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4.

1 Earthquake and Tsunami (I)


What is an earthquake?

An earthquake is a geophysical disaster that is defined as the


shaking and displacement of ground due to seismic waves. It is
the result of a sudden release of energy stored in the Earths
crust. During an earthquake, individuals at the Earths surface
near the epicenter can feel the shaking or displacement of the
ground (CRED, 2009). A tsunami is a consequence of a specific
subtype of earthquake which originates beneath the ocean floor.
A tsunami produces seismic sea waves, which approach the
shoreline. The health impact of a tsunami is similar to that of a
flash flood, which will be discussed in Section 4.8.
How is it reported?

The Richter scale is the most commonly used scale to report the
strength or the amount of energy released by an earthquake. It is
calculated from the amplitude of the largest seismic wave
recorded for a given earthquake and reported on a logarithmic
scale. For each whole number increment of the Richter scale
score, the strength of the earthquake increases ten times. A
level-8 earthquake on the Richter scale is ten times stronger than
a level-7 earthquake. However, the Richter scale itself does not
reflect the severity of impact upon human populations.
The Mercalli scale on the other hand, indicates the amount of
damage and destruction from an earthquake. The scale has no
mathematical basis and is composed of 12 levels of increasing
intensity that ranges from imperceptible shaking to catastrophic
destruction (U.S. Geological Survey, 2014).
What are the known factors associated with adverse health outcomes?

In general, the factors associated with the adverse health


outcomes of an earthquake include: the level of seismic hazard,
population density and the concentration of buildings; the higher
the population and building density, the greater the damage.
Settlements located in earthquake prone regions, or seismic
belts, are at a higher risk of earthquakes. The map below

illustrates where several tectonic plates meet and the resulting


high seismic activity. It is also observed that the timing of an
earthquake may also relate to the magnitude of damage it brings
to the community. More casualties are expected if an earthquake
occurs at midnight since people are not able to react immediately
during sleep (Chou et al., 2004).
What are the direct health impacts of an earthquake?

The major health impacts of an earthquake stem from the


collapse of buildings. Falling debris and entrapment may directly
cause trauma, crush injuries and fractures to victims. Cuts and
bruises are expected for most of the patients presented during
the first week. Other associated health risks of entrapment
include: hypoxia (lack of oxygen), hypothermia (especially during
winter) and electrocution. Fall of debris may also cause dust
inhalation, which in turn may trigger acute respiratory distress.
What are the response needs?

Search and rescue is fundamental to the immediate earthquake


response. Medical services are also needed to manage the
casualties caused by the earthquake. Since earthquakes bring
huge destruction and damage to buildings, management of
homeless populations is also crucial.
A high volume of injuries and fractures are expected in the first
weeks after an earthquake, therefore orthopaedic surgeons and
anesthesiologists are vital. Nephrologists or physicians
specialising in renal care are also needed at the initial phase of
disaster relief as patients with crush injuries may develop acute
kidney failure. In Haiti, after the earthquake in January 2010,
kidney failure became one of the most urgent public health
concerns (Portilla et al., 2010).

4.4 Volcanic Eruption (I)


What is a volcanic eruption?
A volcanic eruption is the transport of magma and/or gases to the
Earth's surface, accompanied by tremors of the ground, and
interactions of magma and water (e.g. groundwater, crater lakes)
below the Earth's surface. Depending on the composition of the
magma, eruptions can be explosive and effusive and result in
variations of rock fall, ash fall, lava streams, pyroclastic flows,
emission of gases etc (CRED, 2009). Since the 18th Century,
there have been more than 270,000 volcano-related fatalities,
with two to four fatal eruptions per year. Many volcanic areas are
densely populated. In 1990, nearly 10% of the global population

lived within 100 kilometres of an active volcano. However,


volcanic eruptions also affect populations that live hundreds of
kilometres away due to the airborne dispersion of gases and ash
(Hansell AL et al, 2006; Ciotonne GR et al, 2006).

What are the known risk factors associated with adverse health outcomes?

The activity level of a volcano, such as the frequency of emissions


of harmful gases and volcanic mudflows between eruptions is a
key factor that indicates the future behavior of the volcano and
the current impact it has on neighboring communities. The
population density and long-term exposure to the hazard means
that a good early warning system and evacuation plans are vital
to mitigating the impact of volcanic eruptions. Of note, most of
the active volcanoes in the 21st century are situated in highly
dense urban areas, such as Tokyo, Mexico City, Jakarta, and
Manila.
The Smithsonian Global Volcanism Program (GVP) is a
means of assessing the hazard risk of a volcano by scoring
eruption characteristics such as type of lava flow, maximum
output capacity, eruption history, volume of surrounding glaciers

and snowcaps etc. There are currently no standardised tools to


estimate the population risk from being exposed to volcanic
activities. Countries typically classify volcanoes into high,
medium and low risk based on the volcanoes eruption history,
number of people affected and potential economic losses.
What are the health impacts of volcanic eruption?

Volcanic eruptions result in the highest mortality rates relative to


injuries when compared with other types of natural disasters. The
high mortality rate is attributable to hazards specifically related to
volcanic eruptions:
1. Pyroclastic flows, which are defined as a mass of hot
volcanic ash, lava fragments, and gases that erupt from a
volcano and move rapidly down its slope, at speeds of up to
a few hundred miles per hour, can result in high level of
deaths, fatal injuries, and severe burns (Jay, 2006). The
content emitted from a pyroclastic flow is called tephra,
which is any fragmentary material originally emitted from
volcanoes (Hansell AL et al, 2006). A pyroclastic flow can
travel more than 300 kilometers per hour and may reach
temperature as high as 600 to 900C.
2. Ash, are tephra fragments that are less than 2 mm in size.
Ashfall that follows an eruption, particularly wet ash, can
damage buildings and contaminate water sources. Heavy
ashfall can cloud the sky leaving people living in complete
darkness during the day. The free silica and high iron
content irritates the upper and lower respiratory airways,
eyes, and skin. High levels of airborne ash (daily average
total suspended particles (TSP) of 3,000-33,000 g/m3) can
result in a 2-3 fold increase in hospital admissions and a 3-5
fold increase in emergency room visits for respiratory
related illnesses (Baxter et al., 1983).
3. Lava bombs or blocks are tephra fragments that are
between 2 and 64-mm in size (Jay, 2006). The ejection of
lava bombs can cause severe head injuries, burns,
and blunt trauma.

4. Volcanic gases, such as sulfur dioxide, carbon dioxide,


hydrogen fluoride, also impose significant health hazards.
Sulfur dioxide can be irritating to respiratory airways, eyes,
and skin. Hydrogen fluoride can also generate the same
effect, but when it is ingested by animals, it will produce
fluorosis and death of the animal. Breathing carbon dioxide
with a concentration greater than 20% can cause
unconsciousness and asphyxiation (Baxter, 1990).
What are the responses needed?

The important health outcomes to consider in responding to the


health needs after volcanic eruptions are providing health care for
burns, injuries, inhalation and respiratory trauma from exposure
to ash and toxic gases.

4.6 Tropical Cyclone (Cyclone/Hurricane/Typhoon) (I)


What is a tropical cyclone?

A tropical cyclone is a type of meteorological disaster,


characterised by low pressure, spiral rain bands and strong winds
of 64 knots or more. Tropical cyclones in the Indian Ocean and
South Pacific are called cyclones, those in the western Atlantic
and eastern Pacific are called hurricanes, and those in the
Western Pacific are called typhoons (CRED, 2009). On the other
hand,storms refers to a wider variety of disturbances in the
atmosphere often accompanied by strong wind, rain, snow,
thunder and lightning, hail, flying sand or dust.
Effects of a tropical cyclone

Tropical cyclones usually bring heavy rain, strong winds, or even


large storm surges. Mudslides may occur near mountainous areas
due to heavy rain, while tropical cyclones falling on land may
spawn tornadoes that bring further health and socio-economic
impacts to the community.

How is it reported?

Cyclone scales vary according to the oceanic basin and the


maximum sustained winds as recommended by the World
Meteorological Organization (WMO).
Region

Scale

Atlantic & East Pacific

Saffir-Simpson Hurricane Scale

Western Pacific

RSMC Tokyos Tropical Cyclone Intensity Scale

North Indian Ocean

India Meteorological Department Tropical Cyclone


Intensity Scale

South-Western Indian
Ocean

Southwest Indian Ocean Tropical Cyclone Intensity Scale

What are the known risk factors associated with adverse health outcomes?

Tropical cyclones affect populations settled in low-lying coastal


areas. Poor building designs, lack of early warning systems and
disaster preparedness make people vulnerable to the impact of
tropical cyclones. Insufficient time for evacuation and inaccurate
perception of risks and safety are also important risk factors.
What are the direct health impacts of a cyclone?

The most common health conditions observed after a cyclone are


minor injuries, including lacerations, blunt trauma and puncture
wounds caused by collapsed buildings and falling debris. 80% of
cyclone related injuries are found in the lower limbs (Shultz et al.,
2005). Asphyxiation, trauma and electrocution are commonly
observed in a tropical cyclone disaster. Post-traumatic Stress
Disorder and depression have also been observed after large
scale tropical cyclones. Unless cyclones are related to floods or
sea surges, they usually cause relatively few deaths and injuries.
Communicable disease outbreaks after cyclones are rare.
What are the response needs?

Injuries are the most common direct health effect of a tropical


cyclone. Victims need wound management antibiotic treatment

and tetanus prophylaxis. Healthcare facilities in at-risk areas


should take precautions in building safety, prepare a contingency
electricity supply and practice evacuation protocols.

4.8 Floods (I)


What is a flood?

Floods are the most common type of natural disaster. They


account for 40% of natural disasters worldwide and are the
leading cause of mortality due to natural disasters, with 6.8
million deaths in the 20th century (Doocy et al., 2013). Almost
half of the flood-related fatalities in the last quarter of the 20th
century occurred in Asia. In many places, floods are an annual
event. The Center for Research on the Epidemiology of Disasters
(CRED) defines a flood as a significant rise in water level in a
stream, lake, reservoir or coastal region. Generally, we can
classify floods into three types: General flood, Flash flood, and
Storm surge/costal flood (CRED, 2009).
As we have learned in the previous section, a tsunami is a type of
earthquake (not flood) originating from the sea floor that
generates a series of waves that causes great damage to coastal
areas. Even though a tsunami is originally an earthquake, it
causes sudden flooding to coastal areas and therefore, the health
impacts of tsunamis are considerably similar to floods.
General flood
The accumulation of water on the surface due to long-lasting
rainfall (water logging) and the rise of the groundwater table
above surface. It can be induced by the melting of snow and
ice, backwater effects, or special causes such as the
outburst of a glacial lake or the breaching of a dam.
Flash flood

A sudden flooding within a short duration. It is typically


associated with thunderstorms and can virtually occur in any
place.
Storm surge/coastal flood
The rise of the water level in the sea, an estuary or lake as a
result of strong wind driving seawater towards the coast.
The areas threatened by storm surges are coastal lowlands.
What are the known risk factors associated with adverse health outcomes?

Settlements in floodplains are more prone to floods than houses


in higher lands. The size of floodplains can be varied. For
example, the Vietnams Mekong River delta flood plain covers an
area of over 12,000km2. People living in a flood prone area can
mitigate the impact of floods by adopting flood resistant
designs in their houses, such as reinforcing walls with waterproof
coatings, and equipping back-up generators.
In urban settings, the damage due to floods is often higher due to
the higher property and population density. With the increasing
intensity of cyclones due to climate change, urban areas are
becoming more susceptible to flash floods because they have
many impervious surfaces and lack green infrastructure to
absorb excess precipitation.
The type of flood is also a risk factor. For example, flash floods
that occur quickly and that leave people with little lead time to
respond, result in higher mortality rates compared to general
floods. On the other hand, general floods, despite the slower
onset, affect larger populations and a wider area. Floods with
higher water depth and greater flow velocity result in greater
damage.
What are the health impacts of floods?

High mortality is rare in floods. In the past 30 years, only four


flood events resulted in over 10,000 deaths and only 58 events
resulted in more than 1,000 deaths. The health impact of floods
is complex and difficult to generalise across contexts. Drowning

and traumatic injuries are common causes of death during floods


as fast-flowing flood water carries vehicles, trees, or building
materials that causes orthopaedic injuries, trauma, and
lacerations. In addition to drowning, victims are prone
to hypothermiaespecially in cold weather, injuries, and animal
bites while being under floodwater from rivers and other water
bodies that may house snakes, or other dangerous animals.
Floodwater also destroys power lines and submerges electrical
equipment that can cause electrical shocks and increase the
risk of fires. Floods cause water contamination that may contain
bacteria and viruses. Floods in Mozambique in 2000 caused a
rising number of diarrhoea cases, floods in Mauritius in 1980
triggered an outbreak of typhoid fever, and floods in West Bengal
in 1998 created a cholera epidemic (Gayer M & Connolly MA,
2005; WHO, n.d). Cholera is an infectious diarrhoeal disease,
caused by Vibrio cholerae. It is estimated that there are 3-5
million cases of cholera annually, and 100,000-200,000 deaths
due to cholera per year (WHO, 2014). Studies had shown
that V.cholerae is native to coastal ecosystems, particularly in the
tropics and subtropics (Colwell R.R., et al, 1977; Lipp E.K., et al,
2002). Therefore, coastal flooding increases the risk of cholera
infections.
Furthermore stagnant water, remaining for days or weeks after
the initial flood, increases the risk of vector-borne illnesses by
providing new breeding sites for vectors.
Floods can be caused by fresh water or salt water. Each type has
particular impacts. For instance, freshwater floods may leave mud
and soil when the waters recede, and saltwater can affect the
salinity of ground water, make water undrinkable, and harm the
aquatic animals (US EPA, 2013).
What are the responses needed?

In general, search and rescue, and evacuation of the affected


population are the primary responses needed in a flood disaster.
It is often exceptionally difficult to conduct search and rescue

during the acute phase of the disaster. Specific attention needs to


be paid to reducing the risk of exposure to water-borne and
vector-borne diseases by increasing the cleanup activities and
maintaining clean water and food security for the affected
population. In this specific disaster, there is also a greater need to
provide primary care physicians and infectious disease
specialists.

4.11 Drought and Famine (I)


Most natural disasters usually last for a short period of time
ranging from a few minutes to a few weeks. Drought and famine
are disasters that slowly affect a large population over months
and years. They have a devastating impact on the health and
livelihood of people. Drought is usually a preceding factor of
famine but not every drought event would result in a famine.
These two disasters will be discussed together in this section
because they often go hand-in-hand with one another.
What is a drought?

A Drought is a climatological natural disaster defined as an


extended period of time characterised by a deficiency in a
region's water supply that is the result of constantly below
average precipitation. A drought can lead to losses of agriculture,
affect inland navigation and hydropower plants, and cause a lack
of drinking water and famine (CRED, 2009). Climate change is
affecting the trends of drought globally. The Intergovernmental
Panel on Climate Change (IPCC) identified that some regions
(southern Europe and West Africa) may experience longer and
more intense droughts while other regions (central North America
and northwestern Australia) would have less frequent and less
intense droughts.
What is a famine?

A Famine is an extreme form of food crisis. It is described as


regional failure of food production or supply, sufficient to cause a
marked increase in disease and mortality due to severe lack of
nutrition and necessitating emergency intervention, usually at an
international level (Cox, 1981). Famines are often accompanied
by an economic and social collapse of the community. Famines
can be a result of a natural disaster, but because much of their
underlying causes are related to how we distribute food, manage
food prices and other economic activities, nowadays they are
considered to be a man-made disaster.
On the other hand, a food crisis is a combination of drought,
rising food prices, poverty, natural disasters, conflicts, disease,
and complex emergencies. A food crisis develops when families
experience these stresses for several years and governments and
aid agencies fail to intervene (World Vision, 2014). When food
crises continue and reach certain measures of mortality,
malnutrition, and hunger, they can develop into a famine. A
famine is per the UN definition when at least 20% of households
in an area face extreme food shortages with a limited ability to
cope; acute malnutrition rates exceed 30%, and the death rate
exceeds two persons per day per 10,000 persons (UN, 2011).
What are the risk factors for drought?

When a period of unusual dryness and a deficit of rainfall occurs


before the harvest season, it can create more devastating health
impacts compared to after the harvest season, because of the
lack of food availability. Drought is usually predictable, therefore
it is important to develop and disseminate an early warning, so
people can prepare and store food before the drought happens.
Poor irrigation systems and water supply infrastructure also play
an important role in increasing the health impact.
What are the risk factors for famine?

Famine is traditionally believed to be associated with the decline


of food supplies. Brown and Eckholm (1974) state that: a
sudden, sharp reduction in food supply in any particular
geographic locale results in widespread hunger and famine. The
decline in food supply is usually due to one or more of the
following: climate events, pestilence (i.e. an infectious epidemic
disease that is virulent and devastating), war, overpopulation,
and economic mismanagement.
However, a new theory regarding the cause of famines is
proposed by Amartya Sen (1981) that focuses on each persons
entitlements to commodity bundles including food, and views
starvation as resulting from a failure to be entitled to a bundle
with enough food. Therefore, famine is not simply a product of
climate or natural disaster, but is also related to the decline in
both income and employment opportunities. Major contributing
factors are a lack of financial access to commodities, climate
change and extreme weather, social, political and human rights.
In the past, it used to be that food crises affected rural food
producers first, but the rise in food prices, which is a key feature
of modern times, puts poor people in urban areas more at risk
(World Vision, 2014).
Another important factor is the decrease in food security, which
consists of three components:
1. Food availability,
2. Food access, and

3. Food use.
As food security continues to decrease, actions taken to sustain
survival become less reversible. When people start to sell
household possessions and productive tools, they lose their
capacity to generate income (endowments) to exchange for food
and other necessities (entitlements). This generates a vicious
cycle that continues to worsen the food insecurity.
What are the health impacts of droughts and famines?

The impact of a drought is dependent on the context and


underlying population vulnerability, such as the underlying wateruse practices, the infrastructure, and the socio-economic
environment (Stanke et al., 2013). Acquiring sufficient nutritional
intake is the greatest challenge in droughts and famines, as these
conditions often decrease the quantity and/or quality of the food
available.
Acute lack of food may drive people to use unsafe food
sources that can lead to an increased risk of developing other
illnesses, such asvector-borne diseases and communicable
diseases. People would adapt to these situations by reducing
their food consumption that may cause protein-energy
malnutrition, or hinder nutritional foods that can lead
to micronutrient deficiency, such as irondeficiency anaemia,scurvy due to vitamin C deficiency, vitamin
A deficiency that increase the risk of
developing measles. Under-nutrition is a major cause of
morbidity and mortality, particularly in children and pregnant
women. Inadequate maternal nutrition may result
in intrauterine growth retardation, low birth weight, or
various gestational problems. A study investigating 7,874 adults
born between 1954 and 1964 during the famine in China revealed
that exposure to famine during fetal life was associated with a
higher risk of developing metabolic syndrome during adult life.
In addition, under-nutrition during the development stage can
cause impairment in physical and cognitive abilities (Li et al.,
2011).

What are the responses needed?

Young children and women are the group most at risk in drought
and famine situations. It is important to give priority to child and
maternal health care as well as nutritional intervention and child
immunisation. Both physical and economic access to food that
meets peoples dietary needs and food preferences must be
considered in the case of famine. Relief organisations must also
pay attention to micronutrient deficiency in the case of long-term
feeding camps and food aid.

4.14 Temperature Extremes: Heat Waves & Cold Waves (I)


What is a cold wave?

A cold wave can be both a prolonged period of excessively cold


weather and the sudden invasion of very cold air over a large
area. Along with frost, it can cause damage to agriculture,
infrastructure and property. The damage is caused by low
temperatures (EM-DAT, 2009).
What is a heat wave?

A heat wave may be defined as a length of five or more


consecutive days of heat exceeding the average maximum
temperature of a particular area by 5C (EM-DAT, 2009). In
general, it is a prolonged period of excessively hot weather,
usually accompanied by high humidity. Heat waves usually
happen during summertime in an area of high pressure with little
or no rain. Since the average temperature differs between

countries, there is no standard operational definition of a heat


wave.
What are the known risk factors associated with adverse health outcomes?

Climate change increases the frequency and intensity of extreme


temperature events, such as heat waves and cold waves. More
intense, frequent and longer lasting heat waves have been
recorded in the last decade (Meehl & Tebaldi, 2004). Extreme
temperatures affect the very young (infants and preschool
children), very old and chronically ill populations whose
metabolisms fail to adjust to the extreme weather. People with
low socio-economic status, who work outdoors, and those with
poor access to air-conditioning or other temperature regulating
machines (such as fans and heaters) are at higher risk (Chan et
al., 2012). Hence, the demographic and disease profile of a
country is highly associated with its vulnerability to temperaturerelated health impacts. In some countries, women and certain
ethnic groups are at higher risk of death during temperature
extremes. In addition, people who live in poverty are more prone
to suffer the health impacts of cold waves because their
household may not have enough resources to produce heat. This
condition refers to fuel poverty, which is defined as having to
spend 10% or more of a households net income to heat their
home to an adequate standard of warmth (Boardman, 1991).
What is the direct health impact?

Both heat waves and cold waves are associated with increased
mortality. When the core body temperature goes far beyond or
below its normal temperature (37C), and the body fails to selfregulate the core temperature, vital organs are at risk. Heat
strokes are common in heat waves and hypothermia is
common during cold waves. Both conditions can be fatal and are
best treated with supportive care in hospital settings. Extreme
temperatures also trigger the deterioration of respiratory diseases
and onset of cardiovascular episodes (Chan et al., 2013). In
extremes, it might lead to excessive deaths. A study in Hong
Kong found that an average 1C increase in daily mean

temperature above 28.2C was associated with an estimated


1.8% increase in mortality (Chan et al., 2012). Other health
ailments include heat exhaustion, heat cramps, and frost bite.
1. Heat stroke is defined as an extreme hyperthermia of core
body temperature which reaches 40C or above. It happens
when the body fails to regulate its own temperature.
Symptoms include weakness, nausea and vomiting,
headache, dizziness, muscle cramps and pain.
2. Hypothermia refers to a core body temperature below 35C.
It occurs when the body loses heat faster than it can
generate heat. The heart, nervous system and other vital
organs are at risk of shutting down. Untreated, hypothermia
is lethal.
In addition to heat stroke and hypothermia, extreme
temperatures increase the risk of cardiovascular events, such as
myocardial infarction, stroke and heart failure, and respiratory
hospitalizations and deaths.
What are the responses needed?

The physiological acclimatisation to extreme temperatures can


occur over a few days, but behavioral changes and technological
changes may take many years. To mitigate the effects of extreme
weather, preparation and health promotion is very important,
these actions include:
1. Reduce exposure to hot/cool temperatures
2. Increase access to temperature-regulating mechanisms and
address fuel poverty
3. Building designs that allow for better indoor thermal
conditions
4. Urban planning to reduce the heat island effect
5. Awareness and education to respond to temperature
warnings
6. Data surveillance to map at-risk populations

4.16 Epidemic
What is an epidemic?
An outbreak of infectious disease can be defined as an
increase in the number of cases of a disease above what is
normally expected in a specific population and area within a short
period of time. An epidemic occurs when an outbreak spreads
through a larger geographical area with a higher proportion of
infected people. Epidemics are classified under the biological
category of natural hazards (ICRC, 2014). They are considered as
disasters as they affect large quantities of people and result in
public health emergencies.

How is it reported?
Disease outbreaks are generally classified by the level of disease
intensity, into one of the following 4 categories:
Sporadic - a disease that occurs infrequently and irregularly
Endemic a disease within the expected prevalence that is
localised in a geographical region and community (E.g. Malaria in
Africa).
Epidemic a disease whose incidence increases unusually and
spreads through a larger geographical area (E.g. SARS in 2003).
Pandemic When an epidemic becomes widespread and affects
a sizeable portion of people in a region, a continent, or the world
(e.g. pandemic influenza).
(CDC, 2012)

What are the known risk factors associated with adverse health
outcomes?

An epidemic may occur due to a recent increase in amount or


virulence, or enhanced mode of transmission of the pathogens.
While different diseases have specific risk factors to become
epidemic, in general the risk increases when the interaction of
host, disease agent and environment becomes abnormal.
Poverty is a main risk factor for epidemics. It leads to
malnutrition and low vaccination uptake that lead to impaired
immunity. Moreover it results in poor access to health care
facilities and lack of resources for disease control when an
outbreak occurs.
The risk of an epidemic will also increase after the occurrence of
other types of disaster. Altered environments might favor the
proliferation of pathogens and/or decreases the immunity of the
host population. In particular those disasters with large-scale
population displacement, the consequent of overcrowding in
temporary settlements and disruption of water supplies and
sanitation, render people to become vulnerable to water borne
and other infectious diseases (Watson et al., 2006; Spiegel et al.,
2007).
Climate change alters the environment of disease transmission
vectors thus becoming another risk factor. Epidemics may happen
due to the introduction of new pathogens in a setting that
previously did not have the disease. People in the region might
not have previous immunity which favors the proliferation of
disease transmission.

What is the health impact of epidemics?


The immediate health impact of epidemics is causing illness and
death. Diseases with high epidemic potential include pandemic
influenza, cholera, dengue fever, malaria, measles, etc. The
consequences of infections range from respiratory illness,
diarrhoea and severe dehydration etc., dependent on the type of
diseases. Many of the severe cases can be fatal. There are also
social and political disruptions and economic losses that impact as

well as indirectly affecting human health after epidemics, both


physically and psychologically.
Epidemics may also occur in animals leading to a reduction in
food production. As a consequence the shortage of food may
eventually lead to economic disaster and malnutrition in poorer
countries. Some animal epidemics are also able to be transmitted
to human populations, for example swine influenza, which
normally circulates among swine species, caused a human
pandemic in 2009. Animal epidemics should not be ignored as
61% of human infectious pathogens are zoonotic (Taylor et al.,
2001).

What are the responses needed?


Specific control measures depend on the route of transmission of
disease agent and setting. The World Health Organisation and
other public health agencies have developed standard guidelines
in handling different types of epidemics (WHO, 2014). Principles
for epidemic response include enhancing disease surveillance,
controlling or eliminating agents at the source of transmission,
improving environmental conditions and increasing hosts
defenses. Common responses include:
- Safe water supply to prevent water-borne disease spread
- Practicing rigorous hygiene to protect humans from
contaminated sources
- Vaccination campaigns to boost up the body immunity
- Isolation and quarantine to prevent further contact with infected
people.

4.17 Mental Health Impact (I)


What is mental health?

The World Health Organization defines mental health as a state


of well-being in which every individual realises his or her own
potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to
her or his community. (WHO, 2013). In ordinary circumstances,
people make three fundamental assumptions about the world,
that:
1. The world is essentially a good place
2. Life and events have meaning and purpose; and that
3. They are valuable and worthy
(Janoff-Bulman, 1992)
However, in disasters, traumatic experiences challenge one's
perception about the world and themselves. Such stressors are
known risk factors for developing mental health issues.
Risk factors for mental health issues during disasters

The mental health consequences of disasters are influenced by


psychological and social factors before, during and after the
disastrous event. These factors are greatly interconnected. They
are also affected by humanitarian assistance, such as food
security, shelter, water and sanitation (WHO, 2011).
Psychological
o Pre-existing (pre-impact) conditions, such as a severe
mental disorder, depression, and substance abuse.
o Those induced by the emergency situation such as
grief; non-pathological distress; alcohol and other
substance use; depression and anxiety disorders
including Post-traumatic Stress Disorder.
o Those arising from circumstances created as a result of
humanitarian aid, such as anxiety due to lack of
information about food distribution.
(World Health Organization, 2011)
Social

o Pre-existing (pre-impact) problems, such as belonging


to a marginalised group or political oppression; these
vulnerabilities may be exacerbated in an emergency
situation.
o Resulting from the emergency e.g. reduced safety,
separation from family members, destruction of
livelihoods, and the destruction of community
structures.
o Circumstances created as a result of humanitarian aid
e.g. overcrowding or lack of privacy in camps, aid
dependency and undermining of local capacity.
(World Health Organization, 2011)
Vulnerable populations, such as socially isolated and marginalised
people and people living in institutions are also key risk factors of
mental health in disasters.
Mental health impact of disasters

It is important to remember that not all distress is abnormal. A


large portion of distress is a normal human reaction in times of
critical incidents (Williams & Alexander, 2009). After the
occurrence of a disaster (impact), the proportion of the affected
population in distress/ disorder peaks in the first week and it
starts to drop as the post-disaster time increases. The impact of
mental health is far-reaching. Poor mental health is associated
with domestic violence, unemployment, early-drop out of school,
divorce and poorer health outcomes (Prince et al., 2007).
Major types of psychological disorders

People develop different kinds of psychosocial distress after a


disaster. A U.S. National Survey reported that more than 18% of
men and 15% of women were exposed to a natural disaster in
their life (Norris FH et al., 2002; North CS, et al., 1999; Galea S
et al., 2004). Post-Traumatic Stress Disorder (PTSD) is the most
reported psychological disorder identified among the victims. The
prevalence of PTSD among direct victims ranges between 30%

and 40%, while the rate among the general population ranges
between 5% and 10% (Neria Y et al, 2008).
Common types of psychological disorders after disasters include:
1. Acute Stress Disorder
It is a disorder characterised by acute stress reactions
manifested between 2 days and 4 weeks after experiencing
traumatic or stressful events (Bryant et al., 2011).
2. Generalised Anxiety Disorder
It is a disorder characterised by experiencing excessive
anxiety for over 6-months (Andrew et al., 2010).
3. Major Depressive Disorder
It is a condition of having depressed mood and/or loss of
interest for at least two weeks and at least five of the
following symptoms, such as depressed mood of the day,
diminished interest in all activities, significant unintentional
weight loss or gain, insomnia or sleeping too much,
agitation or psychomotor retardation noticed by others,
fatigue or loss of energy, excessive guilt, diminished ability
to concentrate, recurrent thoughts of death (APA, 2000).
4. Post-Traumatic Stress Disorder (PTSD)
It is a disorder very similar to acute stress disorder,
characterised by experiences of recurrent flashbacks about
the traumatic event and other acute stress symptoms. It is a
diagnosis used for individuals presented with the duration of
symptoms for more than one month. (DSM-IV-TR, 2000) To
read more about PTSD, you can click on the following
link: http://www.ncbi.nlm.nih.gov/books/NBK83241/.
The psychosocial approach to mental health response

A common approach in addressing mental health needs usually


focuses on the mental deficits and often forgets the available
resources that may help them.
Mental health needs in a post-disaster setting could be addressed
by using a psychosocial approach. The pyramid below

highlights the needs for mental health and psychosocial support


in emergencies.

The first layer of the pyramid includes basic services to ensure


security for survival. The second layer illustrates the importance
of community and family support; relief measures should include
assisting victims to reunite with families and encourage the
activation of social networks. The third layer refers to a
substantially smaller number of people that requires psychosocial
interventions from non-specialised community workers. The top
layer represents a small group of people that may have
experienced difficulties returning to their daily activities and thus
requiring specialised support from professional health workers. To
address the mental health issues, the following measures should
be included, such as general basic services, community support,
psychological first aid, incorporating mental health care and
psychosocial support within education, general health service
delivery and primary healthcare, integrated services, and access
to specialist care and medication for people with severe mental
disorders (WHO, 2011).

Here are a few reminders when planning for psychosocial


interventions:
1. Disaster psychosocial support interventions should be
tailored to the target communities (Oriol & Center for Mental
Health Services, 1999).
2. Interventions should focus on local capacity building and
strengthening self-help abilities (IASC, 2010).
3. Incorporate psychosocial support program into existing
system or program to enhance program sustainability and
reduce social stigma (IASC, 2010).
Immediate responses for mental health

As illustrated by the graph about the mental health impact of


disasters, the greatest mental health needs occur in the first days
immediately after the disaster. It is believed that severe
psychiatric disorder or mental health distress can be prevented if
appropriate actions can be taken during this period. Below are
two such interventions:
Critical incidence stress debriefing
This is a method developed in the 1970s, and this model
had been widely used in the past. It consists of a 7-phased
group discussion which is conducted between 2 and 10 days
after a traumatic experience. This model encourages
participants to express their emotions and thoughts about
the trauma to facilitate reprocessing. However, this model
had been criticised for creating retraumatisation of the
participants. And thus, this model is rarely used in postdisaster settings these days.
Psychological first aid
Psychological first aid is a group of skills identified to limit
distress and negative health behavior, and to cope with
stressful and traumatic events in life. It is used during or
immediately after a disaster. The Institute of Medicine, NIMH
and the WHO have recommended this method as the choice
of intervention (Institute of Medicine, 2003). The concept of

psychological first aid is similar to physical first aid. The


skills can be applied to everyone, and should be taught to
individuals without specialised mental health training,
including:
o Public health practitioners
o Responders in disasters
o Military personnel
o Community volunteers

4.21 Health Services & Key Players in Disaster Response


After understanding the health impacts of disasters, we are now
moving on to address the health needs. The details of public
health disaster response will be discussed in lessons 5 & 6.
However, before we enter the next lesson, we should bear in
mind the specific areas of health that need to be addressed in
disaster response, which include:
1. Health systems and infrastructure
2. Emergency health services

3. Reproductive health care


4. Mental health and psychosocial support
5. Control of communicable diseases
6. Water, sanitation and hygiene
7. Food and nutrition
8. Management
(Rand, 2008)
In addition, the World Health Organization (WHO) has published a
series of fact sheets that underline the key points of essential
health domains as part of disaster management, which cover:
1. Disaster risk management
2. Chemical safety
3. Child health
4. Climate risk management
5. Communicable diseases
6. People with disabilities and older people
7. Mass casualty management
8. Mass fatalities/dead bodies
9. Mental health
10.

Natural hazards

11.

Non-communicable diseases

12.

Nutrition

13.

Radiation emergencies

14.

Safe hospitals: prepared for emergencies and disasters

15.

Sexual and reproductive health

16.
Water, sanitations, and hygiene
(WHO Fact Sheets, 2011)
To understand more on each health domain, you can click on the
following

link: http://www.who.int/hac/events/disaster_reduction_2011/en
/
List of Key Response Agencies
Abbreviation

Agencies

UNDCP

United Nations Drug Control Program

UNESCO

United Nations Educational, Scientific and Cultural Organization

UNDP

United Nations Development Program

WTO

World Trade Organization

UNHCR

United Nations High Commissioner for Refugees

UNICEF

United Nations Childrens Fund

UNEP

United Nations Environment Programme

ILO

International Labor Organization

WIPO

World Intellectual Property Organization

FAO

Food and Agriculture Organization of the United Nations

USAID

United States Agency for International Development

UNFPA

United Nations Population Fund

UNIFEM

United Nations Development Fund for Women

WHO

World Health Organization

WHI

Womens Health Initiative

WFP

World Food Program

MSF

Doctors without Borders, Mdecins Sans Frontires

UNAIDS

Joint United Nations Programme on HIV/AIDS

UN

United Nations

IMF

International Monetary Fund

IDA

International Development Association

GAVI

Global Alliance for Vaccines and Immunizations

GFATM

Global Fund to Fight AIDS, Tuberculosis and Malaria

GAIN

Global Alliance for Improved Nutrition

OHCHR

Office of the United Nations High Commissioner for Human

Rights

NIH

National Institutes of Health

UNIDO

United Nations Industrial Development Organization

IFAD

International Fund for Agricultural Development

UN-HABITAT

UN Human Settlements Programme

UNRWA

UN Relief and Worlds Agency for Palestine Refugees in the Near


East

IAEA

International Atomic Energy Agency

CIDA

Canadian International Development Agency

DFID

Department For International Development

ICRC

International Committee of the Red Cross

IFRC

International Federation of the Red Cross and Red Crescent


Societies

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