SHEMS

OCCUPATIONAL
HEALTH & INDUSTRIAL
HYGIENE MANUAL

Document Number SHE-103

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Document Status

Document Title: Safety, Health, & Environment Management

System

Document Number: SHE-103

Document Custodian: Sonal Panchal

Document Approval: Larry Fisher (Vice President – SE Asia)

Approved By Date

Jan 6, 2015

Document Revision Log:

Revision # Date Reason

Draft December 2004 Initial Draft
1 January 2005 1st Edition
2 Dec 2007 Revision
3 Dec 2008 Review
4 October 2009 Reviewed
5 January 2011 Reviewed
6 February 2014 Reviewed
7 December-2014 Updated

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Distribution List
Manual Manual Holder’s Title Manual Holder’s Name Copies
#
1. Vice President –SE Asia Larry Fisher Soft Copy

Sr. Head-HR & Admin T. M. Sreekanth Soft Copy

2. HAZIRA ASSET
Sr.Head Assets Abhimanyu Biradar Hard Copy
Installation Manager Lal Chand Ram Soft Copy
Principal Coordinator HSE Ravi P Sharma Soft Copy
Sr. Manager C&P Malay Mazumdar Soft Copy
Production Supervisor Alpesh Patel / Bhargav Modi Soft Copy
Principal Coordinator Facilities Hitendra Atodariya Soft Copy
Sr. Officer C&P Arvind Chavda Soft Copy
Offshore Platform Syed Zafar / Umesh Kotnoor Soft Copy
Ankleshwar Unloading Facility Manish Kumar / Sandeep Soft Copy
Bose

3. Document Custodian Sonal Panchal Master Copy

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TABLE OF CONTENTS

1.0 Leadership and Commitment 9

1.1 Involvement 9
1.2 Guiding Principles 10

2.0 Policy 11
2.1 Niko SHE Policy 11
2.2 Applicability 13

3.0 Plans and Procedures 14

3.1 Overview 14
3.2 Control 17
3.3 Recovery Measures 17
3.4 Fitness to Work 17
3.5 Occupational Health Considerations 19
3.5.1 Noise 19
3.5.2 Combustible and Toxic Gas 19
3.5.3 Ergonomics 20
3.5.4 Industrial Hygiene 20
3.6 Planning 20
3.6.1 Health Hazard Identification/Analysis 20

4.0 Implementation and Operations 25

4.1 General Health Protection 25
4.2 Industrial Hygiene 25
4.3 Solvents, Flammables and Combustibles 26
4.4 Dermatitis 27
4.5 Infectious Disease 27
4.6 Immunizations 28
4.7 Health Hazards 29
4.8 Snakes, Scorpions, Insects 29
4.9 Heat Stress 31
4.10 Emergency Medical Aid Preparation 32
4.11 Food and Accommodation Sanitation 32
4.12 Deep Vein Thrombosis 34

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4.13 Niko Tuberculosis Protocol 39

5.0 Checking and Corrective Action 41
5.1 Inspections 41
5.2 Notice of Disease 43

6.0 Management Review 44

6.1 Performance Measurement 45
7.0 Continuous Improvement 46

Procedure:

Identification of Aspects & OHS hazards

Formats:

a) Accident / Incident Report Form

b) Form-V Notice of Disease
c) Hazard Management Process
d) Risk Assessment Tool
e) Industrial Hygiene Checklist

Reference Standards:

OISD-STD–166
Guidelines for Occupational Health Monitoring in Oil and Gas Industry

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LIST OF ANNEXES

Occupational Health Survey

Annex A Hygiene Inspection Checklist 47

Annex B Information on Infectious Diseases 52

Annex C First Aid for Bites and Stings 60

Annex D Supplementary Info – Cobras 61

Annex E Supplementary Info – Kraits 67

Annex F First Aid for Heat Stress 70

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1.0 Leadership and Commitment

1.1 Involvement

A well-planned and well-supported effort, undertaken by a committed

management team, will yield positive results.

It is essential that management demonstrate personal commitment to our SHE

Management System by:

 Being directly involved in planning how to implement it;

 Providing resources; and,

 Managing performance on an ongoing basis.

Management is both responsible and accountable for safety, health, and

environmental performance. However, a collaborative effort by management
and employees is the key to achieving excellence. Such an effort develops
ownership and pride.

1.2 Guiding Principles

The primary objective of the Niko SHE Program is to ensure that business
activities are conducted in a safe, healthy and environmentally friendly manner.
This is achieved by providing the organization, arrangements and resources
required to manage the company’s SHE activities - by recognizing that people are
NIKO’s most important asset and by ensuring that SHE considerations are treated
equally with other business objectives.

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2.0 Policy
2.1 Niko Safety, Health, Environment and Social Programme Policy

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2.2 Applicability to Occupational Health and Industrial Hygiene

The Niko SHE Policy is clearly meant to include occupational health. If not
properly managed, the health effects of our business activities can present
high-risk hazards to our people and the public. Accordingly, Niko will take all
reasonably practicable measures to ensure that no adverse health effects
compromise the safety of our workers, contractors and other third parties as a
result of our business activities.

3.0 Plans and Procedures

3.1 Overview

Niko maintains and regularly updates several plans and procedures, in order
to ensure effective SHE management in all of our operations. These plans
and procedures are complimentary to the Niko SHE MS and incorporate
performance criteria that clearly define action, responsibilities and intended
outcomes.

To be effective, plans and procedures, to the maximum extent possible, must

address the questions of “who, what, when, where, how, and why”. Plans also
require clear, measurable, and achievable objectives.

A variety of factors affect the occupational health of our workers. Some of

these are operational hazards. As such, we apply the Niko SHEMS Hazard
Management Process (HMP), the same as for any other hazard. See Figure
3.1.

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Figure 3.1 – HMP

SYSTEM,
EQUIPMENT, IDENTIFY ANALYSE
PROCESS HAZARD(S) HAZARD
OR
PEOPLE

ASSESS
RISK

SEVERITY LIKELIHOOD
OF OF EXPOSURE
CONSEQUENCE OCCURENCE

MODIFY
OR
INCREASE RISK
CONTROLS RATING

NO HAZARD CONTROLS
CONTROLLED &
TO MEET RECOVERY
RISK MEASURES
ACCEPTANCE TO ALARP
CRITERIA?
YES

DOCUMENTED
& VERIFIED IN
HAZARDS
REGISTER

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Figure 3.2 RAT

NUMERIC SEVERITY OF CONSEQUENCE
VALUE
1  No injury, damage or other adverse consequences.
2  People – first aid injury, no lost time or disability.
 Assets – minor damage, work slow down, some equipment down time.
 Environment – contained release or small spill.
 Reputation – slight impact.
3  People – one or more lost time injuries, no disability.
 Assets – moderate damage, work slow down, equipment down time.
 Environment – small uncontained release or spill.
 Reputation – minor impact, may require repair.
4  People – one or more severe injuries, disabilities.
 Assets – major damage resulting in significant work stoppage or equipment down time.
 Environment – moderate uncontained release or spill.
 Reputation – major local impact, will require repair with clients and the public.
5  People – one or more fatalities.
 Assets – loss of critical equipment or facilities, major business interruption.
 Environment – large uncontained release or spill, blowout, major environmental impact.
 Reputation – significant loss of credibility with clients and the public. Serious impact or loss
of business.
X
NUMERIC PROBABILITY OF OCCURRENCE
VALUE
1  Occurrence practically impossible / Never heard of in industry.
2  Conceivable, but very unlikely / May have occurred in industry.
3  Possible / Unusual, but has occurred in industry.
4  Likely / Occurs in industry on a 5 – 10 year frequency.
5  Highly probable / Occurrence imminent.
X
NUMERIC DEGREE OF EXPOSURE
VALUE (considered in terms of people, assets, environment or reputation)
1  No exposure / Rare exposure (once per year or less).
2  Below average exposure / A few times per year.
3  Occasional exposure / Perhaps monthly.
4  Frequent exposure / Perhaps weekly.
5  Continuous exposure / Daily or more.
=
CALCULATED SCORE RISK INDEX (SEVERITY x PROBABILITY x EXPOSURE)
SCORE RISK LEVEL ACTION
1-40 LOW   Based on RAC, take action as per the Hierarchy of
Control
41-80 MEDIUM  Bowtie Analysis recommended
  Based on RAC, take action as per the Hierarchy of
Control
 Document action taken
81-125 HIGH  Bowtie Analysis mandatory
  Based on RAC, take action as per the Hierarchy of
Control
 Document action taken

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3.2 Control

This manual is meant to serve as an Occupational Health Guideline to Niko

employees and contractors who may be exposed to health hazards in the
workplace. The purpose of the manual is to provide useful information and
advice which, if heeded, should substantially reduce health risks associated
with our operations, while promoting a healthy lifestyle at home.

Regarding the Hazard Management Process, this Manual provides one level
of hazard control.

Additional controls are:

 Niko Safety Rules (Figure 3.1)

 worker skills training;
 hazards awareness;
 worker evaluation;
 regular medical check-ups;
 MSDSs;
 PPE; and,
 daily workplace inspections.

3.3 Recovery Measures

Recovery measures include:

 first aid training for all workers;

 first aid kits in all vehicles and worksites;
 adequate clean water for all persons at all worksites
 vaccination programs;
 Emergency Response Plans
 Qualified medical personnel at the main worksites; and,
 mobile telephones for emergency contact.

3.4 Fitness to Work

Working in upstream oil and gas operations takes ability and concentration. If
anything happens such that you are not up to your ability, you may not be a
safe worker. Your ability to be a safe worker depends on being able to see
clearly, not being overly tired, not being under the influence of drugs or
alcohol, being generally healthy and being emotionally fit to work. In other
words, you are responsible for being in shape to work safely.

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Figure 3.1

SAFETY RULES
================================================================

The following rules outlet some basic requirements for all NIKO worksites.
These rules will be reviewed with all new employees and will be a topic of
monthly safety meetings.

1.0 The use alcohol or illegal drugs while on company business, whether
on client property, or in company vehicles or privately owned vehicles
hired temporarily or permanently by the company will NOT be
tolerated, and will lead to dismissal.

2.0 Hard Hats approved by DGMS will be worn at all times on worksites.

3.0 ISI approved safety toe boots are required on all worksites.

4.0 Clean protective clothing suitable to the job being done and weather
conditions must be worn.

5.0 Appropriate hearing protection and/or ISI approved eye protection will
be worn as dictated by the work being preformed or client regulations.

6.0 Appropriate fire retardant clothing will be worn on worksites by all of

our personnel as dictated by the work being performed or client
regulations.

7.0 Only safety matches and lighters with enclosed mechanisms are
permitted on any work site. “Strike anywhere” matches and open
mechanism lighters (disposable), are prohibited. Smoking is permitted
only in designated areas, but never within 30 meters of well, separator,
storage tank or other sources of flammable gases.

8.0 Appropriate government regulations will be adhered to when

performing any excavations.

9.0 Company vehicles/equipment will be operated as per posted speed

limits, regulations and operating manuals. Seat belts where available
must be worn at all times. Always walk around the vehicle/equipment

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before starting out. Non-essential vehicles are not allowed within 30

meters of well, separator, storage tank.

10.0 Diesel engine within 30 meters of well, shall be provided with an intake
shut-off valve with readily available remote control assembly.

11.0 No electrical appliance, equipment or machinery including lighting

apparatus shall be used in Zone ‘0’ hazardous area.

12.0 Keep the work site clean and organized.

Compliance with these rules is mandatory – non-compliance may lead to

dismissal. These rules shall be posted at all company worksites.

3.5 Occupational Health Considerations in Process Hazards

3.5.1 Noise

Confirm that the equipment being considered for purchase meets the
engineering specifications on equipment noise control.

Assess the impact that equipment-generated noise will have on employees

and the environment outside of our operational boundaries.

NOTE: the 8 hour Occupational Exposure Limit for noise is 85 dBA.

3.5.2 Combustible and toxic gas

Assess and incorporate engineering specifications for Fire and Gas Detection
and Alarm Equipment

Identify and assess the risk of the potential presence of combustible or toxic
gases, and oxygen deficient atmospheres in the work environment.

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3.5.3 Ergonomics

 Evaluate drawings, plans, and equipment to determine the best

human-machine or human-workstation interface.

3.5.4 Industrial Hygiene

From a health risk perspective, identify, assess, and control the critical tasks
associated with operating the modification or installation.

Assess the design and operations requirements. Consider substitutions such

as less toxic chemicals and other modifications to reduce potential risk or
exposure to employees.

3.6 Planning

Occupational Health and Industrial Hygiene are sciences dedicated to

protecting workers’ health through controlling hazards in the work
environment. This includes both hazards that are an immediate threat to
health and hazards that present a risk of occupational illnesses in the future.
This section outlines occupational health and industrial hygiene factors that
are taken into account when assessing and controlling heath hazards.

3.6.1 Health Hazard Identification and Analysis

Potential health hazards take the form of products or substances, produced,

purchased, or otherwise encountered on our work sites. Or, they may be
environmental in origin. Consider the following sources:

 chemical – gases, mists, vapours, fumes, dusts, liquids & pastes;

 biological – bacteria, viruses rickettsia, parasites, protozoa,
insects, larger pests & dangerous animals;
 physical – temperature/humidity extremes, vibration, noise,
lighting, ionizing & non-ionizing radiation, lasers, pressure; and,
 ergonomic – work posture, work station design, lifting, seating,
work/rest cycles.

Potential health hazards may come in various physical states:

• gases – inert (helium, neon, argon), acid (hydrogen chloride,

hydrogen sulfide, hydrogen cyanide, acetic acid), alkaline
(ammonia, arsine, stibine), organic (toluene, chloroform);

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• liquids – including vapours, mists;

• solids – includes dust (silica, grain,organic), fumes (formed by
burning, sublimation, or condensing of a volatilized solid), smoke
(carbon & soot from incomplete combustion); or,
• biological – viruses, bacteria, rickettsia, fungus, parasites, insects,
etc.

Consider the following possible routes of entry:

• inhalation – the most important for occupational exposures.

Depends on concentration in air, duration of exposure, and,
ventilation rate. The surface area of the lungs is approximately 300
sq. ft. at rest to 1000 sq. ft. during inhalation. This is a large surface
area for absorption. With gases and vapours, dose also depends on
solubility. For particulates, dose/effect depends on particle size –
the smaller the particle, the deeper in the lungs it is deposited, and
thus more of a health hazard.
• ingestion – factors include poor personal hygiene, eating, drinking,
smoking. Ingestion is essentially absorption through the gastro-
intestinal tract.
• absorption – through the eyes, skin, and also protective clothing
which has been contaminated. Contact/exposure time is an
important factor. Wet skin, abrasions, scratches, cuts & lesions
increase absorption. Solvents & degreasers enhance absorption.
Oily rags in pockets enhance absorption. Contaminated gloves and
coveralls enhance absorption.

General classification of toxic substances include:

• irritants – ammonia, hydrogen sulphide (secondary), etc;

• asphyxiants – methane, carbon monoxide, etc;
• narcotics – central nervous system depressants, alcohol, etc;
• liver toxins – alcohol, hepatitis, etc;
• kidney toxins – lead, cadmium, etc;
• neurotoxins – damage nerve cells - mercury, hexane, etc;
• sensitizing agents – isocyanates, etc;
• fibrogenic agents – silica (silica dust from sandstone grinding
wheels), asbestos, etc;
• carcinogens – cause cancer - asbestos, tobacco, PCBs, etc;
• teratogens – cause birth defects - alcohol, lead, tobacco,
thalidomide, etc; and,
• reproductive hazards – interfere with reproduction – lead, etc.
Some toxic substances target one or more organs in the body. The following
are some examples:

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• liver – hydrocarbons, alcohols, nitrosamines, etc;

• central nervous system (CNS) – metals, solvents, anesthetics,
alcohol, CO, etc;
• kidney – hydrocarbons, heavy metals (uranium, lead, mercury),
etc;
• reproductive system – lead, hormones, mercury, alcohol,
smoking, ionizing radiation, etc;
• skin – water caustics, acids, organic solvents, PCBs, phenols, and
numerous others.
• Circulatory system (blood) – lead, benzene, mercury, insecticides,
CO, etc;
• Respiratory system (lungs, trachea, bronchi, nose/mouth) –
inorganic dusts (asbestos, silica), organic dusts (grain, cotton,
wood), irritant gases (SO2, O3 or ozone, NO2, ammonia, chlorine,
etc), metal fumes & dusts (beryllium, cadmium, etc), and numerous
others.

Other considerations may include the following:

• hazard concentration;
• route of entry;
• duration of exposure;
• frequency of exposure;
• individual variations;
• work history;
• drug interaction;
• synergism;
• chemical formulation;
• environment (temperature, humidity, wind, etc); and/or,
• Controls in place.

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Biohazard consideration include the following:

• common workplace diseases;

• disease cycle;
• disease vectors (including pests and people);
• personal, living space and workspace hygiene;
• food preparation areas & personal health;
• isolation;
• food preparation materials (wood, plastic, metal);
• refrigeration;
• cross-contamination;
• waste & sewage disposal;
• odour control;
• sterilization – chemicals (10% bleach) or temperature;
• cooking temperature; and/or,
• PPE.

The objectives of controlling health hazards are as follows:

 ensure that personnel are not affected by exposure to any potential

health hazard such as chemicals, noise, temperature extremes,
biological hazards, or ergonomic issues. If exposure is unavoidable,
then protective measures shall be taken.

 promote and evaluate the health and well-being of employees before

their health is negatively affected;

 take preventative measures to anticipate, identify, evaluate, and control

health risks to employees;

 ensure that employees comply with company standards and regulatory

requirements;

 decrease the amount, number, and toxicity of hazardous substances in

our operations;

 educate people about specific health hazards relating to their job; and,

 apply work methods, procedures, rules, and practices to ensure that

employees who are working in a hazardous environment are protected.

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A Health Risk Assessment (HRA) is simply the Niko Hazards Management

Process (HMP) applied to health hazards – see Figure 3.1 and 3.2. An HRA
should include the following:

 establish a baseline;

 evaluate and develop controls to decrease health risks to employees;

 develop a timeline for implementation;

 ensure compliance with regulations;

 incorporate industrial hygiene topics at safety meetings;

 identify industrial hygiene exposures and control methods at pre-job

meetings and turnarounds;

 include industrial hygiene in worker orientations;

 include industrial hygiene in site inspections to ensure compliance with

:
- the hearing conservation program
- the respiratory protection program
- confined space entry
- WHMIS, and
- Safe Work Procedures;

 make sure that Job Exposure Profiles are current; and,

 include health risks when job procedures are analyzed according to

task analysis.

An HRA shall be done whenever medium – high risk health hazards are
encountered.

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4.0 Implementation and Operations

4.1 General Health Protection Procedures

Niko has established health protection standards, procedures and programs

for its workers to assure fitness to work; to provide appropriate services for
managing injury and illness at work sites; and, where appropriate, to provide
health surveillance for workers.

4.2 Industrial Hygiene

Potential health hazards in the form of chemical agents such as liquids,

vapours, dusts, gases, fumes and mists exist in many work places. These
may enter the body either through breathing, skin contact or ingestion, and,
depending upon toxicity and dosage, may cause varying degrees of harm.
Managers and supervisors shall obtain MSDSs for all hazardous products at
their work sites. The information contained in the MSDSs must be
communicated to all workers who may come into contact with those products.
These MSDSs shall be reviewed before handling the product. Airborne
hazards may often be controlled by local ventilation systems. Traces of dust,
smoke and fumes in the air, unusual odours or personal symptoms such as
eye irritation or sneezing, should be reported immediately to the supervisor
and investigated. This could be an indication that a system is not functioning
properly.

Safe Work Procedures must be followed at all times for activities involving the
use and disposal of chemicals which may generate air contaminants. These
may include the use of personal protective equipment such as respirators,
suitable gloves, chemical suits, etc.

Workers handling chemicals must be adequately trained in hazardous materials

handling, storage and transport principles and the proper methods of disposal.
Read all labels and warning signs. Follow instructions for proper handling. Know
the proper cleanup procedures for all substances. Clean up spills immediately.
Food and cigarettes should not be taken into work areas. Toxic substances may
contact them and subsequently be swallowed. For the same reason, hands
should be thoroughly washed before eating.

If a worker suffers from any unusual symptoms such as headaches, eye

irritation, nausea, they shall report immediately to first aid. If symptoms
persist, contact Niko doctor or medic.

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4.3 Solvents, Flammables and Combustible Liquids

The appropriate Material Safety Data Sheet (MSDS) for each solvent, paint,
cleaning agent or chemical that is a controlled product used on the work site
is to be available at the site. The MSDS must be reviewed with each worker
who handles the product, prior to their use if workers are unfamiliar with the
hazards. If a supervisor or worker is unsure of the proper procedure to handle
or use a chemical, the Head –Hazira Assets shall be consulted prior to
commencing work. All requirements for storage, handling, transportation and
personal protection must be followed.

Solvents, paints, cleaning agents and chemicals in quantities greater than that
needed for one day's work are to be stored in properly labeled and ventilated
storage bins. Solvents, paints, cleaning agents and chemicals must not be
stored or used in unventilated areas or in the immediate proximity of any
source of ignition. Smoking is not permitted while using, or in the vicinity of,
any such material. "No Smoking" signs must be prominently posted.

Refer to the appropriate MSDS (Material Safety Data Sheet) SWP for further
information.

4.4 Dermatitis

Many materials used at Niko work sites are skin irritants and sensitizers.
These materials include solvents, acids, resins, alkalis, formaldehyde, etc. In
order to avoid skin problems, the following steps shall be taken:
 Avoid skin contact if possible;
 Wash chemicals off of the skin as soon as possible;
 Personal hygiene is critical – wash frequently during the day,
shower at the end of the day, avoid use of hard soaps;
 Clean equipment regularly ;
 Do not wear rings and watches;
 Wear proper work clothing – durable, closely woven, providing as
complete coverage as possible, laundered frequently;
 Wear appropriate impermeable gloves, or gloves that can be
washed (consult the product MSDS and manufacturers instructions
for the glove);
 Use barrier creams only where other controls are not possible; and,
 Report all cases of skin rash.

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4.5 Infectious Diseases

Niko workers who work in remote and urban areas may be exposed to
infectious diseases. Many of these diseases are common to a certain areas
and are transmitted by insects, contaminated food and water or through close
contact with infected people. Workers can reduce the risk of infection by:

 washing hands frequently with soap and water or hand sanitizers;

 drink only bottled or boiled water, or carbonated (bubbly) drinks in
cans or bottles;
 avoid tap water, fountain drinks, and ice cubes. If this is not
possible, make water safer by BOTH filtering through an “absolute
1-micron or less” filter AND adding iodine tablets to the filtered
water;
 eat only thoroughly cooked food or fruits and vegetables you have
peeled yourself;
 to prevent fungal and parasitic infections, keep feet clean and dry,
and do not go barefoot; and,
 always use condoms to reduce the risk of HIV and other sexually
transmitted diseases.

To Avoid Getting Sick:

 Don’t drink beverages with ice unless you know the source of the
ice;
 Don’t eat dairy products unless you know they have been
pasteurized;
 Don’t share needles with anyone;
 Don’t handle animals (especially monkeys, dogs, cats, bats, etc), to
avoid bites and serious diseases (including rabies, plague, mange,
etc).

4.6 Immunizations

Immunization can protect you and others around you from becoming infected
and spreading a number of diseases. The core vaccinations that are
recommended for all Niko workers include Tetanus & Diphtheria (every 10
years) and Tuberculin skin test (every three years after initial), yellow fever,
hepatitis A, hepatitis B, polio and typhoid. Influenza vaccinations are optional.

Other possible immunizations that may be recommended by a physician

include:

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 Meningococcal Meningitis;
 Rabies (in Gujarat rabies is common);
 Pneumococcal; and,
 Mumps, Measels & Rebella (MMR, if born after 1956)

In addition to the above, malaria and dengue fever are known in Gujarat,
especially in the wet season when mosquitoes are common. Malaria
prophylaxis is something that should be discussed with a physician. Regular
use of insect repellant will reduce the risk of contracting these two diseases.

Personnel should note:

 Almost all vaccinations provide protection for a limited period of

time. In some cases, this may be as short as six months or as long
as 10 years.
 Some vaccination schedules require more than one shot and in
some cases, it may take up to three months to complete a series.

4.7 Health Hazards – Hot Climates

 Blood borne infections such as HIV and hepatitis B;

 Insect borne diseases, possibly malaria;
 Food and waterborne gastro-intestinal diseases;
 Tuberculosis (TB);
 Animal hazards such as rabies, snake bites, and scorpion stings;
 Heat-related problems; and,
 Influenza (March to October).

4.8 Snakes, Scorpion and Insects

Niko workers can avoid being bitten and stung by taking a few simple precautions:

 Familiarize yourself with the most common venomous snake found in

Gujarat – the cobra (Figure 4.1), the krait (Figure 4.2), and the russel’s
viper (Figure 4.3);

 Wear protective clothing and footwear;

 Always watch where you are going;

 Use care when stepping over logs and rocks, walking through brush,
and working around stored materials;

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 Do not put your hands into hole, nooks or crannies;

 Wear leather gloves while working with rubbish or stored materials;

 Avoid walking outside at night without a light;

 Do not try to capture or handle snakes or scorpions, even after a bite;

and,

 Do not consume alcohol or mind-altering drugs where snakes or

scorpions may be present.

Figure 4.1 – Cobra Figure 4.2 - Krait

Figure 4.3 Russels Viper

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4.9 Heat Stress

High air temperatures, as are experienced in the Gujarat region, can put stresses
on workers’ bodies. Anyone living in a hot climate is potentially at risk and in
particular those working outdoors in direct sunlight. Heat stress occurs when the
body cannot cope with excessive heat. High heat conditions can cause the
body's internal temperature to rise. When bodies overheat, heat stress occurs,
sometimes with serious or even fatal results.

Conditions that can affect worker’s body temperature include:

 Air temperature;
 Air humidity;
 Physical activity;
 Time spent working;
 Rest and recovery time between work periods;
 Fluid intake; and,
 General health conditions of the worker.

Types of heat stress include:

 Sunburn;
 Heat rash;
 Heat cramps;

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 Heat exhaustion; and,

 Heat stroke.

Heat cramps in the arms, legs or stomach muscles are danger signals for the
onset of heat exhaustion and they may be experienced after work finishes.
Heat exhaustion and heat stroke can be the most serious forms of heat
stress and should be treated immediately.

Symptoms and first aid for heat stress are provided in Annex C.

4.10 Emergency Medical Aid Preparation

Each Niko work site must be prepared for medical emergencies as follows:

 Posting emergency contact telephone numbers and/or radio numbers

in an accessible central location;

 The provision of sufficient trained first aid workers and/or medical staff
at the work site;

 The provision of adequate emergency first aid and/or medical supplies

and equipment at the work site.

4.11 Food Preparation Sanitation and Accommodation Hygiene

Controlling health hazards where we eat and live is just as important as

controlling hazards where we work. The purpose of this section is to establish
the minimum requirements for sanitation and hygiene procedures and
practices at Niko accommodation and eating facilities.

4.11.1 Responsibilities
It is the responsibility of all workers to comply with this procedure and it is the
responsibility of all supervisors to enforce its compliance.

4.11.2 Kitchen and Dining

All kitchen and dining room workers must wear clean clothing and maintain a
very high level of personal hygiene. The following are key points must be
adhered to:

 Fingernails must be kept trim and clean.

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 Hands must be washed with soap and water just before starting shift and
hands shall be washed with soap and water after visiting the toilet.
FREQUENT hand washing during their shift shall be encouraged.

 Workers shall bathe or shower and shave previous to starting their shift.

 Workers shall change into fresh laundered work clothing before each shift.

 Food handlers shall wear hair restraints throughout their shift.

4.11.3 Camp Accommodations

Clothes washing facilities or laundry service shall be provided or arranged.

Laundry service must be provided at least every 2 days.

Toilet facilities should be cleaned and sanitized daily. If it is a common use

facility, ie. more than four people use the same facility, then cleaning is
required more often to ensure sanitary conditions. A continuous supply of
toilet paper is required. A sign shall be installed stating “Now Wash Your
Hands”, over all urinals and in all bathroom stalls. Cloth towels should be
replaced with disposable towels or air driers for hands.

Beds must be made daily.

Clean linen should be provided on a routine basis (at least every 5 days) or
when a change of occupancy occurs in a bed.

Change rooms and bathing/shower facilities must be kept clean and sanitized
and supplied with continuous clean toweling.

Housekeeping personnel must bathe or shower daily and change into clean
work clothing daily.

The Head –Hazira Asset or designate shall on a weekly basis, conduct an

inspection of the general use facilities and inspect the living quarters at least
monthly for cleanliness and order. These inspections should be documented
and retained on file, using the attached checklists.

4.11.4 Medical Requirements – Food Handlers

The following are requirements for all food handlers:

 A complete medical before being allowed to commence work.

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 A complete medical every 3 months after starting at the work site.

 Medicals are to include:

 testing for any communicable diseases
 annual chest x-ray
 immunization as required for the work area
 medical history
 serology testing
 stool and urine testing.

 Additional medical testing is required if a food handler exhibits signs of

illness, such as open sores, blister, fever, coughing, weight loss, diarrhea,
jaundice or persistent ailments.

 All reports and certificates on the health of any food handler on site shall be
filed on site.

 Any food handler determined to have a communicable disease must have

three successive negative tests before returning to the work site.

4.11.5 Medical Requirements – Housekeeping Staff

The following are requirements for all housekeeping staff:

 A complete medical before coming to the work site.

 A complete medical after 1 year working at the site.

 A new medical is required if he is experiencing severe illness symptoms

such as those itemized for food handlers.

4.12 Deep Vein Thrombosis (DVT)

Niko staff, contractors, and others who travel long distances by air or ground
may be at risk for DVT.

A deep vein thrombosis (DVT) is a blood clot (thrombus) that develops in a

deep vein, usually in the leg. This can happen if the vein is damaged or if the
flow of blood slows down or stops. Deep vein thrombosis can cause pain in
the leg, and can lead to complications if it breaks off and travels in the
bloodstream to the lungs.

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4.12.1 Where do DVTs Happen?

There are two types of veins in the legs: deep and superficial (see Figure 4.3).
The deep veins pass through the centre of the leg, surrounded by the
muscles. It’s here that DVTs most often develop. Less commonly DVTs occur
in the deep veins of the arm or pelvis.

4.12.2 Who Gets a DVT?

Certain factors make a DVT more likely to occur. They are more common in
people aged over 40 and in people who are obese, or who have already had a
DVT. Several inherited conditions make the blood more likely to clot than
usual, increasing the risk. Other factors include:

 prolonged bed rest, (immobility);

 major injuries, or paralysis;
 surgery, especially if it lasts more than 30 minutes, or involves the leg
joints or pelvis;
 cancer and its treatments, which can cause the blood to clot more
easily;
 long-distance travel, because of prolonged immobility. It is unclear
whether or not air travel is more risky than other long journeys - for
example by car or coach;
 pregnancy and childbirth - related to hormone changes that make the
blood clot more easily and because the fetus puts added pressure on
the veins of the pelvis. There is also risk of injury to veins during
delivery or a caesarean. The risk is at its highest just after childbirth;
 taking a contraceptive pill that contains estrogen. Most modern pills
contain a low dose, which increases the risk by an amount that is
acceptable for most women;
 hormone replacement therapy (HRT). For many women, the benefits
outweigh the increase in risk; or,
 other circulation or heart problems .

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Figure 4.3 The Main Leg Veins

4.12.3 Problems Caused by a DVT

A DVT below the knee is unlikely to cause complications and may only need
to be monitored. But when a clot forms in or above the knee, there is a risk
that it will break away and travel up the vein to block a blood vessel in the
lung. This is called a pulmonary embolism (PE). Depending on the size of the
clot, it can be a life-threatening condition. But with appropriate treatment, it is
rare for a DVT to lead to a pulmonary embolism.

A DVT can damage the valves in the vein, so that instead of flowing upwards,
the blood pools in the lower leg. This is called post-thrombotic syndrome, and
can result in pain, swelling, discolouration and sores on the leg.

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4.12.4 Symptoms of a DVT

When a clot forms, it can either partially or totally block the blood flow in that
vein. Symptoms of a DVT can include:

 swelling of the leg

 warmth and redness of the leg
 pain that is noticeable, or worse when standing or walking

These are not always a sign of a DVT, but anyone who experiences them
should contact a doctor immediately.

4.12.5 Symptoms of Pulmonary Embolism

These include shortness of breath; chest pain which may be worsened by

deep breaths; and coughing up phlegm, possibly flecked with blood.

Anyone with these symptoms should seek emergency medical treatment.

4.12.6 Diagnosing a DVT

If a DVT is suspected, the doctor will take a full medical history and carry out
a physical examination. Tests that also may be required include:

 the clotting properties of the blood

 an ultrasound scan
 venography – using X-rays to show the flow of blood when special dye
is injected into the veins.

4.12.7 Treating a DVT

Treatment aims to prevent:

 the clot becoming larger

 the blood clot breaking loose and travelling to the lungs
 new clots from forming
 post-thrombotic syndrome

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4.12.8 General Preventive Advice

Anyone who feels they are at high risk of developing a DVT should seek
medical advice. There are measures anybody can take to help prevent a DVT:

 exercise the legs regularly – take a brisk 30-minute walk every day
 maintain a weight that's appropriate for your height
 avoid sitting or lying in bed for long periods of time without moving the
legs
 women, particularly those over the age of 35, should consider the risks
and benefits of taking the contraceptive pill

4.12.9 Preventive Measures for Travelers

Although the added risk of developing a DVT caused by traveling appears to

be low, it can be reduced even further by exercising the legs at least once
every hour during long-distance travel. This means taking regular breaks if
driving, or walking up and down the aisle of a coach, train or plane.

The muscles of the lower legs (which act as a pump for the blood in the veins)
can be exercised while sitting by pulling the toes towards the knees then
relaxing, or by pressing the balls of the feet down while raising the heel.

Other preventive measures:

 don't take sleeping pills. These cause immobility, increasing the risk of
DVT
 wear loose-fitting clothing
 keep the legs uncrossed
 keep hydrated by drinking normally (urine should be no darker than a
pale yellow). Avoid alcohol to prevent dehydration
 wear graduated compression stockings (TEDs). This is particularly
important for travelers who have other risk factors for DVT

Anyone who develops swelling or pain in the leg, or breathing problems after
traveling should seek medical advice urgently.

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4.13 Niko Tuberculosis Protocol

4.13.1 TB Facts

Tuberculosis (TB) is a contagious disease. Like the common cold, it spreads

through the air. Only people who are sick with TB in their lungs are infectious.
When infectious people cough, sneeze, talk or spit, they propel TB germs,
known as bacilli, into the air. A person needs only to inhale a small number of
these to be infected.

Left untreated, each person with active TB disease will infect on average
between 10 and 15 people every year. But people infected with TB bacilli will
not necessarily become sick with the disease. The immune system "walls off"
the TB bacilli which, protected by a thick waxy coat, can lie dormant for years.
When someone's immune system is weakened, the chances of becoming sick
are greater.

4.13.2 Drug Resistant TB

Until 50 years ago, there were no medicines to cure TB. Now, strains that are
resistant to a single drug have been documented in nearly every country;
what is more, strains of TB resistant to all major anti-TB drugs have emerged.
Drug resistant TB is caused by inconsistent or partial treatment, when patients
do not take all their medicines regularly for the required period because they
start to feel better, because doctors and health workers prescribe the wrong
treatment regimens, or because the drug supply is unreliable. A particularly
dangerous form of drug-resistant TB is multidrug-resistant TB (MDR-TB),
which is defined as the disease caused by TB bacilli resistant to at least
isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-
TB are high in some countries, especially in the former Soviet Union, and
threaten TB control efforts.

From a public health perspective, poorly supervised or incomplete treatment

of TB is worse than no treatment at all. When people fail to complete standard
treatment regimens, or are given the wrong treatment regimen, they may
remain infectious. The bacilli in their lungs may develop resistance to anti-TB
medicines. People they infect will have the same drug-resistant strain. While
drug-resistant TB is generally treatable, it requires extensive chemotherapy
(up to two years of treatment) that is often prohibitively expensive (often more
than 100 times more expensive than treatment of drug-susceptible TB), and is
also more toxic to patients.

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4.13.3 NIKO TB Protocol

As India, and Gujarat in particular, have a relatively high incidence of this

disease, Niko areas of operations are at some risk of an infected worker with
active TB infecting other Niko and Niko contractor staff. This is especially true
where workers are in close contact with each other, such as the Hazira
Offshore Drilling/Production Platform (HODP).

Therefore, supervisors, and medical and HSE staff are to be watchful for
workers with a persistent, productive cough.

If such a worker is identified the following steps are recommended:

1. The worker should immediately be sent to Niko or Rig medical

staff to determine if the cough is suspected TB;
2. If TB is suspected, the worker will, as soon as possible, be
transported to an SOS approved hospital for sputum smear
testing and X-ray.
3. If tests prove positive, the infected worker will begin a
supervised treatment regime as per competent medical
instruction. The worker will not return to work until he/she is
no longer contagious.
4. Close work contacts will be identified by Niko/Rig medical
staff. These close contacts will be instructed to seek proper
medical advice on their next off-work rotation for testing and a
possible preventative treatment regime with an anti TB drug
such as isoniazid.
5. Close contacts will be recorded and monitored by Niko/Rig
medical staff for signs of active infection.

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5.0 Checking and Corrective Action

5.1 Inspections

All worksites are inspected on a daily, weekly and monthly basis according to
the SHEMS program. These inspections are the primary means of identifying
occupational health hazards.

Kitchen and dining areas shall be inspected daily by designated Niko Staff
and/or medical staff.

Any concerns regarding kitchen or dining areas identified by the inspector that
require immediate correction, will be cleared as quickly as possible.

The following kitchen and dining guidelines must be followed:

 Insects should be controlled and kept out of the food area;

 The dining room and kitchen shall be kept in an orderly, clean and
sanitary condition at all times;

 The floors of the dining room shall be cleaned twice daily (as a minimum)
with an appropriate cleansing and sanitizing agent;

 Food shall not be stored on the floor, but raised off the floor on pallets;

 All vegetables shall be fresh, stored properly and any eaten raw must be
cleaned with solution of disinfectant according to manufacturer’s
recommendations;

 Meat shall be defrosted in a Chiller (not at room temperature). Separate

knife sets are to be used for meat handling;

 Leftover food shall be covered completely and stored at the appropriate

temperature. Batches of food should not be made up to last more than
one day;

 Each kitchen or dining room shall be equipped with a fire blanket and at
least one portable CO2 fire extinguisher. A deluge system shall be
installed above the grill, stove and deep frying equipment;

 Walk-in freezers shall be equipped with a working audible alarm (should

the door become stuck closed), as well as outside temperature gauges;

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 Water coolers or cans shall be stored in containers with lids, and disposed
of in a proper manner;

 Garbage and refuse shall be stored in containers with lids, and disposed
of in a proper manner;

 Dishes and cooking utensils shall be washed and sanitized after each
use. Large items that cannot be sanitized must be washed with a
bactericidal detergent. Double sink washing method is to be used;

 Dish cloths, towels, etc. shall be changed and laundered daily;

 No smoking is allowed in the kitchen or dining room;

 A documented inspection of facilities for cleanliness and order shall be

carried out by the Site Manager or designate at least weekly;

 No canned goods that are bent or damaged are to be used;

 The ice-cream machines (where applicable) must be cleaned according to

the manufacturer’s specifications;

 Dry goods are to be stored in bins with lids;

 Infested (e.g. insects, rodents, birds, reptiles) foods or dry goods must be
immediately removed and destroyed;

 All kitchen working tables must be stainless steel;

 A hand-washing sink plus hand soap and paper towels or electric hand
dryer must be provided in the kitchen;
 Food handlers should be provided with first aid training with emphasis on
choking;
 Food waste shall be disposed of separately from other wastes;
 Head/hair coverings and uniforms are required for all food handlers;
 Unpackaged food items on shelves, in storage areas and refrigerators
shall be labeled; and,
 Use of an automatic dishwasher is highly recommended due to the
increase water temperatures achievable.

The Hygiene Checklist at Annex A may be used for this purpose.

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5.2 Notice of Disease

THE Head Hazira Asset must, according to Indian Regulation, within three
day of his being informed of, an occupational disease give notice thereof in
Form V of OMR to the District Magistrate, the Chief Inspector, the Regional
Inspector and Inspector of Mines (Medical). See Annex E.

6.0 Management Review

Niko Management, in conjunction with the Head Hazira Asset, shall on a

regular basis, review all occupational health aspects, including injury and
illness reports, and Accident Investigation Reports, to ensure continuing
suitability, adequacy and effectiveness occupational health hazard control.
Management review shall address the need for changes to occupational
health policy, objectives, program, or procedures due to change in
circumstances or failure to meet objectives.

Niko uses a formal process for monitoring occupational health in the company
through performance measurements and reporting systems. The process is
generally includes a comparison and assessment of stated occupational
health objectives with actual results. Niko has developed health audit and
assessment protocols, inspection procedures and identified key performance
indicators based on relevant Standards, legislative requirements and
recognized industry practices to assist with the measurement and assessment
of occupational health performance. The results of occupational health
performance measurements and assessments are provided to Niko
Management for review and, where necessary, action. The aim is continuous
improvement of the SHE program.

6.1 Performance Measurement

Niko employs the following in measuring occupational health performance:

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Figure 6.1 – Illness Incidence Rate

IIR = # Work Illness/injury x 200,000

total man hours worked

• 200,000 represents average of 2000 man

hours per worker, per year, for 100 full-time
employees.

Figure 6.2 Fatalities Incidence Rate

FIR = # of fatalities x 200,000

man hours worked

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7.0 Continuous Improvement

The primary mechanisms to ensure continuous improvement of the Niko
Occupational Health and Industrial Hygiene Program are contained in the
Management Review provisions of this document. In addition to these
provisions, every Niko worker, supervisor and manager shall consider it their
daily responsibility to implement, maintain, monitor, and continuously improve
occupational health in this company.

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Annex A

Hygiene Checklist For

Food Handling, Kitchen and Dining

Prepared by: Date:

Sat. = When checked and satisfactory.

Unsat = When checked and is unsatisfactory, requires comment
and action to be taken. Must be documented and filed.
Sat Unsat
Goods Receiving Area
Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Comments _______________________________
________________________________________

Garbage Area
Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure. .......................................... ( ) ( )
Insects absent .......................................................... ( ) ( )
Rodents absent ........................................................ ( ) ( )
Collection frequency ................................................ ( ) ( )
Comments: _______________________________
________________________________________

Washing-up Area
Maintenance of fittings ............................................. ( ) ( )
Cleanliness of fittings ............................................... ( ) ( )
Pre-scraping carried out........................................... ( ) ( )
Machine washer provided ........................................ ( ) ( )
Machine temperatures adequate ............................. ( ) ( )
Rinse temperatures above 85oC .............................. ( ) ( )
Equipment sanitised by chemical or heat
if hand washed ......................................................... ( ) ( )
Separate hand-washing facilities provided ............... ( ) ( )
Comments: _______________________________
________________________________________

Clean Equipment and Utensil Storage

Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Maintenance of fittings ............................................. ( ) ( )
Cleanliness of fittings ............................................... ( ) ( )
Stored equipment protected from dust and dirt. ....... ( ) ( )

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Proper wipe/polish cloths available and used .......... ( ) ( )

Separate hand-washing facilities provided ............... ( ) ( )
Comments _______________________________
________________________________________

Bulk Dry Store

Maintenance of Structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Maintenance of fittings ............................................. ( ) ( )
Cleanliness of fittings ............................................... ( ) ( )
Cleanliness of stored goods ..................................... ( ) ( )
Comments _______________________________
________________________________________

Cold Rooms and Refrigerators

Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Cleanliness of shelves ............................................. ( ) ( )
Food in cold room stored at least - 10oC .................. ( ) ( )
Raw and cooked foods adequately separated. ........ ( ) ( )
Thermometer provided and in working order ........... ( ) ( )
Door seals clean and in good condition ................... ( ) ( )
Comments _______________________________
________________________________________

Freezers
Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Cleanliness of shelves. ............................................ ( ) ( )
Food stored at least 30 cm above floor .................... ( ) ( )
Raw and cooked foods adequately separated ......... ( ) ( )
Door seals clean and in good condition ................... ( ) ( )
Frozen foods thawed in cold room before use ......... ( ) ( )
Temperature below -180C ........................................ ( ) ( )
Thermometer provided and in working order ........... ( ) ( )
Comments: _______________________________
________________________________________

Kitchen
Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Maintenance of fittings ............................................. ( ) ( )
Cleanliness of fittings ............................................... ( ) ( )
Sink provided ........................................................... ( ) ( )

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Separate hand washing facilities.............................. ( ) ( )

Comments: _______________________________
________________________________________

Beverage/Ice Area
Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Maintenance of fittings ............................................. ( ) ( )
Cleanliness of fittings ............................................... ( ) ( )
Water supply to ice machine satisfactory ................. ( ) ( )
Ice scoop stored satisfactorily .................................. ( ) ( )
Cold drinks machine regularly dismantled
and sanitised ............................................................ ( ) ( )
Comments: _______________________________
________________________________________

Toilets
Maintenance of structure ......................................... ( ) ( )
Cleanliness of structure ........................................... ( ) ( )
Maintenance of fittings ............................................. ( ) ( )
Cleanliness of fittings ............................................... ( ) ( )
Aerially disconnected from food production area ..... ( ) ( )
Hot and cold water provided .................................... ( ) ( )
Soap and nail brushes provided .............................. ( ) ( )
Single user towels provided ..................................... ( ) ( )
“NOW WASH YOUR HANDS” sign displayed ......... ( ) ( )
Comments: _______________________________
________________________________________

Miscellaneous Overall
Structure basically sound ......................................... ( ) ( )
Premises fly-proofed ................................................ ( ) ( )
Premises rodent/animal proofed .............................. ( ) ( )
Full air-conditioning provided ................................... ( ) ( )
Lighting adequate .................................................... ( ) ( )
Pest control satisfactory ........................................... ( ) ( )
Ultraviolet insect killers installed and maintained ..... ( ) ( )
Water supply safe for drinking ................................. ( ) ( )
Date of last samples taken ___________________
Power supplies properly maintained ........................ ( ) ( )
Cutting and chopping boards sanitised .................... ( ) ( )
Comments: _______________________________
________________________________________

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Procedures
Written cleaning schedule in use ............................. ( ) ( )
Work-tops, cutting boards and other small
equipment sanitised after use .................................. ( ) ( )
Re-usable dry stores items examined before re-use ( ) ( )
Stock rotation of perishable items ............................ ( ) ( )
Perishable out of refrigeration to a minimum ...........
Frozen meat/fish/poultry defrosted in the refrigerator ( ) ( )
Rice to be used is freshly cooked ............................ ( ) ( )
“NO SMOKING” sign in food production area .......... ( ) ( )
“NO SMOKING” in food production areas enforced . ( ) ( )
Toxic items (cleaning materials) labelled correctly ...
and stored in proper places ..................................... ( ) ( )
Contents of opened food cans transferred to
proper containers once opened ............................... ( ) ( )
Comments: _______________________________
________________________________________

Staff
Appearance ............................................................. ( ) ( )
Protective clothing and uniforms .............................. ( ) ( )
Protective clothing and uniforms properly laundered ( ) ( )
Head coverings ........................................................ ( ) ( )
Lighting adequate .................................................... ( ) ( )
Medically examined prior to employment and .........
then at least quarterly .............................................. ( ) ( )
Stool tests included in medical examination ............ ( ) ( )
Infected food handlers excluded from work
until cleared ............................................................. ( ) ( )
Typhoid, hepatitus and cholera vaccinations compulsory ( ) ( )
Comments: _______________________________
________________________________________

Corrective Actions to be Taken:

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Annex B

Information on Infectious Diseases

Diseases Transmitted by Insects

Many diseases are transmitted through the bite of infected insects such as
mosquitoes, flies, fleas, ticks and lice. In general, workers should protect
themselves from insect bites by wearing proper clothing; applying insect
repellent to exposed skin and clothing; avoiding, to the extent possible, high
risk situations. Some of the common diseases that can be transmitted by
insect bites include:

Malaria

Malaria is a serious, parasitic infection transmitted to humans by a mosquito.

Mosquitoes generally bite at night. Symptoms include: fever and flu-like
symptoms; chills; general aches; and, tiredness. If left untreated, malaria can
cause anemia, kidney failure, coma and death. Drugs such as chloroquine,
paludrine, mefloquine and doxycycline are often used as anti-malarial drugs.
Some drugs are not effective for certain types of mosquitoes or for certain
types of malaria. Workers must consult with a knowledgeable doctor to
determine which drug is required and most effective for the area in which they
work.

Recent reports suggest that as many as 32,000 cases of malaria are reported
in Gujarat each year. Untreated, malaria can have serious consequences.

There are four types of human malaria Plasmodium vivax,

P. malariae, P. ovale and P. falciparum. P. vivax and P. falciparum are the
most common and falciparum the most deadly type of malaria infection.

The malaria parasite enters the human host when an infected Anopheles
mosquito takes a blood meal. Inside the human host, the parasite undergoes
a series of changes as part of its complex life-cycle. Its various stages allow
plasmodia to evade the immune system, infect the liver and red blood cells,
and finally develop into a form that is able to infect a mosquito again when it
bites an infected person. Inside the mosquito, the parasite matures until it
reaches the sexual stage where it can again infect a human host when the
mosquito takes her next blood meal, 10 to 14 or more days later.

Malaria symptoms appear about 9 to 14 days after the infectious mosquito

bite, although this varies with different plasmodium species. Typically, malaria
produces fever, headache, vomiting and other flu-like symptoms.

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Fever occurring in a traveler within three months of leaving a malaria-endemic

area is a medical emergency and should be investigated urgently. Early
diagnosis and appropriate treatment can be life-saving. Falciparum malaria
may be fatal if treatment is delayed beyond 24 hours. A blood sample should
be examined for malaria parasites. If no parasites are found in the first blood
film but symptoms persist, a series of blood samples should be taken and
examined at 6–12-hour intervals.

Prevention is the best defense. Preventive measures include:

 Minimizing stagnant water

 Wearing DEET insect repellant products in areas where exposure is
likely to occur (particularly after sunset)
 Wearing long-sleeve shirts and long pants
 Taking anti-malarial drugs as prescribed by a physician.

Dengue Fever

Dengue Fever is primarily a viral infection transmitted by mosquito bites.

Dengue carrying mosquitoes are most active around early evening and early
morning (dusk and dawn) and are frequently found in or around human
habitations. The illness is flu-like and characterized by sudden illness: high
fever, severe headaches, joint and muscle pain and rash. The rash appears 3
- 4 days after the onset of fever. Since there is no vaccine or specific
treatment available, prevention is most important.

Yellow Fever

Yellow Fever is a viral disease found in parts of Africa and Asia. It is

transmitted to humans by a mosquito bite. Yellow fever occurs in certain
jungle locations of Africa and Asia where the virus is maintained in a cycle
among forests, mosquitoes, and monkeys. Infection in desert areas is rare.
General precautions to avoid mosquito bites should be followed. These
include the use of insect repellent and protective clothing.

Other Insect Carried Diseases

Other diseases that can be spread by mosquitoes, sand flies, black flies or
other insects, particularly in rural areas, include: filariasis and chikungunya
(mosquitoes); leishmaniasis (sand fly); typhus (lice); and, plague (flies).

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Diseases Transmitted Through Food and Water

Food and waterborne diseases are the number one cause of illness to camp
workers. Food and waterborne diseases can be caused by viruses, bacteria
or parasites which are found universally. Infections may cause diarrhea and
vomiting (typhoid fever, cholera and parasites); liver damage (hepatitis); or
muscle paralysis (polio).

Cholera

Cholera is an acute intestinal infection. Cholera occurs where sanitary

conditions are less than optimal.

Most infected persons have no symptoms or only mild diarrhea. However,

persons with severe disease can die within a few hours after onset due to loss
of fluid and salts through profuse diarrhea and, to a lesser extent, through
vomiting. The organism that causes the illness is named Vibrio cholerae type
O:1 or O:139. During epidemics, it is spread by ingestion of food or water
contaminated directly or indirectly by feces or vomit from infected persons.

The best protection is to avoid consuming food or water that may be

contaminated with feces or vomit from infected persons. The organism can
grow well in some foods, such as rice, but it will not grow or survive in very
acidic foods, including carbonated beverages, and is killed by heat.

Treatment for cholera involves rehydration with oral rehydration solution or, in
the most severe cases, with intravenous solutions until the patient is able to
ingest fluids. Treatment with antibiotics (usually tetracycline or doxycycline)
will decrease the duration of illness and the excretion of live cholera bacteria
and will decrease the volume of fluid lost but is not necessary for successful
treatment.

A cholera vaccine is available but normally is not recommended. Only 50% of

those who take the vaccine develop immunity to cholera, and this immunity
lasts only a few months.

Typhoid Fever

Typhoid fever is a life-threatening illness caused by the bacterium Salmonella

typhi. It affects about 12.5 million persons each year. Typhoid fever can be
prevented and can usually be treated with antibiotics.

How is typhoid fever spread? Salmonella typhi lives only in humans. Persons
with typhoid fever carry the bacteria in their bloodstream and intestinal tract.
In addition, a small number of persons, carriers, recover from typhoid fever

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but continue to carry the bacteria. Both ill persons and carriers shed S. typhi
in their feces (stool).

You can get typhoid fever if you eat food or drink beverages that have been
handled by a person who is shedding S. typhi or if sewage contaminated with
S. typhi bacteria gets into the water you use for drinking or washing food.
Therefore, typhoid fever is more common in areas of the world where hand
washing is less frequent and water is likely to be contaminated with sewage.

Once S. typhi bacteria are eaten or drunk, they multiply and spread into
bloodstream. The body reacts with fever and other signs and symptoms.

Hepatitis A

Hepatitis A is an enterically transmitted viral disease that is highly endemic

throughout the developing world but is of low endemicity in countries
elsewhere. In developing countries, Hepatitis A virus (HAV) is usually
acquired during childhood, most frequently as asymptomatic or mild infection.
Transmission may occur by person-to-person contact; from contaminated
water, ice, or shellfish harvested from sewage-contaminated water; or from
fruits, vegetables, or other foods that are eaten uncooked but may become
contaminated during handling. Hepatitis A virus is inactivated by boiling or
cooking to 85° C for one minute; cooked foods may serve as vehicles for
disease if they contaminated after cooking. Workers should avoid drinking
water (or beverages with ice) of unknown purity and eating uncooked shellfish
uncooked fruits or vegetables that are not peeled or prepared by a trusted
source.

Hepatitis A vaccine or immune globulin (IG) is available.

Schistosomiasis

Schistosomiasis is caused by flukes whose complex life cycles specific fresh-

water snail species as intermediate hosts. Infected snails release large
numbers of minute free-swimming larvae (cercariae) that capable of
penetrating the unbroken skin of the human host. Even exposures to
contaminated water can result in infection.

Clinical manifestations of acute infection can occur within 2–3 weeks of

exposure to cercariae-infested water, but most acute infections asymptomatic.
The most common acute symptoms are fever, lack of appetite, weight loss,
abdominal pain, weakness, headaches, joint and muscle pain, diarrhea,

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nausea, and cough. Rarely, the central nervous system can be involved to
produce seizures or transverse myelitis as a result of mass lesions of the
brain or spinal cord. Chronic infections can cause disease of the lung, liver,
intestines, and/or bladder. Many people who develop chronic infections can
recall no symptoms of acute infection. Diagnosis of infection is usually
confirmed by serologic studies or by finding schistosome eggs on microscopic
examination of stool and Schistosome eggs may be found as soon as 6–8
weeks after exposure but are not invariably present. Bathing with
contaminated fresh water can also transmit infection. Human schistosomiasis
cannot be acquired by wading or swimming in salt water (oceans or seas).

This infection is estimated to occur worldwide among some 200 million

people. The countries where schistosomiasis is most prevalent include Brazil;
Egypt and most of sub-Saharan Africa; and southern China, the Philippines,
and Southeast Asia.

No vaccine is available. At this time, no available drugs are known to be

effective as chemoprophylactic agents. However, safe and effective oral drugs
are available for the treatment of schistosomiasis.

In problem areas, heating bathing water to 50°C (122° F) for 5 minutes or

treating it with iodine or chlorine in a manner similar to the precautions
recommended for preparing drinking water will destroy cercariae and make
the water safe. Thus, swimming in adequately chlorinated swimming pools is
virtually always safe, even in endemic countries.

Leptospirosis

The monsoon period is the season for spread of Leptospirosis in some rural
areas in Gujarat. This disease is endemic to these areas.

Leptospirosis is a bacterial disease that affects humans and animals. It

is caused by bacteria (genus Leptospira). In humans it can cause a wide
range of symptoms; some infected persons may have no symptoms at all.

Symptoms of leptospirosis include high fever, severe headache, chills,

muscle aches, and vomiting, and may include jaundice (yellow skin and
eyes), red eyes, abdominal pain, diarrhea, or a rash. If the disease is
not treated, the patient could develop kidney damage, meningitis
(inflammation of the membrane around the brain and spinal cord), liver
failure, and respiratory distress. In rare cases death occurs.

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Many of these symptoms can be mistaken for other diseases. Leptospirosis

is confirmed by laboratory testing of a blood or urine sample.

Outbreaks of leptospirosis are usually caused by exposure to water

contaminated with the urine of infected animals. Many different kinds of
animals carry the bacterium; they may become sick but sometimes have no
symptoms. Leptospira organisms have been found in cattle, pigs, horses,
dogs, rodents, and wild animals. Humans become infected through contact
with water, food, or soil containing urine from these infected animals.
This may happen by swallowing contaminated food or water or through skin
contact, especially with mucosal surfaces, such as the eyes or nose, or
with broken skin. The disease is not known to be spread from person to
person.

The time between a person's exposure to a contaminated source and

becoming
sick is 2 days to 4 weeks. Illness usually begins abruptly with fever and
other symptoms. Leptospirosis may occur in two phases; after the first
phase, with fever, chills, headache, muscle aches, vomiting, or diarrhea,
the patient may recover for a time but become ill again. If a second phase
occurs, it is more severe; the person may have kidney or liver failure or
meningitis. This phase is also called Weil's disease.

The illness lasts from a few days to 3 weeks or longer. Without treatment,
recovery may take several months.

Leptospirosis occurs worldwide but is most common in temperate or tropical

climates. It is an occupational hazard for many people who work outdoors
or with animals, for example, farmers, sewer workers, veterinarians, fish
workers, dairy farmers, or military personnel. It is a recreational hazard
for campers or those who participate in outdoor sports in contaminated
areas and has been associated with swimming, wading, and rafting in
contaminated lakes and rivers.

Leptospirosis is treated with antibiotics, such as doxycycline or

penicillin, which should be given early in the course of the disease.
Intravenous antibiotics may be required for persons with more severe
symptoms.

The risk of acquiring leptospirosis can be greatly reduced by not swimming

or wading in water that might be contaminated with animal urine.
Protective clothing or footwear should be worn by those exposed to
contaminated water or soil because of their job.

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Diseases Transmitted Person to Person

Hepatitis B

Hepatitis B is a viral infection with clinical manifestations including anorexia,

abdominal discomfort, nausea and vomiting, often progressing to jaundice.
Severity ranges from cases detectable only by function tests to fatal cases of
acute hepatic necrosis.

Hepatitis B virus (HBV) is primarily transmitted through activities that result in

exchange of blood or blood-derived fluids, as well as sexual activity, either
heterosexual or homosexual, between an infected and a susceptible person.
Principal activities that may result in blood exposure include work in health-
care fields (medical, dental, laboratory or other) which entail direct exposure
to human blood; receipt of blood transfusions that have not been screened for
HBV; and having medical, or other exposure to needles (e.g., acupuncture,
tattooing, or injecting drug use) that have not been appropriately sterilized. In
some cases, open skin lesions in children or adults, due to factors such as
impetigo, scabies, and scratched insect bites, may play a role in disease
transmission if direct exposure to wounds occurs.

The prevalence of chronic HBV infection is high (> 8%) in socioeconomic

groups in certain areas of Africa. Hepatitis B vaccination is available.

AIDS

AIDS is a serious disease, first recognized as a distinct syndrome 1981. This

syndrome represents the late clinical state of infection with the human
immunodeficiency virus (HIV), resulting in progressive damage to the immune
system and in life-threatening infectious and non-infectious complications.
AIDS and HIV infections occurs world wide.

The risk of HIV infection for workers is generally low. Factors to consider
when assessing risk include the extent of direct contact with blood or
secretions and of sexual contact with potentially infected persons. No vaccine
is available to prevent infection with HIV.

HIV infection is preventable. HIV is transmitted through sexual intercourse,

through needle- or syringe-sharing, by medical use of blood, blood
components, or organ or tissue transplantation. HIV is not transmitted
through contact, air, food, water, contact with inanimate objects, or
mosquitoes or other insects. .

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Annex C

First Aid Treatment for

Snake Bites, Scorpion Stings and Insect Bites and Stings

If a person is bitten or stung, there are some general principles of first aid and
medical management that apply throughout the world. First aid measures
should prevent absorption of the venom. First aid advice will vary from place
to place and may include folk cures, treatments of unproven value or even
detrimental treatments. The following recommendations maybe considered
for all types of snake, scorpion or insect venom poisoning:

Rest: Get the casualty away from the snake, scorpion or insect and avoid a
second bite or sting. The casualty should be placed at rest and given
reassurance. Excitement and physical activity increase blood flow and
enhance absorption and circulation of the venom.

Extremity (hand, arm, foot and leg) Immobilization: Over 95% of

snakebites occur on an extremity. Immobilize the affected part and keep it at
or below the level of the heart.

Incision and suction, cryotherapy, electric shock and other "home remedies"
are of no benefit and each of these remedies can be harmful.

Do Not:

 Cut or suck the wound where the bite occurred;

 Apply a tourniquet.

Snub Band: Apply a broad constricting band, but not a tourniquet, 2-4 inches
above the bite (but not around the joint). The constricting band should be left
in place until antivenin therapy is provided. If a non-elastic constricting band
is used, there may be a requirement to occasionally readjust the tension.

Transport: Transport the casualty to the nearest medical facility as quickly

as possible.
Do not spend more than a few minutes on first aid measures because the top
priority following a bite or sting is to get the casualty to a source of medical care.
Early and adequate administration of antivenin is most important for casualty
recovery from snake, scorpion or insect venom poisoning.

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Annex D

Supplementary Information – Cobras

Nikos’ India operations span the range of several types of venomous snakes,
the various species of cobra being the most common.

To many people, the cobra is the quintessential venomous snake. Cobras

discussed in this annexn include species in the genus Naja and other similar
venomous snakes, such as Ophiophagus hannah (king cobra), Hemachatus
haemachatus (ringhals), Walterinnesia aegyptia (desert black snake),
Boulengerina species (water cobras), and Pseudohaje species (tree cobras).

Most cobras are large snakes, 1.2-2.5 m in length. The king cobra, which may
reach 5.2 m, is the largest venomous snake in the world. Cobras live
throughout most of Africa and southern Asia. Their habitats vary. Some
species adapt readily to life in cultivated areas and around villages.

When encountered, cobras usually try to escape but occasionally defend

themselves boldly and may appear aggressive. Most of these snakes elevate
the head and spread the neck as a threat gesture. However, a number of
other snakes, venomous and non-venomous, employ this defense as well.

Most snake bites are inflicted on body extremities. Because cobras are
popular as show snakes, bites on the hands and fingers are common.

By far, rural agricultural workers, and others with outdoor jobs receive most
bites while working outdoors without protective footwear.

Not all snakebites result in envenomation. In the case of cobras, the

percentage of blank bites may be quite high, 45% in one series of 47 cases
from Malaysia. In another series, 1 of 3 snake charmers bitten by large king
cobras showed no signs of envenomation.

In addition to biting, some cobra species have a unique defense; they eject
jets of venom toward an enemy, usually at the eyes. The fangs of these
species are specially modified with the discharge orifice on the anterior face
rather than at the tip. The effective discharge range of a large snake is at least
3 m. The ringhals and certain African species of Naja are the most effective

spitters, but the spitting behavior also is observed among some Asian Naja
species.

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Pathophysiology: Cobra envenomation is an extremely variable process.

The envenomations of some species cause profound neurological
abnormalities (eg, cranial nerve dysfunction, abnormal mental status, muscle
weakness, paralysis, and respiratory arrest). With other snakes, local tissue
damage is of primary concern.

Necrosis is typical of bites by the African spitting cobras (Naja nigricollis, Naja
mossambica, Naja pallida, and Naja katiensis), Naja atra (the Chinese cobra),
Naja kaouthia (monocellate cobra), and Naja sumatrana (Sumatran spitting
cobra). Although the venoms of these cobras contain neurotoxins, necrosis
often is the chief or only manifestation of envenoming in humans.
Occasionally, a combination of neurologic dysfunction and tissue necrosis is
observed.

Cobra venoms have been studied extensively. As with all snake venoms, they
are multi-component systems whose toxins are mostly proteins and
polypeptides.

Venoms can be divided into the following categories:

 With most species, excluding some of the African spitting cobras, the
most clinically significant toxins are postsynaptic neurotoxins that
competitively bind to nicotinic acetylcholine receptors to produce
depolarizing neuromuscular blockade. One group in this category has
60-62 amino acids and 4 disulfide bridges. Another has 71-74 amino
acids and 5 disulfide bridges.
 The second venom category comprises so-called cardiotoxins, which
are actually generalized cell-membrane poisons that produce
irreversible cell depolarization. Such depolarization may cause
dysrhythmia, hypotension, and death.
 Toxins in the third category activate complement via the alternative
pathway (C3-C9 sequence).
 The fourth category is composed of enzyme toxins, such as
phospholipase A2 (variable toxicity), hyaluronidase (facilitates tissue
dispersion of other toxins), L-amino acid oxidase (gives many venoms
a characteristic yellow coloration), and acetylcholine acetylhydrolase
(unknown toxicity). Other proteolytic enzymes are found in the venom
of the king cobra.

Naja philippinensis (Philippine cobra) venom is the most toxic, with a

subcutaneous median lethal dose (LD50) of 0.14 mg/kg in mice. In
comparison, the corresponding LD50 for Naja naja (Indian cobra) venom is
0.29 mg/kg, for Naja haje (Egyptian cobra) venom is 1.75 mg/kg, for king
cobra venom is 1.73 mg/kg, and for Naja nigricollis (black-necked spitting
cobra) venom is 3.05 mg/kg.

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An additional, unique form of toxicity with some Asian and African species is
acute ophthalmia, which occurs when venom is spit into the eyes. Spitting
cobras can spit venom into a person's eyes from up to 3 m away. Immediate
and intense pain results, with blepharospasm, tearing, and blurring of vision.
Systemic toxicity does not occur with eye exposure, but corneal ulcerations,
uveitis, and permanent blindness have been reported in untreated cases.

About one half of the cases ascribed to the African spitting cobras (N
nigricollis, N mossambica, N pallida, N katiensis) showed corneal ulceration,
and some patients experienced permanent visual impairment or blindness.
Cases ascribed to the Asian spitting cobras and the African ringhals are
usually less severe.

Mortality/Morbidity: In India, the annual mortality incidence is 5.6-12.6 per

100,000 population. At one time, Burma listed snakebite as its fifth leading
cause of death. More recently, the annual mortality incidence was 3.3 per
100,000 population. Data from Thailand and Malaysia in the 1980s
demonstrate an annual mortality incidence of 0.1 per 100,000 population.

 Determining the exact contribution of cobras to overall snakebite

morbidity and mortality is difficult. In most cases, bitten individuals are
unable to identify the snake. In India, the tendency is to ascribe all fatal
or serious bites to cobras. Physicians are also likely to attribute all bites
with neurotoxic symptoms to cobras.

 In a Thai survey, cobras made up 17% of the 1145 snakes identified in

bites and were responsible for 25% of the fatalities associated with
those bites. In northern Malaysia, cobras accounted for 23 of 854 bites
in which the snake was identified. In a survey in Taiwan, cobras were
incriminated in 100 of 851 bites in which the snake was identified; none
were fatal. Cobras accounted for 2 of 95 bites on a Liberian rubber
plantation. The ringhals was responsible for 18 of 314 envenomations
in Natal. Based on patients' symptoms alone, 18 other bites in this
series were ascribed to cobras.

 King cobra bites are considered more serious than bites from other
cobra species because of the greater volumes of injected venom and
the more rapid onset of neurotoxic symptoms. Mortality is also higher.
In a series of 35 cases, 10 deaths occurred. Ringhals bites are similar
to other cobra bites but are less serious both locally and systemically.
Deaths are rare. A medical report of 4 bites by the desert black snake
described relatively mild symptoms and reported recovery without
specific treatment. Anecdotal reports of fatal bites exist. No medical
accounts of bites by water cobras or tree cobras exist. Anecdotal
evidence suggests both are dangerous.

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Sex: Because of increased exposure to snakes, men are bitten more often
than women.

CLINICAL

History: The onset of symptoms and signs following a cobra bite can be
extremely variable.

 Immediate, local pain (almost always present)

 Soft tissue swelling (may be progressive)

 Neurologic findings, which may begin early and be rapidly progressive

(in anecdotal cases, victims have suffered respiratory arrest in a matter
of minutes), or may be delayed in onset as long as 24 hours

 Alteration of mental status (eg, drowsiness, occasionally with euphoria)

 Complaints related to cranial nerve dysfunction, such as ptosis (often

one of the earliest neurotoxic findings), ophthalmoplegia, dysphagia,
and dysphasia

 Profuse salivation, nausea, vomiting, and abdominal pain

 Paresis of neck and jaw muscles and generalized muscular weakness

followed by flaccid paralysis

 Shortness of breath, respiratory failure (muscular paresis and

accumulated secretions)

 Chest pain or tightness

 Eye pain, tearing, blurred vision (with eye exposure to venom from
spitting cobras)

Physical:

 Impending respiratory failure

o Respiratory distress or weakness

o Cyanosis

 Neurologic dysfunction

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o Altered mental status

o Ptosis (may be the earliest sign of systemic toxicity)

o Generalized weakness or paralysis

 Cardiovascular collapse

o Hypotension

o Tachycardia or bradycardia

 Soft tissue edema

 Signs of necrosis usually appear within 48 hours of the bite.

o The area around the fang punctures darkens.

o Blistering may follow.

o Necrosis usually is confined to the skin and subcutaneous tissue

but may be quite extensive.

o A putrid smell is characteristic.

 Acute inflammation of the eye follows venom-spitting exposure and is

characterized by ocular congestion, edema of the conjunctiva and
cornea, and a whitish discharge.

Treatment

In India, a multi-snake antivenin is available for treatment of cobra, russel’s

viper, and krait bites, thus, positive identification of the snake is not essential.
Niko medical staff have procured sufficient quantities of this antivenin to
ensure adequate coverage for our workers.

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Annex E

Supplementary Information – Kraits

Krait
(Bungarus caeruleus) - common
(Bungarus fasciatus) - banded

I. DESCRIPTION:

 The krait is a highly venomous snake found in Southeast Asia.

There are 13 species of krait, and two prominent types of krait in
India. All kraits are nocturnal.
 The banded krait is readily identified by its alternate black and
yellow bands. Kraits also have a row of hexagonal scales along the
ridge of their back.
 The common krait is a slate-colored snake with thin white bands
that are absent in the anterior part of its body.
 Since their fangs are not very long, kraits inject their venom by
chewing. The poison affects mainly the nervous system.
 The common krait can reach a maximum length of 6 feet. The
banded krait can reach 8 feet in length.

II. GEOGRAPHICAL RANGE AND HABITAT:

 The common krait inhabits India, Pakistan and Sri Lanka.

 The common krait is essentially a snake of the plains, usually found
in open country, cultivated areas and scrub jungles at low levels.
 The banded krait is found mainly in northeastern India.

III. DIET:

 Kraits feed on small mammals, lizards, frogs and toads.

 They sometimes turn cannibalistic, and begin feeding exclusively
on snakes, often including other kraits and the cobra.

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IV. LIFE CYCLE/SOCIAL STRUCTURE:

 The female lays from 6 to 12 eggs, which she deposits in holes in

the ground or under leaves. She stays with the clutch until the
young emerge.

V. SPECIAL NOTES/ADAPTATIONS:

 Remarkably quiet and inoffensive in disposition, the krait bites only

under severe provocation.
 The venom of the banded krait is highly neurotoxic and estimated to
be 16 times as potent as that of a cobra.

IMMEDIATE FIRST AID

for bites by
Kraits
(Bungarus species)

In the event of an actual or probable bite from a Krait, execute the following
first aid measures without delay.

Snake:

1. Make sure that the responsible snake or snakes have been

appropriately and safely contained, and are out of danger of inflicting
any additional bites.

Transportation:

1. Immediately call for transportation.

Telephone:

Victim:

1. Keep the victim calm and reassured. Allow him or her to lie flat and
avoid as much movement as possible. If possible, allow the bitten limb
to rest at a level lower than the victim's heart.
2. Immediately wrap a large crepe bandage snugly around the bitten limb
starting at the site of the bite and working proximally up the limb (the
full length if possible). The bandage should be as tight as one might
bind a sprained ankle.

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3. Secure the splint to the bandaged limb to keep the limb as rigid and
unmoving as possible. Avoid bending or moving the limb excessively
while applying the splint.
4. DO NOT remove the splint or bandages until the victim has reached
the hospital and is receiving Antivenom.
5. Have the Commonwealth Serum Laboratories Tiger Snake Antivenom
ready for the emergency crew to take with the victim to the hospital.
Give them the following:
1. the available antivenom (at least 10 vials)
2. the accompanying instruction (Protocol) packet
3. the victim's medical packet (if available)

DO NOT cut or incise the bite site

DO NOT apply ice to the bite site

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Annex F

Symptoms and First Aid Treatment for Heat Stress

Symptoms of heat exhaustion include:

 Cramps in the arms, legs or stomach;

 Heavy sweating;
 Intense thirst;
 Cool, moist skin (clammy and pale);
 Weak, rapid pulse;
 Fatigue, weakness, loss of co-ordination;
 Confused thinking, fainting;
 Rapid breathing;
 Tingling in the hands and feet;
 Nausea and headaches.

First aid treatment for heat exhaustion:

 Move the casualty into the shade (and air conditioning if possible);
 Loosen or remove the casualty's clothing and boots;
 Cool the casualty as soon as possible;
 If air conditioning is not available, pour water on the casualty for cooling;
 Elevate the casualty's legs and massage limbs;
 Have the casualty drink water with some salt dissolved in the water if salt is
available - do not administer salt tablets to the casualty;
 Obtain medical assistance for the casualty as soon as possible.

Heat stroke is a medical emergency condition that requires immediate treatment.

If heat stroke is not treated immediately, the casualty often dies. Heat stroke
is caused when the body depletes its salt and water supply to dangerously low
levels, sweating stops and sweat evaporation and body cooling stops. The body's
cooling mechanism breaks down completely and the casualty's body temperature
soars to fatal levels. Heat stroke is more easily caused if a body has previously
suffered heat exhaustion or heat stroke.

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Early symptoms of heat stroke include:

 High body temperature;

 Absence of sweating (in most cases);
 Hot, red (flushed), dry skin;
 Rapid pulse;
 Difficult breathing;
 Constricted eye pupils;
 Headache or dizziness;
 Confusion or delirium;
 Bizarre (crazy) behavior;
 Weakness;
 Nausea and/or vomiting.

Advanced symptoms include:

 Seizure or convulsions;
 Collapse;
 Loss of consciousness;
 Deep coma;
 No detectable pulse;
 Very high body temperature.

First aid treatment:

 The most important step is prompt recognition of heat stroke symptoms

and taking immediate action to treat the condition;
 Follow the same steps as outlined for heat exhaustion;
 Start the cooling process immediately;
 Lower the casualty's body temperature as fast as possible;
 If possible, immerse the casualty's body in water or massage the
casualty's body with ice;
 Evacuate the casualty to a hospital as soon as possible.

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Controlling Heat Stress

There are methods of controlling heat stress that involve sensible working and
living habits.

Acclimatization allows the body to become accustomed to the heat through

a gradual increase in work level over a period of time. One or two weeks are
usually sufficient time for most people.

Give the body a rest by following sensible work procedures. This does not
mean stopping work, but activity in the shade out of direct sunlight is restful.
Alternate between light and heavy work, perhaps by rotating several workers
to protect them from the heat.

Remember that hot food adds to body heat. Sensible food and water intake
is important in the control of heat stress. Take light cool meals at lunch time
and rest for a few minutes afterwards. Most importantly replenish water and
salt lost through sweating. Drink water regularly even if you don’t feel thirsty.

Add a little extra salt to your meals but do not use salt tablets. Never drink
alcohol, coffee or tea to replenish lost fluids as it further de-hydrates your
body.

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