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Integrated Training Package on Emergency Preparedness

and Response for Rapid Response Team (RRT)

Epidemiology and Disease Control Division (EDCD)

Department of Health Services
Ministry of Health
Kathmandu, Nepal
May 2017
Published and Copyright:
Government of Nepal
Ministry of Health
Department of Health Services
Epidemiology & Disease Control Division
Teku, Kathmandu

Financial & Technical Support:

United Nations Population Fund (UNFPA)
Nepal Red Cross Society (NRCS)
 Acronyms
AIDS Acquired Immunodeficiency Syndrome
CDO Chief District Officer
CP Contingency Plan
CRRT Community Rapid Response Team
DDC District Development Officer
DDK Diarrheal Disease Kit
DDRC District Disaster Relief Committee
DG Director General
DOHS Department of Health Services
D(P)HO District Public Health Office
EDCD Epidemiology and Disease Control Division
EPR Emergency Preparedness and Response
FHD Family Health Division
GON Government of Nepal
HA Health Assistant
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
IEHK Inter-agency Emergency Health Kit
INGO International Non- Government Organization
IFE Infant Feeding in Emergencies
ITP Integrated Training Package
KM Kilometer
LDO Local Development Officer
MISP Minimum Initial Service Package
MIRA Multi-Sectoral Initial Rapid Assessment
MoHP Ministry of Health and Population
NGO Non-Government Organization
NHTC National Health Training Centre
NRCS Nepal Red Cross Society
PFA Psychological First Aid
PHN Public Health Nurse
RH Reproductive Health
RHAF Rapid Health Assessment Format
RHD Regional Health Director
RHDO Regional Health Directorate Office
RRT Rapid Response Team
SRH Sexual and Reproductive Health
UNICEF United Nations Children Fund
UNFPA United Nations Population Fund
WHO World Health Organization
 Content

Introduction 1
Objectives 3
Expected Outcome 3
Specific objectives 3
Integrated training package 3
Participants 4
Teaching methodologies 4
Teaching materials to be used in the training 4
Forms, formats and tools as part of teaching materials 4
Training components 5
Suggested Training Schedule for 3 days 6
UNIT I: Disaster Management 9
UNIT II: Management of Epidemic/Outbreak and Nutrition Interventions 15
UNIT III: Minimum Initial Service Package (MISP) for Reproductive Health in
Emergency and Mental Health 23
Integrated training package 29
RAPID HEALTH ASSESSMENT FORMAT 31
RAPID HEALTH ASSESSMENT GUIDELINES 33
Multi‐Cluster Initial Rapid Assessment (MIRA) –Nepal 35
clen]v / k|ltj]bg 47
;?jf /f]u k|sf]k clen]v kmf/d (Outbreak Recording Form) eg]{ lgb]{lzsf 48
Outbreak Reporting Form 49
;?jf /f]u k|sf]k k|ltj]bg kmf/d (Outbreak Reporting Form- 2)- g+= @ eg]{ lgb]{lzsf 51
References 53
Appendix 1 55
Appendix 2 56
Appendix 3 58
Introduction

Nepal is a disaster prone country and faces various types of natural and man-
made disasters, the most frequent natural disasters being floods and landslides.
Nepal also lies in an earthquake prone zone and the earthquake of April 25, 2015
has been a devastating one. All these disasters not only cause deaths and
casualties, but also displace people and cause infrastructural damage.

Landslides
Earthquakes

Food Poisoning
Floods
DISASTERS

Epidemics

Fires
Road Traffic Accidents

Nepal experiences disasters almost on an annual basis, with notable disasters

occurring every few years.

 The most tragic disaster in Nepal are earthquakes:

 In 1934, an earthquake with a magnitude of 8.3 struck Nepal and resulted

in the deaths of 8,500 people.

 In 1988, an earthquake with a magnitude of 6.6 struck Udayapur and

resulted in the deaths of more than 700 people.

 In 2015, an earthquake with a magnitude of 7.6 struck Gorkha and later in

Dolakha resulted in more than 8970 deaths and around 23000 injuries.

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 In the years 1996-2000 nearly, 3,633 people died as a result of various
epidemics

 During the period 1996-2000, nearly 1,380 died as a result of flooding and
landslides

 The Koshi flood and succeeding flash floods in the west during the month of
August/September 2008 displaced 55,000 people, and directly affected
240,000 people in Sunsari and Saptari districts.

In 2000, the Ministry of Health and Population (MoHP), Department of Health

Services (DHS), and the Epidemiology and Disease Control Division (EDCD)
established a mechanism for managing epidemics consisting of a Rapid Response
Team (RRT) at three levels: central (1 RRT), regional (5 RRTs) and districts (75
RRTs). The objectives of these teams is to establish an early warning and
reporting mechanism for potential epidemics, ensure preparedness for potential
epidemics, manage disease outbreaks, and institutionalize disaster management.

Various activities were conducted in the past to address the issue of mobilizing
health workers in case of outbreak or disasters. For example:

 EDCD regularly conducted different training programs on “Disaster

Management and Response (2 days)”

 Epidemic Preparedness and Response (3 days)

 National Health Training Centre (NHTC) also adapted a 3-day training

package for RRT members and health service providers on “Reproductive
Health (RH) in Emergencies or Minimum Initial Service Package (MISP) for
Sexual and Reproductive Health (SRH)", targeted for use during crisis or
post crisis situations

The training package, created for district to Ilaka level RRT members, will also aim
to strengthen its disaster, crisis, and emergency response mechanisms.

The latest integrated training package (ITP) on Emergency Preparedness and

Response (EPR) was developed in 2011 and trainings were carried out for Rapid
Response Teams (RRT) across the country. However, over the years it was felt
that the ITP needs to be updated in the light of the Earthquake of 2015.

In this context the EDCD in collaboration with UNFPA and Nepal Red Cross
Society (NRCS) developed a task force to revise the ITP.

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Objectives
The overall objective of the integrated training package is to enhance the
emergency response capacity of RRT members during any kind of disaster, crisis
or emergency.

Expected Outcome:
The expected outcome is that the RRTs (at the district and community levels) carry
out effective and efficient emergency preparedness and responses at all levels,
and are prepared to support in contingency planning.

Specific objectives:
 To enhance the RRT’s capacity in initiating emergency preparedness and
response actions and plan in close cooperation with relevant stakeholders
 To provide RRTs with the necessary knowledge and skills to conduct rapid
assessments and effectively analyze the results
 To help in prioritizing key intervention areas of the RRTs based on the
rapid assessments results
 To update knowledge in disease surveillance, outbreak investigation, and
response
 To provide knowledge on Reproductive Health (RH) in Emergency which
includes Minimum Initial Service package (MISP) on Sexual and
Reproductive Health, and how to prepare an emergency response plan
during crisis or post crisis situations
 To provide knowledge on other key areas such as mental health,
psychosocial counseling, and nutrition that need to be addressed during a
crisis or emergency
 To support in the logistics management capacity of RRTs

Integrated training package:

The Integrated Training Package on Emergency Preparedness and Response
for Rapid Response Team is developed on the basis of past experiences and
feedback/comments received from relevant stakeholders. The realization that the
ITP needs updating was felt during the Earthquake of 2015 and several other
happenings.

Major components of the integrated training package:

 Unit one deals with disaster management;

 Unit two deals with epidemic outbreak management and nutrition in

emergency;

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  Unit three deals with Reproductive Health in Emergency (Minimum Initial
Service Package (MISP), and mental health in emergency.

This training package is prepared for the members of RRT. It is expected that it will
help in increasing their capacity on emergency preparedness and response for any
kind of disaster, crisis, or emergency.

Participants:
Number of
Training Days Participants
participants
3 days District level RRT members and In- 30
charges of peripheral level health facilities

Teaching methodologies:
Following methodology will be used for training of the RRT on ITP

 Power point presentation and discussion

 Small group discussion
 Demonstration
 Brainstorming
 Video presentation
 Sharing of personal experience in responding to disaster, outbreak, crisis or
emergency situations
 Exercises

Teaching materials to be used in the training:

 Flip chart, markers, board markers, white board, and news print
 Poster, photographs and animated disaster related videos
 Disaster, emergency, and crisis case studies
 Various assessment and analysis forms and formats

Forms, formats and tools as part of teaching materials:

 Rapid Health Assessment (RHA) Format
 Outbreak Recording Form
 Outbreak Reporting Form
 Daily Surveillance Form
 Multi sectoral Initial Rapid Assessment (MIRA)

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Training components
Unit 1: Disaster Management
1.1: Basic concepts of disaster/emergency
1.2: Disaster management mechanism
a) Disaster management policy and process in Nepal
b) Functional Mechanism of RRT
c) Setting priorities, Communication and coordination in disaster
1.3: Rapid Health Assessment and analysis in Emergency
1.4: Logistics and Financial management in emergency
1.5: Water, Sanitation and Hygiene and Environmental Health in Emergency
1.6: Sharing and lessons learnt by the participants
Unit 2: Epidemic/Outbreak Management and Nutrition Interventions
2.1: Communicable disease surveillance
2.2: Outbreak investigation and response
a) Importance of outbreak investigations and its steps
b) Prevention and Control of outbreak in disaster
c) Laboratory investigation in outbreak
2.3: Outbreak investigation- Exercise
2.4: Communication and Coordination in Emergencies
2.5: Nutrition in Emergency
a) Basic concept of nutrition in Emergency
b) Measuring malnutrition and Infant Feeding in Emergencies guidance note
of Nepal
c) Assessing and Responding to severity of crisis
2.6: Child Health in Emergencies
Unit 3: RH in Emergencies and Mental Health
3.1: Overview of RH in Emergency
3.2: Components of MISP
3.3: RH Kits in Emergency
3.4 Monitoring and Evaluation with MISP Indicators
3.5 Mental health and Psychosocial Support in disaster
3.6 Exercise on Forms and Drills

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Suggested Training Schedule for 3 days

Day One : Unit I Disaster management

10:00–11:00  Registration, Welcome, Introduction
 Objectives and expected outcome
 Briefings on agenda /ground rules/remarks
 Pre-test (Optional)
11:00–11:15 Tea-Break
11:15-12:00 1.1 Basic concept of disaster/ emergency (45 Min)
12:00-12:45 1.2 Disaster management Mechanism (total 45 Min),
(a) Disaster management policy and process in Nepal
(15 min)
(b) Functional mechanism of RRT and Contingency
Planning (15 min)
(c) Setting priorities and communication in disaster (15
min)
12:45-13:30 Refreshment (Khaja) – (45 min)
13:30-14:30 1.3 Rapid Health Assessment (RHA) and analysis in
emergency (60 min)
14.30- 15.15 1.4 Logistic and Financial management in Emergency (30
min)
15:15-16:00 1.5 Water, Sanitation and Hygiene (WASH) and
Environmental Health in Emergency (45 min)
16:00 -16:15 Tea-Break
16:15-17:00 1.6 Sharing on lessons learnt on management in EQ 2015
(45 min)

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Day Two: Unit II Epidemic/Outbreak management and Nutrition Interventions
10:00 – 10:15 Recap of day 1
10.15-11.00 2.1 Communicable Diseases surveillance (45 minutes)
11:00-11:15 Tea-Break
11:15– 12:30 2.2 Outbreak investigation and response (Total 1 hour 15
minutes)
(a) Importance of outbreak investigation and its steps (15
min)
(b) Prevention and control of outbreak in disaster (45 min)
(c) Laboratory investigations in outbreak (15 min)
12.30-13.00 2.3 Outbreak investigation Exercise (30 minutes)
13:00 –13:45 Refreshment (Khaja) -45 min
13.45- 14:15 2.4 Communication and Coordination in Emergencies
14:15-15:30 2.5 Nutrition in Emergency (Total 1 hour 15 min)
a) Basic concept on nutrition in emergency (20 min)
b) Measuring malnutrition and IFE Guidance note of Nepal
(30 min)
c) Assessing and responding to the severity of crisis (20
min)
15:30-15:45 Tea-Break
15:45- 16:30 2.6 Child Health in emergencies (30 min)

Day Three: Unit III RH in Emergency (MISP), and Mental Health

10:00 – 10:15 Recap of day 2
10.15 - 11:10 Reproductive Health in Emergency (MISP) – (55 min)
3.1 Overview of RH in emergencies (MISP)
11:10– 11:25 Tea-Break
11:25- 11:55 3.2 Components of MISP (30 min)

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11:55 – 12:15 3.3 RH Kits in Emergency (20 min)
12:15- 13.00 3.4 Monitoring and evaluation with MISP indicators (30 min) +
exercise (15 min)
13:00 – 13:45 Refreshment (Khaja) 45 min
13:45-14:15 3.5 Mental Health and Psychosocial Support in Disaster (30
min)
14:15- 14.45 Exercise on Forms
15:15-15:30 Tea-Break
15:30- 16:30 Mock Drill
16:15- 16.30 Post-Test (optional)
16:30- 17:00 Closing

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 DAY ONE:
UNIT I:
Disaster Management

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Unit 1.1: Basic Concept of Disaster/ Emergency
Duration: 45 minutes (including 15 min discussion)
Objectives:  To update the knowledge and understanding of basic
concept of disasters/emergencies
 To familiarize participants on frequently used
terminologies, disaster management cycles, and
consequences of various hazards.
Contents: 
Introduction to basic concept of
disasters/emergencies,
 Terminology,
 Disaster management cycle and
 Consequences of various hazards
Methodology: Brainstorming, power point presentation, video presentation,
discussion, matching of flash card
Brief on delivery Disaster management cycles, and consequences of various
of the sub-unit: hazards. The session will conclude with a summarization of
key points.
Advance Link with disasters faced by Nepal such as the Koshi floods
preparation: in 2008 and 2015 Earthquake

Unit 1.2: Disaster Management Mechanism

Sub-topic: (a) Disaster Management Policy and Process in Nepal (15
min)
(b) Functional Mechanism of RRT (15 min)
(c) Setting Priorities and Communication in disaster (15
min)
Duration: 45 minutes
Objectives: To familiarize participants on disaster management policy and
processes in Nepal, functional mechanism for Rapid
Response Team, priority setting and communication in
disaster
Contents:  Disaster management mechanism (policy and
process) in Nepal
 Functional mechanisms of the Rapid Response Teams

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  Communication in disaster
Methodology: Power point presentation and discussion

Brief on Power point presentation on the national disaster

delivery of the management policies and processes in Nepal, functional
sub-unit: mechanisms for Rapid Response Teams of different levels
(Central, Regional, District and Community) and
Communication and coordination in disaster
Advance Policy, guidelines
preparation:

Unit 1.3: Rapid Health Assessment and Analysis in

Emergency
Duration: 60 minutes (including 10 min discussion)
Objectives: To orient the participants on rapid health assessment
To orient application of different types of forms and
emergency analysis techniques
Contents:  Rapid Health Assessment Form,
 Syndromic Surveillance Form,
 Outbreak recording and reporting Forms,
 MIRA and its applications
Methodology: PowerPoint presentation and Practice on forms

Brief on delivery Brainstorming questions on different forms and formats used

of the sub-unit: during times of crisis or emergency. Use different types of
forms such as (RHAF, SSF, ORRF and MIRA) and how they
should be filled out during an emergency or disaster
Advance RHA Form, SS Form which need to be filled out daily during
preparation: an emergency
Outbreak Recording and Reporting Forms and MIRA

Unit 1.4: Logistics and Financial Management in Emergency

Duration: 30 minutes (including 5 min discussion)
Objectives: To orient participants on emergency logistics management
with budgets, kits and supplies including adaptation of
international kits (RH kits), and supplies.
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 To ensure proper preparation with buffer stocking of drugs,
supplies and kits
Contents:  Logistics management mechanisms in emergency,
 Logistic estimation and buffer stocking
 Financial management
Methodology: Power point presentation, discussion, and sharing ideas
Brief on delivery Initiation with lessons learnt from recent epidemics in terms of
of the sub-unit: logistic management, followed by feedback from participants on
the logistics management difficulties faced. Identification of the
local procurement process for drugs, supplies, and kits along
with a discussion on how to prepare in advance through buffer
stocking system.
EDCD has allocated some budget for each district to respond to
emergencies. Besides, D(P)HO can request DDRC for more
support in case it is necessary. The session will conclude with a
summarization of key points.
Advance List of supplies, drugs, and kits
preparation:

Unit 1.5: Water, Sanitation and Hygiene and Environmental

Health in Emergency
Duration: 45 minutes (including 5 min discussion)
Objectives: To provide basic knowledge on environmental health and
sanitation during times of emergency (water purification,
sanitation, waste disposal management)
Contents:  Importance of safe water, sanitation and hygiene and
environmental health during times of emergency
 Various methods of water purification for safe drinking
water,
 Prevention and control of communicable diseases
through sanitation and waste disposal
 Minimum standard based on Sphere Guidelines for

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 prevention and control of communicable diseases
Methodology: Power point presentation, demonstration, discussion, and
sharing ideas
Brief on delivery Initiation with a power point presentation on prevention and
of the sub-unit: control of communicable diseases through water purification
and waste disposal management. Demonstration of possible
water purification. The session will conclude with a
summarization of key points.
Advance Pre-visit Jajarkot district experience of diarrhea epidemic and
preparation: case studies from districts during earthquake

Unit 1.6: Sharing and lesson learnt on management in 2015

earthquake by the participants:
(Experience on Epidemics /Emergency /Disaster and
its Response)
Duration: 45 minutes
Objectives: To learn from district experiences on management of 2015
earthquake including epidemic/ emergency/ disaster
Contents:  Sharing of the management during 2015 earthquake
and immediate response on it
 Response activities conducted,
 Coordination and communication
Methodology: Discussion, sharing of experiences and lessons learnt for
further emergency preparedness
Brief on delivery Initiation with sharing of lessons learnt from recent earthquake
of the sub-unit: and epidemics. Analyze the preparedness and response
provided as case studies. Finally come up with some of the
recommendations and preparedness plan for future
Advance Presentation will be made by participants through whichever
preparation: methods they feel are most effective.

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14
 DAY TWO:
UNIT II:
Management of Epidemic/Outbreak
and Nutrition Interventions

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Unit 2.1: Communicable Disease Surveillance
Duration: 45 minutes (including 5 min discussion)
Objectives: To orient participants on communicable disease surveillance
Contents:  Basic concepts, importance,
 principle, function, and
 components of surveillance
Methodology: Power point presentation, discussion, and sharing ideas

Brief on delivery Initiation with a power point presentation on the basic

of the sub-unit: concepts, importance, principle, function, and components of
surveillance, followed by a discussion on past surveillance
experiences. Emphasis will be placed on recording and
reporting of Syndromic Surveillance form. The session will
conclude with a summarization of key points.
Advance Pre-visit Syndromic Surveillance Format
preparation: Recording and reporting format

Unit 2.2: Outbreak Investigation and Response

Sub-topic: (a) Importance of outbreak investigation and its
steps
Duration: 15 minute (including 5 min discussion)
Objectives: To orient participants on importance of outbreak
investigation, and its procedures
Contents: Importance and steps of outbreak investigation
Methodology: Power point presentation, discussion, and sharing ideas

Brief on delivery Initiation with a power point presentation on the importance

of the sub-unit: of outbreak investigation, and its procedures. The session
will conclude with a summarization of key points.

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Advance Pre visit Outbreak Recording and Reporting Format and its
preparation: operation guidelines.
Sub-topic: (b) Prevention and Control of Outbreak in
Disaster
Duration: 45 minutes (including 15 min discussion)
Objectives: To orient participants on the prevention and control of
disaster outbreaks among displaced populations.
Contents:  Consequences of disaster, Transmission of outbreak,
 Prevention, diagnosis and case management,
 Outbreak preparedness and response
Methodology: Power point presentation, discussion and sharing ideas

Brief on delivery Initiation with a power point presentation on the process of

of the sub-unit: prevention and control of various disaster outbreaks,
discussion with sharing ideas on past disaster outbreak
management. The session will conclude with a
summarization of key points.
Advance Pre visit Outbreak Recording and Reporting Format and its
preparation: guidelines to use it.
Sub-topic: (c ) Laboratory Investigation in Outbreak
Duration: 15 min
Objectives: To orient participants on laboratory investigation in outbreak
Contents:  Role and importance of laboratory diagnosis in
outbreak investigation,
 Sample collection and transport procedures
 Common lab diagnostic tools
Methodology: Power point presentation, demonstration, discussion and
sharing ideas

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Brief on delivery Initiation with a power point presentation on the role and
of the sub-unit: importance of common lab diagnostic tools, its procedures,
and laboratory diagnosis preparations needed for outbreak
investigation. Demonstration of possible equipments and kits
use in laboratory diagnosis. The session will conclude with a
summarization of key points.
Advance Possible equipment and kits
preparation:

Unit 2.3: Outbreak Investigation Exercise

Duration: 30 minutes
Objectives: To provide practical knowledge on outbreak investigation
Contents: Different scenario of a Cholera Outbreak
Methodology: Group formation 2-3 persons in each group, Questionnaire will
be distributed & Group work in each questions and
presentation
Brief on Group exercises and presentation by questionnaire forms step
delivery of the by step.
sub-unit:
Advance Materials for group work (Flip chart, markers and so on)
preparation:

Unit 2.4: Communication and Coordination during

emergencies
Duration: 30 minutes
Objectives: To provide knowledge on appropriate communication and
communication during emergencies

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Contents:  Communication during emergencies
 Coordination during emergencies
Methodology: Presentation, Case studies and Discussion

Advance Materials for case studies (Flip chart, markers etc)

preparation:

Unit 2.5 Nutrition in Emergency

Sub-topic: (a) Basic concept on nutrition in emergency
Duration: 20 minutes
Objectives: To orient basic concept on why nutrition is important in crisis,
assessing the severity of crisis and responding to the crisis
Contents:  Vulnerable people prone to nutritional problems,
 Immediate steps for nutritional activities (Focusing on
pregnant woman, lactating woman, newborn, under five
children and old people)
Methodology: Brainstorming, Power point presentation, discussion and
sharing ideas
Brief on Initiation with sharing ideas on the importance of nutrition
delivery of the health during a disaster. This will be followed by a power point
sub-unit: presentation and discussion on vulnerable people prone to
nutritional complications, and immediate steps to be taken to
address nutrition during times of emergency. The session will
conclude with a summarization of key points on the continual
need for of nutritional activities, especially for lactating
mothers, pregnant mothers, the elderly, and children under the
age of five.
Advance Pre-visit guiding principles for feeding infants and young
preparation: children during emergencies, WHO, Geneva

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Unit 2.5 Nutrition in Emergency
Sub-topic: (b) Measuring Malnutrition and IFE Guidance Note of Nepal
Duration: 15 minutes
Objectives: To orient on measurement of malnutrition in emergency
Contents:  technique of measurement of malnutrition
 IFE Guidance note of Nepal
Methodology: Brainstorming, Power point presentation, discussion and
sharing ideas
Brief on Initiate the session with sharing of knowledge on the
delivery of the importance of basic nutrition intervention during an emergency
sub-unit: followed by a power point presentation on measuring
malnutrition among young children and infant. It will be
followed by orientation on IFE Guidance note of Nepal. The
session will conclude with a summarization of key points on the
need for continued collaboration and cooperation to effectively
respond to nutrition needs during an emergency, focusing on
young children and infants.
Advance Sakir Tape for MUAC
preparation: IFE Guidance note of Nepal

Unit 2.5 Nutrition in Emergency (continued)

Sub-topic: (c) Assessing and Responding to Severity of Crisis
Duration: 20 minutes
Objectives: To orient on assessing the severity of crisis and responding to
the crisis
Contents:  Vulnerable people prone to nutritional problems,
 Immediate steps for nutritional activities (Focusing on
pregnant woman, lactating woman, newborn, under five
children and old people)

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Methodology: Brainstorming, Power point presentation, discussion and
sharing ideas
Brief on Initiate the session with discussion on vulnerable people
delivery of the (especially pregnant women, lactating women, newborn and
sub-unit: under five children) during emergencies followed by a power
point presentation on immediate steps for nutritional activities.
Conclude the session with summarization of key points.

Unit 2.6 Child Health in Emergency

Sub-topic: (a) Child Health in Emergency
Duration: 30 minutes
Objectives: To orient and discuss the necessity of child health in an
emergency
Contents: Issues and concerns on child health during crisis
Methodology: Power point presentation and question and answer
Brief on Child Morbidity and Mortality issues and concerns during an
delivery of the emergency followed by a power point presentation on specific
sub-unit: concerns actions focusing on child survival. The session will
conclude with a summarization of key points on need for the
continued collaboration and cooperation to effectively respond
to child survival during an emergency.
Advance International Experiences in dealing with emergencies
preparation:

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22
 DAY THREE:
UNIT III:
Minimum Initial Service Package
(MISP) for Reproductive Health in
Emergency and
Mental Health

23
Unit 3.1: Reproductive Health in Emergency
Sub-topic: (a) Overview of Minimum Initial Service Package
(MISP) for Reproductive Health in Emergency
Duration: 55 minutes (including 5 min discussion)
Objectives: To orient participants on Reproductive Health during an
emergency
To provide basic knowledge on MISP in order to reduce
mortality, morbidity, and disability of displaced populations
Contents:  RH in Emergency and
 MISP
Methodology: Video presentation (Women in war), Brainstorming, Power
point presentation, discussion and sharing ideas
Brief on delivery Initiate the session with a video presentation on disasters,
of the sub-unit: followed by a brainstorming session. A power point
presentation will be made regarding an overview of RH during
an emergency, including importance of MISP for Sexual and
Reproductive Health (SRH) during disaster, crisis, or post
crisis situations. The session will conclude with a
summarization of key points on what is NOT MISP.
Advance Video and speaker. Use reference manual developed by
preparation: NHTC on MISP in Nepali.

Unit 3.2: Components of MISP

Major components of Minimum Initial Service Package
(MISP)
Duration: 30 minutes
Objectives: To orient participants on the five major MISP components and
RRT’s role in monitoring the day to day implementation of

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 MISP during any emergency or post emergency situation.
Contents:  Five major components of MISP and
 RRT’s role in implementation during a disaster.
Methodology: Brainstorming, Power point presentation, discussion and
sharing ideas
Brief on delivery Initiation with a brainstorming on the components of MISP,
of the sub-unit: followed by a power point presentation and discussion of
each component including role of RRTs. Finally sum up the
session with key points on plan for comprehensive SRH
services for the management of post crisis situation.
Advance Use reference manual developed by NHTC on MISP in Nepali
preparation:

Unit 3.3 RH Kits in Emergency

Duration: 20 minutes
Objectives: To orient on 13 different types of RH kits and to make
familiarize with the RH Kits name.
Contents: RH Kits (13 different types of RH Kits)
Methodology: Brainstorming, Power point presentation, discussion and
sharing ideas
Brief on Initiate with Brainstorming on the RH Kits with the support of
delivery of the Public Health Nurses (PHNs). Then display of power point
sub-unit: presentation and discuss one by one RH kits including role of
RRTs. Finally sum up the session with key points on plan for
RH kits in order to make sure availability of RH kits during
disaster.
Advance Identify # of SBAs in district and identify # of RH kits in
preparation: districts

25
 Identify # of CEOC, BEOC and BCs for referral mechanism
during emergency

Sub-topic: (d) Monitoring and evaluation with MISP Indicators

Duration: 30 minutes
Objectives: To orient on conducting basic monitoring and evaluation for
MISP
To orient on needs assessment tools to plan for
comprehensive SRH
Contents:  Five essential M & E components
 MISP Basic Demographic and Health Information
 MISP Indicators based on five major components
 MISP Monthly Data Collection ( by using HMIS
system)
Methodology: Brainstorming, Power point presentation, discussion, and
sharing ideas
Brief on Initiation with a brainstorming session on the importance of
delivery of the monitoring and evaluation during disaster. This will be
sub-unit: followed by a power point presentation and discussion on
monitoring indicators for each MISP components, and the
importance of monthly database updates using the HMIS
system. The session will conclude with a summarization of
key points on comprehensive SRH service planning based on
post disaster situation evaluations.
Advance HMIS Monthly database
preparation: Reporting mechanism
Use reference manual developed by NHTC on MISP in Nepali

26
Unit 3.5: Mental Health and Psychosocial support in Disaster
Duration: 30 minutes
Objectives: To orient participants on the importance of mental health,
psychosocial support, and protection during emergency and
post emergency situations
Contents:  Importance of mental health,
 psychological consequences due to disaster,
 Psychological First Aid (PFA) and Counseling
Methodology: Brainstorming, Power point presentation, discussion and
sharing ideas
Brief on Initiate the session with sharing ideas on the importance of
delivery of the mental health during emergencies. Make a power point
sub-unit: presentation on psychological consequences of a disaster,
Psychological First Aid (PFA), and Counseling. Mention that
the District Women and children's office has mechanism to
provide psychosocial counseling and referral can be made. The
session will conclude with a summarization of key points on the
continual need for psychosocial counseling support during post
disaster situations.
Advance Pre-visit IASC guidelines on mental health and psychosocial
preparation: support in emergency settings

Unit 3.6 Exercise on Forms

Sub Topic: Practice on Various recording and reporting forms
Duration: 30 minutes
Objectives: To make participants confident on filling emergency and
surveillance related forms
Contents: Various forms for recording and reporting
27
Methodology: Group Work
Brief on Form groups with 2-3 persons in each group. Provide them
delivery of the with recording and reporting forms and provide case studies
sub-unit: from the district. Then ask each group to review another
group's form and provide feedback. The session will conclude
with a summarization of key points on contingency planning.
Advance Sufficient number of copies of recording and reporting
preparation: preparation
Case studies to fill in the forms (from the same district
desirable, if not, case from adjacent district)

3.6 Mock Drill

Duration: 60 minutes
Objectives: To make participants mentally ready in case of any
emergency or disaster.
Contents:  Whistle blowing
 Place of gathering/ exit
 Personal Safety
 Preparing Emergency Kit
 Deployment for field
Methodology: Exercise
Brief on Brief the participants about mock- drill. Repeat the major steps.
delivery of the Then create a situation of emergency and ask the participants
sub-unit: to go for relief work.
Advance Case study for drill
preparation: Emergency Kits
Adequate space for drill

28
Integrated training package

Forms, formats and tools as part of teaching materials:

The following forms are included in this ITP for easiness for training.

I. Rapid Health Assessment Form (RHAF) in Nepali and Guidelines in

English

II. Multi sectoral Initial Rapid Assessment (MIRA) in English

III. Daily Surveillance Form for health Facilities

IV. Outbreak Recording Form in Nepali and Guidelines in Nepali

V. Outbreak Reporting Form in Nepali and Guidelines in Nepali

29
30
 g]kfn ;/sf/
:jf:Yo tyf hg;+Vof dGqfno,
:jf:Yo ;]jf ljefu
Olkl8ldof]nf]hL tyf /f]u lgoGq0f dxfzfvf

RAPID HEALTH ASSESSMENT FORMAT

lhNnf÷uf=lj=;=÷j8f g++ : ..................................... k|ltj]bg k]z u/]sf] ldlt: ............. k|ltj]bg g+=: ........

k|sf]ksf] k|sf/ : ……………………….…………...... k|sf]k ePsf] ldlt / ;do: ……..……….………

!= ;"rgfsf] ;|f]t -gfd, kb, ;+:yf, 7]ufgf, kmf]g g+_ : ........................................ .......................................

…………………………………………………………………………………………………………

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< % jif{

lj:yflkt hg;+Vof k|efljt hg;+Vof

≥ % jif{ -k'0f{÷cg'dflgt_ -k'0f{ ÷cg'dflgt_

hDdf

#= :jf:Yo ;+:yfsf] Iflt: k'/} cf+l;s 5}g\ ...........................................................

………………………………………………………………………………………………………

…………………………………………………………………………………………………………
31
$= l/km/ ul/Psf ;+:yf -c:ktfn_ x?sf] gfd / ;+Vof :.............................................................................

.................................................................................................................................................
%= k|sf]kdf klxnf] p4f/sfo{df ;xof]uLM -;]gf, k|x/L, /]8qm; / cGo_: ............................................................

………………………………………………………………………………………………….………

.................................................................................................................................................

^= :jf:Yo ;]jfdf :jf:Yo ;xof]u -j:t'l:yltsf] cf+sng, ;dGjo, pkrf/;]jf, cf}iflw, hg:jf:Yo Pj+ ;/;dfg_:
……………………………………………….……………………………………….……………..…

….…………………………………..……………….………………………………………………….

&= vfg]kfgLsf] cj:yf, kl/0ffd / u'0f:t/ s:tf] 5 v'nfpg' xf];\ : ..............................................................

……………………………………………….………………………………………………..………

*= jftfj/0fLo :jf:Yo / ;/;kmfO{sf] cj:yf s:tf] 5 v'nfpg' xf];\ :.............................................................

……………………………………………….…...……………………………………………………

(= :jf:Yo ;DjlGw k|d'v cfj:ystfx? v'nfpg' xf];:\ ....…………………………………………..………………

…………………………………………………………………………………………………………

………………………………………………………………………………………………………..

!)= k|sf]k :yfndf k'Ug ;Sg] cj:yf : ;lhn} sl7g ;lsb}g

!!= k|sf]k :ynsf] ;'/Iff l:yltM /fd|f] l7s} g/fd|f]

k|ltj]bg tof/ ug]{: ……………...........……………. h=:jf=sf k|d'vsf] gfd: ………………............

;Dks{ g+=: .........…………………………...........… ;Dks{ g+=:..........……………………………..

x:tfIf/: ….……………………………….............. x:tfIf/: ……………………………………..

ldlt: ..…………………………………………...... ldlt: ………………………………………

32
 Government of Nepal

Ministry of Health & Population - Department of Health Services

Epidemiology & Disease Control Division WHO
MoHP

RAPID HEALTH ASSESSMENT GUIDELINES

A rapid health assessment form needs to be filled out by DHO / DPHO, the Rapid
Response Team, or available health staff no later than 24 hours after a public health
emergency occurs. It should immediately be faxed or in other ways communicated
to the addresses given below.

WHEN TO USE THE ASSESSMENT FORMAT:

o An emergency is an exceptional situation exceeding the response capacity of the

affected community
o For field assessment purposes, it can be defined as any event resulting in the death of
more than one person, the injury of 10 people, or significant displacement of local
population
o Rapid health assessments are not expected following road traffic accidents
o Unusual disease incidents need to be reported in the separate post-emergency
syndromic surveillance format
HOW TO USE THE ASSESSMENT FORMAT:

Disaster and report information:

 Indicate district, VDC, ward no, reporting date and report number at the top of the
form
 Categorize the type of disaster (e.g. flood OR landslide) along with the date and
time of occurrence
1. Source of information:
 List name, position, contact number and address of key informant(s)
2. Health data and number of displaced / affected:
 Search accurate figures for the number of deaths / injured / missing and
breakdown by gender / age
 Give exact OR estimated number of displaced and affected people (indicate
validity by tick mark) based on number of families OR persons (indicate data unit
and calculation method)
 Displaced people are homeless due to the disaster event and affected people are
anyone who have experienced mortality, morbidity, loss of livestock or property

33
3. Damage to health facilities:

 Assess damage to health facilities based on condition of physical structures,

supplies and equipment. Indicate whether facilities remain fully operational /
functional / non-functional
4. Referral services and referral hospital:

 Mention referral services and list the referral hospital for seriously injured
casualties
5. Active emergency responders:

 Briefly list active emergency responders and describe response actions being
taken
6. Health response being provided:

 Describe health response being provided including assessments, coordination, first

aid, mass casualty management, referral, provision of medicine, psycho-social
support and logistics
7. Water quantity / quality:

 Describe current status and risks related to water quantity / quality

8. Sanitation and hygiene:

 Describe current status and risks related to sanitation and hygiene

9. Priority health needs:

 Explain in detail priority health needs including medical supplies and equipment
10. Access:

 Assess whether the accessibility to the incident site is good / fair / poor
11. Security:

 Assess whether the security situation at the incident site is good / fair / poor
Signature and contact details of DHO / DPHO and reporter:

 Don’t forget to sign, indicate date and provide contact details of DHO / DPHO and
yourself.
Please complete and return / send to Technical Officer / National
the following addresses: Director / Operations Officer
Disaster Focal Point Emergency and Humanitarian Action
Epidemiology and Diseases Control (EHA)
Division World Health Organization (WHO)
Department of Health Services Pulchowk, Kathmandu
Ministry of Health and Population Tel: 977-1-4264033 Fax: 977-1-
Tel: 977-1-4255796 Fax: 977-1- 4264033/5527756
4262268 [email protected]
[email protected]

34
 Multi‐Cluster Initial Rapid Assessment (MIRA) ‐Nepal
for Multi‐Hazards Scenarios as of July 2012
(This assessment form should be used in close coordination and review with the District Disaster
Relief Committee (DDRC). Stakeholders are requested to use this format to collect and analyze
information of affected VDCs and Districts)
1. Assessment Team Information
Organizations participating Date of assessment
From To
Contact
Name of team leader
Details

2. Geographic information (to be filled up in consultation with DDRC)

2.1 Name of the District
2.2.Type of Hazard/Disasters (Tick appropriate only) :
Flood Epidemic Drought Earthquake
Landslide Fire Hailstorm others
2.3 Using a map of the district, identify the VDCs/Communities that are affected by the
disaster. Use the following categories:
a. Worst affected (Highest impact)
b. Highly affected (High impact)
c. Moderately affected (Moderate impact)
d. Lightly affected (Light impact)
e. Not affected (No impact)
2.4 On the same map, indicate which of the affected VDCs/communities cannot be reached by
vehicle
2.5 On the same map, indicate major concentrations of the Internally displaced people
2.6 On the same map, indicate critical transportation infrastructural damage (roads, bridges,
airports)
2.7 On the same map, indicate potential security threats (dacoit, other groups, …)
2.8. Distance of the most affected VDCs from the DHQs (walking hours: ……………. Driving hours
……………….)

Following questions (3, 4 & 5) should be collected in DHQ in advance by the assessment team or
prepared at the time of Disaster Preparedness and Response Planning in every District

3. District Level data to be considered (Collect Information from DPHO)

3.1 Functioning health facilities in the district

35
 Buildings Adequate staff Accessibility
Type of facility
Total No. No. of affected buildings Yes No Yes No
Sub Health Post
Health Post
Primary Health Care
Hospital

If local (S)HP/PHC are inaccessible for VDC population please explain why:
3.2 How many cases of acute malnutrition are currently under treatment in the Hospital and/or
Nutrition Rehabilitation Home?
(For district level facilities) Number: _______
(Optional)
 Is this different from previous/other years? Explain:
 Is there sufficient treatment capacity? Yes or No
3.3 Participation of community organization or community a. Yes b. No
If yes, provide a) Name………………. b) Contact Number c) Email
If there are concentrations of families displaced outside of their community of origin (in
neighboring VDC or beyond) collects the following additional information for each location:

4. Sampled VDC/Community (Randomly select a community(s) within affected areas for the
detailed information on the following (if time does not allow, select a community from the worst and/or
highly affected areas only)
GPS of the sampled VDC: Mapping impact
District VDC
If not available, P‐code of the VDC: category (1‐5)

Visited Ward Name of Villages

Number of wards affected:
numbers: visited:

Altitude of the
Latitude (Y): Longitude (X):
visited wards

5. Population data (Village/Settlement level)

5.1 Total population
Affected level and population Total Female Male Children Total
Families < 5 yrs population
5.2 Highly affected population
(count)
5.3 Less affected population
(count)
5.4 Number of Male Female Children < Common cause
Persons: 5 hrs
36
Dead:
Injured:
Missing

5.5 Affected groups or Vulnerable groups (Count number of persons in every case)

Families with no Pregnant / Disadvantaged

Unaccompanied Unaccompanied Severely ill / # Female
shelter due to Lactating , Ethnic,
elders >60 years minors Disabled headed
disasters Women religious,
Male Female Male Female Male Female Male Female households
communities

6. Shelter and NFI

6.1 What is the level of housing damage?
a) Total number of houses destroyed, no habitation whatsoever (requires
complete reconstruction and demolished)
b) Total number of severely damaged houses, unsafe for habitation (Walls, roof
and column collapsed, hanging wall etc.)
c) Total number of moderately damaged houses, that are safe for habitation but
requiring minor maintenance (cracks evident but the structure intact)
d) Total number of houses with no visual damage
6.2 Are community shelter facilities with water and sanitation provisions  Yes 
available? No
If yes, indicate the type and number of facilities within the immediate community
boundary and how many people can be adequately accommodated (Narrative):
Public buildings (locations and accommodation capacity):
Host families (locations and accommodation capacity):
Other (locations and accommodation capacities):
6.3 What are the most likely immediate NFI needs of the community:
Emergency shelter / tarpaulin
Shelter tools
Blankets
Cooking utensils
Buckets / jerrycans
Clothing / material
Other (specify):
Narrative:

37
7. Household food security
7.1 What percentage of households lost % of food stocks lost Corresponding %age
percentage of their food stocks? (e.g. HH
40% of households lost 100%)  0‐25%
 25‐50 %
 50‐ 75 %
 75‐100%
7.1 Within these food stocks what type of  Cereal  Pulses  Oil 
food is available Vegetable  Meat
7.2 For those who have stocks remaining,  1‐3 days  4‐7 days  1‐2 weeks 
on average, how long is it expected to 3‐4 Weeks > 1 month
last?
7.3 What is the predominant source of Before Crisis Now
food?  Local  None…….
shops/marketing  Local
 Government aid shops/marketing
 Aid agencies  Government aid
 Own reserves  Aid agencies
 Others  Own reserves
(Specify)………………  Others
(Specify)…………
7.4 What percentage of households has
access to cooking utensils?
7.5 Does the community have access to Yes/ no If yes, what type of fuel used (tick
fuel for cooking purposes? appropriate one)
a) Firewood
b) Charcoal
c) Kerosene
d) Gas
e) Other specify) …………
7.6 As a result of the emergency, are any of the following coping strategies practiced in the
community?
 Reduce food intake Estimated % of HH
 Eating seeds/wild food/ less preferred foods/ _____________
low quality food _____________
 Increase in borrowing for consumption purposes _____________
 Sale of household assets (cooking utensils, _____________
jewellery etc.) _____________
 Sale of productive assets (tools, animals, _____________
machinery, land) _____________
 Migration to other locations
 Reliance on external support (eg food/cash
assistance)
38
 Use of grain bank/emergency community fund
 No coping strategy available
 Others (Specify)
…………………………………………………………………

7.7 Who are the most vulnerable group of people to  child headed households
food insecurity?  female headed households
 elderly headed households
 the disabled/severely ill
 Certain caste groups (Specify)…………
 Others (Specify)………………
7.8 a. Are markets functioning?  Yes If yes, what is the distance/ If no, what is the
 No reason (describe)?
b. Are markets accessible?  Yes  No If yes, what % of households has financial access?
7.9 If available,
what are the prices Unit Now Before disaster
of main _________ _____________ _____________
commodities? ___ _____________ _____________
(please strike _________ _____________ _____________
commodity if not ___ _____________ _____________
available) ___ _____________ _____________
Rice _____________ _____________
Wheat flour _____________ _____________
Oil ______________
Pulses
Milk
Maize
Potato
Other (Specify)
7.10
a) What are the main livelihoods If applicable, % of communities % resumed
of this community? ; that see this as the main
b) Estimate % of the community  Crop livelihood. ______%
that sees this as main livelihood; farming ______% ______%
c) What % families resumed  ______% ______%
their livelihoods? Livestock ______% ______%
 Wage ______% ______%
labour ______% ______%
 Salaried ______% ______%
Job ______% ______%
 Fishing ______% ______%

39
  Trade ______% ______%
 ______%
Business/i
ndustry
 Tourism
 Forest
products
 Others
(specify)
7.11 At what stage of the cropping calendar is the community currently in and what impact will
the emergency have on this?
Describe possible impacts:……………………………………………
Suggestions for coping the situation………………………………
7.12 What is the expected a) Crop area (Ropani/Bigha)
loss as a result of crisis? b) Irrigation infrastructure (number/meter of canal)
c) Fish ponds (number and area)
d) food storage facility
e) Other significant loss (specify)…………………………
7.13 What is loss related to a) cattle: b) buffalo:
livestock? (Number) c) goats/sheep:
d) pigs: e) poultry:
f) animal shelter:
7.14 does this community have if yes, how long will it last
food for livestock?
7.15 a. Has there been or any indication of animal disease outbreak? (yes or No)
b. Is the animal health service accessible? …………………
7.16 Any other relevant comments or observations……………………………………

8. WASH
8.1 Water Supply
Availability of clean drinking water (15 liters /person/day) ?:  0‐24%  25‐49%  50‐74% 
Means of Verification: Interview with local government, utility etc. Verify with community if
possible and observation
Primary water Condition: Alternate water source available?
source:  Working  Yes  No
 Open Well  Damaged (Repair If yes, type/location/water clear or
 Tune Well/Hand required for minimum turbid (cloudy) or information
pump supply) available on water quality:
 Stream/river  Contaminated
 Storage/collection  Destroyed
container  Water Turbid Facilities (material) required to
 Piped water supply minimum quality drinking
system water (e.g. repairs needed to water
 Other system):
40
 Do affected families have water container with lid available at household level used for
drinking water storage?  Yes  No_____
8.2 Sanitary facilities
Affected population with access to functioning sanitary facilities (e.g. Latrines):  0‐24%
Means of Verification: Interview with local government, health dept etc. Verify with community
if possible and through observation.
Adequate personal hygiene supplies available (soap, sanitary cloth/napkins)  Yes
Narrative (no. of family hygiene kit required):

9. Protection
9.1 Is there any displacement of the local population? If possible, note estimated number and where they
have gone
9.2 Are there separated and unaccompanied children? (Y/N) , Numbers ( boys and girls)
9.3 Is there a registration / family tracing system in place? If so who is doing this?

9.4 What are the primary concerns of the most vulnerable groups at present (post disaster situation)?
Shelter/ Food/ Health/ Physical Psychosocial Child Other
security water education safety / support labour/
violence trafficking
including
SGBV
Children 0 – 5 years
Children less than
18 years
Adolescents (10‐24)
Persons with
disabilities
Older persons (aged
60+)
Pregnant/lactating
women
Ethnic Minorities
???
Other
9.5 Any other protection issues identified such as dacoits, loot,SGBV…………………………………………………………….
9.6 Are there any community support mechanisms that can provide or refer to services (example GBV watch
group Women’s Federations, Child Clubs, Child Protection Committees etc.)? If so, which………………….

10. Nutrition (If possible ask Female Health Care Volunteers or local medical staff)
10.1 What types and frequencies of foods are fed to infants and children under five years of age
(most common first)?
6‐12 months: Now: Before disaster:
 Types: _________________  Types: _________________
 Frequencies: ____________  Frequencies: ______________

41
 12‐59 months Now: Before disaster:
  Types: ________________  Types: ________________
 Frequencies: ___________  Frequencies: ______________
10.2 Are there any changes in preparing the foods (hand washing, storage) and storage of
foods? No or Yes, if yes, what are the changes?
Now: Before disaster:
 Duration of storage: ____________  Duration of storage:
 Hand washing : _______________ _______________
 Hand washing:
___________________
10.3 Is there indication of decreased/interrupted breastfeeding? No / Yes, If yes, what are the
reasons?

What is replacing breastfeeding?

 For the children below six months:
 For the Children between 6‐24 months:
10.4 Have there been any donations of infant formula or commercial baby foods or bottles or
teats: No or Yes, If yes, source of donation(s) if known:

11. Health (Ask at health facilities and local communities)

11.1 Main health concerns 11.2 Availability of
medicines/medical supplies
 Diarrhoea  Skin disease Medicines:
 Eye Infections  Injuries/Trauma Equipments and
 Vomiting  Death of Mother and/or supplies
 Dehydration children following delivery (including stretchers):
 Snake Bites  Any chronic conditions i.e.  AdequateAdequate
 Fever Diabetes, hypertension  InadequateInadequate
 Cough and Fever (ARI)  psychosocial illness Specify needs:
Specify needs:
___________________
____________________
11.3 Functioning of the nearest health facilities in village:
Type of facility Damaged Availability Accessible Power Supply Water
of staff Supply
Yes No Yes No Yes No Yes No Yes No
Health Post
Sub Health Post
Private Clinic/Nursing
Home
11.4 Who provides health care in that facility? _ Nurse, _ Doctor, _ Midwife, _ Other (specify) : traditional
healers etc.
11.5 Access to nearest health facility: _ Easy; _ With obstacles (Explain); _ Very difficult (Explain). Distance in
km:
11.6 Have there been any reports or rumors of any outbreaks or unusual increase in illness? ___No, __Yes
(Specify)

42
11.7 Have there been reports of non‐infectious agents (such biological, chemical, nuclear, radiation, poisons or
toxins)? _ No; _ Yes (Specify)

12. Education
12.1 % of school affected
 0‐24%  25‐49%  50‐74%  75‐100%
 Number of schools affected (optional & if possible) …..
12.2 No. of children affected (disaggregate by gender)
ECD (Boy: ) (Girl: )
Basic School (Boy: ) (Girl: )
12.3 No. of teachers affected (disaggregate by gender)
ECD (Male: ) (Female: )
Basic School (Male: ) (Female: )
12.4 Are classes being taught and attended by the community?  Yes  No
12.5 What is the status of the school in the community?
 Fully damaged, cannot be used in present condition
 Partially damaged, cannot be used
 Partially damaged but can be used with some maintenance
 Water logged but can be used with some maintenance
 Not affected
12.6 Have basic SCHOOL materials been affected? (Black boards / Teaching materials, books,
stationeries, furniture, etc.)
 Mostly lost
 Partially lost
 Not affected
12.7 Have EDUCATIONAL materials of the children been affected? (Text books, Stationeries,
schoolbags, etc.)
 Mostly lost
 Partially lost
 Not affected
12.8 Are school being used for any other purpose?  Yes  No (please specify if yes):

13. Emergency Telecommunications

13.1 What means of security telecoms and data services are available in the area?
Means of Communication Service Status (Yes/No) Comments
Radio Room Coverage 24 x 7
HF / VHF Radio
Sat phone
Internet
Other (e.g. HAM radio)
13.2 What means of public communication are available?

43
 Means of Communication Service Status (Yes/No) Comments
FM/AM Radio
TV
Mobile Phone (GSM, CDMA etc.)
Landline
13.3 Any alternate means of power backup available?

14. Logistics
13
14
14.1 Are all affected areas accessible for humanitarian agencies? (please tick as appropriate)
No Don’t know Partially Fully
Remarks: Please describe in short if affected area partially or fully accessible and attach map as
appropriate
14.2 Are logistics basic services functioning post disaster? (please tick as appropriate)
Logistics services No Don’t Partially Fully operational Remarks
know operational
Fuel station
Electricity
Road service
Transportation
means
Air service
Others
Remark: for detail please attach separate sheet
14.3 Since the disaster, what is the biggest logistics concern to the community? (please tick as
appropriate)
Debris/rubble stagnant water Landslide Bridge damage/collapses
Non functionality of Unavailability of Damage of airport River Others:
roads fuel runway crossing
Remarks: Please attach separate sheet in detail as appropriate
14.4 What is the severity of infrastructure damage in the area? (please tick as appropriate)
Infrastructure No damage Partially & Partially & Totally Remarks
functional not destroyed
functional
Warehouses

44
Government
Buildings
Custom office
Private buildings
Business houses
Fuel stations
Power stations
Airport
Helipads
Others…
Remark: for detail please attach separate sheet

15. Displaced Population and Camp Coordination and Camp Management

(CCCM)
13
14
15
15.1Displaced Population
Number of families:
Male = Female = Children under 5 = Elderly ( Over 60) =
Pregnant women = Lactating Mother = Differently able = Total Population =
15.2 Location of IDP site
a. Name of the IDP site: b. Latitude: c. Longitude:
Altitude:
15.3 Type and Classification of Site
Type a. Spontaneous b. Planned
Classification of site a. Camp b. Settlement c. Urban Scattered IDP location
Ownership of land of the site a. Private b. Public c. Other (Specify)
15.4 Origin of IDP
Where do most people originate from?
a. Nearby neighbourhood (1000m radius)………………………… b. Other neighbourhoods (more than
1000m radius)……………….
15.5 Registration of Displaced Population

45
Registration conducted a. Yes b. No
a. Number of registered HHs ……….. b. Number of registered individuals……………
15.6 Movement to and from the site ‐Yes ‐No
How is population trend in the site? a. Increasing b. Decreasing c.
Same as before
15.7 Services Provided at IDP Site
Toilet provided Yes No Number: …… Organisation: ………… Notes: ……
Drinking water Yes No Quantity: ……… Organisation: ………… Notes: ……
Shower facility Yes No Quantity: ……… Organisation: ………… Notes: ……
Garbage Yes No Quantity: ……… Organisation: ………… Notes: ……
management
Other services
(Specify)
15.8 Vulnerable Population
Any Information suggesting that some group are underserved a. Yes b. No
If yes, please specify…………………………………………………………….
16. Prior Relief effort/assistance
16.1 Has the community received any assistance? Yes No
If Yes, who is providing what?
If No, are there any current plans to provide assistance?
16.2 Have all community members informed (regularly) about the disaster and
assistance/response?

46
 clen]v / k|ltj]bg
g]kfn ;/sf/
:jf:Yo dGqfno,
:jf:Yo ;]jf ljefu
Olk8]ldof]nf]hL tyf /f]u lgoGq0f dxfzfvf
;?jf /f]u k|sf]k clen]v kmf/d (Outbreak Recording Form)
lhNnfM ============================:jf:Yo ;+:yfM======================================= z+sf:kb /f]u÷l;G8«f]dM ==================================================
ldlt M====================================
k|of]uzfnf glthf
k|of]uzfnf k|of]uzf
j8f /f]u b]vf hfFrsf nflu
qm=;+= /f]uLsf] gfd pd]/ lnË Uff=lj=;= 6f]n hfFrsf] nf pkrf/ EofS;Lg lgsf] /]km/ d[To' s}lkmot
g+= k/]sf] ldlt lnPsf]
lsl;d gtLhf ePsf] u/]sf] ePsf]
gd"gf

of] k|ltj]bg lhNnf :jf:Yo÷hg:jf:Yo sfof{nodf Aojl:yt ?kdf /fVg'k5{ / dflyNnf] lgsfon] dfu]sf] v08df dfq k7fpg' k5{ .

47
 ;?jf /f]u k|sf]k clen]v kmf/d (Outbreak Recording Form) eg]{ lgb]{lzsf
lhNnfdf ;?jf /f]usf] k|sf]ksf] ;"rgf k|fKt eO{ k|sf]k ;'lglZrt x'g] lalQs} ¥oflk8 /]:kf]G;
6Ld kl/rfng x'G5 . k|sf]k ePsf] :yfgdf k'u]kl5 /f]uLsf] hfFr÷pkrf/ ubf{ ¥oflk8 /]:kf]G;
6Ldn] of] kmf/d k|of]u ug'{k5{ .
!= kmf/dsf] l;/fgLdf lhNnf, :jf:Yo ;+:yf, k|sf]ksf] ?kdf b]vf k/]sf] /f]u ÷l;G8«f]dsf] gfd
/ ldlt n]Vg] .
@= kmf/dsf] klxnf] v08df /f]uLsf] qmd ;+Vof n]Vg] .
#= kmf/dsf] bf];|f] v08df /f]uLsf] gfd n]Vg] .
$= kmf/dsf] t];|f] v08df /f]uLsf] pd]/ n]Vg] .
%= kmf/dsf] rf}yf]] v08df /f]uLsf] lnË n]Vg] .
^= kmf/dsf] kfFrf} v08df :yfgLo txsf] gfd n]Vg] .
&= kmf/dsf] 5}7f}+ v08df /f]uLsf] j8f g+= n]Vg] .
*= kmf/dsf] ;ftf}+] v08df /f]uLsf] 6f]nsf] gfd n]Vg] .
(= kmf/dsf] cf7f}+ v08df /f]uLdf /f]u b]vf k/]sf] ldlt n]Vg] .
!)= kmf/dsf] gjf}+ v08df k|of]uzfnf hfFrsf nflu /f]uLsf] /ut, lb;f, lk;fa, vsf/ s] gd"gf
lnPsf] xf] ;f] n]Vg] .
!!= kmf/dsf] bzf}+ v08df s'g lsl;dsf] k|of]uzfnf hfFr u/]sf] h:t}M Culture, AFB, Blood
Smear s] xf] n]Vg] .

!@= kmf/dsf] P3f/f}+ v08df k|of]uzfnf hfFrsf] gtLhf kf]lhl6e jf g]u]l6e s] xf] n]Vg]
!@= kmf/dsf] afx|f}+ v08df /f]uLnfO{ s] pkrf/ lbPsf] / cf}iflwsf] gfd n]Vg] .
!#= kmf/dsf] t]x|f} v08df /f]uLnfO{ s'g} EofS;Lg lbPsf] eP n]Vg] .
!$= kmf/dsf] rf}wf}+ v08df /f]uLsf] glthf –lgsf] eof], /]km/ ul/of] jf d[To' s] eof] n]Vg] .

48
 RRT-2
g]kfn ;/sf/
:jf:Yo tyf hg;+Vof dGqfno, :jf:Yo ;]jf ljefu
Olk8]ldof]nf]hL tyf /f]u lgoGq0f dxfzfvf
;?jf /f]u k|sf]k k|ltj]bg kmf/d (Outbreak Reporting Form)
lhNnfM ============================ :jf:Yo ;+:yfM ================================== ldlt ==============================
!= k|sf]k ;"rgf tyf /]:kf]G; (Outbreak Information & Response)
:yfgLo tx pkrf/ 6f]nL uPsf] ldlt
-lglZrt k|sf]ksf] ;"rgf EWARS af6 pkrf/
s|= z+sf:kb cg'dflgt /f]uL ;"rgf kfPsf] lhNnfaf6 If]qaf6 klxnf] /f]uL
;d'bfo, 6f]n lbg] JolQm ;"rgf kfPsf] 6f]nLdf ;+nUg
;= /f]u÷l;G8«f]d tyf d[ts ;+Vof ldlt b]lvPsf] ldlt
cflb eP ÷;+:yf xf]÷xf]Og JolQm -kb_
v'nfpg]_

@= k|sf]k cg';Gwfg (Outbreak Investigation)

/f]uL tyf d[tssf] ;+Vof glthf k|of]uzfnf hfFr clGtd
z+sf:kb /f]usf] hf]lvddf
s|=; :yfgLo ! jif{ d'lg !% jif{ dfly lgsf] /]km/ d[To' hDdf hDdf /f]uL
/f]u÷ ;+efljt /x]sf !- $ jif{ %- !$ jif{ gd"gfsf] hfFrsf]
tx ePsf] u/]sf] ePsf] -s± gd"gf glthf b]lvPsf]
l;G8«f]d ;|f]t hg;+Vof lsl;d lsl;d
/f]uL d[To' /f]uL d[To' /f]uL d[To' /f]uL d[To' -s_ -v_ -u_ v±u_ ;+sng ldlt

49
#= k|sf]k lgoGq0fsf pkfox? (Outbreak control measures)

pkrf/÷lgoGq0f sf] ljlw÷lsl;d

(Mass drug distribution, k|sf]k lgoGq0fdf ;+nUg ;+3 ;+:yf / dflyNnf] lgsfoaf6 kfPsf] ;'´fp /
pkrf/÷lgoGq0f vr{ ePsf] ultljlw ;xof]u l6Kk0fL
z+sf:kb Case by case treatment,
s|=;= :yfgLo tx z'? u/]sf] / ;dfKt cf}iflw÷EofS;Lg
/f]u÷l;G8«f]d
u/]sf] ldlt Mopping up, Insecticide cflbsf] laj/0f
;+:yf ;xof]u ultljlw If]qaf6 s]Gb«af6
spraying etc) v'nfpg]

k|ltj]bg tof/ kfg]{sf] gfd M ;b/ ug]{sf] gfd M

kb M kb M
;xL M ;xL M
-of] k|ltj]bg tTsfn} Olk8]ldof]nf]hL tyf /f]u lgoGq0f dxfzfvfsf] ˆofS; g+= )!–$@^@@^* df ˆofS; ug'{ xf]nf -kmf]g g+= )!–
$@%%&(^_ jf Od]n M [email protected] tyf af]wfy{ ;DalGwt If]=:jf=lg=df lbg'xf]nf_

50
;?jf /f]u k|sf]k k|ltj]bg kmf/d (Outbreak Reporting Form- 2)- g+= @ eg]{ lgb]{lzsf
o; k|ltj]bgdf tLg efu 5g\M efu ! df k|sf]k ;"rgf tyf /]:kf]G;, efu @ df k|sf]k
cg';Gwfg, efu # df k|sf]k lgoGq0fsf pkfox? . lhNnfdf k|sf]ksf] ;"rgf k|fKt eO{ k|sf]k
;'lglZrt x'g] lalQs} ¥oflk8 /]:kf]G; 6Ld kl/rfng ul/G5 . ¥oflk8 /]:kf]G; 6Ld kl/rfng ug]{
lalQs} o; kmf/dsf] v08 ! k|sf]k ;"rgf tyf /]:kf]G; e/]/ tTsfn} Olk8]ldof]nf]hL tyf /f]u
lgoGq0f dxfzfvfdf ˆofS; ug'{ k5{ tyf af]wfy{ ;DalGwt If]=:jf=lg=df lbg'k5{ .
!= kmf/dsf] l;/fgLdf lhNnf, :jf:Yo ;+:yfsf] gfd / ldlt n]Vg] .
@= kmf/dsf] efu ! sf] klxnf] v08df qmd ;+Vof n]Vg] .
#= kmf/dsf] efu ! sf] bf];|f] v08df :yfgLo txsf] gfd n]Vg] -lglZrt ;d'bfo, 6f]n, j8f g++=
cflbsf] hfgsf/L eP ;f] klg n]Vg]_ .
$= kmf/dsf] efu ! sf] t];|f] v08df ;"rgf k|fKt ePsf] z+sf:kb /f]u jf l;G8«f]dsf] gfd
n]Vg], /f]usf] nIf0fsf] dfq ;"rgf k|fKt ePsf] 5 eg] nIf0fx? g} pNn]v ug]{ cyjf o;
dxfzfvfåf/f tof/ kfl/Psf] …/f]uL kl/efiff / ;le{n]G; dfkb08Ú k':tssf] ;xof]u lng] .
%= kmf/dsf] efu ! sf] rf}yf]] v08df ;"rgf k|fKt eP cg';f/ cg'dflgt /f]uL tyf d[ts ;+Vof
n]Vg] .
^= kmf/dsf] efu ! sf] kfFrf} v08df k|sf]ksf] ;"rgf s'g} JolQm dfkm{t cfPsf] 5 eg] JolQmsf]
gfd tyf ;+:yf dfkm{t cfPsf] 5 eg] ;+:yf sf] gfd n]Vg] .
&= kmf/dsf] efu ! sf] 5}7f}+ v08df EWARS af6 ;"rgf kfPsf] xf] eg] ;f] n]Vg] .
*= kmf/dsf] efu ! sf] ;ftf}+] v08df s'g ldltdf ;"rgf kfPsf] xf] ;f] ldlt n]Vg] .
(= kmf/dsf] efu ! sf] cf7f}+ v08df ¥oflk8 /]:kf]G; 6Ld kl/rfng ePsf] ldlt n]Vg] .
!)= kmf/dsf] efu ! sf] gjf}+ v08df pkrf/ 6f]nLdf s'g s'g JolQm ;+nUg 5g\ ltgsf] kb
pNn]v ug]{ .
!!= kmf/dsf] efu ! sf] bzf}+ v08df klxnf] /f]uL b]lvPsf] jf k|sf]k z'? ePsf] ldlt n]Vg] .

k|sf]k ePsf] :yfgdf ¥oflk8 /]:kf]G; 6Ld k'u]kl5 k|sf]ksf] cg';Gwfg tyf lgoGq0f ultljlw
z'? x'G5, klxn] lhNnf :jf:Yo÷hg:jf:Yo sfof{nodf k|fKt sltko ;"rgfx? ;+zf]wg ug'{ kg]{
x'G5, t;y{ k|sf]k Joj:yfkgdf vl6Psf] 6f]nLn] o; kmf/dsf] efu ! nfO{ ;+zf]wg cg';f/ e/]/
tTsfn lhNnf :jf:Yo÷hg:jf:Yo sfof{no dfkm{t Olk8]ldof]nf]hL tyf /f]u lgoGq0f
dxfzfvfdf k7fpg' k5{ . tt\kZrft\ 6f]nLn] kmf/d ! sf] pkof]u u/]/ tYof+s ;+sng ug'{k5{ /
To;}sf] cfwf/df kmf/d g+= @ sf] bf];|f] tyf t];|f] efu eg'{k5{ .
!= kmf/dsf] efu @ sf] klxnf] v08df qmd ;+Vof n]Vg] .
@= kmf/dsf] efu @ sf] bf];|f] v08df :yfgLo txsf] gfd n]Vg] .

51
#= kmf/dsf] efu @ sf] t];|f] v08df ;"rgf k|fKt ePsf] z+sf:kb /f]u jf l;G8«f]dsf] gfd
n]Vg] .
$= kmf/dsf] efu @ sf] rf}yf]] v08df /f]usf] ;+efljt ;|f]t n]Vg], h:t} emf8f kvfnf ePdf
Ogf/ jf s'jfsf] kfgL ;|f]t x'g ;S5 .
%= kmf/dsf] efu @ sf] kfFrf} v08df hf]lvddf /x]sf hg;+Vof n]Vg], h:t} emf8f kvfnf
ePdf ;f] Ogf/ jf s'jfsf] kfgL pkof]u ug]{ hg;+Vof hf]lvddf x'g ;S5g\ .
^= kmf/dsf] efu @ sf] 5}7f}+ v08df pd]/ cg';f/ /f]uL tyf d[tssf] ;+Vof n]Vg] .
&= kmf/dsf] efu @ sf] ;ftf}+] v08df /f]uLsf] glthfM lgsf] ePsf], /]km/ u/]sf] jf d[To' ePsf]
n]Vg] .
*= kmf/dsf] efu @ sf] cf7f}+ v08df k|of]uzfnf hfFrdf s'g lsl;dsf] gd"gf lnPsf] n]Vg] .
(= kmf/dsf] efu @ sf] gjf}+ v08df s'g lsl;dsf] k|of]uzfnf hfFr u/]sf] h:t}M Culture, AFB,
Blood Smear s] xf] n]Vg] .

52
References:
1. Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings, A
companion to the inter-agency field manual on reproductive health in humanitarian
settings, September 2009

2. WHO. Child Growth Standard, Geneva, 2008

3. CHD, DOHS. CMAM National Protocol (OTP training guideline, treatment protocol),
Nepal, 2014

4. Guidelines for Gender Based Violence Interventions Humanitarian Settings Focusing

on Prevention of and Response to Sexual Violence (IASC) in Emergencies in English,
September 2005

5. Guidelines for Gender Based Violence Interventions Humanitarian Settings Focusing

on Prevention of and Response to Sexual Violence (IASC) in Emergencies in Nepali,
September 2005

6. EDCD. Guidelines on Best Public Health Practices in Emergencies for District Health
Workers. Kathmandu, March 2003

7. EDCD, MOHP. Guidelines on Emergency Preparedness and Disaster Management for

Hospitals. Kathmandu. February 2002

8. WHO. Guiding Principles for Feeding Infants and Young Children During Emergencies,
Geneva

9. Health Sector Emergency Preparedness and Disaster Response Plan, Disaster

analysis, management framework and planning guidelines, September 2003

10. Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response
(Sphere Handbook), 2004

11. Inter-agency Field Manual on Reproductive Health in Humanitarian Settings, revision

for field review 2010

12. Inter-agency Reproductive Health Kits for Crisis Situations, 4th edition, January 2008

13. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings,
2007

14. IASC Global Nutrition Cluster - Harmonized Training Package – 2008/09

15. IASC Global Nutrition Cluster - A Toolkit for Addressing Nutrition in Emergency
Situations, 2008

16. Infant and Young Child Feeding in Emergencies, Operational Guidance for Emergency
Relief Staff and Programme Managers, UNICEF

53
17. WHO. International Code for Breast Feeding Substitute, Geneva. 1981

18. WHO. Management of Malnutrition in Major Emergencies, Geneva, 2000

19. NHTC, MOHP. Minimum Initial Service package (MISP) for Emergency Preparedness
of Reproductive Health, in Nepali, Kathmandu, 2067 BS (2010)

20. Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations: A
distance learning module, revised November 2007

21. EDCD, MOHP. Nepal District Level Contingency Planning Manual, Kathmandu.
2009/2010

22. MOHP, Macro international and New Era. Nepal Demographic and Health Survey,
2001, 2006, and 2011. Kathmandu

23. EDCD/DOHS Guidelines and Tools for Conducting Integrated Training of Rapid
Response Teams on Emergency Preparedness and Response. 2011. Kathmandu

24. Ministry of Home Affairs. National Strategy for Disaster Risk Management. 2009.
Kathmandu

25. NSET. National Strategy for Disaster Risk Management in Nepal. 2008. Kathmandu,
Nepal

26. Ministry of Home Affairs. Nepal Disaster Report 2015. Kathmandu, Nepal

54
 Appendix 1:

Member of Core Team for revision of Integrated Training Package on

Emergency Preparedness and Response for Rapid Response Team

Committee
SN Name Designation & Organization
Designation
Deputy Health Administrator,
1. Dr Guna Nidhi Sharma Coordinator
EDCD
Deputy Health Administrator,
2. Dr Bhesh Raj Pokharel Member
EDCD
3. Badri Nath Jnawali Under Secretary, EDCD Member
4. Dr. Uttam Ghimire IMO, EDCD Member
Public Health Administrator,
5. Bhim Prasad Sapkota Member
MoH
Humanitarian Coordinator,
6. Mr. Hari Karki Member
UNFPA
7. Damodar Adhikari NPO, WHO Member
8. Sabin Adhikari Program Coordinator, NRCS Member
Member
9. Shambhu Kumar Mahato PHI, EDCD
Secretary
Consultant
1 Dr. Bal Krishna Subedi

Terms of reference for the committee

1. To guide on updating/ revising the Integrated Training package on Emergency and
Disaster Preparedness

2. To support updating/revising the ITP

3. To finalize the ITP and recommend for endorsement

55
 Appendix 2

List of Participants participating in Pre dessimination of integrated training

package on emergency preparedness and response for RRT
Date: 29 December 2016
Venue: Swastik Foodland, Tahachal, Kathmandu

SN Name Designation Office

1 Dr. Bhim Acharya Director EDCD
2 Dr. Guna Nidhi Sharma Dep. Health Administrator EDCD
3. Hari Karki Humanitarian Coordinator UNFPA
4. Bijay Bharati Health Delegate CRC/NRCS
5. Badri Nath Jnawali Under Secretary EDCD
6. Hari Prasad Acharya PHI EDCD
7. Pradip Rimal PHI EDCD
8. Dr. Uttam Ghimire IMO EDCD
9. Dr. Sagar Raj Shakya MSC WHO/IPD
10. Kunj Prasad Joshi HEA NHEICC
11. Dr. Bhesh Raj Pokhrel Dep. Health Administrator EDCD

12. Laxmi Devi Regmi Account Officer EDCD

13. Dhan Prasad Paudel MT EDCD
14. Dabal Bahadur BC LT EDCD
DPHO,
15. Dhruba Kumar Adhikari PHI
Kathmandu

16. Dr. Kedar Marhatta MHC WHO

17. Dr. Sudan Panthi NPO WHO

18. Damodar Adhikari NPO WHO

19. Dr. Rajan Bikram Rayamajhi NPO WHO

20. Madhav Raj Ojha SO EDCD

56
21. Bhola Adhikari Lab Technician EDCD
22. Jay Krishna Yadav Lab Techhncian Teku Hospital

23. Dhan Narayan Tamang Na Su EDCD

24. Hari Narayan Shah PHI EDCD
25 Rishi Ram Satyal CA EDCD
26 Hari Prasad Wagle OH EDCD
27 Sabin Adhikari Program Coordinator NRCS
28 Bishnu Khadka MS NRCS
29 Dr. Santoshanand Jha MO Teku Hospital
30 Shambhu Kumar Mahato PHI EDCD
31 Dr. Prakash Ghimire NPO WHO
32 Minu Adhikari CO FHD
33 Ram Sundar Yadav PHO EDCD
34 Tanka Prasad Chapagain Senior PHA PHC-RD
35 Mohan Kumar Rauniyar Sr AHW Teku Hospital
36 Tek Raj DC PHI CHD
37 Dijay Raj Nair Accountant EDCD
38 Manju Joshi Senior Program Assistant NRCS
39 Lalan Prasad Sah PHI LMD
40 Nripa Chaudahary HA NPHL
41 Deepak Subedi Lab Technologist NPHL

57
 Appendix 3:

List of contents of kits needed for disaster response as part of

teaching materials:
 Diarrhoeal Disease Kit (DDK)
 Inter-agency Emergency Health Kit (IEHK)
 Reproductive Health (RH) kit- (Kit # 0-12)
 Dignity or hygiene kit
 Surgical Kit

58
 Background
• NepalispronetonaturalandmanͲmadedisasters
Unit1.1: • Naturaldisastersarepredictable– occurseveryyear

BasicConceptofDisaster/ • ThisEmergencyPreparednessandDisasterResponse
Training is expected to prepare health workers for
Trainingisexpectedtopreparehealthworkersfor
Emergency theemergenciesanddisastersinNepalandis
expectedtohaveabiggerimpactthaninsituations
wherepreparednessisrandom.
• Sothat,ultimately,wecansavelives!

22

EarthquakeinNepal TypesofEmergencies
• Natural
• 1934KathmanduValley
Earthquake: – Earthquake
– Deaths:8,000 – Flood
– Injuries:25,000
– Landslide/Avalanche
• 2015Earthquake: – Drought
– Deaths:8970 Damaged buildings, 1934 KV EQ
– Fire
– Injuries:23,000
– Buildingsdestroyedand • HumanActivityrelated
damagedͲ morethan5 – Conflict
lakhs
– Bandh/Strike
Damaged health facility
3 4

HAZARD
Someimportantterminologies Arareorextremenaturalormanmadetriggerevent
thatthreatenstoadverselyaffecthumanlife,property
oractivitytotheextentofcausingdisaster.
VULNERABILITY
Thelevelofdisruptionandloss ahazardcan
potentially causeinacommunity/society.
DISASTER
Anyevent thatcausesdamage,ecologicaldisruption,
lossofhumanlife,ordeteriorationofhealthandhealth
servicesonascalesufficienttowarrantanextraordinary
responsefromoutsidetheaffectedcommunity
5 6

59
 EMERGENCY RESPONSE
Astate demandingimmediateandextraordinary Actions taken during and immediately after the
actionthatmaybeduetoepidemics,tonaturalor occurrence of an event, to ensure that disaster
technologicalcatastrophes,tocivilstrifeorother effects are minimized and people are given
manͲmadecauses. immediate relief and support.
PREPAREDNESS
A N SS
Arrangementstoreducesuffering,immediateand
longͲtermavoidablemortality,morbidityand
disabilityinanytypeofemergencyandtobuilda
bridgetodevelopment.
7 8

DISASTEREQUATION TheDisasterManagementCycle
Risk=HazardxVulnerabilityxExposure
Capacity RESPONSE
PREPAREDNESS

Humanfactorsareatplayindetermining
f l d MITIGATION
vulnerabilityandcapacityandthusthe / RISK REHABILITATION /
magnitudeofadisaster(“Earthquakesdo REDUCTION RECONSTRUCTION
notkillpeoplebutbuildingsdo”).

RECOVERY
9

ConsequencesofVariousHazardsinNepal
Disaster Number of Prone Regions Effect on health Effect on health
casualties facilities workers

Earthquake Many All regions of Severe Severe

Nepal

Flood Few/Many Terai regions Severe/Moderate Severe/Moderate

Landslide/ Few Northern hilly Moderate Moderate

Avalanche regions

Drought Few/Many All regions of Moderate Severe/Moderate

Nepal

Conflict Few/Many All regions of Severe/Moderate Severe/Moderate

Nepal

Bandh Low All regions of Moderate Moderate

Nepal

Fire Few All regions of Severe/Moderate Moderate 11

Nepal

60
 Unit1.2:
DisasterManagementMechanism
SubTopic:
(a)Disastermanagementpolicyandprocess
(a) Disaster management policy and process
inNepal

Background CentralNaturalDisasterReliefCommittee
(CNDRC)
ƒ InNepal,theNaturalCalamityReliefActwasformulated
in1982tocoordinate,facilitateandmanagetherelief ƒ MinisterofHomeAffairschairsthecommitteewithmembersfrom
andrescueworksduringdisaster. lineministries,police,army,scouts,redcrossetc
ƒ TheAct,1982hasalreadybeenamendedtwicein1989 ƒ TheCNDRCtakesoverallresponsibilitiesofcoordinationandpolicy
decisionregardinganydisaster.
and1992.
ƒ TheMOHAleadsthecurrentdisastermanagementsysteminNepal
The MOHA leads the current disaster management system in Nepal
ƒ Theactisthemilestonemajorguidingdocumentfor ƒ Definesthenationaldisasterreliefsystemwithreliefcommitteesat
disastermanagementinNepal. thenational,regional anddistrictleveltocoordinatethe
ƒ TheActhasprovisionedforCentralNaturalDisaster implementation
ReliefCommittee(CNDRC) ƒ Meetsasandwhenrequiredinandafterdisasters,mainlyfollowing
floodsandlandslideseveryyear
¾ NationalStrategyforDisasterRiskManagement,2009 ƒ MainroleistocoordinatedisasterreliefoperationsthroughDistrict
DisasterReliefCommitteeschairedbyCDOintheDistrict
AdministrationOffice
3 4

Institutional Framework (in line with 1982 Act) EmergencyResponseMechanism(Government)

Cabinet RescueandTreatment
(Policy,Budget,EmergencyDeclaration) SubͲCommittee
ChairedbyMinisterofHealthand UNResident/ CabinetDeclares
Population Humanitarian InternationalAppeal Emergency
CentralNaturalDisasterReliefCommittee Coordinator (area,time)
(chairedbyHomeMinister) Supply,Shelterand
(Coordination,Response,Rescue,Relief) Rehabilitation
SubͲCommittee CentralNaturalDisaster
Clusters
ChairedbyMinisterofPP&TM
y Government ReliefCommittee
Activated
Agencies meetingheld
NationalEOC I/NGOs&
RegionalNaturalDisasterReliefCommittee bilateral
ChairedbyRegionalAdministrator
Min.ofHomeAffairs/
RegionalEOC International NationEOC
Responders
DistrictDisasterReliefCommittee
DistrictEOC RedCross
Disaster
ChairedbyChiefDistrictOfficer
(Execution,Rescue&Relief,Datacollection) SituationAnalysis
Movements
(CDO/DDRC)
5 6

61
 Clusters in Nepal
Historyofpolicyinitiatives
Cluster Approach is one of the Coordination Mechanisms for an effective

Clusters
humanitarian response
ClusterLeads ClusterCoͲLeads(UNand
sectoral workinggroups1993
Humanitarian Organization)
1.CampCoordination & • MinistryofHomeAffairs IOM
CampManagement
2.Education • MinistryofEducation UNICEF/SavetheChildren
After the severe floods in 1993, the
3.Shelter • MinistryofUrbanDevelopment&(NepalRed IFRC/UNHabitat
Government, UN, donors and NGOs formed
4.Health •
CrossSociety)
MinistryofHealthandPopulation WHO (Where UNFPAis
three sectoral working groups to strengthen
5.Nutrition • MinistryofHealthandPopulation
member)
b )
UNICEF
coͲordination
di ti and d cooperation:
ti
6.Protection • MinistryofWomen,ChildrenandSocialWelfare UNHCR/UNICEF/UNFPA –GBV

7.Water,Sanitation& •
andNationalHumanRightsCommission
MinistryofPhysicalPlanning,Worksand
CoͲlead
UNICEF
ƒ LogisticWorkingGroup,
Hygiene TransportManagement
•
8.FoodSecurity MinistryofHomeAffairsduringemergencyand WFPandFAO(rotational)
MinistryofAgriculturalDevelopmentduring ƒ Food&AgricultureWorkingGroup,and
preparednessphase
9.Telecomm • MinistryofInformation&Communications WFP
10.Logistics
11.EarlyRecovery
•
•
MinistryofHomeAffairs
MinistryofFederalAffairsandLocal
WFP
UNDP
ƒ HealthWorkingGroup
Network Development
7 8

Otherinitiatives
Sectoralworkinggroups1993.... ƒ AEmergencyHealthandNutritionWorkingGroup(EHNWG)
establishedin2005withthefacilitationfromWHOandUNICEF
ƒ EDCDwiththetechnicalassistancefromWHO ƒ WHOisprovidingtechnicalsupporttoMOHP/DHS/EDCDforhealth
revitalizedhealthsectorworkinggroupinyear2000 sectoremergencypreparednessanddisastermanagement
topromotehealthsectoremergencyplanning ƒ UNFPAisprovidingtechnicalandfinancialsupportto
p p
MoH/DoHS/EDCDforhealthsectordisasterpreparednessincluding g
ƒ DevelopedTORandestablishedanactiveinterͲ RRTtraining.
agencyDHWGSecretariatwhichdraftedahealth ƒ NRCS,DPͲNet,NSETͲNepal,NCDMarenationalorganizations
sectoremergencyplan workingondisastermanagement
ƒ UNDP,ECHO,USAID,JICAandICIMODaremaindonorand
ƒ DHWGincorporatedinthehealthsystemin2005 internationalorganizationssupportingemergencypreparedness
withDGasChairpersonandtheDirectorofEDCDas anddisasterresponse
MemberSecretary ƒ I/NGOslikeOXFAMͲGB,ActionͲAid,WorldVision,Merlinalsoare
9 involvedinDisasterManagement. 10

PreparednessManagementCommittee
ProposedOrganizationalStructureforDRM
• Coordinator:MinisterforLocalDevelopment
• NationalDisasterManagementCouncil • CoͲcoordinator:Member,NPC
– Committees(Preparedness,Relief,Rehabilitation) • Members:
– NationalDisasterManagementAuthority – Secretaries(8ministries)
• RegionalDisasterManagementCommittee
R i l Di t M tC itt – DGͲ 8,JointSecretary,AIGͲ 2,Colonel,MS
• DistrictDisasterManagementCommittee – Chairpersons4
• LocalDisasterManagementCommittee – NGO(3women,2Dalitand2Marginalized)
– ExpertsͲ 2
Source:NationalStrategyforDRM,2009 • MemberSecretaryͲ ExecutiveDirector
11 12

62
 DistrictDisasterManagementCommittee
RegionalDisasterManagementCommittee
• Chairperson:ChiefDistrictOfficer
• Members:
• Chairperson: RegionalAdministrator – ChairpersonofDDCordesignee
–
• Members: –
Chiefofalldistrictleveloffices
Chiefsofallsecurityentities
– Chiefsofallregionaloffices – NRCS
– NRCS – Representatives of National Political Parties
RepresentativesofNationalPoliticalParties
– Chair,DistrictIndustry&CommerceAssociation
– NominatedbyRegionalAdministratorDDCChairs – ChiefofMunicipality
– Womenrepresentative(NominatedbyRA) – ThreerepresentativesofVDCchairs
– WomenRepresentative2(NominatedbyCDO)
– RepresentativeofPreparednesscommittee
– ThreeRepresentativeofNGOandsocialactivists
• MemberSecretaryͲ DeputyRA – Tworepresentativesfromexperts
• MemberSecretaryͲ LDOͲ DDC
13 14

63
 Structure
ƒ In2000,theMoHP,DHS/EDCDestablisheda
mechanismformanagingepidemics.
1.2DisasterManagementMechanism
ƒ Thismechanismconsistsofestablishmentof
RapidResponseTeam(RRT)atthreelevels:
SubTopicb: ¾central(1),
FunctionalMechanismofRapid ¾regional(5)and
¾districts(75)
ResponseTeam(RRT)

DistrictRapidResponseTeam
ObjectivesofRRT ƒ Coordinator(DHO/DPHO)
ƒ FocalpersonͲ HA/SeniorAHW
ƒ Toestablishanearlywarningandreporting
ƒ Members:
mechanismforpotentialepidemics. ƒ MedicalOfficer,
ƒ PHN/SN/ANM,
ƒ Tomakepreparationsforpotential
ƒ V t C t l A i t t/MI
VectorControlAssistant/MI,
epidemics. ƒ EPISupervisor,
ƒ AHW,
ƒ Tomanagediseaseoutbreaks.
ƒ LabTechnician/LabAssistant,
ƒ Supportindisastermanagement. ƒ HealthEducationTechnician,
ƒ StatisticalAssistant,
ƒ RHfocalperson
3 4

RoleofRegionalRapidResponseTeam RoleofCentralRapidResponseTeam
ƒ Mobilizeiftheimpactofthedisasterisbeyond
theresponsecapacitiesofthedistrictand
ƒ Supportineffectivecoordinationbetween regionallevelRRTs.
ƒ Facilitateindiagnosisofinfectiousdiseases.
ƒ thecenteranddistricts
ƒ Resourcemobilization.
Resource mobilization
ƒ NGOs,INGOs,UNagencyandrelevantdonors. ƒ Establisheffectivecoordinationforresources
ƒ ProvidebackupservicesfordistrictRRT andadditionalassistancebetween
ƒ NGOs,INGO,UNagencyandrelevantdonorsother
stakeholders

5 6

64
 DisasterManagementͲ Function 1.EmergencyPreparedness
1. EmergencyPreparedness
ƒ PrepareEmergencyPreparednessplan
2. DisasterResponse
ƒ InstitutionalizeEarlyWarningandReporting
3. RehabilitationActivities System(EWARS)andInformation
ƒ CapacityBuilding(Training)
ƒ Keepbufferstockofmedicines,kits,logistics
ƒ ManagesafewaterandSanitation

7 8

3.RehabilitationActivities
2.DisasterResponse

ƒ CarryoutInitialRapidHealthAssessment ƒ HealthServicesPackage:HealthEducation,
(RHA) measuresforcommunicablediseasecontrol,
ƒ Collectionofhealthstatusinformation RHSeries,surveillanceandmonitoring.
ƒ ProvideHealthServices ƒ MentalHealth(Counseling,reducepost
ƒ WaterandSanitation disastermentalhealthconsequences).
ƒ DiseaseSurveillance

9 10

65
 Question

Whensomethinghappens,whatarethe
1.2: keyareasofinterventionthatthehealth
c) Setting of Priorities: Key Intervention
c)SettingofPriorities:KeyIntervention workersmustlookat?
Areas

1 2

ProbableAnswers
ƒ Assessment
Prioritization
ƒ Coordination Attimesofdisasterseveralactivitiesneedsto
ƒ DeliveryofEssentialHealthCareServices bedone.Howeverlimitedtimeandresources
ƒ Outbreakcontrol donotpermittodoalltheactivities.So,
ƒ Reproductive health
Reproductivehealth prioritization should be done to address the
prioritizationshouldbedonetoaddressthe
ƒ Nutrition mostneededactions.
ƒ Immunization
ƒ HIV/AIDS
ƒ TBControl
ƒ PsychoͲsocialSupport
ƒ Others… 3 4

RapidHealthAssessment Coordination
ƒ Mustbedoneimmediately ƒ Inemergencysituations,itisessentialtohave
ƒ Usedtounderstandwhatarethemainissues amechanismtocoordinateallresponse,to
ƒ AmechanismtoactivateanddeploytheRapid avoidconfusion,overlapand/orgaps.
ResponseTeams(RRT) ƒ Coordinationmechanismsmightexist,but
ƒ Keyareastolookatinclude: theseneedtobeactivated.
ƒ Demographics ƒ DDRC:CDOforoveralldisastercoordination
ƒ Potentialhealthhazardsamongtheaffected ƒ HealthandNutritionClusterCoordination:D(P)HO
population ƒ Differenttoolsavailable:WWWtracking,
ƒ Statusofhealthfacilitiesinthesurrounding logisticstracking,situationreportetc.
areas
ƒ Thepossibleimpact
ƒRefertotheRRTassessmentform 5 6

66
1.DeliveryofEssentialHealthCareServices 2.OutbreakDetectionandControl
ƒEnsuretoprovideessentialhealthcareservices • Inemergencies,peopleareoftendisplacedandhaveto
ƒInemergencies,multipleinjuriesmighthappen.So, liveincrowdedconditionsforalongtime.
expandingemergencyunits,settingupfieldhospitalsat • Insuchconditions,outbreaksarepronetooccur.
campsitesmightbeneeded • Toensuretheoutbreaksaredetectedearlyandtreated
ƒBesides,providing,ambulanceservicestosendinjuredto properly,anearlywarningsystemmustbe
the nearest health facility on time
thenearesthealthfacilityontime. implementedimmediately.
ƒMinimumInitialServicePackageforReproductiveHealth
ƒReferralservicesneedstobemoreactiveandsystematic. • Necessarymedicinesandequipmentsshouldbemade
readyfordispatching

7 8

3.Providenecessaryservice 4.Obtainnecessarysupport
• ReproductiveHealthincludingcleandelivery
servicesbecomesimportant • CollaboratewithlocalNGO,clubs,
pharmacies,ITmediaetc
• Immunizationandnutritionservicesneedtobe
continued • RequestRegionalRRTandCentralRRTfor
more support
moresupport
• ServicesforTuberculosiscontrolshouldbe
continued
• TreatmentforHIVandSTIshouldbecontinued
• SupportforestablishingservicesforpsychoͲ
socialsupport
9 10

5.Regulateservices
• Alertingaboutoutbreak
• Reproductivehealth
• Nutrition
• Immunization services
Immunizationservices
• HIVandSTI
• Tuberculosis
• PsychoͲsocialsupport
• Logisticssupply
11

67
 Background

RapidHealthAssessmenthelpsinanalysing
Unit1.3:
thesituationforappropriateandtimely
R id H l h A
RapidHealthAssessment
response.

Sourceofinformation RapidHealthAssessment(RHA)
ƒ Routine: RHAisa“collectionofsubjectiveandobjectiveinformationin
ƒ SurveillanceSystems(EWARS) ordertomeasuredamageandidentifythosebasicneedsofthe
affectedpopulationthatrequireimmediateresponse”(From:
ƒ HealthManagementInformationSystem RHAprotocolsforemergencies,WHO,1999)
(
(HMIS) )
I h l i
Ithelpsin:
ƒ Civilregistration(vitalstatistics) ƒ Confirmingthedisaster/emergency
ƒ NonͲroutine: ƒ Describingthetype,impactandpossibleevolutionof
emergency
ƒ RapidHealthAssessment(RHA) ƒ Measuringpresentandpotentialhealthimpact
ƒ Assessingadequacyofresponsecapacityandadditionalneeds
ƒ Surveys ƒ Recommendingpriorityactionforimmediateresponse

3 4

TypesofAssessments PreͲdisasterRiskAssessment
ƒ PreͲdisasterriskassessment ƒ Riskistheprobabilityofharmorloss
ƒ Situationanddamageassessment(Identifiesthe ƒ Requirestwothings:
magnitudeandextentofthedisasteranditseffectsonthe
society.) ƒHazards:thingsthatcancauseharm
ƒ Needsassessment(definesthelevelandtypeof ƒVulnerability:thingsthatcanbeharmed
assistancerequiredfortheaffectedpopulation).Rapid ƒ Knowthehazards(potentialtocauseharm)
h lh
healthassessment(definesthemagnitudeofdisastersand
(d f h d fd d
actorsinvolvedduringresponse) ƒ Knowwhatorwhoisvulnerabletohazards
ƒ PostͲDisasterSyndromic DiseasesSurveillance(definesthe ƒ People&thingsexposedtohazards=risks
statusofdailydiseasesituation)Ͳ seeannexIIforreporting ƒ Riskscanbereduced
form ƒ Changethehazard
Note:Thegatheringofinformationforthesituationassessmentandneedsassessmentcan
bedoneatthesametime.Theinformationcollectedintheinitialassessmentisthebasisfor ƒ Protectormovethevulnerable
determiningthetypeandamountofreliefneededduringtheimmediateresponsephaseof
thedisaster. ƒ Defertherisk(insuranceormovethehazard)
5 6

68
 PreͲdisasterRiskAssessmentCont…
RapidHealthAssessment(RHA)
ƒ PreͲdisasterassessmentsareimportant
becausetheyguideyouinpreparation
ƒ Mock/drillsyoupracticeinthehospital ƒ Initialsituationreport(seeannexIfor
ƒ Helpyoufocusyourmedicalstafftraining
l f di l ff i i reportingform).
ƒ Helpyouwriteaplanspecifictoahazard
ƒ Helpyouprojecthowmanypatientsyour ƒ AdditionalRapidHealthAssessmentto
healthfacilitymayhavetotreatandhow definefurtherresponseneeds.
manypeoplemaybeexposedandrequire
assistance 7 8

RapidHealthAssessment Cont. AdditionalNeedsAssessment

ƒ RapidResponseTeamsatthedistrictlevelare ƒ Withinthefirst5daysfollowingthedisaster.
keytoinitiaterapidhealthassessments.
ƒ Theassessmentshouldbemadebyajointteam
ƒ Rapidhealthassessmentsshouldbeconducted includingprofessionalsofdifferentsectors(i.e.
immediatelyafterthedisasterinallimpacted , g , , pp y
health,logistics,infrastructure,watersupply
areas.Specialattentionshouldbepaidtothe
S i l i h ld b id h andsanitation).
mostvulnerablegroups.
ƒ Theassessmentshouldbecarriedoutinaway
ƒ Theinformationcollectionshouldbebasedon thatallowstransparentconsistentdecisionͲ
theattachedformat. makingandimplementingresponseactions.
ƒ Theformatshouldbefilledinwithin12hoursof ƒ Shouldrevealgapsinresponseandidentify
anydisasterandsubmittedtoEDCD. needsnotcovered.
9 10

Step1:Plantheassessment
KeyquestionsinaRHA
Step2:Determinewhatinformationto
Howto gather
ƒ Isthereanemergencyornot? conduct
Step3:Coordinatewithotherorganizations
rapidhealth
ƒ Whatisthemainhealthproblem? assessments Step4:Formtheassessmentteam
ƒ Whatistheexistingresponsecapacity?
What is the existing response capacity? Step5:Makeadministrativearrangements
Step 5: Make administrative arrangements
forvisits
ƒ Whatdecisionsneedtobemade?
Step6:CollectData
ƒ Whatinformationisneededtomakethese The“8 Step7:Analyzedata
decisions? steps” Step8:Presentresultsandplanforaction
11
intheappropriatereportingformat 12

69
 ƒ Thepopulation:
MainstepsofaRHA ƒ numbers,characteristics,&trends
ƒ morbidityandmortality
ƒ Settheassessmentpriorities ƒ Thevitalneeds:
ƒ security
ƒ Collectthedata: ƒ food
ƒ water
ƒ reviewexistinginformation ƒ shelter&sanitation
ƒ clothesandblankets
ƒ inspecttheaffectedarea
inspect the affected area ƒ d
domesticutensilsandfuel
i il df l Which
Which
ƒ healthcareincludinghealthresponseto information?
ƒ interviewkeypeople GBV
ƒ Thesupportsystems:
ƒ carryoutarapidsurvey ƒ information
ƒ logistics
ƒ Analyseandinterpretthefindings ƒ coordination
ƒ resourceflow
ƒ Presentresultsandconclusions 13
ƒ Otherrelevantcontextualissues
14

Decide RHA:afewtips
• Arethecurrentlevelsofmortalityandmorbidity
abovetheaverageforthisareaandthistimeofthe ƒ Don’tbetooambitious:timeisshort
year?
• Arethecurrentlevelsofmortality,morbidity, ƒ Beingroughlyrightisgenerallybetterthan
nutrition,water,sanitationshelterandhealthcare
h l dh l h beingpreciselywrongorpreciselylate
acceptablebyinternationalstandards?
• Isafurtherincreaseinmortalityexpectedinthe Beware:wrongconclusionsfromtheRHA
nexttwoweeks?
candomoreharmthannottakingany
• ADVISEACCORDINGLYandFOLLOWͲUPINCLUDESTUDIES action
ONANALYSISBASEDONQUESTIONNAIRES 15 16

70
 TypesofKit

Unit1.4: ƒ Diarrhoeal DiseasesKit(DDK)Ͳ WHO

LogisticManagementin ƒ InterͲAgencyEmergencyHealthKit(IEHK)Ͳ
Emergency
Emergency WHO

ƒ ReproductiveHealthKit(RHKit)– UNFPA

ƒ SurgicalkitͲ WHO
2

WhatdoestheDiarrhoeal DiseasesKit Content/composition

Contain? Diarrhoeal DiseasesKitcont
Itcontains: ƒ BasicModule
• OralRehydrationSolution ƒ Drugs
•Antibiotics
•Intravenous Infusions
•IntravenousInfusions ƒ Renewalsupplies
pp
ƒ Equipment
Itisintendedfor100severecholeracases(choleratreatment ƒ Documents
unit),plus400moderatecholeracases(oralrehydrationunit),and ƒ ORSModule
100adultsplus100childrenaffectedbyShigelladysentery.
ƒ InfusionsModule
3
ƒ SupportModule 4

WhatdoesanInterͲAgencyEmergencyHealth Content/compositionInterͲAgency
Kitcontain? EmergencyHealthKitcont…
ƒTheInteragencyEmergencyHealthKitisdesigned ƒEachBasicUnitcontains:
principallytomeettheinitialprimaryhealthcareneeds ƒ oralandtopicalmedicines,(notinjectables)
ofadisplacedpopulationwithoutmedicalfacilitiesand ƒ medicaldevices,renewable
isforuseintheearlyphaseofemergency.
yp g y ƒ medicaldevices,equipment
, q p
ƒThekitisnotdesignedandnotrecommendedforthe ƒ module:malariaitemsforthetreatmentof
reͲsupplyofexistinghealthcarefacilities. uncomplicatedmalaria
ƒTheIEHKcontainssufficientmedicalsuppliestosupport
atleast10,000peopleforaperiodof3months. Note:BASICUNITisintendedforprimaryhealth
careworkerswithlimitedtraining.
ƒTherearetwounits:BasicandSupplementary
5 6

71
 Content/compositionIEHK… Content/compositionof
ƒOneSupplementaryUnitcontains:
ReproductiveHealthKit
ƒ medicines(MEDS) ƒ TheReproductiveHealthKitshavebeencreated
ƒ essentialinfusions(INFS)
ƒ medicaldevices,renewable(RENW) tofacilitatetheimplementationofreproductive
ƒ medicaldevices,equipment(EQPT)
ƒ module:patientpostͲexposureprophylaxis healthservicesduringtheearlyphaseofacrisis.
(PEP)
ƒ module:malariaitems ƒ TheReproductiveHealthKitsneedtobeordered
ƒ module:psychotropics (Pt) duringthatphase.
ƒ module:narcotics(Nt)(canbereplacedby
tramadol)
ƒTheRHKitscontainessentialRHdrugs,supplies
Note:SUPPLIMENTARYUNITisintendedfor andequipmenttobeusedforalimitedperiodof
professionalhealthworkersorphysiciansand
shouldbeusedwithatleastoneormoreBasic timeandforafixednumberofpeople.
Units 7 8

Content/compositionSurgicalKit Howtogetit?
ƒThekitisestimatedtocovertheneedsfor
ƒ Clusterlead(WHO)cancoordinatewith
medicaldisposableequipmentforapproximately
100surgicalinpatientsfor10days,particularlyin concernedagenciestogetthekits
thepostoperativephase.
And/or
ƒThekitcontainsallessentialmedical
disposables;bandages,compresses,drains, ƒ TheMOHcandirectlyrequestconcerned
tubes,syringes,needles,catheters,infusion
accessories,gloves,sutures,burndressings, agenciesforsupplyingthekit
hygieneequipment,plasterofParisand
sterilisation accessories.
9 10

LogisticestimationandBuffer
FinancialManagement
Stocking
• Necessarylogistics(medicines,materialsetc) • Thedistrict(Public)HealthOfficeisprovided
shouldbeestimatedbeforehandand withsomemoneyeveryyeartoaddressthe
adequatequantitysenttotheaffectedarea needincaseofemergencyanddisaster,which
• Asignificantquantityshouldbekeptat
A significant quantity should be kept at can be used ASAP
canbeusedASAP
district/locallevelasbufferstocking • TheDistrictDRCalsocansupportinsuch
• Advancerequestshouldbesentto scenario
region/centerincaseoflargeepidemicor • TheDDC/urbanorruralmunicipalitiescanalso
disaster supportforaddressingtheemergency/
disaster
11 12

72
 WhatisSphere?
ƒ TheSphereProjectisahumanitarianCharter
Unit1.5: andMinimumstandardinDisasterresponse.It
EnvironmentalHealthand representsthecoreprinciplesregarding
humanitarianassistanceindisaster
Sanitation in Emergency
SanitationinEmergency
ƒ Sphereprojectaimstoenhancethe
(MinimumstandardbasedonSphereGuidelines)
effectivenessandqualityofhumanitarian
assistanceinemergenciesandthusa
significancedifferencetothelivesofpeople
affectedbydisaster.
2

EnvironmentalHealthandControlof
FiveMinimumStandardsofSphere
CommunicableDiseases
ƒ Waterandsanitation
ƒ Watersupplyandsanitation ƒ Excretadisposable
ƒ Vectorcontrol
ƒ Nutrition ƒ Solidwastemanagement
Solid waste management
ƒ Foodaid ƒ Controlofcommunicabledisease
Ͳprevention
ƒ Shelterandsiteplanning
Ͳdiagnosisandcasemanagement
ƒ Healthservicesincludingreproductive ͲoutbreakPreparedness
health 3
ͲoutbreakResponse 4

Minimumstandardofwaterand
KeyIndicatorsofwaterandsanitation sanitationcont…
ƒ Averagewaterforcooking,drinkingand ƒ SanitarysurveyindicateͲlowfaecal
personalhygiene:15litre/day contamination
ƒ Peopledrinkwaterfromtheprotected
ƒ Distancefromhousetowatersource:500
source
meter.
ƒ Nonegativehealtheffectdetectedin
ƒ Atleast1waterpointfor250people shorttermuseofwatercontaminatedby
ƒ Flowofwater:7.5litres/minutes,quing chemical(includingcarryͲoverof
time:15minutestofill20litresofwater treatmentchemicalorradiological
sources.
5 6

73
 WaterRelatedTechnicalGuidelines
Minimumstandardofwaterandsanitation
Healthcentres 5litres/outpatient/day cont…
andHospital 40Ͳ60litres/inpatient/day
ƒ Eachhouseholdhasatleasttwocleanwater
CholeraCentre 60litres/patient/day collectioncontainersof10Ͳ20litreswith
15litres/carer/day
narrowneck
Therapeutic
Th ti 30 lit /i
30litres/inͲpatient/day
ti t/d ƒ Atleast250gmofsoapavailablefor
feedingcentre 15litres/carer/day personalhygiene/person/month
School 3litres/people/dayfordrinking&hand ƒ Sufficientbathingcubiclesavailablewith
washing separateformaleandfemale
Publictoilet 1Ͳ2litres/user/dayforhandwashing ƒ Atleasttwowashingbasinfor100peoples.
2Ͳ8litres/users/dayfortoiletcleaning 7 8

Excretadisposalstandard Vectorcontrolstandard

ƒ Amaximumof20peopleuseonetoilet ƒ Alldisplacedpopulationaresettledin
ƒ Separatetoiletformaleandfemale locationsthatminimisetheirexposureto
ƒ Atleast50metersfromthedwelling mosquito
ƒ Shouldbebuiltinsuchawaythatcanbe
Sh ld b b ilt i h th t b ƒ Vectorbreedingandrestingsitesare
usedbyallincludingchildrenandpregnant modified
women
ƒ Intensiveflycontroliscarriedout
ƒ Easytokeepclean
ƒ Peopleinfectedwithmalariaarediagnosed
ƒ Providesdegreeofprivacy
earlyandreceivedtreatment
ƒ Minimumflyandmosquitobreeding 9 10

Vectorcontrolstandardcont… Solidwastemanagementstandard
ƒ RefusecontainerͲ100meterfrom
ƒ Beddingandclothingareairedandwashed communalrefusepit
regularly ƒ Atleast1(100litre)refusecontaineris
ƒ Peoplewithtreatedmosquitonets(LLIN) availableper10families
usethemeffectively. ƒ Medicalwasteisseparatedanddisposed
M di l t i t d d di d
separately
ƒ Peopleareeducatedproperlyregardingthe
specialattentionandprecaution ƒ Nocontaminatedmedicalwasteatanytime
inlivingareas
ƒ Clearlymarkedandappropriatelyfenced
11
refusepit 12

74
 DrainageStandard Communicabledisease
ƒ Drainsarekeptclean,dwellingarekeptfree (a)Prevention
ofstandingwater ƒ Water,sanitationandhygienepromotion
ƒ Shelters,pathsandwaterandsanitation ƒ Accesstoadequatefoodandmanagement
facilities are not flooded by water
facilitiesarenotfloodedbywater ofmalnutrition
f l t iti
ƒ Waterpointdrainageiswellplanned,built ƒ Communityeducation
andmaintained
ƒ Massvaccinationcampaignandroutine
ƒ Drainagewaterdonotpolluteexisting ongoingvaccination
surfaceorcauseerosion
13 14

Communicabledisease Communicabledisease
(b)Diagnosisandcasemanagement (c)OutbreakPreparedness
ƒ Preparedoutbreakinvestigationandcontrol
ƒ Useofstandardguidelinesandprotocols plan
ƒ Ensureavailabilityoflabservices ƒ Investigationandcontrolprotocolsavailable
ƒ Educatecommunitytoseekearly torelevantstaffs
treatmentandcare ƒ Staffsreceivedtrainingonoutbreak
ƒ Inmalariaendemicregionestablish24hrs management
diagnosisoffever ƒ Reservestockofessentialdrugsandother
suppliedavailable
15 16

Communicabledisease
(c)OutbreakPreparednesscont… (d)OutbreakResponse
ƒ HMISincludesanearlywarningcomponents
ƒ Identifiedsourceofvaccination. ƒ Initiationofoutbreakinvestigationoccurswithin
ƒ Mechanismofrapidprocurement 24hoursofnotification
established ƒ Outbreakshouldbedescribedaccordingtotime,
ƒ Sitesforvaccinationandtreatmentof placeandperson
l d
infectiouspatientsareidentified ƒ Appropriatecontrolmeasuresthatarespecificto
thediseaseandcontextareimplemented
ƒ Alaboratoryisidentifiedfordiagnosis ƒ Casefatalityratearemaintainedatacceptable
ƒ Samplingmaterialsandtransportmediafor levels:
theinfectiousagentsavailable. ͲCholeraͲ1%,Shigella(dysentery):1%orlower,
17
Typhoid:1%orlower 18

75
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(b)Importanceofsafedrinking
waterforpreventionandcontrol
t f ti d t l
ofwaterbornediseases
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ƒ Snfl/g
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kLo"if gfds Snf]l/g emf]n -)=%Ü ;f]l8od xfOkf]Snf]/fO6
emf]n_ pTkfbg / laqmL ljt/0f ub}{ cfPsf] 5 . ƒ Snf]l/gsf] emf]n s]6fs]6Ln] ge]§fpg] 7fpFdf
/fVg'kb{5 .
ƒ jf6/uf8{ M Population Services International/Nepal(PSI)
gfds ;+:yfn] ;g\ @))% df jf6/uf8{ g]kfnL ahf/df ƒ s]xL u/L Snf]l/gsf] emf]n z/L/df k/]df t'?Gt
k|j]z u/fPsf] xf] . k|z:t kfgLn] kvfNg'kb{5 / glhs}sf]
25
:jf:Yo s]Gb|df hfg'kb{5 . 26

@_ pdfNg] Wofg lbg'kg]{ s'/fx?

ƒ e/kbf]{ / k|rlnt ljlw ƒ wldnf] kfgL pdfNbf o;df ePsf 7f];
ƒ tfkqmdn] ubf{ kfgLdf ePsf /f]uhGo hLjf0f'? gi6
kbfy{x? -h:t}, w"nf], df6f]_ cflb x6\b}gg\ .
x'xG5g
5g\ . ƒ To;}n] wldnf] kfgLnfO{ lyu|fPP/ 5fg]kl5 dfq
ƒ ljZj :jf:Yo ;Ë7gsf cg';f/ kfgL pdfNbf sDtLdf pdfNg'kb{5 .
Ps e'Nsf] pdfn]kl5 vfg]kfgL hLjf0f'/lxt x'G5 . ƒ kfgLnfO{ pdfnL ;s]kl5 ;kmf efF8f]df 5f]k]/
ƒ /fd|f];Fu gpdflnPsf] dgtftf] kfgLdf /f]uhGo /fVg'kb{5, h;n] ubf{ kfgL k'gM b"lift x'g
hLjf0f'x? x'g ;Sb5g\ . kfpFb}g .
27 28

#_ lkmN6/
ƒ lkmN6/ eg]sf] kfgLnfO{ 5fg]/ ;kmf ug]{ Pp6f ;lhnf] sf]nfO8n l;Ne/
ljlw xf] . lkmN6/
ƒ ahf/df ljleGg lsl;dsf lkmN6/x? KffOG5g\
ƒ Sof08n lkmN6/, ƒ sf]nfO8n l;Ne/ lkmN6/Ú vfg]kfgLdf ePsf sL6f0f' x6fpg]
ƒ sf]nfO8n l;Ne/ lkmN6/ Ps k|efjsf/L pkfo xf] .
ƒ afof]:ofG8 lkmN6/ ƒ o;sf] k|d'v ljz]iftf eg]sf] rfFlb n]kg ul/Psf] df6f]sf] 7"nf]
;fOhsf] Sof08n÷Kn]6 -l8:s_ xf] .
ƒ of] Sof08nn] sL6f0f'nfO{ l5g{af6 /f]Sb5 eg] SofG8ndf
n]kg ul/Psf] rfFlbn] kfgLdf EfPsf sL6f0f'nfO{{ dfg]{ sfd
29
ub{5 30

77
Wofg lbg'kg]{ s'/fx? afof]:of08 lkmN6/
ƒ vfg]kfgLdf ePsf hLjf0f', wldnf]kg, cfO/g / uGw x6fpg]
ƒ lkmN6/sf] Sof08n g/d bfFt df´\g] a|;n] /fd|f];Fu Ps ;/n 3/]n' ljlw xf] .
;kmf ug'{kb{5 . ƒ sª\lqm6 jf Knfli6ssf] efF8fdf lu§L / afn'jfnfO{ tx ldnfO{
ƒ o;/L ;kmf ubf{ ;fa'gsf] k|of]u slxNo} ug'{ x'Fb}g . /fv]/ :yfgLo txd} tflndk|fKt JolQmåf/f agfpg ;lsG5 .
ƒ lkmN6/sf] wf/f / Sof08nsf] jf;/, g6 /fd|f];Fu ƒ lkmN6/df kfgL vGofpFbf afn'jf / lu§Lsf] txaf6 kfgLdf
s:gkb{
s:g' kb55. ePsf hLjf0f'
hLjf0f, wldnfkg,
wldnf]kg cfO/g cflb 5flgG5 / kfgL lkpg
ƒ lkmN6/nfO{ ;"o{sf] k|sfz gkg]{ ;dyn :yfgdf of]Uo x'G5 .
/fVg'kb{5 .
ƒ lkmN6/sf] Sof08nnfO{ kfgLdf slxNo} pdfNg' x'Fb}g .
ƒ lkmN6/sf] wf/f kmf]x/ xftn] 5'g' x'Fb}g
31 32

ƒ sª\lqm6sf] afof]:of08 $_ ;f]l8;

lkmN6/n] k|lt 306f ƒ ;f}o{zltm4f/f kfgL z'l4s/0f
@%–#) ln6/ . ƒ ;/n / ;:tf] k|ljlw
ƒ Knfli6ssf] afof]:of08 ƒ k/fj}hgL ls/0f / tfkn] ;"Id
lkmN6/n] k|klt
lkmN6/n lt 306f hLjf0f'' gi6 x''g] t/ /;fog gx6fpg]
ƒ v]/ uPsf] af]tnsf] k'gM k|of]u x'g]
!%–@) ln6/ kfgL
ƒ ;fdfGo hfgsf/Lsf] e/df ug{ ;lsg]
5fG5 . ƒ OGwgdf nfUg] vr{ aRg]

33

;Lldttf
ƒ Ps} k6sdf w]/} dfqfdf kfgL z'4Ls/0f ug{ gldNg] .
ƒ Dff};ddf lge{/ x'g] .
ƒ kfgL wldnf] (30 NTU) eGbf a9L ePdf
k|efjsf/L gx'g] .
Wofg
ofg lbg'kgg]{ s'/fx?
ƒ Af9Ldf !) ;]=ld= -rf}8fO_ ePsf], gsf]l/Psf],
gs'lRrPsf] / kf/bzL{ af]tnsf] k|of]u ug'{kb{5 .
ƒ /+lËg tyf lzzfsf] af]tn k|of]u ug'{ x'Fb}g .
ƒ kfl/nf] 3fd jf cf+lzs afbn nfu]df Ps lbg /
k"/f afbn nfu]df b'O{ lbg;Dd af]tnnfO{ 3fddf
35
/fVg'kb{5 . 36

78
 Surveillance
Surveillanceistheongoing systematic collection,
analysisandinterpretationofdata;andthe
Unit2.1: disseminationofinformationtothosewhoneedto
knowinorderthatactionmaybetaken
CommunicableDisease
Surveillance Surveillanceisthesystematicuseofdataforaction

ProcessofDiseaseSurveillance GoalofSurveillance

Thereductionofmorbidityandmortalitythrough
thecontroland/orpreventionofdisease.
• Collection
• Analysis TypesofSurveillance
• Interpretation
ƒ Passive(Healthfacility– District– Region/Centre)
• Dissemination ƒ Active(DesignatedOfficerregularlylooksfordiseases
ofinterestusingstandardcasedefinitionfor
notifiable diseases)
PublicHealthAction
3 4

Surveillance:Function UsesofSurveillance
CoreFunction ƒ Epidemic(outbreak)detection
ƒ Detection ƒ Epidemic(Outbreak)prediction
ƒ Reporting ƒ Monitoringtrendsindisease
ƒ Investigation&confirmation ƒ Toidentifychangesinagentandhostfactors
ƒ Analysis&interpretation
y p ƒ Evaluating an intervention
Evaluatinganintervention
ƒ Action/response
ƒ Monitorprogresstowardsacontrolobjective
Supportfunction ƒ Monitorprogramme performance
ƒ Training
ƒ Estimatefuturediseaseimpact
ƒ Supervision
ƒ Resources ƒ Generatehypothesesandstimulatepublic
ƒ Standardscasedefinitions/guidelines
healthresearch
5 6

79
 Surveillance:GeneralPrinciple SurveillanceReports
HealthCareSystem PublicHealthAuthority
Purposeofsurveillancereports:
Data Reporting Information ƒ Tocommunicatewithpeople
ƒ Todisseminateinformation
Analysis&
Evaluation
Interpretation
ƒ Toeducatethereader

Feedback ƒ Todirect,stimulateandmotivatethe
personresponsibleforaction
Action Decision
7 8

Todetectoutbreaksofdiarrhoea bymonitoring
Surveillance:BasicComponent theincidenceofcasesofacutegastroenteritis
Casesofacutegastroenteritisinahospitalby
ƒ Agoodnetworkofmotivatedpeople epidemiologicalweeks,MayͲ September2008
ƒ Clearcasedefinitionandreporting
mechanism
ƒ Efficientcommunicationsystem
ƒ Basicbutsoundepidemiology
ƒ Laboratorysupport
ƒ Goodfeedbackandrapidresponse
10

DiseaseIndicators
Themeasuresthatyouusetomonitoradisease
e.g.
ƒ Number
– Noofcasesofmalariareported
No of cases of malaria reported
– Noofcasesoffalciparum malariareported
ƒ Rate
– NumberofcasesofARIinchildrenunder5years
per100,000population
ƒ Ratio
11
– ProportionofchildrenwithARIwhodie 12

80
 Surveillance:Tasks
DiseaseIndicators
Peripheral Detect,Treat,
level Report

Analyse,Investigate,
ƒ Theymaybeindicatorsof Intermediate Report,Respond,
–Disease
Diseaseincidence
incidence level Feedback
eedbac

ƒ CasesofKalaͲazarper100,000population Analyse Investigate

ƒ Effectivenessoftreatment Centrallevel ConfirmRespondPlan
andFundFeedback
ƒ Casefatalityinmeasles
Analysisandfeedback
Internationallevel SupportPolicyand
13 targetsFunding 14

Surveillance:DataFlow OurRoleinSurveillance

Peripheral Clinical Identifycasesunder

level (Suspected)
surveillance
+Supportive
Laboratorydata
Intermediate +epidemiological Notifydistrict
level li k ( b bl )
link(probable) ffocalsurveillanceperson
l ill
Diagnostic
Centrallevel Laboratory Activate/NotifyRRT
(Confirmed)
Regional
Internationallevel reference CaseInvestigation NotifyRegional/Central
laboratory 15 DiseaseControl 16

RoleofClinicians
AtHealthfacilities:
IMMEDIATELYNOTIFYHOSPITALFOCAL ƒ AllhealthworkersincludingRRTteam
SURVEILLANCEPERSONSOTHEYCAN shouldhaveabasicunderstandingof
NOTIFYTHEDistrictTeam epidemiology,mainlycommunicable
di
diseasesurveillance,thusdistrictandbelow
ill h di i db l
Adviseparentsaboutthecaseinvestigation, districtlevelhealthworkersshouldget
tellthemhealthofficialswilltakea trainings
history,takespecimenforlabconfirmation ƒ PreͲpositionofdrugsandotheressentials
atdistrictandsubͲdistrictlevels
Knowwheretoreferpatientsfortreatment 17 18

81
 RoleofBasicHealthstaff/ RoleoftheDistrictTeam
CommunityHealthVolunteers
ƒ Makesurestaffathealthfacilitiesinyour
districtknowhowtoidentifyandreport
ƒ Lookfor“suspectcases”ofdiseasesunder cases
surveillance ƒ Investigateeveryreportedcase
ƒ Completecaseinvestigationform,collect
ƒ Immediatelyreportthese“suspectcases” specimen.Completelinelisting
toaclinicianoralertthehospitalfocal ƒ Ensurecoldchain,andtransportspecimen
surveillanceperson. todesignatedlabassoonaspossible
ƒ Providefeedbacktohealthcarestaffonthe
19 laboratoryresults 20

SyndromicSurveillanceduringDisaster
(seeannexIIforsyndromicsurveillanceform)
Functioningdiseasesurveillancesystem
RapidResponseTeams– mustcoordinate andintactenvironmentalhealthservices
withDistrictDisasterReliefCommittee+ arecrucialinprotectingpublichealth
EDCDtoreducefurthermorbidityand p g
andinrespondingtotheoutbreaks
mortality.

ALLHEALTHEVENTSRELATEDTODISASTERS Wellprepared,leastaffected
SHOULDBEREPORTEDPROMPTLYAND
REGULARLY,WITHSUBSEQUENTACTION
21 22

82
 Definitionofoutbreak
Unit2.2: • Occurrenceofmorecasesofdiseasethan
OutbreakInvestigationandResponse expectedinagivenareaamongaspecific
groupofpeopleoveraparticularperiodof
time
Sub Topic: or
(a) Importance of outbreak • Twoormorelinkedcasesofthesame
investigation and its steps illness
1 2

ObjectivesofOutbreakinvestigations Stepsofanoutbreakinvestigation
ƒ Confirmexistenceofanoutbreak/epidemic(clinical&
laboratory)– confirmdiagnosis
1. Tocontrolongoingoutbreaks ƒ Establishaworkingcasedefinitionfortheoutbreak
2. Topreventfutureoutbreaks ƒ Identify,countnumberofcases&determinesizeof
y,
3. Toprovidestatutorilymandatedservices populationatrisk(tocalculateattackrate)
4. Tostrengthensurveillanceatlocallevel ƒ Lookforadditionalcases&followupcontacts
5. Toadvanceknowledgeaboutadisease
ƒ Developandtesthypothesis
ƒ Implementationofcontrolmeasures
ƒ Writeareportwithrecommendations
3 4

Routinesurveillance Outbreakconfirmed
Clinical/laboratory
DETECTION Generalpublic
Immediatecontrol Further
Media measures? Investigation?

Isthisanoutbreak? Treatment Unknownetiology

Prophylaxis (pathogen/source/transmission
( th / /t i i
Exclusion/isolation Casesserious
Publicwarning Casesstilloccurring
Diagnosisverified? Hygienicmeasures Publicpressure
Trainingopportunity
Clinical+laboratory
Scientificinterest
Linkbetweencases?
Expectednumbers? 5
Assistance? 6

83
Epidemiologist Casedefinition
Microbiologist
Outbreak
Environmentalspecialist Investigation
Publichealthpersonnel Team? ƒ Standardsetofcriteriafordecidingif
Physician/MedicalOfficer apersonshouldbeclassifiedas
Paramedics
Labpersonnel
p Assess situation
Assesssituation
sufferingfromthediseaseunder
Healtheducator Examineavailableinformation investigation
Others Preliminaryhypothesis?
Casedefinition
Casefinding ƒ Clinicalcriteria,restrictionsoftime,
place,person
Descriptionepidemiology
7

ExamplecasedefinitionͲ Cholera ExamplecasedefinitionͲ Cholera…

ƒ Probable
Suspect Ͳ Notapplicable
Acutewaterydiarrhea(passageof3or
Acute watery diarrhea (passage of 3 or ƒ Confirmed
C fi d
morelooseorwaterystoolsinthe
Ͳ IsolationofVibriocholerae fromstool
past24hours),withorwithout
ofpatient
vomitinginapatientaged5yearsor
more
9 10

Clearlyidentifiablegroups
Identify& Communities Implementcontrolmeasures
Countcases Hospitals Mayoccuratanytime
Laboratories duringtheoutbreak!!
Schools
Workplace,etc. Controlthesourceofthepathogen

Obtain information
Obtaininformation Identifyinginformation
Interrupt transmission
Interrupttransmission
Demographicinformation
Clinicaldetails
Modifyhostresponse
Riskfactors
Orientcasesby
Performdescriptive ͲTime
Epidemiology ͲPlace
11 12
ͲPerson

84
 Response/control Controlthesourceofpathogen

ƒ Treatcasesaccordingtorecommended
treatmentguidelines ƒ Removethesourceofcontamination
ƒ Implementdiseasespecificcontrol&
preventivemeasures ƒ Removepersonsfromexposure
Remove persons from exposure
ƒ Preventfurtherexposure(isolation, ƒ Inactivate/neutralise thepathogen
quarantine,contacttracing)
ƒ Preventinfection(e.g.vaccination,Public ƒ Isolateand/ortreatinfectedpersons
awareness,enhancedsurveillance)
13

Interrupttransmission Postoutbreakevaluation
ƒ Interruptenvironmentalsources
ƒ Controlvectortransmission ƒ Assesstimelinessofoutbreakdetectionand
response
ƒ Improvepersonalsanitation
ƒ Assessappropriateness&effectivenessof
Assess appropriateness & effectiveness of
controlintervention
Modifyhostresponse
ƒ Integrate/translatelessonslearntintopolicy
ƒ Immunizesusceptible ƒ Writeanddisseminateoutbreakreport
ƒ Useprophylacticchemotherapy
16

Attheend

ƒ Preparewrittenreportanddisseminate
(seeannexIIIforreportingform)
ƒ Communicatepublichealthmessages
Communicate public health messages
ƒ Evaluateperformance

17

85
 ControlofCommunicableDiseases
Unit2.2 ƒ Controlofcommunicabledisease
OutbreakInvestigationandResponse Ͳprevention
Ͳdiagnosisandcasemanagement
ͲoutbreakPreparedness
SubͲunitB.PreventionandControl ͲoutbreakResponse
ofOutbreakinDisaster

Communicabledisease Communicabledisease
(a)Prevention (b)Diagnosisandcasemanagement

ƒ Water,sanitationandhygienepromotion ƒ Useofstandardguidelinesandprotocols
ƒ Accesstoadequatefoodandmanagement ƒ Ensureavailabilityoflabservices
ofmalnutrition
f l t iti ƒ Educatecommunitytoseekearly
ƒ Communityeducation treatmentandcare
ƒ Massvaccinationcampaignandroutine ƒ Inmalariaendemicregionestablish24hrs
ongoingvaccination diagnosisoffever
ƒ VectorControlmeasures
3 4

Communicabledisease
(c)OutbreakPreparedness cont…
(c)OutbreakPreparedness
ƒ Preparedoutbreakinvestigationandcontrol ƒ Identifiedsourceofvaccination.
plan ƒ Mechanismofrapidprocurement
ƒ Investigationandcontrolprotocolsavailable established
torelevantstaffs ƒ Sitesforvaccinationandtreatmentof
ƒ Staffsreceivedtrainingonoutbreak infectiouspatientsareidentified
management ƒ Alaboratoryisidentifiedfordiagnosis
ƒ Reservestockofessentialdrugsandother ƒ Samplingmaterialsandtransportmediafor
suppliedavailable theinfectiousagentsavailable.
5 6

86
 Communicabledisease
(d)OutbreakResponse VectorControl
ƒ HMISincludesanearlywarningcomponents • Itisimportanttocontrolvectorsduring
ƒ Initiationofoutbreakinvestigationoccurswithin emergenciesanddisastertosafeguardpeople
24hoursofnotification
ƒ Outbreakshouldbedescribedaccordingtotime, • Variousmeasurescanbeapplied
placeandperson
l d • Useofbednetisveryimportanttowardoff
fb d i i d ff
ƒ Appropriatecontrolmeasuresthatarespecificto thevectors
thediseaseandcontextareimplemented • Hygienicmeasuresareallimportant
ƒ Casefatalityratearemaintainedatacceptable
levels:
ͲCholeraͲ1%,Shigella(dysentery):1%orlower,
Typhoid:1%orlower 7

87
 LaboratoryPreparednessforOutbreak
Unit2.2: Investigation
OutbreakInvestigationandResponse
ƒ Informationcollection
SubTopic: ƒ Planningforlab.activities
( )L b t
(c)Laboratoryinvestigationin
i ti ti i ƒ Formationoflaboratoryteam
F i fl b
outbreak ƒ Individualrole&responsibility
ƒ Accessoriesmanagement
ƒ Workingtogetherwithoutbreakinvestigation
team
2

Laboratoryformforoutbreakinvestigation
Procedure (seeannexIVforform)
Eachspecimenmustbeaccompaniedbyarequestform
Stepsoflaboratoryprocedureforoutbreak whichdetails:
ƒ Address:Dist/VDC/Municipality/WardNo./Tole/Phoneno.
investigation:
ƒ Occupation
1. Patient’sregistration&Outbreak ƒ Patient'sname,age,gender,outpatientorinpatient
number,wardorhealthcenter.
,
investigation/requisition form fill up
investigation/requisitionformfillͲup
ƒ Typeandsourceofspecimen
2. Patientpreparation&specimencollection ƒ Investigationrequired.
ƒ Specimenstoragetemperature
3. Preservation&storageofthespecimen ƒ Specimentransferredin
ƒ Dateandtimeofcollection.
4. Transportation/shipmentofthespecimen ƒ Samplecollectedby:
ƒ NameͲͲͲͲͲͲͲͲsignatureͲͲͲͲͲͲͲͲdate&timeofcollectionͲͲͲ
3 4

Properspecimencollection SampleTransportMedium
ƒ Propercollectiontechnique.
ƒ Appropriatetime ofcollection. ƒ VTM (virustransportmedium)forNasal,
ƒ Asufficientquantity ofspecimen. throatandrespiratoryspecimen.
ƒ Appropriatecollectiondevicesandcontainer. ƒ Alkalinepeptonewater totransferrectal
ƒ Appropriate transfer media
Appropriatetransfermedia.
swabandfreshstoolsampleforcholeralike
ƒ Wheneverpossible,obtainsamplepriorto
administrationofantibiotics. diarrhoeal cases.
ƒ Forrespiratorysamplecollectassoonaspossible ƒ CaryͲblairmediumͲ forthepreservationand
oncesymptomsoccurs.
ƒ Transporttime/temperature. transportationofsalmonella,shigella,vibrio
ƒ Properlabeling. andyersiniaspecies.
5 6

88
 StorageofSpecimen TransportofSpecimen

ƒ Usetriplelayerpackagingsystemforspecimen
ƒ Allspecimenmustbekeptat2Ͳ80Cafter packing.
collection.
ƒ Thetransporttimeshouldbekepttoaminimum.
ƒ Allspecimenmustbetransportedat2
All specimen must be transported at 2Ͳ8 80Cin
C in ƒ Transportspecimenincoldboxwithicepacksas
Transport specimen in cold bo ith ice packs as
coldboxwithin24hoursofcollection. soonaspossible.
ƒ Ifdelayintransportation,icepackmustbe ƒ Includedetailinformationofsenderandreceiver
changedinevery24hoursformaintaining withnameandmobilephonenumber
propercoldchain. ƒ CoͲordinatewithreferencelaboratorybeforeand
aftersampletransportation.
7 8

Rapiddiagnostictestkits
ImportanceofBioͲsafety&wastedisposal
• Leptospirosis
• Dengue • Influenza

• MalariaͲ pv/pf
ƒ Wearpersonalprotectiveequipment(PPE)egͲ
mask,glovesandgownduringsamplehandling. • KalaͲazar

ƒ Applyaseptictechniqueforsamplecollectionand Availableoftransfermedia
packing.
• NPHL
ƒ Disposeinfectedmaterialsindisinfectant • 5regionalhealthdirectorate
• Regionalhospital
solutionsorincinerate.

11 12

89
 FieldKitforspecimencollection
• Coldboxwithicepack
• VTM:forinfluenzalikeillnessorrespiratorysamplecollection
• Alkalinepeptonewater:totransportstoolsample(choleracase)
• CaryͲblair media:totransportstoolsamplefordiarrhoeal disease
outbreak
• Marker/laboratoryformforoutbreakinvestigation
• P ki t
Packingtape
• Steriledisposableswabstick/syringe
• Gloves
• Gown
• Mask
• 70%alcohol
• Plainsterilevials/testtubes
• ZipͲlockbag 13

90
 LineofCommunicationandCoordination
Unit2.4: ƒ DistrictRRT:DHO/DPHO
CommunicationandCoordination
DuringEmergencies
ƒ RegionalRRT:RHD

ƒ CentreRRT:EDCD

CommunicationduringDisaster BestPracticesforeffectivecommunication

• Veryimportantfunctionduringdisaster • Buildtrust
– Toobtainnecessarysupport • Announceearly
– Toprovideservices • Betransparent
– Tocollaborateandcoordinateactivities
To collaborate and coordinate activities
• Respectpublicconcern
• Planinadvance

3 4

Importantcommunicatingstepsduringa Communicationbeforeanatural
disaster disaster/outbreak
ƒ Reportearly Beforethehazard/outbreakcommunicateaboutrisksofthe
ƒ Alwaysusetheidentifiedfocalperson(spokesperson)to disaster
communicatepublicmessages. ƒ Externalcommunication
ƒ Useanypredevelopedtemplateonreporting (throughthemediaordirectsocialmobilization)
ƒ Ensuretheinformationisaccurate.Ifnoinformation
Ensure the information is accurate If no informationͲ sayso
Ensuretheinformationisaccurate.IfnoinformationͲ say so ƒ Towarnaboutriskorhazard
To warn about risk or hazard
andwhy. ƒ Toeducateaboutpreventionmeasures
ƒ Updatetheinformationonaregularbasis. ƒ Tocopewithpublichealthissuesarisingduringa
naturaldisasteroroutbreak
ƒ Provideconsistentreports.
ƒ Internalcommunication
ƒ Besensitivetoculturaldifferences.
ƒ Todrawaplanondisasterriskcommunicationplan,
ƒ Identifycrediblemodesofcommunication.
ƒ Identifyingthefocalpersons(spokesperson),linesof
ƒ Alwaysfollowuponthemediareportstoensureaccuracy. communication,modeofcommunicationetc
5 6

91
 Communicationduring anatural Communicationafter anatural
disaster/outbreak disaster/outbreak
Externalcommunication(throughmediabriefings,press
releasesorinterviews) ƒ Communicationisimportantduringthe
ƒ Toprovideinformationabouttheevent rehabilitationstage
ƒ Towarnpeoplemostlikelytobeaffected
ƒ Tomotivatepublic,politicalandinstitutionalresponse ƒ RRTsmaynotbeinvolvedtoalargeextentatthis
ƒ Todenyfalserumors stage
InternalCommunication ƒ Reportonthesituationoftheaffectedareas,
ƒ Tolinkscientists,disastermitigationofficials,andthe
public particularlyprogressofrehabilitationand
ƒ Toalertauthorities reconstructionefforts
ƒ Toassessdamage ƒ Provideguidanceonhowthecommunitycan
ƒ Tocoordinaterescueandreliefactivities collaboratewithrehabilitationefforts
ƒ Toaccountformissingpeople
7 8

PublicHealthMessagesforOutbreakSituations
CoordinationduringEmergencies
OutbreakInvestigationMessages
• CoordinatealltheactivitieswithDDRC
Baseyourmessageonthethreefour • Informhigherauthoritiesasearlyaspossibleandseek
componentsofdescriptiveepidemiology helpifneeded
• ConductRRTmeetingasrequiredandmobilizethe
team
• Person • Identifyafocalpersontocoordinatetheactivities
• Place • AllstaffunderD(P)HOmightneedtobemobilized,so
makelistofallthestaff,theircontactnumberandcall
• Time backifoutofstation
• Response • Coordinatewithlocalauthoritiesandcivilsocietyas
necessary

92
 SubTopics:
(a)Basicconceptofnutritioninemergency
(b)Assessingtheseverityofcrisis
(c)Measuringmalnutrition
2.5NutritioninEmergency (d)Respondingtothecrisis

(A)BASIC CONCEPT OF NUTRITION IN EMERGENCIES Whatarethecausesofnutrition

emergencies?
WhatisNutritioninEmergencies
• Emergencieswhereacutemalnutritionratesriseare
usuallydirectlycausedbysevereshortagesoffood
• Severityofnutritionalcrisis.
combinedwithdiseaseepidemics.
• Anemergencyusingacutemalnutritionorwastinginthepopulation • Somepopulationsarevulnerableasaresultofunderlying
asoneindicatorofdistress. factorssuchaspoverty,chronicfoodinsecurityandpoor
infrastructure,e.g.,nutritionemergenciesaremuchmore
• CrisisthresholdofacutemalnutritionasdefinedbyWHOtoset likelytooccurindevelopingcountriesthaninthe
thresholdsabovewhichparticularemergencyinterventionsshould developedworld.
bestarted. • HIVandAIDS,globalclimatechange,naturaldisasters,
conflict,acutefoodandlivelihoodcrisis’,politicalcrisisor
• Severeimpactofdiseases,foodcrisisinanextremestagesas
economicshockscantriggeranutritionemergency.
malnutritionandmortalityaresosevereastobelabelled‘famine’.
3 4

Whoaremostnutritionallyvulnerablein
emergencies? Whatismalnutrition?
• Physiologicalvulnerability(e.g.,youngchildren,
pregnantandlactatingwomen,olderpeople,the
disabledandpeoplelivingwithchronicillnesssuchas
“Astateinwhichthephysicalfunctionofan
HIVandAIDS)
individualisimpairedtothepointwherehe
or she can no longer maintain an adequate
orshecannolongermaintainanadequate
• Geographicalvulnerability(e.g.,peoplelivingin bodilyperformanceprocessessuchasgrowth
droughtͲ orfloodͲproneareasorinareasofconflict) anddevelopment,pregnancy,lactation,
physicalwork,andresistingandrecovering
• Politicalvulnerability(e.g.,oppressedpopulations) fromdisease”
• Internaldisplacementandrefugeestatus(e.g.,those
whohavefledwithfewresources)
5 6

93
 Whattypesofmalnutritionoccurin TheImpactofMalnutrition
emergencies? Malnutrition&ChildMortality
Pneumonia
Themainnutritionalproblemsofconcerninemergencies 19%
are:
Newborn
• acutemalnutrition(wasting),especiallyinyoungchildren 36%
– theclinicalformsofthisarekwashiorkorcharacterized Malnutrition
byoedema(swellingduetofluidretention)and underlies35%
to60%of Diarrhea
marasmus thesedeaths 17%
• micronutrientdeficienciesespeciallyiron,vitaminAand
iodinedeficiencies(commonindisadvantaged
populations)andvitaminC,thiamineandniacin Other
Malaria
deficiencies(outbreakshaveoccurredinemergencyͲ 10% InjuriesAids Measles 8%
3% 3% 4%
affectedpopulations).
7 Source:LancetChildSurvivalSeries 8

HowDoesMalnutritionHappen“aconcept“ NutritionIndicesͲ UNrecommends

continueduseofWHO
Death, Malnutrition
& Inadequate
Developm ent
Manifestation Review newgrowthstandard

Inadequate
Dietary Intake
Disease Stunting (Chronic) Underweight Wasting (Acute)
ImmediateCauses
(Both)
Inadequate Insufficient
Inadequate Care
Access to
Food
for Children
and W omen
Health Services &
Unhealthy
UnderlyingCauses Index Height for Age Weight for Age Weight for Height or
Environm ent
MUAC
Inadequate Education

Moderate < -2 SD < -2 SD < -2 SD

Resources and Control
Human, econom ic and
organizational resources

Political and Ideological Superstructure BasicCauses Severe < - 3 SD < - 3SD < - 3SD
Econom ic Structure

Potential
Resources

9 10

NutritionIndices– Review NutritionIndices– Review Moderate

Acute

EmergencyContexts EmergencyContexts Malnutrition

Stunting Underweight Wasting (Acute) Stunting Underweight Wasting (Acute)

(Chronic) (Both) (Chronic) (Both)

Index H/A W/A W/H or MUAC Index H/A W/A W/H or MUAC
Moderate < -2 SD < -2 SD < -2 SD, 70 - 80% Median, or Moderate < -2 SD < -2 SD < -2 SD, 70 - 80% Median, or
MUAC 115 mm – 125 mm* MUAC 115 mm – 125*
Severe < - 3 SD < - 3SD < - 3SD, <70% Median, or Severe < - 3 SD < - 3SD < - 3SD, <70% Median, or
MUAC <115mm*, or Oedema MUAC <115mm*, or Oedema

*CutoffpointsforMUAChavedifferedfromagencytoagency– *CutoffpointsforMUAChavedifferedfromagencytoagency–
thesecutoffsareconsistentwithclusterguidance 11 thesecutoffsareconsistentwithclusterguidance 12

94
NutritionIndices– Review NutritionIndices– Review GlobalAcute
SevereAcute Malnutrition
EmergencyContexts Malnutrition
(SAM)
EmergencyContexts (GAM)

Stunting Underweight Wasting (Acute) Stunting Underweight Wasting (Acute)

(Chronic) (Both) (Chronic) (Both)

Index H/A W/A W/H or MUAC Index H/A W/A W/H or MUAC
Moderate < -2 SD < -2 SD < -2 SD, 70 - 80% Median, or Moderate < -2 SD < -2 SD < -2 SD, 70 - 80% Median, or
MUAC 115 mm – 125 mm* MUAC 115 mm – 125 mm*
Severe < - 3 SD < - 3SD < - 3SD, <70% Median, or Severe < - 3 SD < - 3SD < - 3SD, <70% Median, or
MUAC <115 mm*, or Oedema MUAC <115 mm*, or Oedema

*CutoffpointsforMUAChavedifferedfromagencytoagency– *CutoffpointsforMUAChavedifferedfromagencytoagency–
thesecutoffsareconsistentwithclusterguidance 13 thesecutoffsareconsistentwithclusterguidance 14

95
 TechniqueofmeasurementofMalnutrition

• Varioustechniquescanbeusedtomeasure
malnutritioninemergencies.Themostused
Unit2.5:
are:
NutritioninEmergency
– WeightforHeight
Weight for Height
– MidͲUpperArmCircumference(MUAC)
SubͲTopicC.MeasuringMalnutrition
– MeasurementofBodyMassIndex(BMI)

• SDorZscore:
(c)MeasuringMalnutrition
SD= Measuredweight– medianweightofreferencepopulation
Standarddeviationofthereferencepopulation
IndicatorCutoffs:WeightͲforͲHeight,MUAC,BilateralPitting
Oedema e.g.9.9kgͲ 11.7kg
Note: cutoffs might vary according to the context, agency and national guidelines. 0.906

WeightforHeightCutoffs,Children6Ͳ59Months
Weight
g for height
g as a p percentage
g of the median Ͳ1.98SDscore
WFHandweightgaintablesforlamination.xls
WFH < 70% of the median: Severe Acute Malnutrition
WFH < 80% and • 70% of the median: Moderate Acute Malnutrition • PercentageoftheMedian:
Weight for height Z-scores PercentageoftheMedian=MeasuredweightX100
WFH < -3 z: Severe Acute Malnutrition Medianweightofreferencepopulation
WFH < -2 z and • -3 z: Moderate Acute Malnutrition
e.g.9.9kgX100
Weight-for-height as a percentage of the median is based on the NCHS 11.5kg
(National Center for Health Statistics) 1978 references and is the measure
most commonly used in /CMAM programmes. Some countries may require 86.1%ofthemedian
use of z-scores, which may be based on the WHO 2006 Growth Standards.
3 4

MeasurementofBodyMassIndex(BMI)
• MidͲUpperArmCircumference(MUAC):
BMI= Measuredweight(kg)
height2(m2)
TargetChildren:Children6monthsto5years
e.g.50Kg
MUACassessment:
1.6m2
•Normal:>12.5cm
•Moderateacutemalnutrition:>11.5cmto<12.5cm
•Severeacutemalnutrition:<11.5cm
BMI=19.5
WFH and weight gain tables for lamination xls
WFHandweightgaintablesforlamination.xls
• PercentageoftheMedian: Status Edema BMI
PercentageoftheMedian=MeasuredweightX100
Medianweightofreference Well nourished No • 18.5
population
Mildly malnourished No 18.4 to 17
e.g.9.9kgX100 Moderately
11.5kg malnourished No 16.9 to 16
86.1%ofthemedian
5
Severely malnourished May be yes< 16 6

96
 (e)IFEGuidanceNoteͲ Nepal

2.6bIFEGuidanceNote

(Subsectionof2.6BasicNutrition
InterventioninEmergencies)

Recommendationsfromguidancenote Recommendationscont...
• Thoseresponsibleforthecareofmothersandchildrenshouldbe
• ProvidefortifiedfoodstoallfamilieswithunderͲfive providedwithadequateinformationto supportbreastfeedingand
childrenand/orpregnantandlactatingwomen appropriatecomplementaryinfantandyoungchildfeeding.
• Strivetoprovidecookingfacilitiesandfueltoall • Forthoseinfantsandyoungchildrenwhosemothersareabsentor
displacedfamiliesforfoodpreparation,including incapacitated, asmuchaspossible,waysshouldbeidentifiedto
preparationofcomplementaryfoods. breastfeed.
• Onlywhereindividualcookingfacilitiesarenot • ThereshouldbenodistributionofbreastͲmilksubstitutes,evento
availablejointcookingfacilitiesshouldbeconsideredto
l bl k f l h ld b d d infantswhosemothersareabsentorincapacitated;inordertofeed
ensureappropriatecomplementaryfeedingforinfants orphans,orinfantsseparatedfromtheirmothers,pleasereferto
inahygienicmanner. thecontactpersonsatDHOforthecurrentguidancefrom
• ProvidehighͲenergybiscuits(BP5)assupplementary CHD/MoHP.(seealsojointstatementonprotectionofbreastfeeding
feedingtochildrenaged2Ͳ5years. inemergencies)
• Ensureearlyinitiationandcontinuationof • Specialattentionshouldbegiventofeedingpregnantandlactating
breastfeedingofinfantsandyoungchildrenuptothe mothers(supplementaryandnutritionalbalancedrations) inorder
ageof24months. toencouragesuccessbreastfeeding.
9 10

97
 (b)AssessingtheSeverityofCrisis
Unit2.5
NutritioninEmergency SeverityofaCrisis
ThreeCriteria
1. Prevalenceofmalnutritioninrelationto
internationallydefinedbenchmarksandthresholds
2. Trendsinratesofmalnutritionovertime– preͲcrisis
SubͲTopicB:AssessingandResponding includingseasonality
toSeverityofCrisis 3. Therelationshipbetweenmalnutritionand
mortality

SeverityofCrisis Emergency SeverityofCrisis

Threshold
BenchmarksandThresholds MalnutritionͲInfectionCycle
Severity Prevalence of GAM
Inadequatedietaryintake
Acceptable <5%
Appetiteloss Weightloss
P
Poor 5–9% Growthfaltering
Nutrientloss
MalͲabsorption Loweredimmunity
Serious 10 – 14 %
Alteredmetabolism Mucosaldamage
Critical > = 15 % Deaths Deaths

Disease

WHO, Management of Malnutrition in Major

Emergencies, 2000 3 4

(c)RespondingtoCrisis
RespondingtoCrisis
PreventionBeforeCure
RespondingtoCrisisPreventionBeforeCure
• EarlyWarningSystems
Early Intervention Late Intervention
• Agriculturalproductionsuchascropproduction
andlivestockfarming
• Marketssuchasdomesticandinternational
Food Supplementary Therapeutic
security/General feeding feeding
trade(import/export),pricesofkeystaplesand
Distribution livestock
• Vulnerablegroupssuchasmonitoringpoverty
Cost/Benefit • Nutritionandhealthstatusofpopulations

5 6

98
 RespondingtoCrisisPrevention
RespondingtoCrisisSelectiveFeeding
BeforeCure

Ensurethepopulationhasadequateaccesstoappropriate Early Intervention Late Intervention

quantitiesofqualityfood(SPHERE=2100kcal/day)

• MarketͲbasedinterventions
Food Supplementary Therapeutic
• Cashtransfers security/General feeding feeding
Distribution
• Generalfooddistributionorblanket
supplementaryfeeding
• NutritionalSurveillance Cost/Benefit

7 8

RespondingtoCrisis Manynowadvocatefor RespondingtoCrisis

usingMUACalone,the
Screening nutritioncluster
Traditionalapproach
recommendscontinued
useofW/H
StageI:MUAC StageIII:Weight Screening
NoMalnutrition
StageII:Height/Length

Moderate(<Ͳ2SDtoͲ3SDor Severe(<Ͳ3SDor<70%
(
70%Ͳ 80%Median)* Median/Oedema)*

Supplementary TherapeuticCare
Feeding
Recovered

9 10

DESIGNNUTRITIONPROGRAMMEINEMERGENCY
SITUATIONS RespondingtoCrisis
ModerateAcuteMalnourished
Screening

SevereAcuteMalnourished
TraditionalApproach
(aged6Ͳ59months) (aged6Ͳ59months)
MUAC<125mmandш115 mm MUAC<115mm
AND:Nobilateralpitting oedema OR:BilateralPittingOedema
Phase II
ChildwithComplications
referredforinvestigation
Phase I Stabilization
AssessmentofComplications Rehabilitation
ChildwithNOComplications
NONComplicated COMPLICATED Treatment Antibiotic, Anti-malarial, Vitamin A, etc.
MUAC<115mm Forspecifications
Counselling
OR:bilateralpittingoedema+ Seetable(2)page(7)
SarbotamPittho
or++
ChildFeedingandChildCare
AtHF:VitA/Albendazole
ReferraltoFCHV
AND:
Appetite Care Attend to complications (e.g. shock, hypoglycemia)
ClinicallyWell
forfurthercounselling
Alert
Inemergency:admissionto
SupplementaryFood
Programme StabilisationCentre
WHOprotocolPhase1
Feed F-75 Therapeutic Milk F-100 Therapeutic Milk
OTPAdmission
RoutineMedicines
RUTFsupply
AfterdischargefromOTPthechildis
referredtoFCHVforcounselling
•Counselling
Afterstabilisationandtransitionphasethe
Quantity 135ml/kg/day 200ml/kg/day
Ifchilddeterioratesitshouldbereferred childcanbereferredtoOTP
toHFforinvestigationandtransferred IfchilddeterioratesinOTPitshouldbe
toSCifcomplicated transferredtoSCforinvestigation Time 1-7 Days, 3 to 4 Weeks
11 12

99
 RespondingtoCrisis >80%of
RespondingtoCrisis Screening– NewApproach severes canbe
treatedas
TraditionalApproach outpatients
AcuteMalnutrition

|Highlyeffectiveinreducingcasespecificmortality,BUT… Without Complications With Complications

y Extremelylaborintensive– Costly
Oedema(+++)ORMarasmicͲ
y Highpotentialforcrossinfection Severes(andmoderates)
KwashiorkerORWHM<80%
y Child&caretakerareawayfromfamilyfor20+days– high 70Ͳ 80%WHM, <70%WHM,MUAC ORMUAC<125mmOR
withcomplications
Moderates Severes
MUAC<125mm <110mmORoedema oedemaANDillness*
opportunitycost
y PoorCoverage
Supplementary Outpatient
InpatientCare
Feeding TherapeuticCare

13 *Anorexia,LRI,Highfever,Severedehydration,anemia,notalert,
14
hypolglycaemia,orhypothermia

RespondingtoCrisis RespondingtoCrisis
SupplementaryFeeding SupplementaryFeeding
“shouldbebasedon
“Blanket” “Wet” Rations drytakeͲhomerations
• Preventmalnutritionbyprovidingafood y Foodispreparedand
unlessthereisaclear
consumedonͲsite
supplementtoallmembersofvulnerablegroups (rationisdetermined rationaleforonͲsite
suchaschildren<5andpregnantandlactating accordingtochild’s
nutritional
nutritional feeding”Ͳ
eed g SSPHERE
women (alluded to earlier)
women(alludedtoearlier) requirements)

“Targeted”
“Dry” Rations
• Preventmoderatelymalnourishedwomenand y Foodistakenhomeand
childrenfrombecomingseverelymalnourishedby consumedwithfamily
providingafoodsupplementtomalnourished (rationoftenincreased
individuals toaccountforintraͲ
householdallocation)
15 16

RespondingtoCrisis RespondingtoCrisis
SupplementaryFeeding OTPͲ Screening
• ARetrospectivestudyofEmergency Complications:
SupplementaryFeedingProgrammes • anorexiaor
notesonly41%achieveobjectives.Carlos • severeoedema(3+)or
NavarroͲColarado.June2007.ENNandSC • marasmuswithanylevelof
UK.Availableat oedema or
oedema,or
www.ennonline.net/research • thepresenceofassociated
• Fortifiedblendedfoodsinadequatein complications(e.g.extensive
bothcaloricandmicronutrientcontentͲ infections,severe
ReadytoUsefoodsarefarsuperior dehydration,severeanaemia,
• PotentialuseofRUFsinsupplementary hypothermia,hypoglycaemia
feedingprograms– bothinpreventionof orthepatientnotbeing
malnutrition,andintreatmentof alert).
moderatemalnutrition
17
Uncomplicated Complicated 18

100
 RespondingtoCrisis RespondingtoCrisis
OTP– FirstContact
OTPͲ WeeklyFollowUp
• MedicalAssessment
• AppetiteAssessment • Medicalexam

• Presumptivetreatment: • RUTF
Antibiotic(amoxicillin), e o g o c de
• DeͲwormingforchildren
AntiͲmalarial,and above1yearofage–
VitaminAand/orFolic Week2
Acidincasespresenting
withdeficiency • Measlesimmunization
symptoms forallchildrenabove9
monthsofage– Week4
• ReadytoUseTherapeutic Uncomplicated Complicated
Food(RUTF)
Uncomplicated 19 20

RespondingtoCrisis RespondingtoCrisis Outpatient

InpatientCare InpatientCare
Care

Phase II Phase II
Phase I Stabilization Phase I Stabilization
Rehabilitation Trans/Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc. Treatment Antibiotic, Anti-malarial, Vitamin A, etc.

Care Attend to complications (e

(e.g.
g shock
shock, hypoglycemia)
Care Attend to complications (e.g. shock, hypoglycemia)
Feed F-75 Therapeutic Milk RUTF
Feed F-75 Therapeutic Milk F-100 Therapeutic Milk
Quantity 135ml/kg/day 200ml/kg/day
Quantity 135ml/kg/day 200ml/kg/day
Time 1-7 Days, 3 to 4 Weeks
Time 1-7 Days, 3 to 4 Weeks
WHO,ManagementofSevereMalnutrition,1999
WHO,ManagementofSevereMalnutrition,1999
21 22

RespondingToCrisis Micronutrients
SimplifiedDecisionTool TheSilentKiller
Finding Action required
Food availability at household level Improve general rations until local food availability and access can be made
< 2100 kcal/person/day adequate • Over2billionpeopleaffectedintheworld
Malnutrition rate (GAM) under 10 % with - Attention to malnourished individuals through regular community • Increasesthegeneralriskofinfectiousdiseaseand
no aggravating factors services[2].
ofdyingfromdiarrhea,measles,malariaand
fd i f di h l l i d
Malnutrition rate (GAM) 10 – 14 % or 5 - Supplementary feeding targeted to individuals identified as malnourished pneumonia
– 9 % plus aggravating factors in vulnerable groups
- Therapeutic feeding for SAM individuals
• Emergencyaffectedpopulationsareatincreased
Malnutrition rate (GAM) • 15 % or 10 – - General rations; plus riskofdeficiency
14 % with aggravating factors[1] - Supplementary feeding for all members of vulnerable groups.
- Therapeutic feeding for SAM individuals

[1] Aggravating factors are: i) General food ration below the mean energy requirement (<2100 kcal/kg/person), ii) Crude Death Rate greater
than 1/10 000/day and iii) Epidemic of measles or whooping cough.
[2] This may include therapeutic care integrated into primary health system (hospitals and health 23
centres). 24

101
 Micronutrients
PreventionBeforeCure
• Ensurethepopulationhasaccesstokey
micronutrients

– Localfoods
– Fortifiedfoods
– OnͲsitefortification
– Supplements
– MultipleMicronutrientPowders

25

102
 Unit2.6:
ChildHealthinEmergency
g y
SubͲTopica):ChildHealthin
Emergency

SpecialPediatricConsiderationsinDisaster
Preparedness
• Childrenaremorevulnerable:Medically,
psychologicalvulnerabilitiesandresponsetoillness
e.g.susceptibilitiestodehydrationandshock.
• Childrenneedspecialmanagementplanse.g.require
different dosages or different antibiotics and
differentdosagesordifferentantibioticsand
antidotestomanyagents.
• Emergencyresponders,medicalprofessionals,and
children’shealthcareinstitutionsrequirespecial
expertiseandtrainingtoensureoptimalcareof
thoseexposedtochemical,biological,ornuclear
agents.
• Children’sdevelopmentalabilityandcognitivelevels
mayimpedetheirabilitytoescapedanger.
3 4

Roleof
Malnutritionand
micronutrient
deficiencies

• Prevalenceofacute
malnutrition(weightͲforͲ
h i ht 2 t d d d i ti
height2standarddeviations
belowthereferencemean
)amongchildren<5yearsof
ageininternallydisplacedand
conflictͲaffectedpopulations
between1988and1995was
31%among11surveys,and
wasashighas80% inthe
Sudanin1993(Toole1997).

5 6

103
Problemofunaccompaniedchildren Othercommunicablediseases
• KoreanWarorNigerianCivilWarmanywere
abandonedinfants(Sapir1993).
• PolioinAngola
• (Rwandanrefugee)Mostdeaths(85%)occurred
morethan2daysafterarrivalatthecenters, • CutaneousleishmaniasisinAfghanistan
suggesting that early and appropriate care could
suggestingthatearlyandappropriatecarecould • MeningococalmeningitisinSudanese
M i l i iti i S d
havesignificantlyreducedmortalityinthisgroup
ofchildren. Refugees
• TyphoidinBosnia
Otherhealthproblems,thatneedtobeaddressed, • TB/HIV
includeHIV/AIDS,physicaland
sexualabuse,psychosocialhealthproblems
andtrauma. 7 8

NeonatalHealth DiarrhoeaͲPreventioninEmergency

• BurundianrefugeesinTanzaniaaccounted • 27%fewerdiarrhoealepisodesinMalawi
16%deathsinneonatesandmothers refugeeswithsoapdistribution
• ProblemofLBW
• Coveredcontainerwithspoutreduced
• 19%NeonatalmortalityinPakistan
diarrhoealdiseaseby31%

9 10

Challenges:ensuringgoodpractices
PriorityinterventionsforChildren
*Howtoachieveuniversalstandardsofcare?
*Training • DiarrheaPrevention,Oralrehydrationtherapy
•needforpreͲemergencytraining (ORT)
•howbesttoconducttraininginanemergency?
•whatlevelsofhealthworkersshouldbetargeted? • Ensuringfoodsecurityandfeedingprogrammes
*
*Implementationandqualityassurance
l d l for severely malnourished infants
forseverelymalnourishedinfants,
•developguidelines • MeaslesimmunizationandVitaminA
•modifyexistingguidelines(e.g.IMNCI,ETAT)
•workwithgovernmentstoendorsestandards supplementation.
•distributeguidelinesthroughpartners

11 12

104
 DifferencesintheCareofChildrenin StrengthsofIMCIGuidelines
ComplexEmergencies&StableSituations
•Addressmajorcausesofchildmortality
•Rapidassessmentandtreatmentoflarge
•Integratecasemanagement&prevention
numbersofseverelyillchildren
• Targeted to clinical officers and Workers
•TargetedtoclinicalofficersandWorkers
•Lessuniformhealthcaredelivery
– multipleorganizations
– differenttypesofhealthcareworker •PotentiallycombinedwithEmergency
– highstaffturnover TriageAssessmentandTreatment
•Inadequatereferralservicesandsupply
deliverysystem •CanbesimplifiedforCHWsandvillage
volunteers
13 14

LimitationsofStandardIMNCIGuidelines
•Trainingcoursetoolongtobeimplementedin
complexemergencies
Detectionofsickchild
•Referralfacilitiestomanageseverediseasefrequently andnewborn
notinplace ManagementofDiarrhea
ManagementofPneumonia
g
FeedingCounseling
•Timerequiredforsinglepatientencountertoolongin Immunizationspecially
acutephaseofemergency Measles
PreReferralCare

•Nocommunityoutreach

•Diseasesurveillancenotaddressed
15 16

Material&LearningPrinciple

• Learnersmodulewith • Interactiveprocess
Photographs
• Drills
• LaminatedChartsas
job aid
jobaid • Learningbydoing
Learning by doing
• Facilitatorguide • Video,photographs
• Videoclippings androleplays
(optional)

17 18

105
 19 20

Potentialusers
• Health(medical&
paramedicalpersonnel)

• NGO

• CHW
21 22

Anticipatedhealthproblemsandinterventions
Phases Anticipated health Possible Interventions Response&Survival:GoldenHours
problems 100
Days 1-3 Injury/drowning and deaths Safe disposal of corpses
Psychosocial problems Injury management 80
Psychosocial support
Survival
Needs assessment for health 60
Days 3-5 Diarrhoeal diseases Health promotion Percentage
Acute respiratory infections – Sanitation, environment 40
Psychosocial problems – Water purification
– Personal hygiene 20
– Immunization (measles)
–ORS
0 30 60 90
Emerging disease surveillance (morbidity/
mortality)
Timeinhours
5-10 days Above plus: Dehydration, Above plus;
Pneumonia, conjunctivitis, and Antibiotics for pneumonia • TimeisacriticalfactorindisasterͲrelatedinjuriesandvictimsurvivalrates
skin infections Drugs for skin infections and conjunctivitis • Postearthquakestudieshavedemonstratedthatthefirst24hours
followingtheeventrepresentsthegoldenwindowoftimeinwhichsurvival
>10 days Above plus: Vector-borne Ongoing surveillance
ratesishigher
diseases (malaria, DF), Health education, measures for vector control,
antimalarial • Correlationbetweenvictimsurvivalratesandtherapidityofsearchand
Typhoid fever, Measles, and
Malnutrition Supplementary feeding program rescuecapability
Rebuilding health infrastructure 24

106
 ReproductiveHealthinEmergencyorCrises
3.1:ReproductiveHealth(RH)in
Emergency

SubTopic:
(a)OverviewofRHinEmergency

LearningOutcomes
StartwithMISPvideo
• ProjectthevideoonMISP
Bytheendofthesession,theparticipantsshouldbeable
• Explaintoparticipantsthattheywillnowwatcha
to:
shortvideotoprovideavividexamplesofthe
ƒ ExplainwhySRHandtheMISPareimportantincrises context.
ƒ Knowwheretoaccesskeytoolsandresourcesto • Takeapproximately5minutesandinvite
supportimplementationofSRHincrises participantstosharetheirimpressionsofthe
video
• Discussontheparticipantsideasaroundwhyitis
importanttoaddressSRHneedstopeoplein
crisissituationssuchasshowninthevideo.
4

WhyRHinemergencies? RighttoSRH
ADVOCACY
• Mandatoryprovisionasaright
• dutyofstate(asperits “Allmigrants,
commitmentsexpressedthrough refugees,asylum
internationaltreaties, seekersand
conventions....) di l d
displacedpersons
• Needfulfillment(bothbiological
shouldreceive
andpsychosocial)
basiceducation
andhealth
services”
Chapter10,ICPDProgramme of
5
Action,1994

107
 RHneedscontinue…
EmergencyHaltsOtherLifelinesbut.... infact,increaseduringcrisis
• Peoplewon'tstopbeingpregnant • Riskofsexualviolencemayincreaseduringsocialinstability
• Peoplewon'tstophavingsexuallife • STI/HIVtransmissionmayincreaseinareasofhighpopulation
(eveninshelters) density
• Peoplecan'tstopgivingbirth • LackofFPincreasesrisksassociatedwithunwantedpregnancy
p g y
• Exploitation,violencerather • Malnutritionandepidemicsincreaserisksofpregnancy
increases complications
• .... • Childbirthoccursonthewaysideduringpopulationmovements
• Lackofaccesstocomprehensiveemergencyobstetriccare
increasesriskofmaternaldeath

7 8

NewbornMortalityinNepal
Newborn
Why
Maternal
• Globally,9to33babiesoutofevery1000borndieinthe
and perinatal period.
Newborn • InNepal33babiesoutofevery1000borndieinthe
Health perinatal p
p period.
in • Everyhour2Ͳ3newborndie
• Majorcasues ofnewborndeathare:
Crisis ƒ Asphyxia,
and ƒ Infection,
PostͲCrisis ƒ Hypothermiaand
ƒ lowbirthweight
Situations Neonatal and perinatal mortality : country, regional and global estimates, WHO 2006 10

ReproductiveHealth(RH)inEmergency Howlongdoesittaketodie?
Estimatedaverageintervalfromonsettodeathformajor
Can’tpredictorpreventcomplications… obstetriccomplications,intheabsenceofmedical
…butcanpreventdeathsbyreducingDELAY: intervention
“Thethreedelays”
Complications Hours Days
1.FirstDelay:Delayindecisiontoseekcare • Hemorrhage
2 S
2.SecondDelay:Delayinreachinghealthfacility
dD l D l i hi h lth f ilit – Postpartum
P 2
– Antepartum How to prevent it?
3.ThirdDelay:Delayinreceivingappropriatetreatment 12
orEmergencyObstetricCareServices • RupturedUterus 1
• Eclampsia 2
Canyouthinkaboutthreedelaysduringcrisis/
• Obstructedlabor 3
Disaster? • Infection 6
11
Source: Maine et al, 1991

108
 WhatshouldbeofPrimaryFocusduring Referralmechanisms:
Emergency? challengesandsolutions
Continuumpromotinghealthymothersandbabiesthrough:
Careduringpregnancy Whatifensuring24/7referralservicesmaynotbe
(AntenatalCare– ANC)…………….YesorNo? possibleduetoinsecurityinthearea?
Pitfalls:ANCnotpartofMISP!
Ͳ EnsurethatstaffqualifiedinbasicEmONCare
Careatthetimeofdelivery, availableatalltimesattheprimaryhealthcarelevel
IncludingEmergencyObstetrics tostabilizepatientswithbasicEmONC
Ͳ Establishsystemofcommunication(radio)to
MISP communicatewithmorequalifiedpersonnelfor
Careafterdelivery
medicalguidanceandsupport
(PostnatalCare– PNC)………YesorNo?
NotpartofMISP 13 14

ChallengestomeetingSRHneedsinCrises “Standard“population
• LackofprioritisationofSRHinemergencies; x Adultmales 20%
x Womenofreproductiveage(WRA) 25%
• LimitedofawarenessoftheMISPamongstlocal,national, x Crudebirthrate 4%
development&humanitarianactors; ¾Numberofpregnantwomen
¾Numberofdeliveries
• Poorimplementationofthepriorityservicesoutlinedin x Complicatedabortions/pregnancy 20%
theMISP; x Vaginaltears/delivery 15%
• Lackofrespondersqualifiedortrainedtoimplementthe x Caesareansections/delivery
C i /d li 5%
x WRAwhoareraped 2%
MISP; x WRAusingcontraception 15%
• Inadequatecoordination; ¾Oralcontraception 30%
¾Injectables 65%
• InadequatededicatedfundingtoimplementtheMISP; ¾IUD 5%
• Lackofawarenessamongbeneficiariesaboutbenefits&
In displaced population, 4% of the total population will be
locationofMISPservices pregnant at a given time

InterͲAgencyWorkingGroup
onRHinRefugeeSituations(IAWG) WhatistheMISP?
Formedin1995:>30UN,NGO,Academic,Donors
¾ MinimumInitialServicePackage(MISP) Mimimum • basic,limitedreproductivehealth
¾ InterͲagencyFieldManual(IAFM)
TheMISP Initial • foruseinemergency,withoutsiteͲspecific
Comprehensive RH
ComprehensiveRH needs assessment
needsassessment
Maternal Health Service • servicestobedeliveredtothepopulation

Family Planning • supplies(e.g.RHkit)andactivities

Package • coordinationandplanning
Gender-based Violence

STI, HIV/AIDS

109
 What weshouldprovidetopeoplelivingin
Thecontinuumofanemergency crisissituations
Emergency Post-emergency

Destabilizing Durable
event solutions

Comprehensive Comprehensive SRH services

SRH services? MISP

Loss of Restoration Relative Return to

essential of essential stability normality
services services

ComprehensiveSRH careservices Earlyphaseofacrisis

• Familyplanningprogramme
• Safemotherhood:abortioncare,ANC/delivery/newborn/PNC
• STI/HIVpreventionandmanagement
• GBV preventionandmanagement
• Gynaecology:infertility,fistula,cervicalandbreastcancer
screening/treatment
• Urology:infertility,malesexualdysfunction,malereproductive
cancerscreening/treatment
• Activediscouragementofharmfultraditionalpractices;FGM,early
marriage,selectiveabortions…
• Accessibleforall:adolescents,elderly,sexworkers/clients,ex
combatants,uniformedstaff,IDUs...
• IntegratedinPHCandpublichealthpackages
• Linkstootherservicesectors

Exercise
THESITUATION WhatisNOTMISP?
• Afterflooding20,000peopledisplacedtoaimprovisedcampinamountainous
region. • ExtensiveRHneedsassessmentbeforestarting
• Someoverwhelmedhealthcentresscatteredinthedistrict services
• Thenearesttownwithahospitalis20kmaway.
• ComprehensiveRHservices:
• Womenfetchwaterintheriverandwalkfor2hourstofindfirewood
– AnteͲ andpostͲnatalcare
• Therearereportsofrapesandabductions
There are reports of rapes and abductions
– Familyplanning
THERESPONSE – STIprogram
• Whataretheimmediateneedsofthesepeople? – PreventionofotherformsofGBV(notSV)
• Training(CHWs,midwives,TBAs,doctors
• YouareparticipatingastheRHcoordinator inthefirsthealthcoordination
meeting.WhichRHinterventionsshouldbeimplementedasapriority? • IECcampaigns(i.e.forcondomdistribution)

24

110
 MinimumStandardsin www.iawg.net
HealthAction www.rhrc.org
www.who.int
Essentialhealthservices–
sexualandreproductivehealth
standard1:
Peoplehaveaccess
tothepriorityRHservicesof
theMinimumInitialService
Package(MISP)attheonsetof
anemergencyand
comprehensiveRHasthe
situationstabilizes.

ADVOCACY

InterͲAgencyRHKitsforCrisisSituations OtherimportantSRHinterventions
13Kits • Ensureavailabilityinhealth
• Kit0to5 facilitiesof
Primaryhealthcare/healthcentrelevel 9 contraceptivemethodstomeet
10000peoplefor3months demand
• Kit6to10
Kit 6 to 10 9 syndromictreatmentofSTIs
syndromic treatment of STIs
Healthcentrelevelorreferrallevel 9 AntiͲretrovirals(ARV)for
30000peoplefor3months continuingusers,incl.PMTCT
• Kit11and12 • Meettheneedformenstrual
Referrallevelhospital
150000peoplefor3months protection
9 “Hygiene”or“dignity”kits

MISP implementation in Nepal : Progress so far Key finding of MISP implementation in Nepal
• KoshiFloodResponseͲ2008/2009
• MidͲwesternFloodͲ2014ͲRHkitsdistribution • AllMISPservicesandpriorityactivitieswerelargely
• EarthquakeresponseͲ2015 availableinbothKathmanduandSindhupalchowk
9 RHservicessincebeginning • Someserviceswereonlypartiallyavailablebasedon
9 RHCamps theavailabilityatalimitednumberoffacilitiesinthe
9 Maternityhome/transitionhomes district
9 RHKitsandsupplies • Comprehensiveness/qualityisconcernedinsome
9 TrainingonCMR healthfacilitiesoftheremoteareas
9 Supporttobirthing centres • Majorgapincommunityknowledgeaboutculturally
– MISPEvaluationͲ2015ͲKathmanduandSindhupalchowk sensitivereproductivehealthissues,thebenefitsof
– IntegratedtheMISPcomponentsin20districtsDPRPs seekingcare,andthelocationofservicesforsexual
– AdaptedtheMISPtrainingpackagebyNHTC violence,STIs,andHIV
– AdaptedtheASRHtoolkitinhumanitarianSettings
• Manykeyinformantswerenotawareofwhatservices
– Trainedalmost500healthServiceProvidersandstakeholdersonMISPandASRH
toolkitinhumanitarianSetting
wereavailableateachhealthfacilityfortheCMR,
– PrepositioningofRHkitssince2013 specificallytheuseofECandPEP

111
 Lessons learned KeyMessages
x Identifyastrongandrespectedcoordinator • MISPisaninterͲagencystandard
x Transparantcollaboration facilitatesimplementation • MISPensuresbasicRHservicesincrises
x PreventionofGBV requiresaconcertedeffort,sensitivityand • PromptlyimplementedMISPsaveslives
staffpreparation
x Peopleusecondoms duringanemergency
x Cleandeliverykits provideessentialsuppliesfordeliveries
outsidehealthfacilities
x ReferralCenter requiresstrong24/7referralcenterstoprovide
comprehensiveRHservices
x Logisticspreparedness isessentialforpromptuseofRHkits
x SatisfactoryimplementationrequirespreͲplanning

112
 LearningOutcomes
RHinEmergency
Bytheendofthesession,theparticipantsshouldbeable
to:
Unit3.2: ƒ DescribethecomponentsoftheMISPincludingkey
actions
SSubTopic:
bT i
ƒ KnowtheroleofRRTinpreparednessand
b)MajorComponentsofMISP implementationofMISPduringdisaster/emergency

ComponentsofMISP
Component#1:
Thereare5componentsofMISP:
Identifyagency/personstofacilitate
• Component#1:Identifyagency/personstofacilitate
COORDINATION&IMPLEMENTATION
CoordinationandImplementation
• Component#2:Preventandmanagetheconsequences 9 Organization
of sexual violence
ofsexualviolence 9 Individual
• Component#3:ReducetransmissionofHIV/STIsin • RHissueswillbetakenupbyHelathCluster
Crises • LeadbyDHO/DPHO

• Component#4:Preventexcessneonatalandmaternal • HealthclusterwillbetheworkingplatformforallRHrelated
morbidityandmortality actors
• Component#5:PlanforcomprehensiveSRH services,
• Thefocalperson/coordinatorwillbeidentified
integratedintoprimaryhealthcare,assoonaspossible 4

Component#2:
Preventandmanagetheconsequencesofsexual
violence
• Preventandmanagetheconsequencesofsexualviolence
9 plancampdesign
9 medicalresponse(EmergencyContraceptives(EC),STI/HIV
prevention)
9 informthecommunityandotheractors
9 protectionofatriskgroups
• AllcommunityhealthworkersneedtobeawareofGBVincrisis
• SeekmultiͲsectoral support;involvingpolice,watchgroup,volunteers,
WomenHumanRightsDefenders(WHRD)
5 PreventionandresponsetoSVisaminimumstandardinemergencies(SPHERE&MISP)

113
 HealthConsequences ofRape
GuidingprinciplesinrespondingtoSexual
Violence(SV)

• Safety Social Health

sector

• Confidentiality
• Respect Physical
• NonͲdiscrimination Psychological

7 8

RoleoftheHealthSector Clinical Care

Tipsforhistorytakingandexamination
• Respond tosexualviolence
– CompassionateandnonͲjudgemental
– Provide clinicalcare
– Survivor‘sownpace,nounnecessaryrepeating
– Collectforensicevidence
– Referforfurthercrisisintervention – Explaineverythingyouaregoingtodo
• Prevent sexualviolence andstigmatisation,in – Donotdoanythingwithoutconsent
collaborationwithothersectors – FollowHistoryandExaminationforms
– Documenteverythingthoroughly

9 10

Medicalmanagement:forensicevidence Clinicalcare:treatment

Forensicevidenceis Typesofevidencethatcan • Treatlifethreateningcomplicationsfirst

collectedduring the becollected
clinicalexamination – Medicaldocumentation
• Injuries • STI prevention
– toconfirmrecent • Presenceofsperm(<72 Ͳ Syphilis,chlamydia,gonorrhoea(otherinfectionsif
sexual contact
sexualcontact hours) common)
– toshowthatforceor • State ofclothes Ͳ Uselocaltreatmentprotocols
coercionwasused – Clothes
Ͳ HepatitisBvaccination,ifindicated
– topossiblyidentifythe – Foreignmaterials
– Foreignhairs?
assailant • PreventHIVtransmission(PEP)
– DNAanalysis?
– tocorroboratethe – Bloodorurinefortoxicology Ͳ Ifincident<72hours andriskoftransmission:
survivor’sstory testing?
Ͳ Zidovudine(AZT)+Lamuvidine(3CT)for28days
11 12

114
 ConsiderationswhenprovidingPostexposure Clinicalcare:treatment
prophylaxis(PEP) • Preventpregnancy:
• HIVtesting is notarequirement forsupplying PEP Ͳ <5days
Ͳ Preferred:levonorgestrel1.5mgsingledose
• PEPifsurvivor presents <72hours ofrape,but: Ͳ Or:ethinylestradiol100mcg+levonorgestrel0.5mg,
twodoses12hoursapart(Yuzpe)
first dose thesooner
firstdose the sooner thebetter
the better
Ͳ Alternative:IUD(veryeffective,butneedskills!)
• ProvideoneͲweek,thenthreeͲweeksupplybut:
fullsupplyifthesurvivorcannotreturn • Injurycare

• Schedulereturnvisitonedaypriortolastdose Ͳ Cleanandtreatwounds
Ͳ Providetetanusprophylaxisandvaccination
• Forrecurrent exposures requiring repeat PEP:
Crisis intervention.Offer protection • Referforhigherlevelcareifneeded
13 14

From Gender and HIV/AIDS

Component#3: Possiblelinksbetween – Adapted from Heise, L,

Ellsberg, M and Gottemoelle,
M ‘ Ending Violence Against

ReducetransmissionofHIVinCrises SexualViolence,STIsandHIVincrises Women, Population Reports,

Dec 1999, Series L (11).

Emotional/Behavioural
Change
ReduceHIVtransmissionby •Lowselfesteem
• standardprecautions •Depression
• freecondoms •Posttraumaticstress

• Safeandrationalbloodtranfusion •Excessivedrugandalcohol
use
Domesticviolence HighRiskSex

Rape •Multiple
peopleaffected partners
Childsexualabuse bycrises
•Unprotectedsex
•Prostitution

15 STIsandHIV 16

Wastemanagement
Instrumentprocessing
Itisimportanttoperformthestepsin
theappropriateorderforseveralreasons:
1. Decontamination killsviruses(HIVandHep B)
andshouldalwaysbedonefirsttomakeitems
safertohandle
2. Cleaningshouldbedonebeforesterilizationor
HLD to remove debris
HLDtoremovedebris
3. Sterilization (eliminatesallpathogens)should
Doublechamber
bedonebeforeuseorstoragetominimizethe
incinerator Drumincinerator riskofinfectionsduringprocedures.(HLDmay
noteliminatespores)
4. Itemsshouldbeusedorproperlystored
immediatelyaftersterilization

18
Burialpit 17

115
 Guaranteeavailabilityoffreecondoms
Ensurerationalandsafebloodtransfusion

• Inordertoensuresafebloodtransfusion • Condomsareaneffectivemethodforpreventionof
servicesduringcrisisoremergencyordisaster, HIVandSTItransmission
needtolinkwithNepalRedCrossSociety
• Makegoodqualitycondomsavailable
(NRCS)andBloodBank.
• Ensuresufficientsupplies
E ffi i t li
• Distributionstrategy
• Humanitarianstaffalsousecondoms
Thispartwillbetakencareof
byNRCS/BloodBank • WherepossibleincludeexistingIECmaterials
• Monitoruptake(т “use”)
19
• ReͲorderbasedonuptake 20

Component#4: MaternalandNewbornHealth(MNH)
Preventexcessneonatalandmaternalmorbidity
Continuumpromotinghealthymothersandbabiesthrough:
andmortality
Careduringpregnancy
Preventexcessneonatalandmaternalmorbidityandmortality (AntenatalCare– ANC)
• Emergencyobstetricandnewborncare(EmONC) Pitfalls:ANCnotpartofMISP!
9 BasicEmONC inprimaryhealthcarefacilities
C
Careatthetimeofdelivery,
h i f d li
9 ComprehensiveEmONC inreferralhospitals IncludingEmergencyObstetricCareservices

• Referralsystemfor emergencies(transport/communication)
• Cleanhomedeliveries MISP
Newborncare

MISP
21 22

The3Delays:Whatcanbedoneinyour
Referralmechanisms:challengesandsolutions
setting?
Whatifensuring24/7referralservicesmaynotbepossible
1)Delayinthedecisiontoseekcare: duetoinsecurityinthearea?
TeachCHWs,women,menaboutthecomplicationsthatneed
emergencytreatment NOTPARTOFTHEMISP
2)Delayinreachinghealthfacility:
Ͳ Initiateestablishmentof24/7 referralsystemtomanageEmONC Ͳ EnsurethatstaffqualifiedinbasicEmONC areavailable
(EmergencyObstetricsandNeonatalCare) atalltimesattheprimaryhealthcareleveltostabilize
Ͳ Communicationsystem(radio,mobilephone,medicalrecord)
Communication system (radio mobile phone medical record)
Ͳ Transportation(stretchers,vehicle,security,transportatnight)
patientswithbasicEmONC
Ͳ Cleandeliverykitsdistributedtoallvisiblypregnantwomenincase2nd
delaycannotbeovercomeandwomenneedtodeliveroutsidethe
healthfacility Ͳ Establishsystemofcommunication(radio)to
communicatewithmorequalifiedpersonnelformedical
3)Delayinreceivingappropriatecareatthehealth guidanceandsupport
facility:
Ͳ Equiphealthcentersandhospitals
Ͳ Trainhealthworkersinemergencyobstetricprocedures Kits Ͳ Utilizeambulancenetworkmobilization
6,8,9,10,11,12
23 24

116
 ComprehensiveEmONC(CEmONC) Summary:MNHCrisisSituations
Summary:

Athospitalwithoperatingtheater • Establishreferralsystem
(1per150,000– 200,000people) • Supplyreferrallevel(CEmONC)
• Providedbyteamofdoctors,anesthetists,midwivesand • Midwifedeliverykits(healthfacility,BEmONC)
nurses • Cleandeliverykits(homedeliveriesincaseaccessto
• BEmONC(steps1Ͳ6),plus
BEmONC (steps 1 6) plus health facility not possible)
healthfacilitynotpossible)
• Performsurgery(Cesareansection,laparotomyfor • Planforantenatalcare(ANC)andpostnatalcare(PNC)
ectopicpregnancy,anesthesia) Kit11 integratedintoprimaryhealthcare(PHC)servicesas
• Performsafebloodtransfusion soonaspossible

Kit12
25 26

Component#5: RoleofRRTinimplementingMISPduringDisaster
PlanforcomprehensiveSRHservices Preparedness
• IntegrateMISPforSRHinHealthSectordisasterPreparedness
• PlanforcomprehensiveRH services,integratedintoPHC
Plans(e.g.Fivecomponents)
9 collectbackgroundinformation • Ensurethecapacitybuildingofserviceproviders
9 plantointegrateRHinhealthsystemreconstruction • EnsuretheprepositioningoravailabilityofRHKits
• Strengtheningcoordinationmechanism(Health&Protection
Healthsystemsbuildingblocks PlanforcomprehensiveRHservices,e.g.
Clusters,interͲclusterandDDRC)
Servicedelivery Ͳ IdentifyRHneeds • EstablishstrongcoͲordinationwithexistingpartners
Ͳ identifysuitablesitesforRHservicedelivery
• ContinueadvocacyontheimportanceofSRHduringemergency
Health workforce Ͳ assessstaffcapacityandtrain
Response
Healthinformationsystem Ͳ Include RHinformationinHIS
• Ensure the coordination through established mechanism
Medicalcommodities Ͳ support/strengthenRHcommoditysupplylines
• Early identification of RH needs
Financing Ͳ identify RHfinancingpossibilities
• Ensure the RH services including the GBV
Governance,leadership Ͳ reviewRHͲrelatedlaws,policies,protocols
• Collect the information and availability of data

117
 RHinEmergency LearningOutcome

Bytheendofthesession,theparticipantwillbe
ableto:
Unit3.3: • PreparearationalorderofRHkitsforthe
SSubTopic:
b i provisionofRHservicesincrisesor
ii f RH i i i
emergencies
c)RHKitsinEmergency
• Knowwheretoaccesskeyresourcesto
supportimplementationofRHincrises

“Standard“population
x Adultmales 20%
x Womenofreproductiveage(WRA) 25%
x Crudebirthrate 4%
¾Numberofpregnantwomen
¾Numberofdeliveries
x Complicatedabortions/pregnancy 20%
x Vaginaltears/delivery 15%
x Caesareansections/delivery 5%
x WRAwhoareraped 2%
x WRAusingcontraception 15%
¾Oralcontraception 30%
¾Injectables 65%
¾IUD 5%

RHkitsforemergencysituations Rapidassessment&SRH
13Kits:
ƒ Block 1(kit0to5) - Numberandlocationoftargetpopulation
Primaryhealthcare/healthcentrelevel Ͳ Numberandlocationofhealthfacilities
Suppliesfor10000peoplefor3months Ͳ Numberandtypesofhealthcarepersonnel
Ͳ SRHsupplieslogistics
ƒ Block 2(Kit6to10)
Health centre level or referral level
Healthcentrelevelorreferrallevel
Suppliesfor30000peoplefor3months
ƒ Block 3(kit11and12)
Referrallevel
Suppliesfor150000peoplefor3months

118
 RHKitsforemergencysituations
Kit2:CleanDeliveryKit
Block 1
Primaryhealthcare/healthcentrelevel
10000peoplefor3months
Kit
0 • Trainingandadministration
1A&B • Condoms(male&female)
2A&B • Cleandelivery (individual&attendant)
3A • PostͲrape(EC/STIprevention)
3B • PostͲrape(PEP)
4 • Oralandinjectablecontraception
5 • STIdrugs
7 8

RHKit5:STIDrugs
Kit3:RapeTreatmentKit

9 10

RHkitsforemergencysituations
Kit6:ClinicalDelivery(HealthFacility)
Block 2
Healthcentrelevelorreferrallevel
30000peoplefor3months
Kit
6 • Delivery(HealthCentre)
7 • IUDinsertion
8 • Managementofcomplicationsofabortion
9 • Sutureofcervicalandvaginaltears
10 • Vacuumextraction

11 12

119
ManagementofObstetricComplicationssuchas Kit8:ManagementofComplicationsofabortion
PPH,eclampsia (MVAset)

13 14

Kit10:VacuumExtractionforDelivery
RHkitsforemergencysituations
(Manual)Kit
Block 3
Referrallevel
150000peoplefor3months

Kit
11A • Surgical(reusableequipment)
11B • Surgical(consumableitemsanddrugs)
12 • Bloodtransfusion(HIVtesting)

15 16

Importanttoremember
Kit12:BloodTransfusion

• RHKit6&11:Diazepamandpentazocinarecontrolled
substancesͲ requiredimportlicencefromthecountryof
destinationpriortoshipment,thereforeshouldbe
procuredlocally
• RHKit6,8,11B&12:Oxytocinandtestsforbloodgroup,
HIVandHepatitisaswellastheRapidplasmareagin(RPR)
testneedtobekeptcool.
• Coldchainmustbemaintainedduringtransportationand
storage

17 18

120
 HygieneSupplies
Provideotherimportantsupplies
ƒ Thereisno“global”kit,itiscommunityspecific
ƒ MeetpreͲexistingfamilyplanningneeds
ƒ Forwomen:
ƒ BasicFPmethodstomeetspontaneousdemand(Kit4
&7) – sanitarysuppliesfor3months
– Underwear(3large)
ƒ EnsuresyndromictreatmentforSTIs
Ensure syndromic treatment for STIs – soap,soappowder,toothpaste,toothbrush,aspirin
ƒ AntibioticstotreatpeoplepresentingwithanSTI – bucketforwashing
symptom(Kit5) – whatelse?ASK!
ƒ Meetneedsformenstrualprotection ƒ Formen
ƒ “Hygiene”or“dignity”kits – shavingsupplies,soap,toothbrush,toothpaste
– condoms
19 20

Hygienesupplies InͲcountrytransportanddistribution
• No“global”kit,communityspecific
• Forwomen:DignityKits(17items)
• ReusablesanitaryNapkins,underwear,
Petticoat,Maxi,TͲshirt,Sari/Dhoti,Sweater,
Shwal,ThinTowel(Gamchha),FlashLight,
Clothwashingsoap,Comb,NailCutter,Tooth
Brush,ToothPaste,BathigSoap,Bagtokeep
ClothesorBucket
¾ whatelse?ASK!
• Formen
¾ shavingsupplies,soap,toothbrush,
toothpaste
¾ condoms
¾ whatelse?ASK!

RHkitsforemergencysituations
Whodoeswhat?
www.womenscommission.org
• Determineneedsandmakeadistributionplan
• ContactUNFPACountryOfficeorHQ(HRBorPSB)
www.rhrc.org
(ReproductiveHealthResponseinConflict)

• Funding:NGO’sownfunds,Flash,CERF,CAP
• UNFPAͲ HRBcanassistindeterminingneeds
• UNFPAProcurementServices:proͲformainvoice,contacts
shippingagents,shippingarrangements
• Suppliesshippedwithin48hours

24

121
 Learningoutcomes

Bytheendofthesession,theparticipantshouldbeable
RHinEmergency to:
• ConductbasicmonitoringandevaluationfortheMISP
implementation
p
• Outlineexistingneedsassessmenttoolstoplanfor
Unit3.4: comprehensiveSRH
SubTopic:
d)MonitoringandEvaluationof
MISPIndicators

MonitoringandEvaluationofMISP PlanforCOMPREHENSIVESRHservices,
Indicators integratedintoPrimaryHealthCare

• BaselineSRHinformationandMonitoringand
Evaluation
• Identifysitesforfuturedeliveryof
comprehensiveSRH
• Assessstaffandidentifytrainingprotocols
• Procurementchannels

Fiveessentialcomponentsof MISPBasicDemographicandHealthInformation
MonitoringandEvaluation Basic demographicandhealth 1st 2nd 3rd
information month month month
1.Definitionofessentialdatatocollect TotalPopulation
#ofwomenofreproductive age(age15Ͳ
49,estimatedat25percentpopulation)
5.ReͲevaluation y
2.Systematic # Number of adult male (estimated
#Numberofadult (estimatedat20%
at 0%
ofinterventions collectionofdata ofpopulation)
Crudebirthrate(estimatedat4% of
population)
Agespecificmortalityrate(including
4.Implementationof
neonataldeath0Ͳ28days)
healthinterventions 3.Organizationand
Sexspecificmortalityrate
basedonthedata analysisofdata

122
 MISPIndicatorsforM&E MISPIndicatorsforM&E
Coordination 1st 2nd 3rd
Maternalandneonatalmortalityandmorbidity 1st 2nd 3rd
month month month
month month month
OverallRHcoordinatorinplaceand functioningunderhealthcoordination Cleanhomedeliverykit(CHDK)availableanddistributed
teamorhealthcluster
Calculatethe#of CHDKneededtocovergotbirthsfor3months
MaterialforimplementationoftheKitavailableandused (estimatedpopulationx0.04x25)
SexualViolence RHincludingEmOC kits availableinthehealthcentres
CoordinatedmultiͲsectoral systemstopreventsexualviolenceinplace Referralhospitalassessedandsupportedforadequatenumberofqualified
staff,equipmentsandsupplies
staff equipments and supplies
Confidential healthservicestomanagecasesofsexualviolenceinplace
ReferralsystemforObstetricemergenciesfunctioning 24/7
Stafftrained(retrained) insexualviolencepreventionandresponse
Postreferral/ servicesshelterprovisioned
HIVTransmission
PlanningforComprehensiveRH
Sufficientmaterials inplaceforuniversalprecautionsbytrained
knowledgeablehealthworkers Basicbackgroundinformationcollected

Condom procuredandmadeavailable SitesidentifiedforfuturedeliveryofcomprehensiveRHservices

Staff assessed,trainingprotocolsidentified
Blood fortransfusionconsistentlyscreened(LinkwithNRCSandBlood
Bank) Procurementchannelsidentifiedandmonthlydrugconsumptionassessed

MISPIndicatorsforM&Econt…
MISPmonthlydatacollectionlinkingwithHMIS
MaternalandNeonatal MortalityandMorbidity
Monthlydatacollection 1st 2nd 3rd
%ofObstetriccomplication month month month
#ofcondom distributed
#ofmaternaldeath
#ofCHDKdistributed
Ͳ#ofneonatal death
#ofsexualviolencecasesreportedinallsectors
SGBVintegratedintohealthcaredeliverymechanism #ofhealthfacilitieswithsuppliesforuniversal
precautions
- Basicdemographicandhealthdatacollected

DistrictDisaster(RH)ActionPlan
MISP Current Gap/s Actiontobetaken Budget Remarks
checklist status identified (WHAT,WHERE,
activity (WHAT, (WHAT, WHEN,WHO)
WHO, WHERE,
WHERE) WHO)
Response Preparedness

11

123
 CONTENT
• Introduction
• MentalhealthConsequencesofDisaster
Unit3.5: • NepalPerspective
• Intervention:Prevention/Treatment
MentalHealthinDisaster
• Q&A
Q&A
OBJECTIVE
• Increaseawareness
• Motivationforallstakeholders
• “DoNoHarm”

INTRODUCTION
WhoareAffected?
• Disaster=Distress
– Physical/economic/ecologicaldimension • “Nopeoplewhoexperiencedisasteris
– Emotional untouchedbyit”
– Psychological/social/Cultural • Directlyaffectedpeople
– Spiritual
Spiritual • Indirectlyaffected:
Indirectly affected:
– Witnessingatraumaticevent(eyewitnessor
television)
– Learningofafamilyorfriend’straumaticexperience
• Responders alsoexperiencestress

PsychologicalConsequencesofa PhasesofDisaster:Emotional
For Example: Disaster For Example:
 Change in travel
Response Honeymoon
 Insomnia (Community Cohesion)

 Sense of vulnerability patterns 2-24wks

 Smoking “Heroic”(1-2wks)
Reconstruction

 Alcohol A New Beginning

Pre-disaster Disillusionment (2-24mths)

Distress Behavioral consumption withdrawal, anger, frustration,
negetivity, hostility,impulsive,

Changes
violence, alcohol
Responses Warning
W i
EvaluationThreat
Apathy
Fear anxiety
Surprise
Impact
Psychiatric perplexity

Illness •PTSD Helplessness

disorientation
•Abn Grief
•Adjustment Trigger Events and Anniversary
Disorder Inventory Reactions

•Acute Psychosis
•Major Depression 1 to 3 Days -------------------TIME-------------------------------1 to 3 Years
•Anxiety disorder Zunin/Meyers
Zunin /Meyers

5
•Alcohol & Sub use

124
 CommonResponsestoaTraumaticEvent FactorsInfluencingResponsetoTraumatic
Cognitive Emotional Physical Behavioral
x poorconcentration x shock x nausea x suspicion
Events:
x confusion x numbness x lightheadedness x irritability 1. TheDisaster:
x disorientation x feeling x dizziness x argumentswith – Degreeandnatureofexposure
overwhelmed x gastroͲintestinal
friendsandloved
x indecisiveness problems ones 2. Thecommunity
x depression
x shortenedattention x rapidheartrate x withdrawal – Levelofpreparedness,availableresourcesandsocial
span
p x feelinglost
g
x tremors x excessivesilence support,pastexperience,culture,leadership
t t i lt l d hi
x memoryloss x fearofharmtoself
and/orlovedones x headaches x inappropriatehumor 3. TheVictims
x unwantedmemories
x feelingnothing x grindingofteeth x increased/decreased – Developmentallevel:Age,education
x difficultymaking eating
decisions x feelingabandoned x fatigue
– Mechanismsorcopingstrategies/personality
x changeinsexual
x uncertaintyof
x poorsleep
desireorfunctioning – Abilitytounderstandwhathashappened
feelings x pain
x increasedsmoking – Personalmeaningoftheevent:
volatileemotions HyperͲarousal
x x
• perceiveddisruption,support andbenefit
x increasedsubstance
x jumpiness useorabuse

TypicalReactionsͲchildren
fears and anxieties irritability PopulationsatRiskforPsychiatricProblems
crying, whimpering, screaming confusion

excessive clinging disobedience

• Thoseexposedtothedeadandinjured
fear of darkness or animals depression
• Theelderlyortheveryyoung
fear of being left alone refusal to go to school • Peoplewithahistoryofpreviousexposure
fear of crowds or strangers reluctance to leave home totraumaticevents
problems going to sleep/bedwetting behavior problems in school • Previoushistoryofmentalillness.
nightmares poor school performance

sensitivity to loud noises fighting

alcohol and other drug use

Help:GeneralPrinciple SomeDo’s
• Reassurance:verbalsupport
• CorrectInformation:honestbutdiscrete • DoSayͲ
frighteningdetails.Whenviewingnewsbetter • Thesearenormalreactionstoadisaster.
together,withvolunteerstoanswerquestions
• Encouragetoexpressemotions.Listen • Itisunderstandablethatyoufeelthisway.
attentively
tt ti l • Youarenotgoingcrazy.
• Trytomaintainanormalhousehold,socialand
recreationalactivitieswhenappropriate. • Itwasn'tyourfault,youdidthebestyou
• Acknowledgereactionsassociatedwiththe could.
traumaticevent,andhelptakestepstopromote • Thingsmayneverbethesame,buttheywill
physicalandemotionalhealing(appropriatehelp
seeking) getbetter,andyouwillfeelbetter.

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 Don'tsay: PsychologicalFirstAid(PFA)

• Itcouldhavebeenworse. Definition………
• Youcanalwaysgetanotherpet/house. • Anapproachdesignedto
• It'sbestifyoujuststaybusy.
y j y y ¾ providebasiccomfortandsupport

• Iknowjusthowyoufeel. ¾ reducetheinitialstresscausedbytraumaticevents
• Youneedtogetonwithyourlife. ¾ fostershortandlongtermadaptivefunctioning

PsychologicalFirstAid PsychologicalFirstAid
Who?When?Where? BasicObjectives
• Usedduringandimmediatelyafter • Listen
trauma/disaster • Helppeoplefeelsafe
• PFAcanbeusedbyanyone • Offerpracticalassistance
• Maybeusedforeveryone,adultsandchildren • Connecttosocialsupports
• Maybeusedanywhere • Provideinformationonresponse,recovery,stress
• Providesimmediateemotionalandpractical andcoping
support • Enabletotakecareofself

PsychologicalFirstAid PsychologicalFirstAid
Delivery… BehaviorsToAvoid
• Bevisible
– Neverpresumetoknoweverythingwhatthe
• Maintainconfidentiality
personisexperiencing
• Operatewithinyourorganizationalrulesofsurvivor
p y g
engagement – Donotassumethateveryoneistraumatized
• Becalm,courteous,organizedandhelpful
• Besensitivetocultural,ethnicandcommunity – Donotlabel/diagnoseorpatronize
concerns
• Operatewithinyourcomfortlevel

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 DISASTERCOUNSELINGSKILLS DISASTERCOUNSELINGSKILLScont…
• Disastercounselinginvolvesbothlisteningandguiding,but • Paraphrase –
notimposing!
• repeatportionsofwhatthesurvivorhassaid,understanding,interest,
• ESTABLISHINGRAPPORT andempathyareconveyed
• Conveyingrespectandbeingnonjudgmentalarenecessary • checksforaccuracy,clarifiesmisunderstandings,andletsthesurvivor
ingredientsforbuildingrapport. knowthatheorsheisbeingheard.

• ACTIVELISTENING • Reflectfeelings –
• Sometipsforlisteningare: • noticethatthesurvivor'stoneofvoiceornonverbalgesturessuggests
anger,sadness,orfear
• AllowsilenceͲ timetoreflectandbecomeawareoffeelings,prompt
• helpsthesurvivoridentifyandarticulatehisorheremotions.
thesurvivortoelaborate.Simply"beingwith"thesurvivorandtheir
experienceissupportive. • Allowexpressionofemotions–
• Attendnonverbally Ͳ Eyecontact,headnodding,caringfacial • tearsorangryventingisanimportantpartofhealing;I
expressions,andoccasional"uhͲhuhs"letthesurvivorknowthatthe
• workthroughfeelingssothatbetterengageinconstructiveproblemͲ
workerisintunewiththem.
solving.
• letthesurvivorknowthatitisOKtofeel

WhentoRefertoMentalHealthServices? POSTͲTRAUMATICSTRESSDISORDER
• Disorientation Ͳ dazed,memoryloss,inabilitytogivedateor FollowingS/Spresentforlongerthanonemonth:
time,statewhereheorsheis,recalleventsofthepast24
hoursorunderstandwhatishappening • ReͲexperiencing theeventtraumaͲspecificnightmares
• MentalIllness Ͳ hearingvoices,seeingvisions,delusional orflashbacks,ordistressovereventsthatresembleor
thinking,excessivepreoccupationwithanideaorthought, symbolizethetrauma.
pronounced pressure of speech (e g talking rapidly with
pronouncedpressureofspeech(e.g.,talkingrapidlywith • Routineavoidance
R ti id ofremindersoftheeventora
f i d f th t
limitedcontentcontinuity)
generallackofresponsiveness
• InabilitytocareforselfͲ noteating,bathingorchanging
clothes,inabilitytomanageactivitiesofdailyliving • AutonomicArousal:Increasedsleepdisturbances,
• Suicidalorhomicidalthoughtsorplans/acts irritability,poorconcentration,startlereaction,
• Problematicuseofalcoholordrugs
regressivebehavior
• Domesticviolence,childabuseorelderabuse

PostTraumaticStressDisordercont... PreventSuicide
• Rates:2Ͳ29%
• Gethelpfromprofessionals.Askforhelp
• Mayariseweeksormonthsaftertheevent
fromdoctorsorotherleaderswhoaretrained
• Mayresolvewithouttreatment,butsomeformof
tohelp
therapybyamentalhealthprofessionalisoften
required
q • Stayintouchwithfamily.
y y
• VulnerabilitytodevelopingPTSD: • Stayactive
• characteristicsofthetraumaexposureitself
• Keepbusy.Helpothersinneed,communityor
• characteristicsoftheindividual
schooletc
• postͲtraumafactors(e.g.,availabilityofsocialsupport,
emergenceofavoidance/numbing,hyperͲarousaland • SuicideHELPLINE..
reͲexperiencingsymptoms)

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 KeyMessages
• Manymentalhealthconsequences:
• Disasterstressandgriefreactionsarenormalresponses
toanabnormalsituation
• SeveralMentaldisordermaybeprecipitated
• Theburden/morbiditynotlessthananyphysicalillness
The burden/ morbidity not less than any physical illness
• Socialsupportsystemsarecrucialtorecovery
• Mentalhealthinterventionmustbeincorporated
alongwithotherhealthplans:
• Preventable+treatablewithproperintervention

128
Financial and technical support by
United Nations Population Fund (UNFPA) and
Nepal Red Cross Society (NRCS)