peak. weeks. PTSD usually appears within 3
months of the trauma and its symptoms
Andrews et al. (2007) emphasized that persist for more than few weeks, (U.S
PTSD may develop years after the Department of Veterans Affairs). A
traumatic event and that some will show longitudinal study also explored the effect
the symptoms earlier and be affected for of social support availability, personal or
years. Kato et al. (2012) agreed that the work related that may contribute to PTSD
mental health of an individual who development (Renck et al., 2002) (Table
experiences disaster/trauma may be 4).
affected immediately and may persist for
about a week. However, many studies
Table 4: Category of Post Traumatic Stress Disorder (PTSD) symptoms

No Category Examples
1 Avoiding reminders of the Staying away from places, events, or objects
trauma that are reminders of the experience.
Isolating from other people.
Feeling emotionally numb.
Strong guilt, depression, or worry.
2 Re-experiencing the traumatic Recurrent nightmares or flashbacks,
event Recurrent images or memories of the event,
Intense distress at reminders of trauma.
Frightening thoughts.
3 Increased arousal Difficulty falling asleep or staying asleep.
Feeling on guard, irritable.
Startling easily.
Source: The National Alliance on Mental Illness

55
When CPRC MOH deployed its first group prevent mental and physical
of volunteers, they were given assignment exhaustion.
for duration of two weeks. During the 4. To establish social support
second week of duty, some of the networks for both victims and
volunteers were already physically and volunteers and appropriate referral
mentally exhausted. A study by Long et al. to counselors or clinical psychiatrist.
(2007), the duration of exposure only
Conclusion
weakly correlated to symptoms of PTSD.
Mitchell et al. (2004) also reported the In a large scale disaster, the role of
association between trauma severity or volunteers are vital in helping the authority
length of exposure and PTSD and found in the evacuation and rescue operation,
significant relationship. Volunteers should continuing of service such as in health
be given a break from the disaster setting services, and recovery process. Like the
before being re-deployed to the affected victims, volunteers also are exposed to the
area again. Volunteers should be offered harmful and traumatic events during the
psychological support especially who had disaster setting and these can be the
experienced stress and psychological stressor. If left unrecognized or treated it
disturbance following prolonged or several can lead to mental health disease such as
deployments (Adams, 2007). PTSD. Awareness of volunteers wellbeing
and their psychosocial state should be
Recommendations highlighted and included as part of
preparedness in handling disaster.
1. Training programs and sharing of
best practices in disaster response Acknowledgement
such as effective orientation to the
The authors wish to thank the Director
disaster operation at all levels
General of Health for permission to publish
emergency planner, coordinating
this report and special thanks to all who
officers, front liners and volunteers.
were involved in CPRC Institute for Health
2. To monitor and establish
Management.
intelligence during the disaster
response to ensure effective
communication and monitoring of
service provided.
3. To identify the appropriate length
of exposure at disaster area to

56
References 6. Dyregrov, A., Kristoffersen, J.I. &
Gjestad, R. (1996). Voluntary and
1. Adams, L. (2007). Mental Health Needs
Professional Disaster-workers:
of Disaster Volunteers: A Plea for
Similarities and Differences in
Awareness. Perspective in Psychiatric
Reactions. J Trauma Stress, 9, 541-
Care, 43, 1.
555.
2. Agency for Clinical Innovation. A Guide

7. Green, B.L., Goodman, L.A., Krupnick
to the Depression, Anxiety and Stress
J.L., Corcoran, C.B., Petty, R.M.,
Scale (DASS) (2010). (cited : 6
Stockton, P. & Stern, N.M. (2000).
February 2015). Available from
Outcomes of Single Versus Multiple
http://www2.psy.unsw.edu.au/groups/
Trauma Exposure In a Screening
dass/.
Sample. J Trauma Stress, 13, 271-286.
3. Armagan, E., Engindeniz, Z., Devay,

8. Hagh-Shenas, H., Goodarzi, M.A.,
A.O., Erdur, B. & Ozcakir A. (2006).
Dehbozorgi, G. & Farashbandi, H.
Frequency of Post-traumatic Stress
(2005). Psychological Consequences of
Disorder Among Relief Force Workers
The Bam Earthquake on Professional
After the Tsunami in Asia: Do Rescuers
and Non-professional Helpers. J
Become Victims?. Prehosp Disaster
Trauma Stress, 18, 477-483.
Med, 21, 168-172.
9. Kato, Y., Uchida, H. & Mimura M.

4. Andrews, B., Brewin, C.R., Philpott, R.
(2012) Mental Health and Psychosocial
& Stewart, L. (2007). Delayed-onset
Support After the Great East Japan
Post traumatic Stress Disorder: A
Earthquake. Keio J Med, 61(1), 15-22.
Systematic Review of The Evidence. Am
J Psychiatry , 164, 1319 -1326.
10. Long, M.E., Meyer, D.L. & Jacobs, G.A.
(2007). Psychological Distress Among
5. Duncan, R.D., Saunders B.E., Kilpatrick,
American Red Cross Disaster Workers
D.G., Hanson, R. & Resnick, H.S.
Responding to The Terrorist Attack of
(1996). Childhood Physical Assault As a
September 11, 2001. Psychiatry Res,
Risk Factor for PTSD, Depression and
149, 303-308.
Substance Abuse: Findings From a
National Survey. Am J Orthopsychiatry,
66, 437-448.

57
11. Mitchell, T.L., Griffin, K., Stewart, S.H. Available from:
& Loba, P. (2004). We will never ever www.nami.org/factsheets/ptsd_factsh
forget: The Swissair flight 111 Disaster eet.pdf.
and Its Impact on Volunteers and
Communitys. J Health Psychol, 9, 245- 17. Thormar, S.B. , Gersons, B.P.R., Juen,
262. B., Marschang, A., Djakababa ,M.N. &
Olff, M. (2010). The Mental Health
12. Paton, D. (1994). Disaster Relief Work: Impact Of Volunteering in a Disaster
An Assessment of Training Setting. The Journal of Nervous and
Effectiveness. J Trauma Stress, 7, 275- Mental Disease, 198(8), 529-538.
288.
18. U.S Department of Veterans Affairs.
13. Perrin, M.A., DiGrande, L., Wheeler, K., The National Centre of Post-Traumatic
Thorpe, L. & Farfel, M., Brackbill, R. Stress Disorder (1920). (cited : 11 April
(2007). Differences in PTSD Prevalence 2015). Available from:
and Associated Risk Factors Among http://www.ptsd.va.gov/public/pages/
World Trade Center Disaster Rescue what-is-ptsd.asp.
and Recovery Workers. Am J
Psychiatry, 164, 1385-1394.
14. Polusny, M.A. & Follette, V.M. (1995).

Long Term Correlates of Child Sexual
Abuse: Theory and Review of The
Empirical Literature. ApplPrev Psychol,
4143-4166.
15. Renck, B., Weisaeth, L. & Skarbo, S.

(2002). Stress Reactions in Police
Officers After a Disaster Rescue
Operation. Nord J Psychiatry, 56, 7-14.
16. The National Alliance on Mental Illness.

Posttraumatic Stress Disorder FACT
SHEET (1979). (cited : 11 April 2015).

58
Lessons from the Remediation of a Flood-damaged Health Clinic
Alzamani MI, Malathy R, Hafiz SM, Abu HAA
Abstract
Introduction: Following a flood, health facilities may be damaged. The Kuala Krau Health
Clinic in Temerloh, Pahang was badly affected by the floods that occurred at the end of
2014.Following the floods, the Health Clinic was non-functional and the entire clinic and
equipment was filled with mud and badly damaged. We describe our experiences in planning
the remediation and restoration activities of this clinic till it became functional again.
Materials & Methods: The cleaning project was strategically planned. A total of 44
volunteers from various departments at Hospital Kuala Lumpur (HKL) was assembled. We
worked with the National Welfare Foundation to provide us with cleaning equipment. The HKL
team was joined by members of the Tzu Chi organization and students from Jerantut Nursing
College in the planned remediation process. After macro-cleaning, usable and valuable items
were returned to the clinic. This was followed by Micro-cleaning phase which entailed
cleaning the equipment on day 2. Results: All activities in the remediation were performed
by all the volunteers. On the third day, the clinic was functional again. Conclusion: From
this experience, co-ordination between stakeholders, volunteers and partners is essential in
facilitating an efficient cleaning exercise. Cleaning equipment, water and water jets and
power generator for electricity are essential to ensure effective cleaning.
Keyword:remediation, cleaning, macro-cleaning, micro-cleaning
Introduction We report our experience in remediation of

the Kuala Krau Health Clinic in Temerloh,
The flood that occurred between 15th
Pahang following the flood. Based on our
December 2014 and 3rd January 2015 in the
analysis team which was despatched on 2nd
east coast of West Malaysia, damaged
January 2015, the Health Clinic was non-
many health facilities. By 29th December
functional and the entire clinic and
2014, 102 health facilities were affected.
equipment were filled with mud.

59
Materials & Methods
We describe our approach and experience in cleaning up the Kuala Krau Health Clinic in
Temerloh, Pahang in the east coast of Malaysia. A fact-finding visit was made to the operations
room of the Temerloh Health Clinic. At the briefing, the District Health Officer informed us
that the clinic was inundated with mud. A visit was made to the clinic for assessment of
damage. A strategy to get the clinic up and running again was agreed upon.
Results
I. Damage Assessment
Photo 1: Damage at the Kuala Krau Health Clinic
The assessment team included a senior equipment and drugs were damaged with
consultant in Emergency Medicine, two mostly beyond repair and use. The clinic
Emergency Physicians, a Matron, three was rendered non-functional. The smell of
staff nurses, one Assistant Medical Officer mud was very strong. The dried mud would
and four officers from the National Welfare also lengthened the cleaning process long
Foundation. and made it more challenging. Water-
The clinic was completely submerged in logged equipment included the ultrasound
muddy flood water during the major east machine, laboratory equipment,
coast flood of 2014/2015. The river near refrigerators and a television set. None of
the clinic rose and the water submerged the drugs at the clinic were usable. The
the clinic up to the ceiling. The clinics clinic interior was dark as there was no
sewerage system had overflowed and electricity. Tap water was not available.
contaminated the whole clinic. Furniture,
60

II. Strategy for Mega Cleaning III. Pre-Deployment Instruction
Project
Following a co-ordination meeting at HKL, On the cleaning day, the other volunteers
permission was obtained from the hospital joined the HKL team; one group was from
director to send assistance. A total of 44 the Tzu Chi organization and another group
volunteers from various departments at of about 50 people were from nursing
Hospital Kuala Lumpur were assembled. colleges and other hospitals. A briefing was
They ranged from clinical specialist, staff held for all volunteers. Safety precautions
nurses, assistant medical officers, dietitians were advised. All volunteers were advised
and hospital attendants. Preparation of to wear personal protective equipment
food and drink was made for volunteers. A (PPE), hats, sports attire, water-resistant
list of cleaning equipment was prepared to boots and to bring extra clothes and
ensure all needs would be met for the towels. Spades, shovels, wheel-barrows,
cleaning exercise. Funds were needed to water jets and power generators were
purchase the cleaning equipment. We made available by the National Welfare
worked with the National Welfare Foundation. They were also briefed on the
Foundation to acquire shovels, spades, ethics of disaster assistance. Volunteers
mops, wheel-barrows, water jet pumps, were divided into various areas of the clinic.
electric generators, water-resistant boots, Food and drinks were prepared by the
aprons, masks, gloves and rubbish bags. cleaning team so as not to burden the host.
The foundation also assisted with logistics The cleaning process started at 8.30 am.
in the form of rented four-wheel drive The fire and rescue services came upon our
vehicles as well as food for volunteers. request and assisted not only in provision
A cleaning project was strategically of water but also in ensuring volunteer
planned. A plan was laid out via a special safety before entering the clinic. There
meeting at HKL. Contact was established were no dangerous animals such as snakes
with the Family Physician in-charge of the found inside the clinic.
Kuala Krau Clinic to arrange the time and
date for our team to carry out the cleaning
exercise. The district Fire & Rescue
Department was contacted to provide
water for the remediation exercise. They
would also assist in opening the clinic doors
to ensure there were no dangerous animals
such as snakes inside the clinic.

61
In this cleaning exercise, all volunteers were reminded of the ethics of assistance. We made
sure that the host was not inconvenienced by our presence. Volunteers worked as a team and
wherever possible, publicity was avoided. Finally, when all processes were completed, the
premises were left in order. The flood victims were encouraged and respected at all times.
IV. Cleaning Process

Macro-cleaning: Removal of damaged furniture and rubbish
Photo 2: Damaged furniture and equipment at the Kuala Krau Health Clinic
Volunteers began by removing all furniture and rubbish. The pervasive mud made this a labour
intensive exercise. Spades and wheel-barrows proved very useful. The Wellington boots
provided safety and comfort as volunteers waded through the mud inside the clinic. The masks
were necessary as the stench was unbearable. All rubbish was collected in garbage disposal
bags for final removal by the municipal garbage trucks. The removal of furniture, equipment
and rubbish took time.

62
Micro-cleaning: cleaning of small items
In this process, salvaged equipment were cleaned and then replaced in the clinic.
Photo 3: Micro-cleaning team: cleaning salvaged equipment
Removal of mud with water
Photo 4: Cleaning with water from water tanker & water jet required to remove thick mud
stain

63
The water for the clean-up was provided by the Fire and Rescue Department tanker. The
floors were scrubbed. Later, one of the taps was found to be working. Two water jets and
power generators donated by the National Welfare Foundation had to be used to remove the
mud stains in the clinic.
Scavenger Teams: Salvaging Valuable Equipment and Material
After the removal of damaged furniture, scavenger teams were sent in to salvage precious
material and equipment. These equipment were then returned into the clinic and locked for
safekeeping.
After the cleaning was completed on Day 1, it was observed that more cleaning was needed
to make the clinic functional. For example, cleaning the stains with water jets took time.
Hence, the team returned for a second day to continue cleaning until all items had been
cleaned and the state of the clinic became functional.
Photo 5: Some of the equipment salvaged by scavenger team
V. THE RESUMPTION OF HEALTH CLINIC

The cleaning activities began on 4th January 2015. The clinic was functional again on 7th
January 2015. It was the first clinic to be functional of all Ministry of Health clinics damaged
by the floods.

64
Discussions essential part of communitys recovery
Cleaning a health clinic following a flood is after a flood.
a challenge. The number of volunteers In the cleaning process, we asked for the
needed is often underestimated, and there assistance from the Fire and Rescue
can never be an oversupply of volunteers. Department for provision of water and their
This undertaking also requires the right help enabled our mission to be completed.
equipment. Water supply is a challenge and Adams et al (2015) asserted that primary
teams must make this a priority in order to care hospitals are a decisive part in the
make the cleaning process effective. chain of medical supply and are confronted
Cleaning teams should expect immense with great challenges, which demand
damage during such activity. Our detailed emergency plans and also
experience showed that rubbish and repeated exercises. In planning and
damaged equipment filled the whole clinic exercises, special attention should be given
compound. to the cooperation with the fire and rescue
department and other medical services.
Post-flood needs had to be determined so Having a network of help which includes
that they could be addressed. In this case, the department would be handy as evident
the clinic required assistance for a major in our experience of cleaning up the clinic.
cleaning exercise. There was no water or
electricity, both of which are essential for a The recovery of a health centre takes time.
speedy cleaning process. Wisitwong and Water takes time to recede and therefore
McMillan (2010) focused on the process of access is a challenge as well. During this
managing a flood situation and the event, the water level stayed level with the
experiences of flood victims at Chainat clinics roof for almost two weeks. The
Province, central Thailand, so as to develop longer furniture and equipment were
expertise in the handling of such disasters. submerged, the more damage is sustained.
There was a lack of sanitation and clean After the water receded, more time was
drinking water, people were sick, and needed for the clinic to dry up. In addition,
stressed. The government assisted by the sewerage from the toilets had risen and
supplying the needs that had been contaminated the whole clinic. Evans
damaged or cut-off by the floods such as (2012) found that more than a month after
electricity, food and clean water, sanitation superstorm Sandy, five hospitals were still
and health services and water drainage. scrambling to restore inpatient services in
Having a functioning health centre is an New York, while hospitals were assessing
the changes they would need to make to
65
withstand future storms that may be caused unnecessary delays in the
worse. restoration effort.
In order to reduce the public health risk Given that community seeks treatment at
posed by flooded buildings that have been health clinics, they should not be a source
restored, it is important to understand their of infection. Proper post-flood remediation
drying behaviour. In our experience, we lowers illnesses. Hoppe et al (2012) found,
observed that drying mud was heavy and following the Cedar River flooding that
needed shovelling. The smell was very bad proper post-flood remediation led to
as the sewerage had contaminated the improved air quality and lower exposure
already muddy water. According to Taylor among residents living in homes that had
et al (2011), floods can bring pathogens been flooded. Proper remediation of flood-
indoors and cause lingering damp and damaged homes can reduce bio-aerosols to
microbial growth in buildings, with the level acceptable levels but exposure is
of growth and persistence dependent on significantly increased while remediation is
the volume, chemical and biological in-progress leading to an increased burden
content of the flood water, the properties of allergy and allergic rhinitis. An increase
of the contaminating microbes, and the in illnesses was found in households living
surrounding environmental conditions, in flooded homes. It is feared that a clinic
including the restoration time and affected by floods would harbour
methods, the heat and moisture transport infections. A thorough cleaning is required.
properties of the building design, and the Waringet et al (2002) described
ability of the construction material to assessment of household needs during
sustain the microbial growth. The public Tropical Storm Allison, which hit landfall
health risk will depend on the interaction of near Galveston, Texas, in 2001 and caused
these complex processes and the the most severe flood-related damage ever
vulnerability and susceptibility of occupants recorded in the Houston metropolitan area.
in the affected areas. This was illustrated They found a 4-fold increase in illness
after the 2007 floods in the UK, when the among persons living in flooded homes
Pitt review noted that there was a lack of compared with those living in non-flooded
relevant scientific evidence and consistency homes. These findings suggest a need for
with regard to the management and rapid resolution of flood-related damage
treatment of flooded homes, which not only and the recommendation that residents
put the local population at risk but also should seek temporary housing during
clean-up and repair. The findings
66
withstand future storms that may be caused unnecessary delays in the
worse. restoration effort.
In order to reduce the public health risk Given that community seeks treatment at
posed by flooded buildings that have been health clinics, they should not be a source
restored, it is important to understand their of infection. Proper post-flood remediation
drying behaviour. In our experience, we lowers illnesses. Hoppe et al (2012) found,
observed that drying mud was heavy and following the Cedar River flooding that
needed shovelling. The smell was very bad proper post-flood remediation led to
as the sewerage had contaminated the improved air quality and lower exposure
already muddy water. According to Taylor among residents living in homes that had
et al (2011), floods can bring pathogens been flooded. Proper remediation of flood-
indoors and cause lingering damp and damaged homes can reduce bio-aerosols to
microbial growth in buildings, with the level acceptable levels but exposure is
of growth and persistence dependent on significantly increased while remediation is
the volume, chemical and biological in-progress leading to an increased burden
content of the flood water, the properties of allergy and allergic rhinitis. An increase
of the contaminating microbes, and the in illnesses was found in households living
surrounding environmental conditions, in flooded homes. It is feared that a clinic
including the restoration time and affected by floods would harbour
methods, the heat and moisture transport infections. A thorough cleaning is required.
properties of the building design, and the Waringet et al (2002) described
ability of the construction material to assessment of household needs during
sustain the microbial growth. The public Tropical Storm Allison, which hit landfall
health risk will depend on the interaction of near Galveston, Texas, in 2001 and caused
these complex processes and the the most severe flood-related damage ever
vulnerability and susceptibility of occupants recorded in the Houston metropolitan area.
in the affected areas. This was illustrated They found a 4-fold increase in illness
after the 2007 floods in the UK, when the among persons living in flooded homes
Pitt review noted that there was a lack of compared with those living in non-flooded
relevant scientific evidence and consistency homes. These findings suggest a need for
with regard to the management and rapid resolution of flood-related damage
treatment of flooded homes, which not only and the recommendation that residents
put the local population at risk but also should seek temporary housing during
clean-up and repair. The findings
66
underscore the usefulness of a rapid-needs clinic. A disaster plan for the clinic could
assessment as a tool to identify actual also take into account measures for early
health threats and to facilitate delivery of detection and early response for future
resources to those with the greatest and floods.
most immediate need.
Phalkey et al (2012) asserted that early
In this disaster, laboratory equipment were warning of an impending flood and the
damaged from submersion in water. The availability of counter measures to deal
water supply following the floods may also with it can significantly reduce its health
be contaminated and may damage them as impact. In developing countries, public
well. Yamada et al (2011) described the primary health care facilities are the
damage of analytical devices following frontline organizations that deal with
flood inundating Okazaki City Hospital in disasters particularly in rural settings. To
Aichi, Japan in 2008. Hospital functioning develop robust counter reacting systems,
did not stop, but some devices were evaluating preparedness capacity within
damaged by the water. There was no direct existing systems becomes necessary. The
damage to the clinical laboratory area, but authors showed that the healthcare
an abnormality in the measurement of facilities were ill prepared to handle the
Troponin-I occurred after the downpour. It flood despite being faced by them annually.
was suggested that this measurement Basic utilities like power generators and
abnormality was caused by the pollution of essential medical supplies were lacking
the water supply to the analyzer. For our during floods. Lack of human resources
health clinic, all the laboratory equipment along with missing standard operating
were damaged in this event. procedures, pre-identified communication
and incident command systems, effective
The recovery phase after disaster leadership and weak financial structure
represents an opportunity to improve were the main impending factors in
services. The Kuala Krau clinic needs to mounting an adequate response to the
acquire new equipment and materials. floods. Simple steps like developing facility
Following the cleaning exercise, it was able specific preparedness plans which detail
to function again after three days with very standard operating procedures during
few equipment salvageable. The floods and identify clear lines of command
management however, would need to will go a long way in strengthening the
obtain a budget allocation to acquire new response to future floods. Each facility
equipment and to repair and renovate the should maintain contingency funds for an
67
emergency response along with local by the Government are met in non-flood
vendor agreements to ensure stock periods in order to improve the response
supplies during floods. The facilities should during floods. Building strong public
ensure that baseline public health primary health care systems is a
standards for health care delivery identified development challenge.
Recommendation
Guidelines on Remediation and Restoration of a flood-damaged Health Clinic

The experience of cleaning the Kuala Krau Health Clinic gave us a clear idea of how to conduct
an efficient and successful cleaning exercise. This experience enabled us to establish a basic
guideline for cleaning a health clinic following floods. The followings are included in the
guideline:
1. Determine date for cleaning up with the District Health Officer
2. Gather volunteers at your place for the determined date
3. Give advisory to volunteers: hat/head cover, rubber gloves, Wellington boots, plastic
apron, face mask, clean clothes and towel for change and shower after cleaning up
exercise
4. Get tools (may team up with donors): spade, shovels, wheelbarrows, brushes, water
containers, water jets, generators, rubbish bags and torch lights
5. Get information of availability of clean piped water. If not, dry cleaning can be done
i.e removal of furniture and equipment out of clinic. Co-ordination with Fire & Rescue
or local municipal authorities can be made to bring water tankers
6. Brief volunteers on ethics of volunteerism: not to trouble the victims, bring the right
assistance, bring own food and complement gaps when joining work if other group
already started the work
7. Get briefing with clinic stakeholders. Divide groups to tackle areas to clean. Work in
teams
8. Start by taking out all furniture and equipment outside
9. Use shovel and spade to scoop muds. Expect bad stench as equipment, papers, files
and wood are soaked for days
10. Take care of safety: beware of broken glasses, needles and even poisonous animals
which might have gotten lost in the premises
11. Use rubbish bags and place all disposables into them. This shall enable municipal
lorries to clear the rubbish later on
68
12. If clean water is available, water jets can be used by connecting them to generators
13. Salvaging of useable and valuable items should be performed. These items should be
placed back in the clinic and locked
14. Micro cleaning can be performed in teams to clean up each dirtied equipment
15. If time is enough, arrange for a second phase cleaning
16. Have fun, exchange positive vibes among volunteers. Have a sincere heart
17. Leave the premise in orderly manner. Give words of encouragement and respect to
the victim
Conclusion References
Co-ordination between stakeholders, 1. Wisitwong, A., McMillan M.
volunteers and assisting partners is Management of flood victims:
essential for the efficient and effective Chainat Province, Central Thailand.
remediation and restoration of a health
clinic. Cleaning equipment, water supply 2. Adams, H.A., Flemming. A., Lange,
and water jets and power generators were C., Koppert, W., Krettek, C. (2015).
essential in ensuring an effective cleaning Care concepts in mass casualty
exercise. Volunteers must observe the incidents and disasters. Concept for
ethics of assistance in disaster and work in primary care clinic. Med Klin
a true spirit of volunteerism. The guideline, Intensivmed Notfmed, 110(1), 27-
established from our experience, may be 36.
used as a reference for future cleaning
exercise. 3. Evans, M. (2012). Recovery mode.
Mod Healthc, 42(50), 6-7, 16, 1.
Acknowledgement
We would like to acknowledge the Director 4. Taylor, J., Lai, K.M., Davies, M.,
General of Health, Malaysia for permission Clifton, D., Ridley, I., Biddulph, P.
to publish this article. We also would like to (2011). Flood management:
thank to all who directly and indirectly prediction of microbial
involved in this activity. contamination in large-scale floods
in urban environments. Environ Int,
37(5), 1019-1029.

69
5. Yamada, O., Ishii, M., Hayashi, K. Ranzinger, S., Marx, M. (2012).
(2011). Hospital flooding caused by Prepared to react? Assessing the
torrential rain--what happened to functional capacity of the primary
analytical devices?. Rinsho Byori, health care system in rural Orissa,
59(2), 146-151. India to respond to the devastating
flood of September 2008. Glob
6. Phalkey, R., Dash, S.R., Health Action, 5.
Mukhopadhyay, A., Runge-

70
Post-Deployment Activities and Challenges at the Crisis Preparedness Response
Center Institute for Health Management (CPRC IHM)
M Fairuz AR, Pangie B, Krishan O, Noriah B, N Filzatun B, N Izzah AS
Institute for Health Management
Abstract
Introduction: Volunteerism is the heart of disaster management. A disaster spurs people
from walks of life into volunteering to provide economical, physical or emotional support to
disaster victims. Consequently, the management of volunteers is crucial. Among other things
that the effort is effective and efficient, it does not burden the local authority and volunteers
are not compromised in any way. Objective: Managing volunteers in time of a disaster is
crucial especially during return of the volunteers from disaster sites. This article examines the
processes and workflow practised by CPRC IHM in its role as a transit centre for healthcare
volunteers, with particular focus on the management of the post-deployment activities phase.
Results and Discussions: Healthcare volunteer management in CPRC IHM transit centre
was phased into pre and post-deployment activities. Pre-deployment activities focused
primarily on the mental and physical status of the volunteers before they deploy to the
assigned area. Meanwhile, post-deployment team responsible for post- deployment activities
such as registration, medical screening, mental health assessment, accommodation and
logistics. For the 20 operating days, IHM received 272 post-deployment volunteers at CPRC
IHM transit centre. 84.4% (n=224) post-deployment volunteers completed mental and
physical assessment at CPRC IHM. 17.6% (n=48) of post-deployment volunteers decided to
have their medical and psychological assessment at their respective state health office. Among
the challenges experienced by IHM were inconsistencies on content and timing information
relayed and inadequacy of post- deployment debriefing due to the preference of returning for
briefing at their own centres. Conclusion and Recommendation: The experience of IHM
as post-deployment centre for the Ministry of Health volunteers was value added to the
institution. As this is the first mandate and experienced by IHM, there are challenges in
volunteer management. The IHM needs to develop Standard Operating Procedures for the
management of disaster volunteers at transit centre. This would help other MOH transit centre
in future.
Keyword: Post-deployment, volunteer, flood, human management

71
Introduction deep in soils and raises the likelihood of
Volunteerism is the heart of disaster volunteers being exposed to this organism.
management. A disaster spurs people from The process of cleaning disaster sites using
walks of life into volunteering to provide air-jets also increases the risk of infection,
economical, physical or emotional support as the exposure is over a prolonged time
to disaster victims. Consequently, the period. Without proper guidelines and
management of volunteers is crucial. awareness training from the management
Among other things that the effort is regarding the risks, these enthusiastic
effective and efficient, it does not burden volunteers are at risk of being infected. In
the affected local authority and volunteers this regard, Vollaard AM (2004) reported
are not compromised in any way. flooding as a significant risk factor for
diarrheal disease caused by Salmonella
The flood disaster which occurred in the enterica serotype Paratyphi A (paratyphoid
East Coast of Malaysia had opened many fever) in a large study carried out in
eyes. The flood damage was estimated at Indonesia from 1992 to 1993. In a separate
about RM1 billion and affected public study, Katsumata T (2004) evaluated the
schools, roads, homes, agriculture loss and risk posed by Cryptosporidium parvum in
causing landslides (The Malay Mail Online, Indonesia between 2001 and 2003 to be
2015). four times because of floods.
A major issue following a flood disaster is Vector borne diseases were a concern too,
the spread of communicable diseases. This as Malaysia is endemic for dengue
not only affects the victims, the volunteers infection, a viral disease transmitted by the
at the disaster sites as well. Largely, the mosquito. Floods would make stagnant
communicable diseases can be classified water available for the vector and cause
into two broad categories, water borne and spreading of the disease. Thus increasing
vector borne diseases. risk of dengue in the affected population
and volunteers. Multiple factors such as
Flooding causes risk escalation in the overcrowding and stagnant water will
spreading of water borne diseases such as exacerbate the outbreak.
cholera, typhoid, leptospirosis and hepatitis
A (WHO). Leptospirosis, a zoonotic It is crucial for to obtain information
bacterial infection is known to be locally regarding disaster sites as outlined by
endemic at the affected sites. Flash flood Watson JT (2007) that is the 1) endemic
releases bacteria which mainly resides and epidemic diseases that are common in
72
Introduction deep in soils and raises the likelihood of
Volunteerism is the heart of disaster volunteers being exposed to this organism.
management. A disaster spurs people from The process of cleaning disaster sites using
walks of life into volunteering to provide air-jets also increases the risk of infection,
economical, physical or emotional support as the exposure is over a prolonged time
to disaster victims. Consequently, the period. Without proper guidelines and
management of volunteers is crucial. awareness training from the management
Among other things that the effort is regarding the risks, these enthusiastic
effective and efficient, it does not burden volunteers are at risk of being infected. In
the affected local authority and volunteers this regard, Vollaard AM (2004) reported
are not compromised in any way. flooding as a significant risk factor for
diarrheal disease caused by Salmonella
The flood disaster which occurred in the enterica serotype Paratyphi A (paratyphoid
East Coast of Malaysia had opened many fever) in a large study carried out in
eyes. The flood damage was estimated at Indonesia from 1992 to 1993. In a separate
about RM1 billion and affected public study, Katsumata T (2004) evaluated the
schools, roads, homes, agriculture loss and risk posed by Cryptosporidium parvum in
causing landslides (The Malay Mail Online, Indonesia between 2001 and 2003 to be
2015). four times because of floods.
A major issue following a flood disaster is Vector borne diseases were a concern too,
the spread of communicable diseases. This as Malaysia is endemic for dengue
not only affects the victims, the volunteers infection, a viral disease transmitted by the
at the disaster sites as well. Largely, the mosquito. Floods would make stagnant
communicable diseases can be classified water available for the vector and cause
into two broad categories, water borne and spreading of the disease. Thus increasing
vector borne diseases. risk of dengue in the affected population
and volunteers. Multiple factors such as
Flooding causes risk escalation in the overcrowding and stagnant water will
spreading of water borne diseases such as exacerbate the outbreak.
cholera, typhoid, leptospirosis and hepatitis
A (WHO). Leptospirosis, a zoonotic It is crucial for to obtain information
bacterial infection is known to be locally regarding disaster sites as outlined by
endemic at the affected sites. Flash flood Watson JT (2007) that is the 1) endemic
releases bacteria which mainly resides and epidemic diseases that are common in
72
the affected area; 2) living conditions of the healthcare volunteers after their stint at the
affected population, including number, affected sites. This article examines the
size, location, and density of settlements; processes and workflow practised by CPRC
3) availability of safe water and adequate IHM in its role as a transit centre for
sanitation facilities; 4) nutritional status healthcare volunteers, with particular focus
and immunization coverage of the on the management of the post
population; and 5) degree of access to deployment activities phase.
healthcare and to effective case
management. For 20 days of operation, we received 272
post-deployment volunteers at its CPRC
CPRC IHM Post-Deployment Team IHM transit centre. 84.4% (n=224)
Healthcare volunteer management in CPRC volunteers were completed post-
IHM transit centre was phased into pre and deployment mental and physical
post deployment activities. Pre-deployment assessment at CPRC IHM while 17.6%
activities focused primarily on the mental (n=48) volunteers were decided to have
and physical status of the volunteers before their post-deployment medical and
they deploy to the assigned area. While, psychological assessment at their
post-deployment activities, assessed the respective state health offices.
physical and mental status of the
Table 1: Job Description of Post-Deployment Volunteers Who Transit at CPRC IHM

No Job Description Total Volunteer Percentage (%)
1. Specialist 3 1
2. Medical Officer 17 6
3. Nurse 172 63
4. Assistant Medical Officer 11 4
5. Pharmacist/ Pharmacist Assistant 17 6
6. Counsellor 10 4
7. Engineer 7 3
Penolong Pegawai Kesihatan
8. 8 3
Persekitaran
9. Social Worker 3 1
10. Pembantu Kesihatan Awam 2 1
11. Driver 11 4
12. Pembantu Perawatan Kesihatan 9 3
13. Pembantu Rendah Awam 2 1
Grand total 272 100

73
The Head
The Head
The of
Head of CPRC
of CPRC IHM
CPRC IHM was
IHM was the
was the Director
the Director of
Director of Institute
of Institute for
Institute for Health
for Health Management.
Health Management. The
Management. The post
The post
post
deployment team
deployment team
deployment was
team was responsible
was responsible for
responsible for management
for management
management of of volunteers
of volunteers who
volunteers who had
who had returned
had returned
returned
from disaster
from disaster
from sites.
disaster sites. The
sites. The several
The several tasks
several tasks assigned
tasks assigned
assigned toto the
to the post-deployment
the post-deployment team
post-deployment team are
team are
are
depicted in
depicted in
depicted Figure
in Figure 1.
Figure 1. The
1. The team
The team was
team was also
was also required
also required to
required to ensure
to ensure the
ensure the orderliness
the orderliness of
orderliness of post
of post
post
deployment activities
deployment at
activities at CPRC
at CPRC IHM
CPRC IHM transit
IHM transit centre
transit centre by
centre by following
by following the
following the established
the established
established
workflow. Finally,
workflow. Finally,
workflow. the
Finally, the wrap-up
the wrap-up session
wrap-up session at
session at the
at the end
the end of
end of each
of each operating
each operating day
operating day was
was aa
day was forum
a forum
forum
for the
for the
for team
the team to
team to share
to share their
share their issues
their issues and
issues and discuss
and discuss solutions
discuss solutions to
solutions to improve
to improve the
improve the post-
the post-
post-
deployment or
activities or management
or management
management of of volunteers.
of volunteers.
volunteers.
Figure
Figure 1:
Figure 1: The
1: The CPRC
The CPRC IHM
CPRC IHM Post-deployment
IHM Post-deployment team
Post-deployment team workflows
team workflows
workflows
Post-Deployment
Post-Deployment Activities
Post-Deployment Activities
Activities at at CPRC
at CPRC IHM
CPRC IHM Transit
IHM Transit Centre
Transit Centre
Centre
Post-deployment
Post-deployment activities
Post-deployment activities involved
activities involved several
involved several processes
several processes that
processes that were
that were executed
were executed by
executed by the
by the CPRC
the CPRC IHM.
CPRC IHM.
IHM.
These
These processes
These processes were
processes were based
were based
based on on the
on the Pre
the Pre and
Pre and Post-Deployment
and Post-Deployment Healthcare
Post-DeploymentHealthcare Volunteers
HealthcareVolunteers Guideline
VolunteersGuideline
Guideline
by
by CPRC
by CPRC MOH
CPRC MOH issued
MOH issued on
on 77
issued on
th
January
7thth January 2015.
January 2015. The
2015. The guideline
The guideline states
guideline states that
states that the
that the MOH
the MOH healthcare
MOH healthcare
healthcare
volunteers
volunteers who
volunteers who returned
who returned and
returned and transit
and transit at
transit at CPRC
at CPRC IHM
CPRC IHM were
IHM were required
were required to
required to attend
to attend the
attend the in-
the in- house
in- house PFA
house PFA
PFA

74
74
74
briefing, undergo Depression, Anxiety, Stress Scale (DASS) assessment and physical
examination. The post-deployment activities for the volunteers included (Figure 2):
i. Registration of the post-deployment volunteers
ii. Medical/physical screening
iii. Post-Deployment PFA briefing and DASS screening
iv. Accommodation and Catering facilities
v. Logistics
Figure 2: The Post-Deployment Process for Volunteers in CPRC IHM
1.0 Registration of Post-deployment Volunteers

Upon arrival at CPRC IHM, post-deployment volunteers needed to register at the counter
located at the IHM lobby. They were requested to complete the daily volunteer attendance
form. The completed forms were collected by the post-deployment registration team and
despatched to the CPRC IHM operation room. The operation room secretariat used the
information to update the daily census and to prepare the report for CPRC MOH.

75
Photo 1: Post-deployment volunteers being registered at IHM lobby before PFA briefing and
medical screening
2.0 Medical/Physical Screening

Medical or physical screening of post-deployment volunteers was conducted in collaboration
with other NIH Institutes. Medical officers from the Clinical Research Center, Institute for
Health System Research and Institute for Health Management examined and advised the
volunteers about water borne related diseases. In the event that a post-deployment volunteer
had a medical issue or problem, they would be referred to the nearest health clinic or hospital
for further diagnostic assessment and prompt treatment. The signs and symptoms of flood
related communicable diseases were also highlighted to the post-deployment volunteers. The
information on water borne diseases especially meloidosis, leptospirosis, cholera and typhoid
was displayed at the IHM lobby to increase awareness among volunteers.
Table 2: Medical problems detected in post-deployment medical screening of volunteers in

transit at CPRC IHM
No Medical problem No of Volunteers Affected
1. Upper Respiratory Tract Infection 4
2. Hypertension 4
3. To Rule Out (TRO) Dengue Fever 3
4. Acute Gastroenteritis (AGE) 2
5. Tachycardia for investigation 2
6. Fever for investigation 1
7. Anal fissure 1
8. Hyperthyroidism 1
Grand Total 18

76
As shown in Table 2, no volunteer was diagnosed with these communicable diseases at CPRC
IHM. However, the volunteers were reminded to seek medical attention immediately if they
showed any sign or symptom of infection.
Photo 2: Medical Officers examining post-deployment volunteers at the Kristal Room
3.0 Post-deployment PFA Briefing and this group. As instructed by CPRC MOH,
DASS assessment DASS was the tool used for mental
The mental assessment was carried assessment at CPRC IHM. 224 post-
according to the National Guidelines for deployment underwent DASS assessment
Mental Health and Psychosocial Response and 5.3% (n=12) of them had at least two
to Disaster developed by the Ministry of abnormal scores on the scales (Table 3).
Health. Post traumatic stress disorder Volunteers who showed moderate to
(PTSD) among the post-deployment severe DASS scores were counselled by a
volunteers was the main concern. In view PFA trained counsellor. They were followed
of this, mental assessment was crucial for up two weeks later at a hospital.

77
Table 3: Distribution of Abnormal DASS Findings at Psychosocial Screening
Table 3: Distribution
(Munirah I, NorhidayahofMD,
Abnormal
InstituteDASS Findings
forFindings
Health at Psychosocial
Management - TransitScreening
Center for Flood
Table 3: Distribution of Abnormal DASS at Psychosocial Screening
(Munirah
DisasterI,I,
Jan Norhidayah MD, Institute
2015; Psychosocial Impact for Volunteers.
Health Management - Transit Center for Flood
(Munirah Norhidayah MD, Institute for on )
Health Management - Transit Center for Flood
Disaster Jan 2015; Psychosocial Impact
NoImpact
Of Days on Volunteers.) DASS
Disaster Jan 2015; Psychosocial on Volunteers.
Flood)
Spent
No Of In The
Days DASS
No Occupation No OfFlood
Days Affected
Flood DASS
Spent In The Flood Stress Anxiety Depression
No Occupation Spent In The Area
Affected
No Occupation Affected
Flood Area Affected Stress Anxiety AnxietyDepression
Depression
1. Nurse Flood 15 Area
Kelantan StressMild Mild Normal
Affected Area Area
Affected Area
2. Nurse 15 Kelantan Mild Mild Normal
1. Nurse
Kelantan MildMild MildMild Normal
Normal
2. Nurse
Kelantan MildMild MildMild Normal
Normal
3. 4. Nurse
Assistant 15
15 Kelantan
Kelantan Extremely
Moderate Extremely
Severe Moderate
Severe
Medical Officer Severe Severe
4. Assistant
4. Assistant 1515 ExtremelyExtremely
Kelantan Extremely
Kelantan Extremely Moderate
Moderate
5. Information 15 Kelantan Severe Moderate Moderate
MedicalOfficer
Medical Officer Severe Severe
Severe Severe
Technology
5.
5. Information
Information 1515 Kelantan Severe
Kelantan Severe Moderate
Moderate Moderate
Moderate
Officer
Technology
Technology
6. Officer
Nurse 14 Kelantan Mild Moderate Normal
Officer
6. 7. Nurse 14 Kelantan Mild Moderate
MildMild Moderate Mild
6. Nurse
Nurse 1414 Kelantan
Kelantan Moderate Normal Normal
8. Nurse 14 Kelantan ModerateModerate
Mild Severe Severe
7.
7.9. Nurse
Nurse
Nurse
1414
10
Kelantan
Kelantan
Kelantan
Mild
Mild
Moderate Mild
Moderate
Mild
Normal
8.
8. Nurse
Nurse 14 14 Kelantan
Kelantan Moderate
Moderate Severe
Severe SevereSevere
9.10. Nurse
Nurse 10 10 Pahang
Kelantan Moderate
Normal Moderate
Mild Mild
Normal
9.11. Nurse 10 Kelantan Mild Moderate
Moderate Normal
10. NurseAssistant 10 10 Pahang
Pahang Normal
Normal Moderate MildMild
10. NurseMedical Officer 10 Pahang Normal Moderate Mild
11. Assistant 10 Pahang Normal Moderate Mild
11. Assistant
12. Medical
Assistant
Officer 104 Pahang
Kelantan Normal
Normal Moderate
Moderate Mild
Mild
Medical
Engineer
12. Assistant Officer 4 Kelantan Normal Moderate Mild
12. Engineer
Assistant 4 Kelantan Normal Moderate Mild
Engineer
Photo 3: Post-deployment volunteers undergoing DASS assessment before the PFA.

78 78
78
Photo 4: Counsellor giving PFA to the post-deployment volunteers
4.0 Accommodation and Catering Wilayah Persekutuan Kuala Lumpur,

Facilities Putrajaya, Selangor, Perak and Melaka.
The volunteers who decided to lodge at
IHM were given access to the hostel room A catering team was in charge of ordering
by the hotel supervisor upon registration. and providing food for the volunteers. Food
Only 5 post-deployment volunteers from and beverage were prepared by the in-
Johor lodged for two days at CPRC IHM. house caterer according to the number of
The majority (98.2%, n=267) of post- volunteers to transit at CPRC IHM for that
deployment volunteers returned to their particular day. The volunteers had their
state on the same day using their health meals at the IHM cafeteria.
departmental transportation. These
volunteers were healthcare staff from

79
Photo 5: The volunteers who lodged at IHM registering with Hostel Supervisors
5.0 Logistics time as logistic matters need to be sorted
The transport from the airport to IHM for prior to the arrival of volunteers. CPRC IHM
post-deployment volunteers was arranged needed prior notification to arrange
and coordinated by the logistics team. The accommodation, food and most
logistics officers arranged airport transfer importantly, transportation to fetch
according to the returnee and their flight volunteers from the airport.
schedule information supplied by CPRC
MOH. CPRC IHM also worked with CPRC Due to the inconsistencies of information,
Institute of Public Health (IPH) on the resources were wasted in that the buses
assignment of drivers and vehicles for this came back with few or no passengers at all.
purpose. Transport for volunteers to return The main reason for this was that
to their state was arranged and provided volunteers made their own transport
by their respective departments. arrangements.
Challenges and Recommendation Consequently, most of the volunteers did

Post-Deployment Information undergo the required medical and mental
One of the challenges in managing post- health screening.
deployment volunteers was the information
relayed by CPRC MOH. There were
inconsistencies in and timing information
relayed. It is important to get clear and
correct information from CPRC MOH and in-

80
Post-Deployment Briefing deployment volunteer management, CPRC
Feedback from the volunteers included IHM has contacts CPRC MOH to ascertain
that, certain states had organised post each volunteer teams transport needs for
deployment briefing for volunteers at the the return to their respective health
respective affected sites. During transit in facilities. With clear information, CPRC IHM
IHM, volunteers reported that the briefing will make the necessary arrangements for
was more of an appreciation and these volunteers. These arrangements
recognition of their assistance. There was would include catering, transport and
no medical or psychological screening lodging.
carried out by the medical and certified
Psychosocial First Aid (PFA) team. Due to the lacking of cohesion in providing
appropriate post deployment briefing, the
Recommendation task of giving psychosocial and medical
In a time of crisis, a large number of screening is left to the State Office. It is the
volunteers is needed to ensure that aid is responsibility of the State Offices to screen
given to the affected areas. Volunteerism returning physically and mentally before
has reduced the cost of rebuilding and releasing them for work. This ensures that
recovery of affected areas. However, any volunteer found ill is referred to experts
management of a large number of for treatment and only healthy and able
volunteers can be challenging as the volunteers are allowed to resume work.
fundamental principle of volunteerism is to
provide aid and not to burden the local Conclusion
authority. Furthermore, efficient and The experience of IHM as post deployment
thorough post deployment management of centre for the Ministry of Health volunteers
volunteers is vital to screen and prepare was value added to the institution. As this
the volunteers to resume work. is the first mandate and experienced by
IHM, there are challenges in volunteer
In any crisis control room, intra- management. The IHM needs to develop
organisation and inter-organisation Standard Operating Procedures for the
communication determines the management of disaster volunteers at
effectiveness and proficiency of volunteer transit centre. This would help other MOH
management. In this case, effective transit centre in future.
communication between these three
organisations, that is CPRC MOH, CPRC
IHM and CPRC IPH is vital. As for post-
81
Acknowledgment Training Volunteers in Disaster
We would like to acknowledge the Director Response. Japan.
General of Health, Malaysia for permission 6. Vollaard, A.M., Ali S., Van, Asten,
to publish this article. Special thanks also to H.A., Widjaja, S., Visser, L.G.,
all those involvedand support the operation Surjadi, C., et al. (2004) Risk
of the CPRC IHM. factors for typhoid and paratyphoid
fever in Jakarta, Indonesia. JAMA,
Reference 291, 26072615.
1. Volunteers of America (2008). 7. WHO: Flooding and communicable
Disaster Related Volunteerism: diseases fact sheet. (Cited: 20
Best Practices Manual Based on August 2015). Available from:
Lessons Learned from Hurricanes http://www.who.int/hac/techguida
Katrina and Rita. Greater New nce/ems/flood_cds/en/.
Orleans. 8. Watson, J.T., Gayer, M., Connolly,
2. Faye S. (2003). Managing M.A. (2007). Epidemics after
Spontaneous Disaster Volunteers, natural disasters. Emerg Infect.,
North Carolina Commission on Jan. Available from
Volunteerism and Community http://www.cdc.gov/ncidod/EID/13
Service. Washington, USA. /1/1.htm
3. Katsumata, T., Hosea D., Wasito, 9. The Malay Mail. Flood damage
E.B., Kohno, S., Hara ,K., estimate tops RM1b (2015). (cited
Soeparto, P., et al. (1999). : 20 August 2015). Available from
Cryptosporidiosis in Indonesia: a http://www.themalaymailonline.co
hospital-based study and a m/malaysia/article/flood-damage-
community-based survey. Am J tops-rm1b.
Trop Med Hyg, 59, 628632.
4. Points of Light Foundation &
Volunteer Center National Network
(2004). Managing Spontaneous
Volunteers in Times of
Disaster:The Synergy of Structure
and Good Intentions. USA.
5. The Jamsetji Tata Centre for
Disaster Management (2010).

82
Managing Child Flood Victims by Psychological Engagement: A Pilot Project
Alzamani MI, Mona KG, Nurul LR, Hafiz SM, Ahmad IKB, Abu HAA
Abstract
Introduction: After a disaster, the focus of assistance for victims is usually on basic survival needs
such as shelter, food and water. The psychological needs of the children are often neglected. This
study reports the intervention used to meet the childrens psychological needs during the major
flood that occurred in Temerloh, Pahang from 3 December 2014 to 3 January 2015.
Material & Methods: We describe the employment of psychological intervention in children via
play and art therapy. A team of 15 personnel including 1 Emergency Physician, 4 Medical Officers,
3 Staff Nurses, 2 Assistant Medical Officer from Kuala Lumpur Hospitals Emergency Department,
established an Emergency Medical Services and Observation Ward at the Temerloh Relief Center
in Pahang which housed about 3,000 victims. In addition, a team of 3 psychologists was recruited
to provide psychological intervention. The team stayed at the center for 1 week to provide medical
services. The play therapy and art therapy was specifically targeted at the children. This was a
pilot project to provide mental support for children. A walkabout team consisting of an emergency
physician, a medical officer and a psychologist screened children for change of behavioural. 10
children who had noticeable behavioral changes were recruited for this study on voluntary basis.
Results: Subjects were able to express their state of mind via play and art therapy. Psychologists
provided mental therapy to affected victims. The walkabout team was able to screen for children
who had a troubled mental state. Early detection and therapy could mitigate symptoms and
prevent progress to more serious problems such as anxiety disorder or post-traumatic stress
disorder.
Conclusion: Play and art therapy are useful modes of mental therapy for children affected by
disaster. Psychological engagement should not be forgotten as disaster victim are often mentally
troubled. Without close observation, this aspect may be missed. Psychologists can play effective
roles by engaging the victims in activities that help them express themselves, and therapeutic
measures such as play and art therapy.
Keyword: Child, flood victims, psychological engagement, play and art therapy

Introduction the means of communicating with the child
After a disaster, the focus of assistance is usu- (McKinney Clark, 2015). Proactive screening
ally on basic survival needs such as shelter, food via medical walkabout was done to identify
and water. The victims psychological needs are children who needed psychological first aid
often neglected. Children, who are at a critical or critical incident stress management. This
age in development, can suffer tremendous- screening was based on parental communica-
ly when their experiences are not given any tion of behavioral changes they had observed
form of expression. Since childrens preferred in their children following the disaster. From
form of expression is action and play, using this screening, 10 children were identified and
language-based therapy is akin to providing asked to voluntarily participate in our study.
therapy for an adult in a foreign language (La
Art Therapy
Motte, 2011). The purpose of this crisis inter-
Materials provided for art therapy were drawing
vention is to restore the victims functioning to
paper and coloring pens. Subjects were asked
pre-disaster levels. It is crucial for children to
to draw anything they pleased, whether it was
make sense of the events so that they regain a
related to the flood or not. Subjects would then
sense of control. This report describes the art
describe the finished drawings. Interpretation
and play intervention used to address the chil-
of emotions was done by psychologists based
drens psychological needs following the major
on objects drawn and the choice of color. For
flood that occurred in Temerloh, Pahang from
example red represents aggression, danger,
3 December 2014 to 3 January 2015.
excitement and yellow represents happiness,
Material & Methods joy and fear.
We describe the employment of psychological
Play Therapy
intervention in 10 children as a pilot project.
Nine different stuffed animals of various shapes
A group of 3 psychologists were recruited to
were provided. Each toy represented a certain
work alongside a medical services unit at the
character or emotion. Play Therapy comprised
Temerloh relief center located at a school. A
patient selecting one or more stuffed animals
team of 15 personnel including 1 Emergency
given to them. The subjects were asked the
Physician, 4 Medical Officers, 3 Staff Nurses, 2
following questions:
Assistant Medical Officers from Kuala Lumpur
Which of these stuffed animals makes you
Hospitals Emergency Department established
feel happy?
an Emergency Medical Services and Observa-
Which of these stuffed animals do you like
tion Ward at the Temerloh Relief Center in Pa-
the most?
hang. This center housed about 3,000 victims.
Which of these stuffed animals represents
In additional, a team of 3 psychologists was
you?
recruited to provide psychological intervention.
Why did you choose it?
The team stayed at the center for 1 week. The
All results were then interpreted by the psy-
intervention applied for children was play and
chologists.
art therapy. Art and play therapy were adapt-
ed psychological using the medium of play as

Results
Part 1: Art therapy
Child 1: A 10 year old girl drew her dream house; a wooden house on stilts on the beach side,
surrounded by animals (cats, dogs, fish). There was a swimming pool and next to it there were
two palm trees with a hammock suspended between them. (Figure 1)
Figure 1: Drawing of Child 1
Interpretation: The drawing filled up the entire page and this represents a range of normalcy.
The birds represent freedom and her need to be free. The animals that she has around her house
show that they keep her company when she is alone. The two palm trees represent mother
figures; her mother & her aunt that she has close relationships with. The position of the house
near the beach shows that what she built may not be permanent and may be destroyed in the
long run. This reflects her current view of the situation of her home at the time of therapy session.
Child 2: A 6 year old boy drew his family; parents, him and his sister. There was a cat that sat
on the roof (Figure 2)
Figure 2: Drawing of child 2

Interpretation: The color red (mud brought by the flood) may represent courage, danger and
determination. The drawings done in thick lines shows trauma or aggression. What he experienced
was very traumatizing for him.
Child 3: An 8 year-old girl who was trapped with her family in the flood and who was looking for
ways to stay safe indoors while the water level was rising. She drew houses that were submerged
with the roof visible; two men floating in the water.
Interpretation: This child described the two men afloat whom she saw as corpses. The stick
figures that represented her family represent the feeling of being insecure or depressed. The thick
lines used to draw the roof and corpses represent trauma or aggression.
Child 4: A 9 year old boy drew his favorite toy; a robot in blue and red. It has a huge head and
large metal hands holding a weapon.
Interpretation: The large head represents fantasy thinking and this represents an egoistic person.
Large hands show that he may be aggressive or hostile. The red color represents aggression or
excitement in him. The color blue represents authority, depression and confidence.
Child 5: An 8 year old girl drew a rainbow in red, yellow, blue and green with the rain still falling.
There was a stick figure of herself under the rainbow smiling.
Interpretation: The color red represents compassion, courage, emotions; blue represents
balance, calmness, confidence; yellow represents energy, expression, happiness; green represents
adventure, calmness and faith. Stick figure represent the feeling of being insecure or depressed.
The roof of the houses, and the corpses that she saw were drawn in thick lines and they represent
trauma or aggression.
Note: Actual drawing pictures for child 3, 4 & 5 were not available as they were not captured
during the activity.
Our observation of children experiencing the Art Therapy:

1. The children were able to convey traumatizing experiences that may not have come
through if done using the conventional therapy.
2. The children enjoyed themselves and the therapy served as a distraction while living in a
shelter.
3. They were happier after completion of therapy.
4. The art therapy promoted communication skills between children when they interacted
between to explain their drawings.
5. Some of the children sought therapy repeatedly because it made them feel good about
themselves.

Part 2: Play Therapy
Children were asked to choose from an array of stuffed animals. Stuffed animals were used as
play and communication medium between the child and the counsellor (Figure 3). Explanation
was given to the patients that the interpretation of their selection would usually unraveled deep
seated issues. Those issues were not easily obtained by typical verbal therapy (Figure 4). Children
often found relief in being able to share their experience and emotions that were extremely trau-
matic. Children who participated in the Art or Play Therapy were rewarded with candy (Figure 5).
Figure 3: The stuffed animals used as play and communication medium between child and the
counselor
Figure 4: The stuffed animals used in play therapy
Figure 5: Candy offered to participating children

Child 1: A 12 year old boy was asked which one of the stuffed animals that he liked the most and
why. He picked up a grey koala because it reminded him of his silly brother.
Interpretation: A koala is a wild animal, thus it represents power and strength that he may see
in his brother.
Child 2: A 10 year old girl was asked which of the stuffed animals made her happy and why?
She chose the cat that had big eyes and head because she loved cats and they always made her
smile. She had a cat at home and was not sure where it was after her family was evacuated from
their home during the flood. She also said that thinking of her cat made her worry.
Interpretation: The girl was not only able to identify the animal that made her happy but she
managed to convey a very traumatic event that she experienced during the flood; she had lost her
cat and it worried her that the cat may have drowned. On the other hand, the cat is a domestic
animal that represents family and vulnerability. The child may be feeling vulnerable from losing
the cat, which is also a part of her family.
Child 3: A 5 year old boy was asked to choose the animal that represents him and why?
He chose the tiger with the long, large tail because the tiger is a fierce animal like him and he
loves the large tail because it looked funny.
Interpretation: The tiger is a wild animal that represents aggression, anger and survival. The
child went through a traumatic experience with the flood but was coping with it well.
Child 4: A 4 year old boy was asked to choose an animal that he loved the most.
He chose a black cat with large teeth but did not give any reasons for it.
Interpretation: The cat represents dependency; relations or family and the large teeth may
represent anger or aggression. The child may have an issue of anger with one of his family
members or relations.
Child 5: A 9 year old girl was asked to choose a toy that she liked the most and why.
She chose the panda because it was very cute and cuddly.
Interpretation: The panda is a wild animal thus it represents power and strength. She needed
someone friendly whom she would feel safe with and count on. She loves to hug which indicates
the presence of a loving character and very likely an experienced caring caretaker(s) in her life.

Our observation of children experiencing the Play Therapy:
1. Encouraged the children to talk about the traumatizing circumstances events that they had
experienced in their lives especially during the flood devastation.
2. The children became more playful and enjoyed the time they spent with their peers and
the counsellors in therapy.
3. They became comfortable in expressing their anxieties or problems to the counsellors
because they trusted them.
4. Encouraged creativity in role-playing with the toys.
5. The children enjoyed themselves and the therapy served as a distraction and a form of
activity for them to enjoy while in shelter.
Discussion devastating flood, so that they were more

Psychological engagement should not be playful and enjoyed the time they spent with
forgotten as disaster victims are often mentally their peers and the counsellors. We observed
troubled. Without close observation, this that they became comfortable at expressing
aspect may be missed. Counsellors can play their anxieties or problems to the counsellors
effective roles by engaging victims in activities because they trusted them. It also encouraged
such as play and art therapy which can help creativity in role-playing with the toys.
them express themselves. Mental health effects in disaster vary from
Through Art Therapy, the children were able population to population. A lot of factors
to convey their traumatizing experience that may affect the population and more studies
may not have emerged with conventional are required to understand the state of mind
therapy. They enjoyed themselves and of a displaced population. Wind et al (2014)
the therapy served as a distraction and an explained that the types of disaster and
enjoyable activity while housed in a temporary individual event characteristics also affect
shelter. We observed that they emerged survivors emotional and cognitive reactions.
happier after therapy. Art Therapy promoted Grimm et al (2012) compared survivors
communication skills between children when perceived post- and peri-traumatic emotional
they interacted amongst themselves to explain and cognitive reactions across different types
their drawings. Some of the children attended of disasters. The authors found that there
therapy repeatedly. were differences in perceived post- and peri-
Play Therapy effectively encouraged the traumatic emotional and cognitive reactions
children to talk about the traumatizing with different types of disasters.
events that they had experienced during the
The psychological effects of disaster on

victims vary depending on fatigue and distress mechanism for distributing donations. These
in handling disaster situation. Fatigue and factors contributed to a decrease in the negative
psychological distress also correlated with psychological effect on the community.
workload. During the Japanese Earthquake in Social background and character too may
2011, Kitamura et al (2013) found that two- be suppressive in psychiatric disorders. The
thirds of the employees suffered fatigue and people at this relief center were positive
psychological distress, which were significantly and co-operative. They had a strong culture
correlated with workload but inversely of helping each other in non-disaster times
correlated with emotional stability, personality through their village committee. In weddings
traits and psychological resilience. Together and deaths, the villagers would unite cooperate
with substantial workload, individual differences to help each other. Perhaps this may explain
in emotional stability and, to a lesser degree, the cohesion in this community. A culture of
in resilience were found to have an impact helping leads to greater community resilience
on perceived fatigue. These individual factors and indirectly less psychiatric disorders such as
should be considered as potential mediators of acute stress disorder or post-traumatic stress
distress among local government employees disorders (PTSD). Ishikawa et al (2013) studied
responding to disasters. PTSD in flood victims and found that PTSD
Intangible losses have an important and depression were less common in Tibetan
psychological effect on community culture than in other cultures. The social
redevelopment and recovery from trauma. background and temperamental characteristics
Hawkins and Maurer (2010) examined the of the Tibetan culture may play a suppressive
physical and psychological loss of home and role in psychiatric disorders.
community following Hurricane Katrina. It was Following a disaster, the communitys daily
found that a breakdown in their social fabric activities would be disrupted. Some social
at the individual and structural or community change is bound to take place. Henry (2010)
levels contributed to a sense of community stated that for some time, disaster studies
loss and social displacement, disrupting their had looked for social change and mostly found
notion of safety, routine and trust in a stable continuity. He argued that shifting the focus
environment. In our experience, we observed from investigating social change to documenting
a somewhat resilient community at this relief continuity may enhance the understanding and
center in which the victims co-operated closely planning of post-disaster situations especially
by taking turns to cook meals and helping each in industrialized societies like the United States.
other. The teachers in the school too showed The analysis of long-term recovery plans,
exemplary attitude by establishing a systematic along with field observations and interviews

with evacuees, suggest that despite the well- the ability to recognize what was happening
documented emergence of conflict in post- varied in different disasters the survivors
Katrina New Orleans, the likelihood of social responses tended to be more universal across
change appears limited. Once the victims in events, and most often were adaptive and
Temerloh were adapted to the changes in their unselfish. Several peri-traumatic factors related
environment they would find continuity in their to current levels of post-traumatic were also
daily activities. identified. With multiple aspects potentially
Sleep problems, pain or suicidal thoughts affecting them, the psychological state of the
are directly related to adverse mental health victims should be addressed.
outcomes. Boscarino et al (2014) evaluated At the relief center, no suicidal behavior was
mental health outcomes in the New Jersey observed. Nevertheless, further research is
shore residents with health impairments and needed to assess the health status of affected
disabilities after Hurricane Sandy. The authors residents with serious health impairments over
concluded that having physical impairments time following disasters. Kolves et al (2013)
and health conditions were not directly related showed different trends in suicide mortality
to adverse mental health outcomes following following natural disasters. Nevertheless,
Sandy, but having sleep problems, pain, or there seemed to be a drop in non-fatal suicidal
suicidal thoughts were. Nevertheless, we behavior in the initial post-disaster period,
observed that many of the evacuees did not which has been referred to as the honeymoon
get good sleep and some of them had body phase. A delayed increase in suicidal behaviour
aches due to the lack of a proper mattress. has been reported in some studies. However,
Nevertheless, none of them had suicidal other factors that raise the risk of suicidal
thoughts. behaviour after natural disasters have been
The behavior response to a disaster would be reported, such as previous and current mental
an interesting subject to study. The responses health problems. Furthermore, contributing
are more universal, mostly adaptive and factor, such as economic status, should also
unselfish as most need to survive. The victims be considered. Mental health and suicidal
at this relief center adapted to sleeping on mats behaviour should continue to be monitored for
in school classrooms. They took responsibility several years after a disaster.
for the meals and the cleanliness of the place.
Conclusions
Grimm et al (2014) conducted interviews in
Play and art therapy are useful modes of
seven countries to explore survivors emotional,
mental therapy for children affected by disaster.
behavioural, and cognitive responses to
Psychological engagement should not be
disasters. While the environmental cues and
neglected as disaster victims are often mentally
troubled. Without attention and observation, this status in evacuees following a disaster and
this aspect may be missed. Counsellors can play the effectiveness of our intervention need to
effective roles by engaging with victim in play be done.
and art activity therapy which can help them
Acknowledgements
express themselves. Psychological engagement
We would like to acknowledge the Director
would render our response more holistic
General of Health, Malaysia for permission to
and enable the integration of psychological
publish this article. We also would like to thank
management into the disaster response. This
to all who directly and indirectly involved in this
effort is a start in the cognizance of evacuees
activity.
mental status. However, more studies to assess
References 5. Annas Toy Depot: The Symbolic Mean-

1. La, Motte, J. (2011). Psychotherapeutic ing of Toys. (cited : 14 May 2015). Avail-
Techniques and Play Therapy with Chil- able from: http://www.annastoydepot.
dren Who Experienced Trauma: A Re- com/index.php?main_page=page&id=7.
view of The Literature Bridgewater State 6. Wind, T.R., Joshi, P.C., Kleber, R.J., Kom-
University Undergraduate Review 2011, proe, I.H. (2014). The effect of the post
7, 15. disaster context on the assessment of
2. Art Therapy: Color Meanings and individual mental health scores. Am J
Symbolism. (cited : 14 May 2015). Orthopsychiatry, 84(2), 134-141.
Available from: http://www.artther- 7. Grimm, A., Hulse, L., Preiss, M., Schmidt,
apyblog.com/online/color-meanings- S. (2012). Post- and peritraumatic stress
symbolism/#colormeanings. in disaster survivors: an explorative
3. McKinney, Clark, K. (2015). Play Thera- study about the influence of individual
py: A Comprehensive Guide to Theory and event characteristics across differ-
and Practice The Gillford Press. New ent types of disasters. Eur J Psychotrau-
York. matol, 3.
4. Creative Counselling 101: Interpret 8. Kitamura, H., Shindo, M., Tachibana, A.,
Drawings for Play Therapy and Art Honma, H., Someya, T. (2013). Person-
Counselling. (cited : 14 May 2015). ality and resilience associated with per-
Available from: http://www.creative- ceived fatigue of local government em-
counseling101.com/interpret-drawings- ployees responding to disasters. J Occup
art-counseling.html. Health, 55(1), 1-5.

9. Hawkins, R.L., Maurer, K. (2011). You fix 14. Grimm, A., Hulse, L., Preiss, M., Schmidt,
my community, you have fixed my life: S. (2014). Behavioural, emotional, and
the disruption and rebuilding of ontolog- cognitive responses in European disas-
ical security in New Orleans. Disasters, ters: results of survivor interviews. Di-
35 (1), 143-159. sasters, 38(1), 62-83.
10. Ishikawa, M., Yamamoto, N., Yamanaka, 15. Apisarnthanarak, A., Khawcharoenporn,
G., Suwa, K., Nakajima, S., Hozo, R., T., Woeltje, K.F., Warren, D.K. (2013).
Norboo, T., Okumiya, K,. Matsubayashi, Hospital flood preparedness and flood-
K., Otsuka, K. (2013). Disaster-related related psychological consequences in
psychiatric disorders among survivors of 15 provinces in central Thailand after
flooding in Ladakh, India. Int J Soc Psy- implementation of a national guideline.
chiatry, 59(5), 468-473. Infect Control Hosp Epidemiol, 34(6),
11. Henry, J. (2011). Continuity, social 655-6.
change and Katrina. Disasters, 35(1), 16. Butterly, S.J., Indrajith, M., Garrahy, P.,
220-242. Ng, A.C., Gould, P.A., Wang, W.Y. (2013).
12. Boscarino, J.A, Hoffman, S.N., Adams, Stress-induced takotsubo cardiomyopa-
R.E., Figley, C.R., Solhkhah, R. (2014). thy in survivors of the 2011 Queensland
Mental health outcomes among vulner- floods. Med J Aust. 198(2), 109-10.
able residents after Hurricane Sandy: 17. Bhamani, A., Sobani, Z.A., Baqir, M.,
implications for disaster research and Bham, N.S., Beg, M.A., Fistein, E. (2012).
planning. Am J Disaster Med, 9(2), 107- Mental health in the wake of flooding in
120. Pakistan: an ongoing humanitarian cri-
13. Klves, K., Klves, K.E., De, Leo, D. sis. J Coll Physicians Surg Pak, 22(1),
(2013). Natural disasters and suicidal 66-68.
behaviours: a systematic literature re-
view. J Affect Disord, 146(1), 1-14.

Public Health Challenges During Flood Disaster: Managing Food Poisoning
Outbreak In Pusat Pemindahan MRSM Pasir Salak Perak Tengah District
January 2015
Nor Samsiah AR, Ariza AR
Perak State Health Department
Abstract
An outbreak of food poisoning occurred on 10th January 2015 in Pusat Pemindahan (PP) MRSM
Pasir Salak in the Perak Tengah district during the flood of January 2015. PP MRSM Pasir Salak
was the biggest evacuation centre sheltering about 1061 flood victims. It involved fifty victims
which treated as outpatient. A case control study was conducted to define the epidemiological
characteristics of the outbreak and to determine the source of infection. The prominent clinical
features were diarrhoea (100%), abdominal pain (100%), vomiting (14%) and giddiness (4%).
None of them complained of fever. The onset of symptom occurred 5-14 hours after the suspected
meals and median incubation period was at 8 hours. The possible sources of the outbreak were nasi
minyak (OR=30.00, 95% CI: 9.18, 105.24, p<0.001 food attack rate 71%) and ayam masak merah
(OR=96.00, 95% CI: 18.88, 658.48, p<0.001, food attack rate 78%). However, microbiological
investigations of rectal and stool culture didnt isolate any pathogenic organism. The food was
cooked by 2 teams of volunteers, team A and B. From our investigations, the food poisoning was
associated with food prepared by team A which involved 14 temporary food handlers. All of them
had been vaccinated with Ty2 (Typhoid-ThyphimVI) and 10 of them were trained in the food
handling. The most probable contributing factor identified was related to the poor food safety
technique practiced by food handlers. The cleanliness rate on 9th January 2015 was 79%. The
outbreak ended on 11th January 2015. All the victims received outpatient treatment, there were no
case hospitalisation or case fatalities recorded. Nevertheless this experience highlighted that the
management of an outbreak in a disaster setting was a challenge in terms of case investigation,
case handling and implementing prompt and adequate prevention control measures.
Keywords: food poisoning, outbreak, public health challenges, flood disaster
Introduction
Disaster-affected communities are particularly vulnerable to communicable diseases as its
immediate consequences reduce resistance to disease because of malnutrition, stress, fatigue and
when post-disaster living conditions are unsanitary. (1).The five most common causes of death in
emergencies and disasters are diarrhoea, acute respiratory infection, measles, malnutrition and,

in endemic zones, malaria. (1). was nasi minyak, nasi arab, ayam masak
A flood causes damage to property, farms, merah, jelatah, nasi putih and sirap. The food
disrupts agriculture practise ad business and was cooked by team A which comprised 14
increases the risk of communicable diseases temporary food handlers and it was served to
especially waterborne and vector borne 554 flood victims.
diseases. The length of time that people This study describes the epidemiological
spend in temporary shelters is an important characteristics of the outbreak, including
determinant of the risk of disease transmission. the source of infection and the challenges of
Poor hygienic practice at the temporary shelter managing an outbreak during a flood.
is typical of a situation that may cause epidemic Materials and Methods
outbreaks of infectious diseases. This report The Epidemiological investigation
describes how Pejabat Kesihatan Daerah Perak The investigation began on 10th January 2015
Tengah managed a food poisoning outbreak and ended the next day. A case control study
during the major flood of 2015 as well as the was done. There were two groups involved
related challenges. in this study; a control group of 65 victims
MRSM Pasir Salak, a relief centre was the biggest who did consume the same food prepared
of 19 relief centres housing 1061 victims were by the food handlers and the affected group
stayed who were provided with basic facilities of 50 victims which fulfilled the criteria of a
to ensure their survival. Food was provided by case; having eaten food prepared by the food
the organisation in charge, cooking was done handlers and developed signs and symptoms
by two teams, team A and B. of food poisoning.
10th January 2015, was the last day that team The source of the infection was identified as
A prepared food for the victims. Unfortunately the menu served by team A food handlers and
on that day, 50 flood victims complained of it was served to flood victims staying at the
abdominal pain and diarrhoea and some also MRSM Pasir Salak hall. The Rapid Response
complained of vomiting and giddiness. All of Team (RRT) was activated and the investigation
them were diagnosed with food poisoning and initiated.
treated as outpatients. Notification of food The cases and controls were directly interviewed
poisoning was done on 11th January 2015 at and information regarding symptoms, illness
12am. Investigations began at 9.00 am on the onset, the food taken and treatment was
morning of 11th January 2015. treatment was collected.
The onset of the disease 5 hours after victims The analysis was done using SPSS software
had had their lunch which was at 5pm 10th version 17.0 (SPSS inc; Illinois) to determine
January 2015. The food served for lunch and the food that most probably caused the

illness. The Microbiological Investigations
Environmental Investigation A total of 10 samples was taken from
Team A premises were assessed by food symptomatic victims for investigations (9 rectal
control team. This team was from Perak swabs and 1 stool sample). The rectal swab
Tengah district food safety and quality unit and stool samples were sent for culture and
and they will do the environmental assessment sensitivity. However no food holding sample
included kitchen condition, cooking area, type was sent for investigation because there was
of water supply, water flow and drainage. They no leftover food available. All the samples were
were using a risk based form KKM-PPKM-2/09 sent to the Public Health Laboratory, Ministry
as the assessment tools. However assessment of Health, Ipoh, Perak for analysis.
in method of food preparation was not done Results

because the premise operation was closed after Epidemiological investigation
the onset of the outbreak. The assessment 554 victims were exposed to food poisoning.
of 14 temporary food handlers was done by However 50 cases and 65 controls were
interviewing to determine whether they had identified. Of the 50 cases, 58% were female
Results health screening, immunization
undergone and 42% were male. All of them were treated
Epidemiological investigation
for typhoid fever (Typhoid-ThyphimVI) or had as outpatients and no fatality was recorded.
554 victims were exposed to food poisoning. However 50 cases and 65 controls were
attended to any food handling course. Majority of the cases were aged between 18-
identified. Of the 50 cases, 58% were female and 42% were male. All of them were treated
55 years old.
as outpatients and no fatality was recorded. Majority of the cases were aged between 18-55
years old.
Number of cases
16
14
onset
12

10
last onset
8

6
4
2
0
12pm 2pm 4pm 6pm 8pm 10pm 12am 2am 4am 6am
Time
Figure 1: Epidemic curve of distribution of 50 cases identified by onset time of illness.
88 JOURNAL
Figure 1 shows epidemic OF of
curve HEALTH MANAGEMENT
50 cases distributed- by
SPECIAL
onsetEDITION VOL II: It
time of illness. DECEMBER
displayed2015
a
point source pattern. The first onset of illness was at 5 hours and the onset time was between
5-13 hours. The median incubation period was 7 hours. The acute symptoms lasted for 18
Figure 1 shows epidemic curve of 50 cases distributed by onset time of illness. It displayed a point
source pattern. The first onset of illness was at 5 hours and the onset time was between 5-13
hours. The median incubation period was 7 hours. The acute symptoms lasted for 18 hours and
all cases recovered within a week.
Clinical Manifestation
Figure 2 shows the clinical manifestation of the cases in the outbreak. The main symptoms were
abdominal pain and diarrhoea. Among of the 50 cases 100% of them had both main symptoms,
followed by 7 victims (14%) had vomiting and 2 victims had giddiness (4%). No fever was
reported.
Figure 2: Clinical Presentation Among The Affected Cases
Food attack rate

The menu for breakfast was nasi lemak and teh O, for lunch was nasi minyak, nasik arab, ayam
masak merah, jelatah, and air sirap and for dinner was nasi putih, kurma ayam, sayur kobis and
air sirap.
The highest food attack rates were nasi minyak and ayam masak merah (75% and 78.7%
respectively). Nasi minyak (OR=30, 95% CI: 10.0933 to 89.1680) and ayam masak merah
(OR=96, 95% CI: 20.5898 to 447.5997) showed significant association with illness (p>0.005).
From the interview feedback, majority of the victims claimed nasi minyak and ayam masak merah
were undercooked and smelt bad.

Environmental Investigations handlers participated in food preparation.
The operation of Team As premises ended on 100% had been vaccinated with typhim (Ty2)
10th January 2015. However these premises and 71.4% had attended a course for food
were assessed by the food control team every handlers.
3 days and the rating ranged between 71-85%. The 9th January 2015 assessment form showed
The rating was done by using risk base form that the evaluation of cooking utensils rating
KKM-PPKM-2/09. The last assessment was was moderate (score 7/10). However other
done on 9th January 2015. At that assessment facilities such as the area the hand washing
the rating for overall safety and cleanliness of and the garbage bin were not limited. The
the premise was 79%. toilets were clean and in good condition and
Team A comprised 30 food handlers. However they used treated water for preparing the food.
on 10th January 2015, only 14 temporary food
Microbiological Investigations
The laboratory analysis of rectal and stool samples is shown in table 2. Suspected organisms
were Staphylococcus aureus, Salmonella, E. Coli and Barcillus Cereus. However, no pathogenic
organisms were isolated.
Table 1: Laboratory analysis of rectal and stool samples
No Samples No of sample Result
1. Rectal swab 9 Pathogenic organism was not isolated
2. Stool 1 Pathogenic organism was not isolated
Discussion a flood (incidence rate ratio = 1.29, 95%

An epidemiological study was done on the confidence interval: 1.06, 1.58), and this was
food poisoning outbreak resulting from meals more pronounced among persons with potential
eaten on 10th January 2015 that is during the sensitivity to infectious gastrointestinal illness.
flood in Perak Tengah last year. Fifty cases (Wade, Sandhu et al. 2004).
were identified which comprised 9% of the In general, children had a higher relative risk
victims staying at MRSM Pasir Salak Evacuation of gastrointestinal symptoms for most types
Centre. No hospitalization or case fatality was of flood exposure, which is consistent with
recorded. their greater susceptibility to gastrointestinal
The management of a food poisoning outbreak pathogens. This finding may also be related
during a flood is the most challenging issue to a poorer hygiene among children following
because a study has shown that the incidence exposure to floodwater and flood-contaminated
of gastrointestinal symptoms increases during items. However this study showed that the
majority of cases were aged between 18 and the dishes were undercooked and smelt bad.
55 years. Therefore the possible causes of the food
Flooding accounts for about 40% of all natural poisoning are poor cooking technique and a
disasters worldwide and causes about half of prolonged holding time that lead to a high risk
all deaths. Every year, for the past two decades of food contamination.
more than 400 million people on average have Food poisoning is caused by contamination
been directly affected by floods. The health which can occur at various points of the
impacts on and response to the 2010 flood that preparation process and these have been
occurred in Pakistan (Shabir 2013) were similar classified into 4 categories. Contamination
to those in Perak Tengah. Majority of the land during storage, transportation and serving
was inundated with water which damaged of food was found to account for 47.8% of
the houses, educational and health facilities, the entire food poisoning event, followed by
communication networks, power plants and general contamination 24.6%, contamination
grids, irrigation channels, agricultural land and during cooking/secondary to processing
livestock. technique 15.0% and contamination of raw
This is the challenge for the public health team materials 12.6%.
managing an outbreak during a flood. The Most of the points of contamination identified
damage to health facilities and communication were related to poor food safety practices
network limits the ability for the public health among the food handlers such as poor personal
team to manage the outbreak following the hygiene, inappropriate holding time and
standard operating procedure. In this study the inappropriate holding temperature. The unsafe
transmission was interrupted by terminating food safety practices among the food handlers
team As food preparation operation. In could be due to their lack of knowledge on
addition, the quick response of the investigation food safety (Malaysias Health 2008).
team and its effort at health education of to This poses another challenge to public health
the victims helped to control the outbreak. in managing food poisoning outbreaks during
In this study 14 temporary food handlers were a disaster is their attitude during preparing
involved in the preparation of the food. 100% the foods. Even though majority of the food
had been vaccinated with Ty2 and 71% of them handlers were trained in handling food but not
had attended a food handling course. However all of them practice it correctly. Interestingly,
investigation showed that nasi minyak and all of them were volunteers that they were also
ayam masak merah were the foods associated victims of the flood disaster. An assessment
with the infection. No pathogenic organism of the health impacts of the 2011 summer
was isolated but majority of the victims claimed floods in Brisbane, Australia was done for

residents whose households were directly Conclusion
affected by flooding. The assessment showed The food poisoning outbreak on 10th January
flood disaster had significant impact on the 2015 that occurred at the MRSM Pasir Salak
physical and psychosocial health of residents. settlement centre was mainly due to the poor
(Alderman, Turner et al. 2013). So in managing cooking technique and the prolonged holding
an outbreak during a disaster, the public time that lead to contamination of the food.
health team must not forget the physical and No pathogenic organism was isolated from
psychological status of the victims. samples taken from the victims. The water
In this regard, health education and counselling supply was safe and pathogen-free. Interviews
sessions were arranged for all the victims with the victims revealed that majority of the
including food handlers. Victims that showed victims thought the meals were undercooked
symptoms of depression or anxiety were and smelt bad. Even though majority of the
referred to a medical officer and a psychiatrist. food handlers were trained in food handling
Furthermore disaster victims were constantly to not all of them practiced it correctly. The
trained and made aware of the importance of lack of knowledge and their attitude to food
proper food handling technique, hand hygiene, preparation was one of the issues that need
information regarding infection control and further examination to prevent food borne
other health promotion activities. disease. However the counselling sessions and
Lastly, an issue that surfaced in previous health education helped the public health team
floods was the importance of a clean water in their effort to control and stop the outbreak.
supply. A study done during severe flooding
Acknowledgement
in the Mid-Western United States in 2001 and
We would like to acknowledge the Director
showed a marked deterioration in water quality
General of Health, Malaysia for permission to
(Wade, Sandhu et al. 2004). However standard
publish this article. We would also like to thank
precautions had been taken to monitor water
the PKD Perak Tengah Inspectorate staff for
supply quality. Hence, in this study, water
their support in the writing of this article.
supplied to the centre was safe and pathogen-
free from pathogen and not the cause of food
poisoning.

References
1. World Health Organization. Control of 5. Connolly, M. A. (2005). Communicable
communicable diseases and prevention of disease control in emergencies: a field
epidemics (2002). (cited : 15 May 2015). manual. World Health Organization.
Available from: http://www.who.int/water_ 6. Lowe, D., et al. (2013). Factors increasing
sanitation_health/hygiene/emergencies/ vulnerability to health effects before, during
em2002chap11.pdf and after floods. International journal of
2. Shabir, O. (2013). A summary case report environmental research and public health,
on the health impacts and response to the 10(12), 7015-7067.
Pakistan floods of 2010. PLoS currents, 5. 7. Warraich, H., et al. (2011). Floods in
3. Alderman, K., et al. (2013). Assessment Pakistan: a public health crisis. Bulletin
of the health impacts of the 2011 summer of the World Health Organization , 89(3),
floods in Brisbane. Disaster Med Public 236-237.
Health Prep, 7(4), 380-386. 8. Ministry of Health (2008). Food Poisoning
4. Wade, T. J., et al. (2004). Did a severe flood In Malaysia 2008 - Issues And Challenges.
in the Midwest cause an increase in the Kuala Lumpur.
incidence of gastrointestinal symptoms?
Am J Epidemiol, 159(4), 398-405.

Journal of Health Management Special Edition Vol II December 2015

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Journal of Health Management Special Edition Vol II December 2015

Uploaded by

Copyright:

Available Formats

JOURNAL OF HEALTH MANAGEMENT

SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 1

Dr. Shahnaz Binti Murad

Dr. Nor Izzah Binti Hj Ahmad Shauki

Dr. Nor Filzatun Binti Borhan

Dr. Pangie anak Bakit

2 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

Rapid Assessment Of Floods In Kelantan: Information For Action 5

Saraswathi BR1, Fadzilah K2, Rosemawati A2

Post Flood Delivery Of Humanitarian Assistance To 13

Bugs In The Water: A Review Of Effects Of Floods 20

Institute For Health Management - Transit Center For 38

Lessons From The Remediation Of A Flood-Damaged Health Clinic 49

Alzamani MI, Malathy R, Hafiz SM, Abu HAA Emergency Department,

Post Deployment Activities And Challenges In Crisis 62

Managing Child Flood Victim by Psychological 75

Public Health Challenges During Flood Disaster: Managing 86

Nor Samsiah AR, Ariza AR

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 3

Key words: floods, information, disaster

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 5

threats, take immediate measures where possible to street interviews

of potential health threats. the health centres, at the evacuation

Table 1: Summary of Health facility and evacuation centres visited

District Health facility visited Evacuation centre (EC) Date of

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 7

Scope Summary of Findings Our recommendation Action taken by

CPRC 1. In some districts the 1. CPRC to be located 1. Sourcing of gen sets by

8 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

Human Many health facilities 1. Deploy more staff from 1.

Medical 1. Disinfection was 1. Suggest providing 1. The medical supplies

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 9

Discussion and Terengganu had reached dangerous levels.

and insured loss and it is stated there that eight inaccessible.

10 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 11

health response team with a vehicle such as a bus

12 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 13

Photo 2: On the way to Kuala Betis via off-road access

Photo 3: Medical Team operating under a tent

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 15

Table 1: Distribution of Cases Managed at both Kuala Betis and Tohoi

Location URTI Acute AGE Herpes Fungal Goitre Total

Kuala Betis 148 5 5 1 5 0 174

Tohoi 238 25 20 0 18 1 302

16 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

2. Buckland, J., Rahman, M. (1999). Community- 5. Buajaroen, H. (2013). Management of health

18 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 19

Clinical Research Center, Duchess of Kent Hospital

Keywords: pathogen, bioecological, waterborne, flood, worker

Introduction on waterborne diseases and water-related diseases

20 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 21

22 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 23

24 JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015

JOURNAL OF HEALTH MANAGEMENT - SPECIAL EDITION VOL II: DECEMBER 2015 25

Pathogen Hosts Mode of transmission Clinical features and

1 Vibrio cholera5 1. Zooplan 1. Shellfish consumption 1. Acute and intense diarrhoea

2 S. typhi and Various 1. Oro-faecal 1. Myalgia

3 Burkholderia 1. Sheep 1. Entry via breaks in skin 1. Soft tissue abscess