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Powered by TCPDF (www.tcpdf.org) 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT JOURNAL OF HEALTH MANAGEMENT SPECIAL EDITION VOL. I: AUGUST 2015 1 supplement-flood disaster.pmd 1 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT ADVISOR Dr Shahnaz Binti Murad Deputy Director General of Health (Research and Technical Support) EDITOR IN-CHIEF Dr Nor Izzah Binti Hj Ahmad Shauki Director, Institute for Health Management MD (USM), MCommHealth (H&HM) (UKM) EDITORIAL BOARD Dr Nor Filzatun Borhan MD (USM), MPH (UM) YBhg. Datin Dr Noriah Bidin MBBS (DOW), MPH (UM) Dr Nor Haniza binti Zakaria MD (AIR LANGGA UNIVERSITY) MANAGING EDITOR Dr. Pangie anak Bakit Dr. Munirah Ismail Siti Zubaidah Ahmad Mohd Idris Omar Nooreyzan Manangin 2 supplement-flood disaster.pmd 2 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT ACKNOWLEDGEMENT The Editorial Board of Journal of Health Management (Special Edition) would like to thank Director General of Health Malaysia for the permission to publish the articles in this journal. We would like to convey our gratitude to all reviewers for their time and contributions in the publications of this special edition. We also would like to extend our sincere appreciation and gratitude to YBhg. Datin Dr Ang Kim Teng and Dr Harvindar Kaur Gill for their contribution in this publication. We also dedicate this special edition to all the Ministry of Health Malaysia teams who have provided excellent service during the flood disaster. Dr. Tahir bin Aris Institute for Public Health Ministry of Health Malaysia Dr. Noormawati Ahmad Institute for Health Behavioral Research Ministry of Health Malaysia Dr. Mohd Azahadi Omar Institute for Public Health Ministry of Health Malaysia Nazirah Gulam Mohd Institute for Health Behavioral Research Ministry of Health Malaysia Dr. Jasvinder Kaur Institute for Public Health Ministry of Health Malaysia Dr. Amal Nasir Mustafa Institute for Medical Research Ministry of Health Malaysia Dr. Roslinah Ali Institute for Health Systems Research Ministry of Health Malaysia Dr. Ahmad Faudzi Yusoff Institute for Medical Research Ministry of Health Malaysia Datin Dr. Siti Haniza Mahmud Institute for Health Systems Research Ministry of Health Malaysia Adilius Manual Institute for Health Systems Research Ministry of Health Malaysia 3 supplement-flood disaster.pmd 3 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Impact of The Big Flood on Blood Donation Pattern Ailin Mazuita M, Noryati AA, Norasrina I, Rosalind Choo PY, Suriani O National Blood Centre ABSTRACT The big flood that hit our country during the end of December 2014 until January 2015 had touched the public nationwide. A tremendous response from the public to assist the flood victims was witnessed and this included blood donation. The pattern of blood donation during this period was studied which included the demographic distribution of blood donors who attempted to donate blood and the outcome of donations. This study was conducted in National Blood Centre, Kuala Lumpur. It was a retrospective observational study based on data collection from Blood Bank Information System. Data of all donors who attempted to donate blood during the big flood period, 28 December 2014 until 11 January 2015 was collected. Another group of all donors who came in the same period one year earlier was taken as the control group. A total of 11,637 (85% increment) donors attempted to donate blood during the big flood period of which 9,979 (85.78%) donors were eligible to donate. Majority of the donors were male, Malay, Malaysian, aged between 21-30 years and either from managers or professional workers group. There was no significant difference in the rate of donations which were screened reactive for Transfusion Transmitted Infection and deferral rate compared to control group. Keywords: flood, disaster, blood donor response, blood donation Sabah in East Malaysia[1]. The season starts in early November and ends in March, causing floods in the regions mentioned during this period. The last Northeast Monsoon was exceptionally wet, bringing floods tomost states in the country. It started at the end of December 2014 until early January 2015. According to the expert of Climatology and Physical Oceanography, Professor Dr Fredolin Tangang from the National University of Malaysia, the overwhelming rain during that period wasthe result of Madden-Julian Oscillation phenomenon, combined with the annual Northeast Monsoon. MaddenJulian Oscillation is the variation of weather in the tropics which originates INTRODUCTION Malaysia is made up of two geographical regions, Peninsular Malaysia which is part of the Asia continent and East Malaysia in the Borneo Island, separated by the South China Sea. Being surrounded by the ocean, rainfall is largely influenced by seasonal wind flow in the region. There are four distinct seasons according to the wind flow patterns namely the Northeast Monsoon, the Southwest Monsoon and two shorter inter-monsoon periods. The Northeast Monsoon brings heavy rainfall to the east coast of Peninsular Malaysia, and western region of Sarawak and north-easterncoast of 5 supplement-flood disaster.pmd 5 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT from the Indian Ocean and passes Malaysia four times a year[2]. is also experienced at the start of the year as the population settle in to their jobs and other activities after the long year end break. This was one of the worst floods in many decades, paralysing social functioning of the affected areas with Kelantan, Terengganu, Pahang and Perak being most affected states. Health services including blood transfusion services were badly affected. Some hospitals including blood banks were inundated with water, while many staffs were stranded in their homes due to the flood. Blood collection was badly hit because donors were not able to come, and hospitals were not able to hold any blood donation campaigns. This study looks at the response in blood donation after the big flood disaster at the end of 2014 to the beginning of 2015. It analysed the demographic profile of blood donors who responded to the disaster. By doing this study, blood transfusion service hope to identify and target potential blood donors from among disaster-driven donors to increase its blood donor pool. Blood donors who came to donate blood during the same period one year earlier were taken as a control group. The pattern of donation, deferral rate and screened reactive donation rate between these two periods were compared. The impact of the great flood touched the hearts of many and caused a tremendous response from the public in unaffected states to donate blood. There was a surge in the number of walk-in blood donors at the National Blood Centre and other hospital blood centres that were not affected by the flood. This experience is not unique, as post-disaster surge of blood donors had been reported elsewhere including China after a severe earthquake hit Sichuan Province[3], the great earthquake in East Japan in 2011[4] and in the United States of America after the coordinated terrorist attack on September 11[5]. MATERIALS AND METHODS This was a retrospective observational study using secondary data from the Blood Bank Information System (BBIS) which provides donors’ demographic profile, contact number and donation history. The study was conducted at the National Blood Centre, Kuala Lumpur (NBC). NBC is fully Government funded Institution under the Ministry of Health Malaysia. It is the centre for blood donation, processing and distribution of blood and blood components to all government and private hospitals in the central region (Klang Valley, Negeri Sembilan and West of Pahang). Catchment areas for blood collection in NBC include the Federal Territory of Every year, seasonal variations are seen in the number of blood donations in the National Blood Centre. Seasonal blood shortages usually occur during the school holidays, term breaks and long festive holidays, for example during Aidilfitri and Chinese New Year where most of the regular blood donors return to their home towns outside the Klang Valley.This shortage 6 supplement-flood disaster.pmd 6 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Kuala Lumpur, Federal Territory of Putrajaya and some parts of Selangor. For the state of Selangor, NBC’s catchment area overlaps with other collection centres namely Hospital Tengku Ampuan Rahimah Klang, Hospital Banting and Hospital Kuala Kubu Bharu. Therefore, the statistic for blood collection as shown in Fig. 1 combines the data for NBC and these other collection centres. NBC alone had managed to collect 166,787 units of blood which accounted for 25.54% of blood units collected in the whole country for the year 2013. Blood donation services were organised at the centre and in mobile blood collection clinics which operated for a certain number of hours in various public places, offices and etcetera. Figure 1: Total Number of Blood Collection in 2013 according to state. (* total blood collection for Federal Territory of Kuala Lumpur, Selangor and Federal Territory of Putrajaya) Study population The study population comprised of two groups of donors at NBC. The study group comprised of all donors who came to donate blood during the big flood, from 28 December 2014 to11 January 2015 while the control group were donors who came to donate blood over the corresponding period the year before. All allogeneic blood donors in NBC are voluntary non-remunerated donors. No replacement donations are allowed in NBC. Donors come to the blood donation centres on walk-in basis. Information regarding the site and 7 supplement-flood disaster.pmd 7 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT schedules of mobile donation clinics are available online at the NBC website www.pdn.gov.my, NBC official facebook and information booth at the NBC. In addition, NBC also gets help from co-organisers of blood donation drive campaigns by promoting the upcoming campaigns through their social media networks. RNA and Hep B DNA. Serological test for TTI markers are done to detect the presence of HBsAg, anti-HepC virus, anti-HIV and RPR for Syphilis. Blood units that are screened reactive will then undergo confirmation test for the relevant infection. If confirmed positive, the blood unit will be discarded and the donor will be called to NBC for counselling. There are two types of blood donation in NBC, namely whole blood donation and plasma or platelet apheresis donation. Regular whole blood donors are eligible to donate their plasma or platelet through apheresis method. However, this type of donation is only available at the centre. Whole blood donors are encouraged to return 3 months after their last donation date while apheresis donors can donate again after 14 days from the last apheresis donation. Variables Variables collected for each donor include demographic data of the donor (age, gender, occupation, race, and nationality), data regarding the donation (place of donation and number of donation), result of the donation attempt (succeeded to donate or deferred), result of TTI screening for donors who were eligible to donate (reactive or non-reactive) and whether donor return to donate in the future (yes or no). Donor screening All potential donors are screened to check for eligibility to donate blood. Pre-donation screening tests done at the site of donation include donor’s blood group and haemoglobin level. Trained medical officers or nurses are responsible for conducting medical interviews to determine eligibility by evaluating the donor’s health history, risk behaviour against transfusion transmitted infections and physical screening prior to blood donation. Donors who do not fulfil the criteria are deferred either permanently or temporarily from donation. Age was analysed as both numerical and categorical variable. The minimum age for giving informed consent in Malaysia is 18 years old while the minimum age for donating blood in this country is 17 years old. For donors who are between 17 to 18 years old, a guardian consent form must be produced by these donors during donation. The maximum age for blood donation in Malaysia is 60 years old. However, regular donors who are above 60 years old and are certified as healthy by their physicians are eligible to donate. The rest of the donors are categorised into 20s, 30s, 40s and 50s age cohorts. Transfusion-transmitted infections (TTI) screening At NBC, all donated blood units must undergo TTI screening. Nucleic Acid Amplification Test is carried out to detect the presence of HIV and Hep C Gender was a categorical variable and divided into male and female. Race was also a categorical variable and divided into Malay, Chinese, Indian and 8 supplement-flood disaster.pmd 8 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Others according to the data given by donors in their donor registration form. There were also donors who did not state their race and this group was categorised as race not stated. the control group because data collection was done only 3 months after their visit. Not all donors who attempted to donate were eligible to donate. Donors who were not eligible to donate were deferred for various reasons during pre-donation testing or interview. In this study, total number of donors who attempted to donate during the studied periods was taken to reflect the actual response to the big flood and the total number were then broken down into donated and deferred donors. Donor’s occupational status was taken from their registration form as stated by the donor in the form. Donor occupations were then categorised according to the International Standard Classification of Occupations version ISCO-08 published in 2008[6]. It is an International Labour Organization classification structure to organize information regarding labour and jobs. The major groups in this structure were managers, professionals, technicians and associate professionals, clerical support workers, service and sales workers, skilled agricultural, forestry and fishery workers, craft and related trades workers, plant and machine operators and assemblers, elementary occupations and armed forces occupations. Additional categories added from data compiled were students, housewife, pensioners, unemployed and others. There were also donors who did not state their occupation and these were categorised as occupation not stated. Among the donors who were able to donate their blood, a small proportion were tested reactive for TTI markers. Therefore, the donors who were able to donate were further subcategorised into non-reactive to TTI markers and reactive to TTI markers. Data analysis Data were statistically analysed by Statistical Package for Social Sciences (SPSS) version 20 for windowsoftware[7]. There were numerical and categorical variables in this study. The distributions of numerical variables were explored and the mean and standard deviation were checked. The difference of mean between the numerical variables with the groups of donor from 28 December 2014 until 11 January 2015 and one year earlier were tested by independent t-test. Other categorical variables were nationality where donors were divided into Malaysian and Non-Malaysian while place of donation were either centre (NBC) or mobile. Donors were also categorised into first time attempt to donate or repeat donors. The donors’ return behaviour were also analysed and categorised into return or not-return to donation. For the donors who came in during the big flood period, their return rate was taken within a shorter period compared to For categorical variables, the frequencies were explored and percentages were calculated. Chi square test was used to determine the association between the categorical variables with the outcome. Significance was taken at a P-value of <0.05. 9 supplement-flood disaster.pmd 9 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT RESULT the same period a year earlier where only 6,264 donors attempted to donate blood at the NBC. During the big flood period, 9,979 (85.78%) donors were eligible to donate, either whole blood or plasma and platelet through apheresismethod, whilst the number of eligible donors during the same period one year earlier was 5,438 (86.81%). Descriptive Analysis A total of 11,637 of donors attempted to donate blood with National Blood Centre during the big flood period from 28 December 2014 until 11 January 2015. The total number of donors showed an 85% increase compared to a. Socio-demographic distribution Table 1: Socio-demographic distributions of donor who attempted to donate blood during the big flood period (28 December 2014 – 11 January 2015) and the same period one year earlier as a control group. 28 Dec 2014 – 28 Dec2013 – 11 Jan2015 (Big 11 Jan 2014 Characteristics flood) n (%) (Control) n (%) Age (years) mean (s.d.), range (min,max) < 18 18 - 20 21 - 30 31 - 40 41 - 50 51 - 60 > 60 Gender Male Female Race Malay Chinese Indian Others Not stated Occupa- Managers tional Professionals status Technicians and associate professionals Clerical support workers Service and sales workers Craft and related trades workers Plant and machine operators, and assemblers 33.09 (9.56), (17-61) 52 (0.45) 688 (5.91) 4650 (39.96) 3648 (31.35) 1896 (16.29) 695 (5.97) 8 (0.07) 6562 (56.39) 5075 (43.61) 6628 (56.96) 3583 (30.79) 1149 (9.87) 182 (1.56) 95 (0.82) 1626 (13.97) 2060 (17.70) 924 (7.94) 33.39 (9.77), (17-64) 22 (0.35) 378 (6.03) 2428 (38.76) 1877 (29.96) 1182 (18.87) 375 (5.99) 2 (0.03) 3957 (63.17) 2307 (36.83) 3706 (59.16) 1849 (29.52) 535 (8.54) 118 (1.88) 56 (0.89) 1350 (21.55) 693 (11.06) 561 (8.96) 1400 (12.03) 1152 (9.90) 98 (0.84) 444 (3.82) 395 (6.31) 675 (10.78) 56 (0.89) 433 (6.91) 10 supplement-flood disaster.pmd 10 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Characteristics Nationa -lity Elementary Occupations Armed forces Occupations Student Pensioner Housewife Unemployed Others Not stated Malaysian Non-Malaysian Table 1 shows the mean (SD) age for blood donors during the big flood period was 33.09 (9.56) years old (range 17 – 64), whilst the mean (SD) age for blood donors during the same period one year earlier were 33.39 (9.77) years old (range 17 – 61). Majority of the blood donors in both groups aged between 21 to 30 years 28 Dec 2014 – 11 Jan2015 (Big flood) n (%) 28 Dec2013 – 11 Jan 2014 (Control) n (%) 171 (1.47) 472 (4.06) 797 (6.85) 37 (0.32) 389 (3.34) 102 (0.88) 676 (5.81) 1289 (11.08) 11538 (99.15) 99 (0.85) 97 (1.55) 285 (4.55) 330 (5.27) 22 (0.35) 174 (2.78) 48 (0.77) 258 (4.12) 887 (14.16) 6206 (99.07) 58 (0.93) old (38.76% and 39.96% respectively) (Figure 2). Male, Malay and Malaysian donors were the majority of donors who came forward to donate blood during both periods. Meanwhile, based on occupational status, majority of the donors were managers and professional workers (Figure 3). Figure 2: Donor distribution according to age group 11 supplement-flood disaster.pmd 11 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 3: Donor distribution according to occupation b. Donation characteristics Table 2: Donation characteristics distributions during the big flood period (28 December 2014 – 11 January 2015) and the same period one year earlier as a control group. Characteristics Place of donation Centre Mobile Previous donation history No Yes Return for next visit Return No return 28 December 2014 – 11 January 2015 (Big flood) n (%) 28 December 2013 – 11 January 2014(Control) n (%) 2824 (24.27) 8813 (75.73) 1814 (28.96) 4450 (71.04) 4444 (38.19) 7193 (61.81) 1793 (28.62) 4471 (71.38) 1,292 (11.10) 10,345 (88.90) 2,982 (47.61) 3,282 (52.39) 12 supplement-flood disaster.pmd 12 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 4: Donor distribution according to place of donation Among those who attempted to donate during the big flood period, 4,444 (38.19%) had no history of previous blood donation. The percentage of these donors increased in comparison to the same period one year earlier where only 1,793 (28.62%) donors who never donated before attempted to donate (Table 2). Out of the 4,444 donors who come to donate regardless of any experience of previous donation, 3,570 (80.33%) of them were eligible to donate blood while 874 (19.67%) were deferred due to various reason during the pre-donation test or interview (Figure 5). This percentage of eligible first time donors increased compared to the same period one year earlier where only 1,393 (77.69%) first time donors were eligible to donate (Figure 6). Table 2 and Figure 4 show that majority of the donors (75.73% during the big flood period and 71.04% during the period one year earlier) came to our mobile collection clinics (mobile) compared to our static blood collection centre in the National Blood Centre. Table 2 also shows that majority of donors who attempted to donate blood during both period had previous experience with blood donation (61.81% among those who came during the big flood period and 71.38% among those who came at the same period one year earlier). However among those who attempted to donate blood during the big flood period only 11.10% had return to donate on the next visit. Meanwhile the control group showed 47.61% of return rate (Table 2). 13 supplement-flood disaster.pmd 13 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Donor with NO previous history of donation, eligible to donate Donor with previous history of donation Donor with NO previous history of donation, NOT eligible to donate Donor with NO previous history of donation Figure 5: Outcome of donors with no previous history of donation who attempted to donate during the big flood period from 28 December 2014 - 11 January 2015. Figure 6: Outcome of donors with no previous history of donation who attempted to donate from 28 December 2013 - 11 January 2014. 14 supplement-flood disaster.pmd 14 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT c. Outcome of donation Table 3: Outcome of donation based on total donated during the big flood period (28 December 2014 – 11 January 2015), n=9,979 and the same period one year earlier as a control group, n=5,438. 28 December 2014 – 11 January 2015 (Big flood) Outcome n (%) Screened reactive donation for TTI markers Yes 33 (0.33) No 9,946 (99.67) TTI: transfusion transmitted infection Table 3 shows out of the 9,979 donors who were eligible to donate during the big flood period, 33 donations or 0.33% were screened reactive to transfusion transmitted infection 28 December 2013 – 11 January 2014 (Control) n (%) 13 (0.24) 5,425 (99.76) markers. The percentage is higher compared to the same period one year earlier where 13 (0.24%) donations out of 5,438 were found to be reactive. STATISTICAL ANALYSIS a. Socio-demographic distribution Table 3: Difference of socio-demographic distributions between the big flood period (28 December 2014 – 11 January 2015) and the same period one year earlier as a control group. 28 December 2014 28 December 2013 – 11 January 2015 – 11 January 2014 p-value Outcome (Big flood) n (%) (Control) n (%) Age (years) < 18 52 (70.27) 22 (29.73) 0.001* 18 - 20 688 (64.54) 378 (35.46) 21 - 30 4650 (65.70) 2428 (34.30) 31 - 40 3648 (66.03) 1877 (33.97) 41 - 50 1896 (61.60) 1182 (38.40) 51 - 60 695 (64.95) 375 (35.05) > 60 52 (70.27) 8 (80.00) Gender Male 6562 (62.38) 3957 (37.62) < 0.001* Female 5075 (68.75) 2307 (31.35) Race Malay 6628 (64.14) 3706 (35.86) 0.003* Chinese 3583 (65.96) 1849 (34.04) Indian 1149 (68.23) 535 (31.77) Others 182 (60.67) 118 (39.33) 56 (37.09) Not stated 95 (62.91) 15 supplement-flood disaster.pmd 15 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Outcome 28 December 2014 – 11 January 2015 (Big flood) n (%) 28 December 2013 – 11 January 2014 (Control) n (%) Occupational status Managers 1626 (56.64) Professionals 2060 (74.83) Technicians and 924 (62.22) associate professionals Clerical support 1400 (77.99) workers 1152 (63.05) Service and sales workers Craft and related 98 (63.64) trades workers Plant and machine 444 (50.63) operators, and assemblers Elementary 171 (63.81) Occupations Armed forces 472 (62.35) Occupations Student 797 (70.72) Pensioner 37 (62.71) Housewife 389 (69.09) Unemployed 102 (68.00) Others 676 (72.35) Not stated 1289 (59.24) Nationality Malaysian 11538 (65.02) Non-Malaysian 99 (63.06) Place of donation Centre 2824 (60.89) Non-Centre 8813 (66.45) Chi-square test *Significant if p-value < 0.05 Based on Table 3, there were significant differences in sociodemographic distributions between the two groups of donors based on age group (p=0.001), gender (p<0.001), 1350 (45.36) 693 (25.17) 561 (37.78) 16 < 0.001* 395 (22.01) 675 (36.95) 56 (36.36) 433 (49.37) 97 (36.19) 285 (37.65) 330 29.28) 22 (37.29) 174 (30.91) 48 (32.00) 258 (27.65) 887 (40.76) 6206 (34.98) 58 (36.94) 0.617 1814 (39.11) 4450 (33.55) < 0.001* race (p=0.003), occupational status (p<0.001) and place of donation (p<0.001). However, there was no significant difference for nationality (p=0.617). 16 supplement-flood disaster.pmd p-value 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT b. Outcome of donation Table 4: Difference of outcome of donation between the big flood period (28 December 2014 – 11 January 2015) and the same period one year earlier as a control group. 28 December 2014 – 11 January 2015 (Big flood) n (%) 28 December 2013 – 11 January 2014 (Control) n (%) Screened reactive donation Yes No 33 (71.74) 9979 (64.78) 13 (28.26) 5425 (35.22) 0.324 Deferral Yes No 1658 (66.75) 9979 (64.73) 826 (33.25) 5438 (35.27) 0.052 Outcome p-value Chi-square test *Significant if p-value < 0.05 Based on the outcome of donation, there were no significant difference intherate of screened reactive donation (p=0.101) and deferral rate (p=0.052) for donors in the period of big flood and the control group (Table 4). In Iran, the great earthquake in Bam also caused a very huge increment in blood donors of over 600% compared to the control [8]. There were significant differences in the pattern of donors who attempted to donate during the big flood period compared to the same period the previous year for age group, gender, race, occupational status and place of donation. DISCUSSION This study showed that there was a spontaneous surge of donors who attempted to donate blood in response to the big flood disaster in Malaysia, with an increase of 85% compared to the same period a year earlier. The influx of blood donors in response to disaster were also seen in other places in the world. Guo et. Al. reported an increase of 38.14% in whole blood donors post Sichuan earthquake compared to the control period[3]; while Glynn et. al. reported an increase of about 145% of whole blood donation after the September 11 terrorist attack in the United States[5]. The majority of donors (39.96%) who attempted to donate blood during the big flood period were from the 21-30 years old age group. This could be due to the “snowball” effect among the young where one donor can strongly influence other members in his/her peer group to donate blood[9]. The increase in number of young blood donors is actually in tandem with WHO campaign to increase recruitment and 17 supplement-flood disaster.pmd 17 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT retention of donors from this age group projected during the World Blood Donor Day celebration for the year 2010 with the theme “New Blood for the World”[10]. likely to return to donation if they felt uncomfortable during donation. However, their motivation to donate blood was not lost[12]. Therefore, it is important to follow up on female donors who temporarily deferred from donation to increase their return rate. Reassurance and making them feel comfortable during donation are essential to encourage them to return in the future. This finding also corresponds to the population census in Malaysia whereby the biggest population in Malaysia in 2010 were aged between 20-24 years old, followed by 15-19 and 25-30 years [11]. This study also found that the majority of donors who attempted to donate blood were from the managerial and professional occupation group. However, it was the professional and clerical support groups that showed the biggest increase during the big flood period. A study done by Michel on the prosocial behaviour and volunteerism after Hurricane Katrina concluded that education was one of the significant positive factors in exerting feeling of personal responsibility for helping victims[13]. This study did not look at the education background of donors. However, donor occupational status does usually reflect their education background. Therefore, the finding of this study is consistent with the study done by Michel. This study showed that majority of donors who came forward to donate blood during the big flood period were male, corresponding to the population sex ratio in Federal Territory of Kuala Lumpur and Selangor. However, population sex ratio in Federal Territory of Putrajaya actually was the reverse. The population in Federal Territory of Putrajaya was very small compared to the other two states (F.T. Putrajaya 0.07 million, F.T. Kuala Lumpur 1.67 million, Selangor 5.46 million)[11]. Nonetheless, the percentage of female donors increased in comparison to the same period a year earlier. Female donors appeared to attempt to donate more in response to the big flood. This finding is similar to the study done by Dr Kasraian on characteristics of blood donors post great earthquake in Bam, Iran[8]. The majority of donors (75.73%) during the big flood period and 71.04% of the control group donated through mobile collection clinics (mobile) compared to our static blood collection centre in the National Blood Centre. The mobile collection clinics appeared to be more convenient for donors as these were held in public places such as shopping complexes, public transport stations, community centres and also in corporations with big employee numbers. The reasons why women were less represented in long term blood donor pool in Oslo, Norway were studied by Misje, Bosnes and Heier. The authors found that young female donors were associated with a higher deferral rate mostly due to low haemoglobin level, low body weight, pregnancy and lactation. Female donors were also less 18 supplement-flood disaster.pmd 18 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT respectively)[8]. The finding of our study echoed their findings. This study showed a return rate of only 11.10% among all donors for the post-big flood period while the control group showed a higher rate of 47.61%. However,data collected on this was for only three months after the big flood. Amore correct picture on the return rate would require a fulll year evaluation after the big flood. As described by Kapuchu in his article on Non-Profit Response to Catastrophic Disaster, non-profit organizations play important roles in strengthening the response operation to the disaster victims. For example, non-profit organizations teamed up with the public in the recovery efforts, and in offering aids to victims of the September 11 attack[14]. This collaboration was also seen in response to the big flood in Malaysia. Many non-profit organizations or nongovernment bodies came forward and organize blood donation drives with the National Blood Centre. This resulted in a tremendous response from the public who came to donate blood during that period. From the analysis of donors who had no experience of previous blood donation, 19.67% were deferred from donating blood during the big flood period and the percentage was higher in the control period at 22.31%. These donors who were temporarily deferred need to be followed up by sending an invitation message after the deferral period is over. Donors who donated in a busy mobile clinic especially during the big flood period might be turned off due to long queues for donation during such periods. A special appreciation message should be sent to these donors, especially first time attempted donors to entice them to attempt donating again in the future. Analysis on donation characteristics of this study showed that 38.18% of the donors who attempted to donate blood during the big flood period had no previous experience on blood donation. This category of donors showed an increment compared to the control group (28.62%). This finding is consistent with a meta-analysis done by Bednall and Bove who reported was that 73% of 2,615 first time donors would donate blood following catastrophic event[15]. The awareness to donate blood all year long should be propagated as the need for blood and blood component does not arise after disaster period only. Although the number of donations that were confirmed reactive to TTI markers was higher for the big floodgroup, the difference was not statisticaly significant. This finding is consistent with studies by Guo et. al. and Kasraian[3, 8]. Guoet. al. had shown that the return rate of first time donors who donated in response to disaster was low compared to the control period (8.00% and 13.00% respectively)[3]. Similar to this, Kasraian found the same pattern of return rate of first time donor postBam earthquake compared to control group (14.80% and 32.1% Deferral rate during the big flood period was about the same compared to the same period a year earlier (13.19% and 14.25% respectively) and was not statistically signicant. This finding suggests that there are potential eligible blood donors who only donated in response to disaster. 19 supplement-flood disaster.pmd 19 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT This group of donors should be targeted to become regular blood donors to ensure adequate and safe blood supply all the time. Voluntary non-remunerated blood donor pool should be increased to achieve a state of self sufficiency with the rate of 5% donation per population. REFERENCES 1. Ministry of Science, T.a.I.; Available from: http://www.met.gov.my/index.p hp?option=com_content&task= view&id=75&Itemid=1089. 2. Malaysia, U.K.; Available from: http://www.ukm.my/lestari/en/ banjir-20142015/. 3. Guo, N., et. al.., First time CONCLUSION Influx of blood donors in response to a national disaster is common[3-5, 8]. This finding is also shown in this study. Demographic analysis showed that the majority of donors who attempted to donate during the big flood period were male, Malay, Malaysian, aged between 21-30 years and from managerial or professional workers group. The majority of these donors donated through mobile clinics and had previous donation history. This information is useful in strategising blood donation promotions to the targeted group as a means of increasing the blood donor pool. donors responding to a national disaster may be an untapped resource for the blood centre. 4. Vox Sanguinis, 2012. 102 (4): p. 338-344. Nollet, K.E., et. al.., The great East Japan earthquake of March 11, 2011, from the vantage point of blood banking and transfusion medicine. 5. Transfusion Medicine Reviews, 2013. 27(1): p. 29-35. Glynn, S.A., et. al.., Effect of a national disaster on blood supply and safety: the September 11 experience. There were significant differences in pattern of donors who attempted to donate during the big flood period compared to the same period one year earlier based on the age group, gender, race, occupational status and place of donation. However, there were no statistically significant differences in the rate of screened reactive donation to Transfusion Transmitted Infection and deferral rate which means no increase in safety risk in the donated blood in response to national disaster. 6. Jama, 2003. 289 (17): p. 22462253. Organization, I.L. International Standard Classification of Occupations. 2008; Available 7. 8. from: http://www.ilo.org/public/englis h/bureau/stat/isco/isco08/. IBM SPSS Statistics for Windows, V., (2011). 20.0. IBM Corp., Armonk, NY., 2011, IBM Corp: Armonk, NY. Kasraian, L., National Disasters in Iran and Blood Donation: Bam Earthquake Experience. ACKNOWLEDGEMENT The authors would like to acknowledge the Director General of Health Malaysia for his permission for this article to be published. 9. Iran Red Crescent Med J, 2010. 12(3): p. 316-318. Symvoulakis, E.K., C.I. Vardavas, and P. Fountouli, Adverse reactions 20 supplement-flood disaster.pmd 20 8/6/2015, 2:32 PM to blood 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT after a natural disaster: The case of Hurricane Katrina. donation among adolescents. 10. 11. Jama, 2008. 300 (15): p. 17591760. Organisation, W.H., World Blood Donor Day 2010, 2010. Population Malaysia, D.o.S. 14. to Distribution and Basic Demographic Characteristic Report 2010 (Updated: 05/08/2011). 2011. 12. Misje, A.H., V. Bosnes, and H.E. Heier, Gender differences in 15. catastrophic Disaster Prevention and Management: An International Journal, 2007. 16(4): p. 551561. Bednall, T.C. and L.L. Bove, Transfusion Medicine Reviews, 2011. 25(4): p. 317-334. Sanguinis, 2010. 98(3p1): p. e241-e248. Personal Michel, L.M., responsibility and volunteering 21 supplement-flood disaster.pmd 21 disasters. Donating Blood: A Meta-Analytic Review of Self-Reported Motivators and Deterrents. presentation rates, deferrals and return behaviour among Norwegian blood donors. Vox 13. Sociological Spectrum, 2007. 27(6): p. 633-652. Kapucu, N., Non-profit response 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Hospital as a Disaster Relief Centre for Staff and Community in a Flood Disaster Ngah B, Nyak Abdullah N, Lim F, Nicholson MA, Ahmad A Hospital Sultan Haji Ahmad Shah ABSTRACT From the 25th December 2014 to the 4th January 2015, the District of Temerloh was hit by a major flood which resulted in 29,204 flood evacuees of which 6,450 were in the Mukim Perak II, where Hospital Sultan Haji Ahmad Shah (HoSHAS) was located. Seven hundred and thirty (730) hospital staff were also affected, of which slightly over half (383 staff) had their houses flooded while the rest were cut off by floods. A hundred and twenty eight (128) staff moved to stay in the hospital, bringing with them 124 family members. Thus, the hospital became a relief centre for its own staff. This unintentionally, helped to ensure the hospital was not short of staff during this critical moment as otherwise, those affected might not have been able to come to work. Due to over-crowding in the designated relief centres, some evacuees also used the hospital a relief centre. This paper shows the need for a hospital to be prepared to take on the role as a relief centre during a serious flood disaster, beyond its traditional role of patient care service. PURPOSE OF THE STUDY Hospital Sultan Haji Ahmad Shah’s disaster plan was geared towards responding to the sick and injured in a disaster but not as a relief centre during a flood. This paper presents the need for a hospital’s flood disaster response plan to include an additional function as a disaster relief centre, especially for its own staffs who are victims, and the community around it. hospital is situated on a small hill, about 5 km from the major Pahang River. The surrounding areas of the hospital are low lying and are flood prone. Many of the staff stay in housing estates in these areas. The hospital employs slightly over 2,000 staff of various categoriesand provides living quarters for 330 staff and their families. There are five schools designated as flood relief centres in the area. INTRODUCTION Hospital Sultan Haji Ahmad Shah (HoSHAS) is located in the state of Pahang in the district of Temerloh. The 550 bedded specialist hospital was opened in 2005, as a replacement for the old Mentakab Hospital. It is a main referral centre for six other districts, namely Jengka/Maran, Jerantut, Bentong, Raub, Lipis and Bera. The Pahang River, which is 435km long, is the longest river in West Malaysia. The river starts from the hills in the District of Lipis and is joined by the Kuala Tahan. Tembeling River also forms the Pahang River. It is joined by the Semantan River at Temerloh town before flowing towards the sea. This River drains three-quarters of land 22 supplement-flood disaster.pmd 22 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Data for the study were collected from the Malaysian National Security Council, Temerloh Disaster Operation Control Centre, Ministry of Health Malaysia (MOH), Pahang State Health Department and HoSHAS hospital census. water in the State of Pahang. When water levels are high in all the three tributary rivers, major flood will occur in the District of Temerloh and its downstream region. Major flood disasters were recorded in this District in 1926, 1971 and 1988. In recent years, there has been rapid development in Temerloh town with many new housing estates being developed around the river bank, which are flood prone areas. Thus, the impact of the latest flood is more severe as the number of houses and people affected are much higher as compared to previous floods. RESULT 1.1. Pahang River Water Situation On the 22nd December 2014, Kuala Lipis town was hit by flood. Water levels reached its town area. On the 23rd December 2014, Kuala Tahan reported that flooding has occurred in its areas. The water level in Temerloh was still below its warning stage. Table 1 shows the river water levels of three main tributaries to Temerloh (Lubuk Pasu) area. METHODOLOGY This is a retrospective study using secondary data documented by various Government Departments during the recent major flood between 25th December 2014 and 4th January 2015. 23 supplement-flood disaster.pmd 23 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Table 1: Pahang River levels from 24th December 2014 to 6th January 2015 Tembeling Yap LubukPasu Semantan (Kuala Date/River (Jerantut) (Temerloh) (Temerloh) Tahan) (meters) (meters) (meters) (meters) Normal 60.00 44.00 26.00 49.00 Alert 64.00 48.00 29.00 51.00 Warning 66.00 50.00 31.00 52.00 Danger 68.00 52.00 33.00 53.00 th 24 Dec 2014 77.52 59.12 32.90 47.99 25th NA 55.40 35.80 48.49 26th NA 55.39 36.01 49.05 th 27 NA 55.09 37.92 50.54 28th NA 55.09 38.08 50.98 th 29 NA 55.40 37.91 62.55 th 30 NA 50.24 37.88 62.55 st 31 55.28 48.63 37.86 62.55 1st Jan 2015 49.86 48.23 38.02 62.52 2nd NA 48.07 37.50 62.37 rd 3 NA 47.94 35.50 62.19 th 4 NA 47.89 31.89 62.08 5th NA 47.83 29.61 62.04 th 6 NA 48.05 28.56 62.00 Source: Web Portal Department of Irrigation and Drainage Malaysia 1.2. The Pahang River at Temerloh rose rapidly at about 1 meter/day from the 25th December 2014. This resulted in many of the population being caught unprepared. From the 25th December 2014 to the 2nd January 2015, all major roads were affected except for the old trunk road from Temerloh to Kuala Lumpur, making most towns and villages inaccessible by road. A total of 29,204 people were displaced by the flood to relief centres in the District of Temerloh. Immediate Flood Contingency Plan The Hospital Flood Committee met on 23rd December 2014 to look at its flood preparedness plan. Blood products, food, water, petrol and medication were at the required levels as specified in the Standard Operating Procedure (SOP) for patient care. All elective surgeries were cancelled. Three hospital quarters were designated for staff evacuees and additional beds were placed in the nursing hostel to cater for nurses. 24 supplement-flood disaster.pmd 24 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 1.3. Community Evacuation the area were inaccessible by road, leaving the Seberang Temerloh Secondary School as a relocation site for the community surrounding the hospital area. During the flood, 3,000 evacuees were placed in the school leading to over-crowding. Many of the evacuees stayed with relatives or friends to avoid the congestion. Ten families were evacuated to the hospital while many used the hospital facilities such as toilets and power supply. There were five flood relief centres in Mukim Perak II, where HoSHAS is located with a capacity for 4,200 evacuees. However, there were a total of 7,020 evacuees which was 67% more than their capacities (Figure1). The nearest relief centre to HoSHAS was Seberang Temerloh Secondary School. It could accommodate 2,000 evacuees. The other four relief centres in Figure 1: Disaster Relief Centre (DRC) in Mukim of Perak II (Source: Temerloh Disaster Operation Control Centre) 1.4. Hospital Staff Affected By Flood able to come to the hospital (Figure 3) by lorry, boat and Multipurpose Vehicle (MPV). Throughout the duration of the flood, the hospital was able to maintain it clinical staffing numbers, enabling the hospital to function without staffing problem. Figure 2 shows the number of hospital staff affected by the flood. Of the 730 staffs that were affected, 128 moved into the hospital with 124 family members (Figure 3). However, 1,855 (90.3%) staffs were still 25 supplement-flood disaster.pmd 25 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 2: Number of HoSHAS staff whose houses were affected by flood (Source: Hospital Census) Figure 3: Overall staff attendance to work and stayed in hospital hostel/quarters from 25thDecember 2014 to 5thJanuary 2015 (Source: Hospital Census) 26 supplement-flood disaster.pmd 26 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 1.5. Impact on hospital services was also use for evacuees from old folk homes, resulting in its bed occupancy exceeding 100% in some days (Table 2). Two temporary wards were opened to meet the increase demand for beds (Figure 5). Some patients had to be transferred to other accessible hospitals in the west of Pahang as temporary measures to reduce congestion at HoSHAS. 1.5.1. Hospital Bed Occupancy Rate (BOR) In line with the flood SOP, residents in the flooded areas who were bed ridden, pregnant women in their third trimester and end stage renal failure patients were evacuated to the hospital (Figure 4). The hospital Figure 4: Number of patients admitted or not discharged due to flood from 24thDecember 2014 to 5thJanuary 2015 (Source: Hospital Census) Table 2: Number of inpatients and BOR of Hospital Sultan Haji Ahmad Shah from 25th December 2014 to 3rd January 2015 Date No. of Inpatient BOR th 25 Dec 2014 441 80.18% th 26 434 78.90% th 27 446 81.10% 28th 472 85.80% th 29 563 102.04% th 30 573 104.10% st 31 559 101.60% 1st Jan 2015 514 93.50% nd 2 439 79.80% rd 3 417 75.81% Source: Hospital Census 27 supplement-flood disaster.pmd 27 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 5: Number of patients in two temporary wards from 24thDecember 2014 to 5thJanuary 2015 (Source: Hospital Census) Patients are usually evacuated with at least one family member, as it is the culture of the community to fend for their sick relatives. With the failure of utility supply in the town and nearby districts, end stage renal patients were transferred to the hospital, thus there was a need to work at maximum human resource capacity, especially for nursing staff (Figure 6). Patients discharged were also kept at minimal numbers as surrounding disaster relief centres were congested and the roads were inaccessible to send patients back to their homes. Newly delivered babies and infants were kept in the hospital in accordance to the directive. 28 supplement-flood disaster.pmd 28 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 6: Number of renal patients admitted due to flood (Source: Hospital Census) 1.5.2. Outpatient Services and Emergency Specialist outpatient services were cancelled. Emergency attendances were minimal due to flooded roads and hence services were directed to communication and dispatch operations with other flood relief agencies. This allowed resources to be redirected to the wards and the formation of more medical teams to help with the flood relief evacuation centres. 1.5.3. Food and Medication As a standard flood preparation procedure, food and medication were stocked for inpatient services for three months. However, food was only stockpile for patients. Staff evacuees and relatives accompanying patients were not provided with food. As the hospital was not gazetted as a flood relief centre, supply from central agencies for flood evacuees were also not provided to them. There was temporary shortage of food in the town due to electricity supply disruption in the town and panic buying. However, electrical and water supply to the hospital were unaffected. 1.6. Hospital As A Disaster Relief Centre For Volunteer From MOH During the flood, there was shortage of medical and health personnel in the District to attend to the relief centres. Emergency relief staff were mobilised from unaffected States. The hospital was used to house these relief personnel (Figure 7). 29 supplement-flood disaster.pmd 29 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 7: Number of relief staff staying in HoSHAS from 25thDecember 2014 to January 2015 (Source: Hospital Census) 2. DISCUSSION be prepared for such a role during a disaster. 2.1. The Need For Hospital As A Relief Centre This study showed that Hospital Sultan Haji Ahmad Shah was used to its capacity during the flood. Bed occupancy rate increased by about 20% - from 80% to 102% within three days. Hospital services are labour intensive, especially nursing personnel. Hospitals with intensive care units require even higher number of nurses. Thus, there is a need to ensure they have a place to be accommodated during a disaster to ensure their availability for critical patient care service. In the Temerloh flood, HoSHAS staffs were also affected by the flood – both material loss as well as emotional distress. It is therefore essential that emotional needs of affected staff be properly managed in a disaster where staffs who are victims continue to work during this moment of need. When disaster happens, members of the community look to the hospital as a safe place for refuge. With the availability of basic amenities, hospital inadvertently becomes a relief centre for the community during a major disaster, in addition to providing its own patient care service. The role of hospital as a relief centre during disasters is not something new. For example, hospitals had been designated as conflict free zone in times of war. However, the September 11th (2001) attack on the World Trade Centre was an eye opener to this role. St. Vincent’s Hospital New York, for instance, treated only 800 victims at that time, but housed a crowd of close to 25,000 people who were unsure of where to go(7). Thus, hospitals need to As there was over-crowding designated Disaster Relief Centres (DRCs), the 30 supplement-flood disaster.pmd 30 3rd 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT volunteers together with the staff evacuees helped ensure the hospital operated at its optimal level without disruption of services. community turned to the hospital for shelter and used the hospital facilities for their daily needs such as toilet and bathing facilities. This will create sanitation and cleaning problems for the hospital if no forward planning is done. Hospital security was an issue as the security services were also affected by shortage of manpower. Measures were taken by HoSHAS to ensure the well-being of these volunteers, staff and their families together with the volunteers by providing them with all the basic necessities. The Hospital Disaster Plan by the American Hospital Association on Hospital Preparedness for Mass Casualty and WHO Hospital Emergency Response Checklist do not appear address the use of hospitals as a relief centre for staff or for the community during a disaster(8,9). Their approach is still oriented towards caring for the sick and communities are directed to designated relief centres. But in our case, the DRCs were already congested and could not handle the load themselves. 2.2. i) Housing for the Staff Evacuees and Volunteers Fortunately Hospital Sultan Haji Ahmad Shah was newly built in 2004. Hence, there was ample spare space to be converted into temporary bedding areas. Most of the evacuees were female nurses, thus nurses hostels were used to house them. Extra beddings were provided and bought using the Hospital’s Social Society Fund. The three quarters allocated for disaster were used to house families. Some of the male staffs were allowed to use their working place, single rooms in wards and the on-call rooms to stay. Volunteers were housed in converted seminar rooms. Hospital Sultan Haji Ahmad Shah Experience 2.2.1. Hospital Staff and Relief Staff The issue of human resource availability of medical personnel was dealt with by the Ministry of Health by sending volunteers from its various facilities to Hospital Sultan Haji Ahmad Shah. These 31 supplement-flood disaster.pmd 31 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT ii) Clothing Some of the staffs were working while their houses were flooded. They were left with only the clothes on their back. Donation drives were carried out among staff to help them and some of the clothes were also donated to the community evacuees. iii) iv) Stress Management Several measures were taken to help reduce stress for the staff. a) Temporary Nursery Centre For Staff’s Children An ad hoc nursery service was setup by the staff from Medical Rehabilitation Department for children of staff while their parents were at work. Hence, the staff could focus on their work without having to worry about the welfare of their children. Food The hospital disaster manual only addresses availability of food supply for patients. With the occupancy reaching 100%, there was hardly enough food supply for the 2,000 hospital staff and families of those that stayed in the hospital. As the hospital was not a designated flood relief centre, it was unable to source help from flood agencies. Food was initially bought from nearby towns using emergency funds available. b) Communal Cooking Due to the flood, almost all shops near the hospital were closed. To enhance the feeling of hospital oneness, all daily meals were prepared and cooked together. Staffs were assured of at least one full meal a day. 32 supplement-flood disaster.pmd 32 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT c) Daily Trip to Nearby Town ensure staff with highly stress behaviour are detected early and managed properly. The hospital management also provided scheduled transportation for staff to visit nearby towns daily. It enabled staff take a short break from the stressful working environment. d) f) Daily Updates Briefing for staff and Heads of Department were carried out daily on the flood situation. Worst case scenarios, river water levels and recovery planswere discussed. These daily briefings enabled staff to be updated as well as voice their opinions and suggestions to the management. Monitoring of Double Shifts Double shifts were monitored so that the same staffs were not put in an unbearable stressful situation. With the help of relief staff, no staff were put on double duty during this period. e) Monitoring of Stress Behaviour 2.2.2. Community The hospital had developed a stress protocol two years earlier for detection of staff with stressful behaviour, especially those working in the emergency and critical care area. It was developed with the Psychiatry and Mental Health Department to Ten displaced families had used the hospital lobby as their temporary evacuation area. The hospital allocated an area and set up four temporary tents for their use through the Hospital social club. Foods and clothing donated to the hospital were also distributed to these victims. 33 supplement-flood disaster.pmd 33 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT The hospital facilities were also used to conduct Friday prayers as most of the surrounding mosques were flooded. Designated washing facilities were allowed to be used for the public. The hospital’s helipad which is normaly used for patient evacuation became a distribution despatch facility to transport supply to victims in other flood relief centres. 2.3. The Recovery in the post-flood expected to be high. Four hospital voluntary groups were formed to help in the cleaning of staff’s houses that were flooded, health clinics, schools and mosques that were similarly flooded. With the help of the hospital’s social club, high power water jets were purchased. The aim was to get the staff and community to return to normalcy as soon as possible, and allow the hospital to function effectively as the number of patients 34 supplement-flood disaster.pmd 34 8/6/2015, 2:32 PM period was 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT CONCLUSION ACKNOWLEDGEMENT Although the main function of the hospital is to provide treatment for the injured in a disaster, its role as a relief centre for its own staff and the immediate community should not be over-looked. This would ensure adequate staffing during such critical period where workload would be higher. Caring for your own staffs who are victims is as important as it promotes loyalty and motivates the staff to work harder. Many of the actions taken by HoSHAS at the recent flood were impromptu. With better planning and preparedness, staff welfare and patient care service can be further improved. One missed opportunity was in helping staff to evacuate as part of the Hospital’s staff mobilisation plan before the flood occurred. In conclusion, Hospital Disaster Management Plan should incorporate contingencies for its role as a relief centre for its affected staff as well as the local community who may seek refuge in the hospital. The authors would like to acknowledge the Director General of Health Malaysia for his permission for this article to be published. REFERENCE 1. Report and Statistics, Malaysian National Security Council. 2014-2015 2. Report and Statistics, Temerloh Disaster Operation Control Centre. 2014-2015 3. Report and Statistics, Ministry of Health Malaysia. 2014-2015 4. Report and Statistics, Pahang State Health Department. 2014-2015 5. Report and Statistics, Hospital Sultan Haji Ahmad Shah. 2014-2015 6. River Water Level. Department of Irrigation and Drainage, Malaysia. 2014-2015 7. Meyer, Susan. Disaster Preparedness: Hospitals Confront the Challenge. Trustee Magazine. February 2006 8. Hospital Emergency Response Checklist: An all-hazard tool for hospital administrators and emergency managers. WHO. Europe. 2011 9. Hospital Preparedness for Mass Casualties. Final Report. American Hospital Association/U.S. Department of Health and Human Services. August 2000 35 supplement-flood disaster.pmd 35 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Challenges of Logistical Management During The Flood Disaster in Malaysia Lim KK, Jasvindar K, Chong ZL, Abdul Aiman AG, Mohamad Naim MR, Azli B, Muslimah Y, Faizah P, Cheong SM Institute for Public Health ABSTRACT Institute for Public Health Crisis Preparedness and Response Centre (CPRC-IPH) was established and given the task of logistic management during the major flood disaster in Malaysia on the eve of 2015 new year. The objective of this paper is to share the experience and challenges faced in the process. Upon establishment, CPRC-IPH recruited its members, set up a designated flood operation room, created an inventory of stand-by vehicles, deployed them to flooded areas for aids, monitored their activities thoughout, devised the idea of vehicle-day to quantify the intensity of involvement of the stand-by vehicles provided by different parties, and submitted feedback daily to Ministry of Health Malaysia Crisis Preparedness and Response Centre (CPRC-KKM) in Putrajaya. The result wasa 22-member team running CPRC-IPH for 20 days, different tasks outlined in the terms of reference. Eighty-seven (87) vehicles were on stand-by, of which 55 were from various agencies under Ministry of Health (MOH) Malaysia, 15 from concessionaries, and 17 from a private rental company. In total, 281 vehicle-days were completed throughout the period; out of which 39 vehicle-days were contributed by MOH vehicles, 124 by concessionaries, and 118 were rented. On average, around 14 cars were deployed each day with two from MOH. This greatly reduced the impact to the exisiting core business of the participating MOH agencies. Three challenges faced by CPRC-IPH in the process were shortage of vehicle supply, communication breakdown, and difficulties in monitoring. Governmentprivate partnership, establishment of standard operation procedure for disaster management, prior structured training for CPRC members, utilisation of diverse information systems, and creative simplification of quantifying measurement were the keys in solving the problems faced. In conclusion, CPRC-IPH fulfilled the logistic management successfully. It is hoped that its experience may help to improve the logistic management for flood disaster in the future. Keywords: Logistic management, flood disaster, CPRC, Malaysia Introduction weather disaster in the world and the costliest in terms of economic losses (1). Flood disasters have been reported in many regions and countries. In many cases, the observed magnitude and frequency of the floods have been Flood takes place when water from heavy rainfall exceeds the flow capacity of the river system and happens more frequently worldwide due to a variety of human and environmental factors. It is the commonest 36 supplement-flood disaster.pmd 36 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT CPRC-KKM in management of this flood disaster. Institute for Health Management (IHM) was responsible for the deployment of medical and health personnel from nonaffected States to the flooded ones, whilst Institute for Public Health (IPH) was given the task of logistic management, i.e. to create an inventory of stand-by vehicles and to plan their deployment according to needs. Accordingly, each of the Institutes established their flood operation room on 31st December 2014, known as CPRC-IHM and CPRC-IPH respectively. Apart from logistics, CPRC-IPH also provided hostel facilities for medical and health staff who were deployed to flood areas by CPRC-IHM for their duties. In addition, individual experts from other Institutes of NIH were involved in the flood operation in various ways, especially in CPRC-KKM. Experts from Institute for Medical Research (IMR) were also called to study the soil in flooded areas for communicable diseases agents, such as meliodosis. found to be more severe than expected (2). Flood brings casualties, destroys infrastructures, annihilates crops, and negatively impacts human health physically as well as psychologically. On average, more than 196 million people are affected by disastrous floods each year globally (3). The victims always need prompt attention in several areas such as health care, food, water, safety and childcare (4). Malaysia is among the countries that experience negative influences of floods yearly. Based on the existing reports, 40% of the total damages in Malaysia were brought by floods (5). In 2006, the state of Johor was hit by one of the worst floods in Malaysian history with about 160,000 populations being displaced (6). The record was renewed in December 2014, when Malaysia suffered an even worse flood disaster which affected several States simultaneously. Many of the areas affected were not considered as flood-prone prior to this. Health care providers faced many challenges in delivering their services to flood victims due to devastation of healthcare facilities and other infrastructures. The Ministry of Health (MOH) Crisis Preparedness and Response Centre (CPRC-KKM) was mobilised to provide short-term relief responses and interventions by deploying additional medical and health personnel to restore the health services to the affected states. Many disaster studies have their focus on documenting the ways disasters affect individuals, households and communities. However, documentationon transportation problems and vehicle management for disaster response operations is very limited. The aim of this paper is to provide a general overview of the issues and challenges experienced by CPRC-IPH in the management of vehicles and transportation during this major flood disaster. Data and informations were obtained from CPRC-IPH reports and through observations made during the flood period in various the flood operation rooms. Following the decision of the CPRC-KKM meeting on 31st December 2014, two research institutes were selected to assist 37 supplement-flood disaster.pmd 37 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Materials and Methods other stakeholders. CPRC-IPH was to fulfill the needs by deploying vehicles with or without drivers from its inventory of stand-by vehicles according to requests. Following instructions received in the meeting at CPRC-KKM, a techincal committee for CPRC-IPH was formed immediately. Members were recruited from among staff based on availability and willingness to participate. Each member was given a task according to the terms of reference outlined later on. A meeting room equiped with necessary facilities within the main block of IPH was converted into the flood operation room. It was staffed according to pre-arranged rosters. Meetings were held regularly in the flood operatioin room to update members on the latest developments. Upon deployment, the vehicles were monitored daily by CPRC-IPH. Information such as schedule, tasks and locations were obtained from the drivers or responsible officers and updated each morning. Communications were carried out using landline, mobile network and internet. Among them, the most used was instant mobile messaging application, in particular, which WhatsApp® contributed to rapid information updates between all the stakeholders. Besides, photos sent by the drivers also provided a glimpse into the latest condition of the flooded areas. As soon as it was established, CPRC-IPH created an inventory of stand-by vehicles by contacting various agencies under MOH in States which were not affected by floods, such as State Health Departments, Hospitals, Allied Health Colleges, Research Institutes, and various Divisions within the head office at Putrajaya. These agencies were requested to identify and set apart idle vehicles and drivers, if any, for flood rescue operation purposes. Contact persons were also appointed by each participating agency. On the other hand, the MOH Engineering Division in Putrajaya was given the mandate to coordinate with various hospital support service concessionaries for vehicle contribution, whilst the Administrative Unit in Putrajaya was to hire appropriate vehicles in case of shortage. In order to measure the amplitude of involvement of the stand-by vehicles from the three main providers, CPRC-IPH devised and proposed the idea of vehicleday. When any one vehicle was deployed for any activity in a day, regardless of the number of trip it made during that particular day, it was counted as one vehicle-day. For example, two vehicles deployed in a day was counted as two vehicle-days; one vehicle deployed for two days was also counted as two vehicle-days. Vehicle-day represents neither the exact number of vehicle deployed nor the exact number of day a vehicle was deployed. It merely quantify the intensity of vehicle usage over a particular period. This means the higher the number of vehicle-day, the higher the number of vehicles deployed and the longer the time these vehicles were away. At the same time, CPRC-IPH started to receive transportation and vehicle requests from CPRC-IHM and CPRC-KKM, which in turn received them from the affected State Health Departments and 38 supplement-flood disaster.pmd 38 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Results Further more, by dividing the vehicle-day with the total period of operation, one will get the number of deployed vehicle per day. The CPRC-IPH technical committee consisted of 22 members, 14 of whom were officers and the rest were support staff. For smooth operation, each member were given a position with specific terms of reference (Table 1). Two duty shifts were formed, which were morning (8.00 am – 2.30 pm) and afternoon (2.30 pm – 9.00 pm) shifts. The members were rotated to go on duty according to prearranged roster to prevent fatigue. In the end, CPRC-IPH operated for 20 days in total between 31st December 2014 and 19th January 2015. All information on CPRC-IPH activities, in particular the logistics were updated on a daily basis and recorded in both hard and soft copies. These informations were summarised into a daily reportwhich was submitted through email to CPRC-KKM. Table 1: Terms of reference for CPRC-IPH members Position Terms of reference (TOR) Liason officer (LO) Attend CPRC-KKM meetings in Putrajaya Coordinate activities in the flood operation room Coordinate and colloborate with other stakeholders Head Assist LO in coordinating the activities in the flood operation room Communicate with other stakeholders in daily operation Prepare and submit daily report to CPRC-KKM and LO Operation officer Establish the flood operation room for usage Maintain the flood operation room daily Staff the flood operation room by preparing duty roster Update daily record of duty officer Document officer Record all the activities of the flood operation room according to chronological order Keep a record of all documentation and forms Ensure all the documentation and forms are updated 39 supplement-flood disaster.pmd 39 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Duty officer Update the inventory of stand-by vehicles Monitor the movement of deployed vehicles Record all incoming/outgoing calls in the record book. Check the CPRC-IPH official email ([email protected]) Update the contact numbers of relevant organizations andpeople Liase with other stakeholders when needed Record all the informations received and decisions made Receive and pass-over shifts from and to the other duty officers Drivers Be eveready for deployment Update the flood operation room with informations on activities, working schedule, and location of the vehicle A total of 87 vehicles comprised the inventory of stand-by vehicles.Among them were 55 vehicles of different classes such as 4-wheel-drive (4WD), multipurpose vehicle (MPV), van, sedan car, and bus from various agencies of the MOH Malaysia (Table 2); 15 4WDs from concessionaries; and another 17 rented 4WDs from a Car Rental Company. Out of the 15 4WDs contributed by the nine concessionaries, 5 were from Radicare; 2 each from Medivest and AVP; and 1 each from Continental, Technohouse, Alshem, KBE, George Kent, and Besta. Table 2: Total vehicles available from various agencies under the Ministry of Health Malaysia Type of Vehicles (in number) Contributors 4WD MPV Van Car Bus Ministry of Health (MOH) Research Institutes 9 1 1 3 1 National Blood Centre 1 1 Allied Health College 1 State Health Departments 26 4 6 1 Total 36 6 7 3 3 There were two guiding principles in the selection of stand-by vehicles for deployment. Concessionary and rented vehicles were the first to be deployed to reduce the impact on exisiting core business of the participating MOH agencies. Secondly, whenever a MOH vehicle was deployed, it was preferably for short distance day trip. As a result, throughout the 20 days of operation, the MOH agencies contributed merely 39 vehicle-days out of a total of 281 vehicle- 40 supplement-flood disaster.pmd 40 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT days. The rest were evenly distributed between the concessionaries (124 vehicledays) and private car rental company (118 vehicle-days). This means that on the average, around 14 cars were deployed each day; out of which two were from the MOH, and six each were from concessionaries and rental company. Figure 1 demonstrates the number of daily deployed vehicles according to different parties in details. The number rose steadily, peaking on 6th January 2015, and plateauing on the 17th day from the start. The area below each line represents the number of vehicle-day contributed by the respective providers. Number of Vehicles 35 30 25 20 15 10 5 19-Jan 18-Jan 17-Jan 16-Jan 15-Jan 14-Jan 13-Jan 12-Jan 11-Jan 10-Jan 9-Jan 8-Jan 7-Jan 6-Jan 5-Jan 4-Jan 3-Jan 2-Jan 1-Jan 31-Dec 0 Date Total MOH Concessionaries Rented Figure 1: Daily deployed vehicles Discussion Most of the logistic systems are designed to operate under regular conditions. When a disaster takes place, the means to deliver aids are usually disrupted and hence, the logistic operation faces difficulties in accomplishing the tasks (4). However, with improvements in information communication technologies and preparedness, logistic plans to reach the affected areas with all the urgent needs have been proven to be successful (7). Logistic management during flood disaster involves dispatching commodities such as medical materials, equipments, rescue teams to the affected areas as soon as possible(8). The damage caused by the recent floods was unprecedented to the residents as well as infrastructures, especially roads and health facilities. The MOH Malaysia responded immediately through CPRCKKM during the flood disaster to restore the services of medical care in the affected areas by mobilization of emergency supplies, equipments and personnel. The workload was enormous as additional flood-related emergency medical services were urgently needed, on top of the regular day-to-day medical services provided. Since logistic management is one of the most important elements of disaster management itself, CPRC-IPH was established to focus only on this task and do it well. 41 supplement-flood disaster.pmd 41 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT In fulfilling its calling, CPRC-IPH faced many challenges. Although most of the problems were solved promptly, three underlying key issues that gave rise to them must be addressed here to improve the efficacy of disaster logistic management in the future. These three issues are shortage of vehicle supply, communication breakdown, and monitoring difficulty. when most of the trips were completed by concessionary and rented vehicles. Apart from that, multi-party involvement in disaster management with no training or no standard prior training and experience led to a common mistake – communication breakdown. Throughout the operation, CPRC-IPH received conflicting instructions from different parties through different channels, which greatly affected the arrangement and monitoring of the vehicles. Most of the mis-informations were sorted out properly prior to decision making. Unfortunately, one incident happened towards the end of the operation where two buses departed forthe airport to fetch 90 returning health staffs but returned with only one person as the rest of them dispersed upon landing following their own family or department vehicles (11). This problem can be solved by improving the communication channels under existing standard operating procedures (12). Proper training for CPRC staffs may also enhance their efficacy in future as most of those involved were first-timers. Nevertheless, the decision to allocate three vehicles and two drivers fully to CPRC-IHM for its use from the beginning helped to prevent the mistake from happening earlier. Despite all efforts, effective communication between various agencies remained a persisting issue in logistic mamagement and is still being cited as the main area that needs attention in disaster or crisis management (13). The flood left affected areas with limited availability of all resources, for example, transportation, supplies, manpower, hospital capacity et cetera. The communities and agencies depend heavily on transports from non-affected areas to fill up the gaps. The transportation system is the most important lifeline system, because damage to it imposes extra burden on their other lifelines (9). In addition, these disruptions are costly and it is crucial that authorities take appropriate measures of response to reduce it’s negative effects (10). CPRC-IPH attempted to minimize these problems by requesting standby vehicles from various health agencies not affected by floods directly. However, many State Health Departments and Hospitals had already deployed their own vehicles voluntarily to the flooded areas, and thus were unable to provide extra vehicles for standby. In addition, the remaining vehicles were just enough for their exisitng daily core activities. However, some State Health Departments, Research Institutes under MOH, National Blood Centre and Sungai Buloh Allied Health Colleges were able to spare some vehicles for stand-by. Fortunately, the fear of disturbing the core business of various MOH agencies was alleviated eventually As an extension of the communication issue, difficulty in monitoring the activities of the deployed vehicles troubled CPRCIPH. Lack of coordination and poor telecommunication network in the affected areas were identified as the main 42 supplement-flood disaster.pmd 42 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT culprits of this issue. Prompt communication between CPRC-IPH and the drivers was crucial as timely and accurate informations were crucial in logictic management (14). Fortunately, this issue was minimised with the availability of information and communication technology. The existence ofinstant mobile messaging applications provided a reliable communication platform for stakeholders to converse with each other. These information system provided timely access to comprehensive, relevant and reliable first-hand informations. Therefore, it is not a suprise that social networks are becoming more attractive for agencies in addressing communication issue during a disaster (15). standard operation procedure for disaster management, prior structured training, utilisation of diverse information systems, and creative simplification of quantifying measurement proved to be a lifeline in the time of need. By raising the issues and recommending steps for improvement, it is hoped that the logictic management for flood disaster may be perfected in the future. Acknowledgement The authors would like to thank the Director-General of Health, Ministry of Health Malaysia for permission to publish this paper. We are grateful to all the members of CPRC-IPH, CPRC-KKM, and CPRC-IHM, who together contributed to the country during this disaster. Last but not least, we extend our deepest condolence to the flood victims and sincerely hope for them to recover from the lost soon. As part of vehicle monitoring issue, it was realised that to quantify the intensity of involvement of stand-by vehicles from different parties, information on mileage covered and time spent by each vehicle is necessary. This will require a methodical checking mechanism and an effective feedback loop, which is time-consuming during a disaster. A more accurate method would be through installing a global positioning system in each vehicle, but this is expensive and needs additional funding. The idea of vehicle-day might be a solution to this due to its simplicity in contrast to the widely used conventional measurements (16). References [1]. Bruce, W.C. (2009). Disasters and public health: Planning and response. Amsterdam: Academic Press. [2]. Chatchai, J., Chow, H., Kowit, B., Murugesu, S. (2013). Assessing the impact of climate and land use changes on extreme floods in a large tropical catchment. Journal of Hydrology, 490, 88–105. Logistic management is one of the most important elements during flood disaster. CPRC-IPH managed to fulfill the task successfully, albeit troubled with transport shortage, communication problem, and difficulty in monitoring. Governmentprivate partnership, establishment of [3]. Garrido, R., Lamas, P., Pino, F.J. (2015). A stochastic programming approach for floods emergency logistics. Transportation Research, Part E, 75 18– 31. 43 supplement-flood disaster.pmd 43 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT [4]. Wardah, T., Abu Bakar, S.H., Bardossy, A., Maznorizan, M. (2008). Use of geostationary meteorological satellite images in convective rain estimation for flash-flood forecasting. Journal of Hydrology, 356, 283– 298. Engineering. Los Angeles: Society of Civil Engineers. [10]. Hishamuddin, H., Sarker, R.A., Essam, D. (2013). A recovery model for a two-echelon serial supply chain with consideration of transportation disruption. Computers & Industrial Engineering, 64, 552–561. [5]. Tehrany, M.S., Pradhan, B., Mansor, S., Ahmad, N. (2015). Flood susceptibility assessment using GIS-based support vector machine model with different kernel types. Catena;125, 91-101. [11]. Institute for Public Health. (2015). CPRC-IPH final report. Kuala Lumpur. [12]. Garland, T. (2006). Disaster Management. In: Peterson, M.E., Talcott, P. A. Small Animal Toxicology. 2nd ed. Missouri: Elsevier Saunders; p. 420-430. [6]. Badrul Hisham, A.S., Nor Azian Shaharom, C.M.D., Marzukhi, M.I., Norli, R., Fatimah, O., Kee, K.F., Arbaiah, O., Mohd Yusof, M., Adam, A.M. (2009). Spectrum of flood related diseases encountered during flood disaster in Johore, Malaysia. Journal of Community Health. S, 15(1), 15-23. [13]. Roux, T.L. (2014). DR4 communication in the South African context: A conceptual paper. Public Relations Review, 40, 305–314. [7]. Holguin-Veras, J., Pérez, N., Ukkusuri, S., Wachtendorf, T., Brown, B., (2007). Emergency logistics issues affecting the response to Katrina: A synthesis and preliminary suggestions for improvement. Transport. Research, 2022, 76–82. [14]. Horita, F.E.A., de Albuquerque, J.P., Degrossi, L.C., Mendiondo, E.M., Ueyama, J. (2015). Development of a spatial decision support system for flood risk management in Brazil that combines volunteered geographic information with wireless sensor networks. Computers & Geosciences, 80, 84–94. [8]. Chang, M.S., Tseng, Y.L., Chen, J.W. (2007). Scenario planning approach for the flood emergency logistics preparation problem under uncertainty. Transportation Research, 43, 737–754. [9]. Hopkins, D.C., Lumsden, J.L., Norton, J.A. (1991). Wellington’s lifelines in earthquake project: An outline of a major review. Proceedings of the 3rd US Conference on Lifeline Earthquake [15]. Lu, Y., Yang, D. (2011). Information exchange in virtual communities under extreme disaster conditions. Decision Support Systems, 50, 529–538. [16]. Krumm, J. (2012). How People Use Their Vehicles: Statistics from the 2009 National Household Travel Survey. SAE International, doi:10.4271/2012-01-0489 44 supplement-flood disaster.pmd 44 American 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Pre-deployment Flood Disaster Volunteer Activities in Crisis Preparedness Response Centre of Institute for Health Management (CPRC IHM): Our Maiden Experience Pangie B, M Fairuz AR, Noriah B, N Filzatun B, N Izzah AS Institute for Health Management ABSTRACT Flood disasters are closely related with the states that lie on the East Coast and Northern parts of Malaysia. The flood that occurred recently in December 2014 and January 2015 was regarded as one of the worst crisis that Malaysia has ever experienced in recent decades. It affected more than 250,000 people and disrupted the services of many hospitals and clinics. The serious impact on healthcare services in the three affected states (Kelantan, Pahang and Terengganu) has necessitated the Crisis Preparedness Response Centre (CPRC) in the Ministry of Health (MOH) to mobilize other healthcare professionals from non-affected states to provide services at these affected areas. During crisis, human resource management plays a vital role which includes the deployment of volunteers. This article is mainly about workflow and process in CPRC Institute for Health Management (IHM) as a transit centre for deployment of healthcare volunteers to the affected area. CPRC IHM was established on the 28th December of 2014 and headed by the Director of IHM. Several teams have been formed, namely the operational room, logistic, predeployment registration, post-deployment registration, data management, Non-MOH volunteer registry, Information Technology and catering teams. All the teams had synergistically worked together throughout the deployment process. CPRC IHM in collaboration with other divisions like CPRC MOH, CPRC Institute of Public Health (IPH), Disease Control Division particularly Environmental Health Section and Mental Health Section, MOH were working hand in hand in providing the services. As this is a maiden experience for IHM managing such a crisis, many lessons were learnt which were valuable for future preparation. As this was a new experience for IHM, standard operating procedures (SOP) and guidelines needed to be developed which cover all aspects of deployment for future preparedness. This spans initiation of the operational room to deployment of healthcare volunteers to the disaster area with better coordination from CPRC MOH. Keywords: Flood disaster, CPRC MOH, CPRC IHM, pre-deployment volunteers, transit centre 45 supplement-flood disaster.pmd 45 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Introduction Malaysia is blessed as she is located outside the “Pacific Ring of Fire”. However, Malaysia encounters other disasters such as floods, man-made disasters and haze annually. Flood disasters are associated mainly with states that lie on the East Coast and Northern part of Malaysia. Based on the Department of Irrigation and Drainage Malaysia, about 29 800 km2 or 9% of land in Malaysia is prone to flash flooding. It is due to the cyclical monsoon which usually peaks from October to January annually. However, no states in Peninsular Malaysia are totally spared from experiencing the flood phenomenon. Building experience and exposure of the staff Preparedness for disaster Fast response towards disaster Assessment of severity and effect of any disaster Evacuation, rescue and relief Recuperation and rebuilding In disaster and crisis management, human resource management plays a vital role especially in the deployment of volunteers. The coordination to meet demand of human capital during the crisis is important in response to the shortage of functioning healthcare providers in the affected area. Alerted by this paralysis of health services in all three states, CPRC MOH had to mobilize other healthcare providers from non-affected states to provide relief to already exhausted healthcare workers in the area. The flood that Malaysia experienced in December 2014 till January 2015 was regarded as one of the worst flood crisis that ever happened in recent decades. It had affected more than 250,000 residents and adversely affected many health services including hospitals and clinics. Background of CPRC IHM CPRC IHM was established on the 28th December of 2014 based on the mandate given during the CPRC MOH Meeting which was held on the previous day. In view of the availability of accommodation and training facilities, IHM was appointed the transit centre for MOH healthcare volunteers. Two main tasks for CPRC IHM were the pre and post deployment of healthcare volunteer management. This article mainly discusses pre-deployment activities in CPRC IHM. Lesson learnt from this experience is the disaster and crisis management need to be strengthened. Arora (2013) discusses about the process of disaster management which involves a continuous and integrated process of planning, organising and implementing measures which are; Prevention of potential danger or threat of any disaster Migitation or risk reduction of a disaster of the severity or consequences 46 supplement-flood disaster.pmd 46 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT During the 20-day operation from the 28th December of 2014 until the 16th January of 2015, CPRC IHM had managed and deployed 494 volunteers mostly consisted of MOH healthcare providers from West Coast, Peninsular Malaysia to Kelantan, Pahang and Terengganu. The breakdown of the volunteers by job position is shown in Table 1. Table 1: Number of pre-deployment volunteers in transit at CPRC IHM by job position No Job Position Total Volunteer 1. Specialist 15 2. Medical Officer 40 3. Dental Officer 3 4. Nurse 163 5. Assistant Medical Officer 30 6. Assistant Dental Officer 4 7. Counsellor 12 8. Engineer 25 9. Penolong Pegawai Kesihatan Persekitaran 50 10. Social Worker 1 11. Laboratory Technician 4 12. Pembantu Kesihatan Awam 18 13. Driver 61 Pembantu Perawatan Kesihatan 14. 20 Pembantu Rendah Awam 15. 20 Grand total 494 The CPRC IHM Operation Structure CPRC IHM task force was formed which comprised the IHM administration, financial department and technical officers. It was led by the Director of IHM and assisted by a dedicated officer heading the CPRC IHM Operation Room and supported by seven teams with various functions and roles (as in figure 1). 47 supplement-flood disaster.pmd 47 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 1: The Functional Structure of CPRC IHM and the Respective Teams’ Responsibility Pre-Deployment CPRC IHM Team Scope of Work the affected areas. To ensure efficient and quality services were given to the volunteers, the workflow illustrated in Figure 2 was developed and adopted by the pre-deployment team. As a transit centre during the flood disaster, CPRC IHM was tasked to facilitate the deployment of volunteers to 48 supplement-flood disaster.pmd 48 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 2: The workflow for the CPRC IHM pre-deployment team Pre-deployment Volunteers Management iii. iv. In general, the management of the predeployment volunteers in CPRC IHM was: i. Volunteer registration; ii. Pre-deployment Psychological First Aid (PFA) briefing; Accommodation and facilities; and Logistic arrangements All pre-deployment volunteers were required to follow the process flow as set by CPRC IHM as shown in Figure 3. 49 supplement-flood disaster.pmd 49 catering 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 3: Pre-deployment Volunteer’s Process Flow 1.0 Volunteers Registration Once the volunteers arrive at IHM, they will be registered promptly. All volunteers were registered using standard format provided by CPRC MOH. For those who were not on the list, CPRC IHM contacted CPRC MOH via a Liaison Officer (LO) for further action. Once registered at IHM and the details received from CPRC MOH, the CPRC IHM officer-in charge will notify the volunteer of their flight schedule. The main purpose of the complete and detailed registration was for inclusion in the daily census report and MOH volunteer registry database. Essential information such as contact person at affected states, return flight details (if available), flood or water-borne related disease such as leptospirosis, meloidosis and typhoid and precaution or safety practice during flood were also conveyed to the volunteers during the briefing session. The protective equipments which were supplied by the Occupational Safety and Health Unit, Ministry of Health were distributed to the volunteers. 50 supplement-flood disaster.pmd 50 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Photo 1: The volunteers were given safety jackets and sleeping bags before deployment Photo 2: The Secretariat of CPRC IHM updating the daily census of the pre-deployment volunteer 2.0 Psychological First Aid (PFA) and Pre-Deployment Briefing Based on National Guidelines for Mental Health and Psychosocial Response to Disaster, the mental health needs of disaster response workers should be given priority. This should include appropriate training and surveillance during and post deployment. All volunteers who registered to volunteer underwent a session of PFA by a trained counsellor. The purpose of the PFA session was to provide 51 supplement-flood disaster.pmd 51 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT psychological support and to ensure preparedness for the volunteers so that they were mentally well prepared to serve in the affected area. The content of PFA was based on the national guideline which comprised information on emotional and psychological impact (short and long term) disaster on individuals. It includes the recognition and management of distressed feelings, anxiety, depression, post traumatic stress disorder and other mental health issues that may occur. This guideline also outlined how the volunteers manage their mental health needs and simulation exercise. The PFA sessions were conducted in groups or face-to-face, depending on the number of volunteers present during the session or the particular time before their departure to the affected areas. Photo 3: PFA trained counsellor giving PFA in Delima Hall to the group of pre-deployment volunteers 3.0 Accommodation and Catering Facilities Upon registration in IHM, the volunteers were provided with accommodation according to their flight schedule. Food and beverages were also provided throughout their stay in IHM. A total of 151 volunteers were lodged at IHM accommodation during their transit. The hostel supervisors were responsible in managing and arranging the room for volunteers. The Catering Unit was in charge of providing food for all volunteers who transit in CPRC. 52 supplement-flood disaster.pmd 52 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Photo 4: The Catering team monitoring the catering service at the cafeteria 4.0 Logistics Arrangements deployment volunteers who were using CPRC airport transfer were notified early. They were asked to gather at the IHM lobby before the departure. The logistic officer in charge would ensure that all the listed volunteers embarked on the provided vehicle. The volunteers were also reminded to bring all of their belongings. Other than that, CPRC MOH also had allocated one liaison officer at every airport to facilitate the process of check in of the volunteers at the airport counter. For logistic arrangements, CPRC IHM collaborated with CPRC IPH and other institutes namely Institute for Health Behavioural Research (IHBR) and NIH Secretariat to provide more drivers for this task. IHM has also provided 1 bus with maximum of 25 passengers, 1 sixseater four-wheel-drive and three cars. CPRC IHM arranged the transport accordingly i.e by number of volunteers and type of airport locations. Pre- 53 supplement-flood disaster.pmd 53 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Photo 5: The Logistic Officers assisting the volunteers into the bus before they departed for Subang Airport Challenges and Recommendations Flood disaster management involved inter-organisational commitment and each organisation has their chain of command, information and communication resources (Sufiza, 2012). The synchronization between these organisations and the units within the organisation affect the efficiency of overall disaster management country wide. Centre for Public Policy Studies (2015) reported that there were weaknesses in disaster management such as lack of coordination, dissemination of information and inadequate standard operating procedures. Being assigned as the transit centre for flash flood, CPRC IHM faced many challenges as this was our first experience involved in disaster management. this timing, many of the volunteers were not physically and mentally prepared. Realising this, CPRC MOH reminded respective departments that volunteer recruitment must emphasise the importance of physical and mental preparation. In the light of disaster, each volunteer should be briefed on the expectations, adequate and suitable belongings. Foods, medical supplies and personal belongings should always follow these two criteria; ready-to-go & easy-tocarry. As a transit centre, IHM has displayed the related information on its official website. Other medium of dissemination was through MOH official website and DG’s official Facebook page which announced IHM as a transit centre and invited volunteers to visit the IHM website for further information and clarification. Relevant information was available on display boards at IHM. 1.0 Preparation and Information for Pre-deployment Volunteers As this was a big scale flood disaster, MOH had to send extra healthcare volunteers to the affected area. Due to 54 supplement-flood disaster.pmd 54 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Early notification should be given to the volunteers prior to their departure to the affected area. However, during this crisis, some of the volunteers were informed by their superior late e.g the night before their departure. During PFA briefing, volunteers who were not ready to go were asked to return to their workplace. Experiences of earlier batches of volunteer were also shared during PFA briefing. This would help volunteers to be prepared on what to expect when they were in affected area. number of volunteers that will transit at IHM, there will be either inadequate or excess food preparation. Normally, early information from CPRC MOH helped to overcome this issue and food will be prepared based on number of volunteers at particular time. Conclusion Effective and efficient communications are the main pillars in any effective disaster management. The networking and excellent teamwork among those involved had benefited others in ensuring the smoothness of transiting volunteers, thus the credit should be given to CPRC MOH as the main recruiter and managed the air transport, CPRC IHM as the main transit for MOH volunteers and CPRC IPH which was in-charge of the land transportation for MOH vehicles. At the beginning, there were a few hiccups especially in conveying the volunteer profile to the relevant department, flight schedules and logistic arrangements. However, once the Liaison Officers were appointed as the contact person between CPRC MOH and CPRC IHM to convey all the information, suggestion and queries, the process went smoothly. Based on this valuable experience, it is recommended that a standard operating procedure (SOP) and guidelines should be developed which consists of the setting up of an operation room with a clear functional organisational structure with responsibility and work process for a transit centre. 2.0 Short Period of Time for Logistic Notification The major issue in the logistics management was when CPRC IHM received late flight itinerary from the CPRC MOH. The shortest notice was 3 hours before the departure time especially during the first three days after the establishment of CPRC IHM. It was extremely short notice considering the time required for transport to the airport, current traffic conditions and the flight check-in time. As an immediate solution, a liaison officer from NIH was appointed as focal person in CPRC MOH. As a result, many issues were solved and overcome such as the itinerary of the volunteers was sent a day before they were deployed to the affected state. 3.0 Issues on Food Preparation Other issue faced was the food preparation for the volunteers. When CPRC IHM does not receive the correct 55 supplement-flood disaster.pmd 55 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Acknowledgement We would like to acknowledge the Director General of Health, Malaysia for permission to publish this article. Mental Health Unit, Non-communicable Disease Section, Disease Control Division, Ministry of Health Malaysia in Collaboration with World Health Organization (2013). National Guidelines for Mental Health and Psychosocial Response to Disaster. Kuala Lumpur. Mental Health Unit, Non-communicable Disease Section, Disease Control Division, Ministry of Health Malaysia (2013). Manual on Mental Health and Psychosocial Response to Disaster in Community. Kuala Lumpur. Mohd Sukeri K, Shazwani S. (2015). Flood Disaster Management: An Evaluation of Effectiveness Flood Delivery System. Reference Arora P. (2013) Leveraging Human Resource for Effective Disaster Management: Comparative Lessons from the 2011 Tohoku and the 2004 Indian Ocean Tsunami. Visiting Researcher Report submitted to the Japan Institute for Labour Policy and Training (JILPT), Tokyo, Japan, p. 90. Centre for Public Policy Studies (2015), CPPS Policy Fact Sheet: Malaysia’s Flood Management. Chan, N. W. (2012), ‘Impacts of Disasters and Disasters Risk Management in Malaysia: The Case of Floods’, in Sawada, Y. and S. Oum (eds.), Economic and International Journal of Social Science and Humanity, 5(4):398-402. Safiza Suhana KB, Abdul Samad S, Zahriah O. (2009). Disaster Management in Malaysia: An Application Framework of Integrated Routing Application for Emergency Response Management System. International Conference of Soft Computing and Pattern Recognition. Third AIPA Causus Report (2011), ASEAN Inter-Parliamentary Assembly. Welfare Impacts of Disasters in East Asia and Policy Responses. ERIA Research Project Report 2011-8, Jakarta: ERIA. pp.503-551. Harpal S. Shamala S. (2009), Health Emergency and Disaster Preparedness in Malaysia. South East Asian Journal of Tropical Medicine of Public Health, 40(1):11-15. 56 supplement-flood disaster.pmd 56 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Collaboration Via ‘Smart Partnership’ in Flood Disaster Assistance Alzamani MI, Hafiz S, Abu Hassan AA Hospital Kuala Lumpur Abstract In any disaster, resources are limited. Various agencies have different resources and strengths. The major floods that swept across the East coast from late December 2014 to early January 2015 caused a population displacement of more than 200,000 people and enormous property destruction. We describe a strategy of engaging ‘smart partnership’ via collaboration with various organizations for the common purpose of humanitarian assistance. Our ‘smart partnership’ had enabled us to unite resources and strengths and distribute them based on victims needs in Kelantan and Pahang. An assessment team was dispatched and based on findings; strategy was laid out to provide effective and relevant form of assistance to meet there needs. A total amount of RM 295,711.10 worth of goods was channeled to victims effectively and systematically. The ‘smart partnership’ via multiorganization collaboration is a good working model in uniting effort, resources and strength in providing assitance during and after disasters. Such a working model is recommended for future assitance efforts for disasters. Introduction organizations partnership. In any disaster, resources are limited. Various agencies have different resources. Massive floods struck the East coast areas of West Malaysia affecting mainly the states of Kelantan, Terengganu and Pahang from 15th December 2014 to 3rd January 2015. More than 200,000 people were displaced and 21 people died during this disaster. A lot of property was lost or damaged and the total loss was estimated to be worth more than RM500 million. About 200,000 individuals were displaced by the floods in the East Coast with Kelantan having the higher number. Critical patients from affected hospitals in Kelantan had to be evacuated. In an attempt to provide humanitarian assistance to affected people, the Emergency Department of Hospital Kuala Lumpur collaborated with different through 57 ‘smart’ Method & Materials We describe a strategy of smart partnership through multiple organizations in galvanizing an effective response for assistance during the flood. ‘Smart Partnership’ is a concept introduced by Steven R. Covey through his book, 7 Habits of Highly Effective People (Covey, 2013). Value and respect are attained by people understanding a ‘win’ for all is ultimately a better long-term resolution than if only one person or one organization in the situation had got his way. This was the basis of our partnership for this project. 57 supplement-flood disaster.pmd a 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT The smart partnership was established among three main parties: Emergency Department of Hospital Kuala Lumpur (EDHKL) The committee of ‘Projek Banjir ‘Aids’ HKL (Projek BAH)’ The National Welfare Foundation set up by the Hospital Director to pool contributions from the whole hospital. The EDHKL also collaborated with the National Welfare Foundation to provide assistance for the floods victims in Kelantan and Pahang. Results The objectives of our ‘smart’ collaboration are as stated below: To provide medical assistance based on needs at selected evacuation centres in Kelantan & Pahang To assist in getting affected medical centres like Health Clinics affected by floods into working conditions To provide mental support for affected victims To provide care and psychological support for children To identify needs and provide appropriate and relevant assistance To work with multiple agencies for relief care This strategy of collaboration is the first of its kind applied to our hospital. The strategy of engagement of this smart partnership is described below. From the initial meetings, the modus operandi for this project was determined and the following were exercuted: Deployment of expert analysis team to Kelantan and Pahang for needs assessment Deployment of HKL medical team to evacuation centres for medical support as well as mental and community support Establishment of medical centres which included clinic/ sickbay/ treatment corners for evacuation centres. Provision of water tanks and water purifier Support for drugs replacement for chronic illnesses Provision of ‘healthcare walkabouts’ at evacuation centres Engagement of counselors for mental support Profiling of family members at evacuation centres Children psychological support programme institution like ‘art therapy’ etc Provision of health talks on waterborne diseases in anticipating infectious disease contraction during recovery phase Wellness Kit distribution for victims. Health clinics clean-up Postfloods aboriginal settlement humanitarian assistance Strategy of Assistance A smart partnership was established via a series of meetings with stakeholders. These meetings were initiated by the Emergency Department of HKL. Subsequently the stakeholders agreed to assemble each organization’s resources to meet the demands of victims. Emergency Department of Hospital Kuala Lumpur (EDHKL) collaborated with ‘Projek Bantuan Air Banjir HKL (Projek BAH)’ which consisted of a committee specially 58 supplement-flood disaster.pmd 58 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT o Planning and strategy o Logistics and planning Resource 2 : ‘Banjir Aids HKL’ Project (Project BAH) o Collection of donations from all HKL staff o Manpower resources Resource 3 : National Welfare Foundation o Logistics support - vehicles o Equipment to be purchased o Wellness kits for family members o Support of food and shelter for assistance providers o Engagement of councillors and psychologists Resources from ‘smart partnership’ The ‘smart’ partnership enabled assistance to be provided and through this collaboration multiple resources were combined for a workable function of assistance strategy (Figure 1). The various resources attained are listed below: Resource 1 : EDHKL resources o Emergency Medicine and Disaster Management consultation expertise o Risk assessments o Trained personnel as field medical responders Figure 1 : ‘Smart Partnership’ via collaboration with multiple organization Total Expenses logistics purpose such as transport and food for volunteers. Through this ‘smart partnership’, the project managed to raise and distribute a total of RM 295,711.10 to flood victims in Kelantan and Pahang. This excludes more resources which were obtained for 59 supplement-flood disaster.pmd 59 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Transport & Logistics and hence the paralysis of the community safety system including local National Security Council personnel, police, fire and rescue services and ambulance services. Many affected victims lost belongings and houses were swept away. An oversupply of volunteers was noted in Kelantan in the week following the flooding. HKL established contacts and cooperation with the Air Force and Fire & Rescue Department for transport assistance. The HKL Transport Unit provided land transport for closer areas such as Temerloh, Pahang. Assessment in Kelantan The Intervention in Kelantan An expert analysis team was sent to Kota Bharu Kelantan on 30th-31st December 2014. The assessment team despatched consisted of a Senior Consultant of Emergency Medicine, 2 Emergency Physicians, an Emergeny Medicine Registrar, an Assistant Medical Officer and 3 officers from the National Welfare Foundation. The floods had brought strong currents in certain areas like Kuala Krai where travel by boat was risky. Helicopters could not land in certain areas. A ‘third wave’ of rain was expected according to the Metereological Department (but did not occur in the end). Certain areas were not accessible by medical teams due to deep floods on the roads. A sizeable number of clinics were damaged. Hospitals like Kuala Krai became an ‘island’ and were not accessible via land vehicles. The floods brought mud which required a lot of clean water for the cleaning-up process. Piped water and electricity were not available. Many public workers were also victims The team established a medical centre at the Sultan Ismail School which housed about 4,000 evacuees. 2 water tanks and a purifier were donated to the centre. An assessment was also performed at Sekolah Kebangsaan Pengkalan Kubor in Tumpat Kelantan with a view to establish a medical center there as well. A 24 hours Emergency Medical Service and Observation Ward was established in both side. At the time of assessment, there was already an excess of medical volunteers in Kelantan. Water had receded and most evacuation centres were being closed. In view of this, the reconnaissance team decided to switch attention to Temerloh, Pahang to optimize assistance in areas needed. 60 supplement-flood disaster.pmd 60 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Donation of Water Tanks for Relief Centre Use Aborigines Medical & Humanitarian Assistance Krau were damaged by flood which left mud and dirt with a strong stench which rendered medical services there not feasible until a full proper cleanup. Most furniture was not usable. The floods brought mud which required a lot of clean water for cleanup. Many affected victims lost belongings which were damaged in their houses. A team was sent to Gua Musang, Pahang for humanitarian assistance for the aborigines at Kampung Liggi, Kuala Betis and Tohoi. The team provided a mobile medical team as well as wellness kits, mattresses, pillows and food to the affected community. The immediate needs were clean water, basic survival items to restart life such as cooking stove, personal hygiene kits and cleaning up of the health clinic. A follow up meeting was held the next day at HKL with the Projek BAH committee member and it was decided to send assistance the following day. At the time of assessment, there were 62 evacuation centres in Temerloh with about 23,000 evacuees. Many areas were not reachable due to access issues. There were also family members not contactable or whose fates were uncertain. Assessment in Temerloh, Pahang An expert analysis team was despatched on 2nd December 2014 to Temerloh Pahang. The team included a senior consultant, 3 Emergency Physicians, a Matron and three staff nurses and a dietitian. The team visited the Hospital Sultan Ahmad Shah, the Floods Operations Room at the Health Department, and the Evacuation Centre at Sekolah Sukan Pahang in Temerloh which housed about 4,000 evacuees, evacuation centres in Kuala Krau and a Health Clinic at Kuala Krau. Certain areas were not accessible to medical teams due to deep floods on the roads. Clinics like Kuala 61 supplement-flood disaster.pmd 61 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT The Intervention in Pahang College volunteers and the Tzu Chi organization. The clinic was in very bad shape and the stench from the mud made its function not feasible. The National Welfare Foundation provided cleaning equipment like shovels, spades, wheel barrows, mops, brushes, 2 water jet machines and 2 generators. The teams removed all damaged and tainted furnitures, equipment and drugs from the clinic and started cleaning. The Fire & Rescue provided water. Later in the day the water jet was used as there was running pipe water. The team also salvaged valuable and useable equipment and stored them in a safe room. A ‘microcleaning’ where equipment were cleaned was planned for the next day and another team was sent on 5th December 2015. This intervention was executed via a smart partnership earlier established for Kelantan floods response with the collaboration between Projek Banjir Aids HKL 'BAH', Emergency Department HKL and National Welfare Foundation. A hospital bus, a large truck and four 4WDs were engaged for logistics support. Distribution of family wellness kits, gas stoves, water tanks and water purification systems were carried out at to relief centres. Human resources were pooled for health facility major clean up. Cleaning equipment were purchased. A 24-hours Emergency Medical Services and Observation Ward was established at the Relief Centre at the Temerloh Sports School where the team, made up of 1 Emergency Physician, 2 Registrars, 2 housemen, 2 Assistant Medical Officers and 3 Staff Nurses stayed in for a week. Pyschological aid for children was also provided as a service embedded within the clinic. Establishment of 24-hour Emergency Medical Services and Observation Wards On 3rd January 2015, a team of 9 volunteers made up of a specialist, 2 doctors, 33 assistant medical officers, 2 staff nurses ran the medical centre at Sekolah Sukan Temerloh on 24 hours basis. They treated on average of between 30-40 patients a day which included emergency cases such as acute coronary syndrome. Health Clinic Major Cleaning Based on the needs assessment, on 4th January 2015, a team of 44 volunteers from HKL was sent by HKL bus to Klinik Kesihatan Kuala Krau for clean up works. Assistance was sought from Fire & Rescue Agency to provide a water tanker. The Family Medicine Specialist of Kuala Krau received the volunteers who immediately started work. The cleaning up team was also joined by volunteers from National Welfare Foundation, Jerantut Nursing 62 supplement-flood disaster.pmd 62 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Distribution of Goods and Donations at evacuation centre at Sekolah Sains Pahang and Sekolah Kuala Krau A truckload of donations Distribution of goods at relief centre HKL through Projek ‘BAH’ and the National Welfare Foundation joined together in distribution of donations in the form of 260 cooking stoves and donations of 200 family wellness kits. forming this partnership which enabled all the objectives to be achieved. Collaboration with external and local organizations was shown to be effective in providing care during disaster. Following Typhoon Haiyan which affected the Philippines in 2013, Kim H et al (2013) asserted that collaboration with the local medical team resulted in great synergy. The assisting team then was able to function by focusing on collaborative efforts with the local medical team. The Korean team was capable of providing primary care, and the Filipino team provided incomplete secondary care which was insufficient for covering the patient load. The Korean team provided electricity for hospital operation and various materials, but also supplemented medical personnel, who covered the emergency and outpatient departments. Collaborative efforts filled in each other's gap, and resulted in great synergy. Kim et al suggested that disaster medical relief missions should be cooperated with a systematic coordination. Collaboration with the local resources can be a great opportunity for both parties, and should not be overlooked in any disaster situations. Discussion Responding to disaster requires a lot of resources which may be in the form of manpower, equipment and money. A lot of resources may be obtained by combining strengths from various organizations with varying strength and capabilities. A synergistic result would ensue through such endeavours. Frank Covey introduced the concept of ‘win-win’ strategy via his principles embodied in his book,7 Habits of Highly Effective People, which was first published in 1989 (Covey, 2013). Covey advocated an approach to being effective in attaining goals by aligning oneself to what he calls ‘true north’ principles of a character ethic that he presented as universal and timeless. The book introduced the seven habits in a proper order. The fourth habit was called ‘think win-win’. This habit promotes genuine feelings for mutually beneficial solutions or agreements in relationships whether personal or organizational. Smart partnership such as that we described based on our experience following the east coast floods is the first of its kind in our hospital. We found a lot of benefit in Smart partnership as in this project provided a win-win phenomenon. Synergistic outcome was achieved in this project where Emergency Physicians in 63 supplement-flood disaster.pmd 63 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT the Emergency Department provide their expertise in co-ordination, planning, analysis and recommendaiton of assistance. Human resources and central collections were garnered by the ‘Project BAH’ committee for all donations at our hospital. The National Welfare Foundation provided what we did not have in the form of logistics support, monetary resources, wellness kits, transport as well as equipment needed for assistance. service responses, especially during crisis. Interlocal collaboration too contributes to disaster preparedness. Errett et al (2014) studied the impact of interlocal collaboration and emergency preparedness via semistructured interviews. The study showed interlocal collaboration was found to impact preparedness by promoting the perceived dissolution of geopolitical boundaries, developing self-reliant regions, developing regional capabilities, promoting regional risk identification and creating an appreciation of the importance of interlocal collaboration. Interlocal collaborations contribute to overall national preparedness. Apart from smart partnership, coordinated collaboration with operation centres of the State Health Department enabled us to function effectively. The operation centres provided us with vital information of areas covered or where help needed. In establishing a smart partnership, common ground interests were a powerful unifier for collaboration. This partnership worked because of similar interests that all parties had. Work was made much easier with the contribution of each organization’s expertise. Kuziemsky et al (2015) believed that common ground was necessary for developing collaboration as part of building resilience for public health preparedness. While the importance of common ground as an essential component of collaboration has been well described, there was a need for studies to identify how common ground develops over time, across individual and group dimensions, and the contexts that influence its development. A working collaboration framework should be outlined by extracting the expertise of each organization. Lu and Xu (2015) analyzed on NGOs collaboration in community post-disaster following 2008 Wenchuan earthquake in China. Nongovernmental organisations (NGOs) that attend community post-disaster reconstruction were often unable to deliver all requirements and have to develop cooperative approaches. However, this collaboration can cause problems because of the complex environment, the fight for limited resources and uncoordinated management, all of which result in poor service delivery to the communities, adding to their woes. Collaboration framework was proposed for interrelated Collaboration with the community helps in mobilizing and integrating knowledge and skills during crisis. In establishing emergency medical services and an observation ward, our team collaborated with the managers of the relief centres for better reception apart from effective services. Kotarba et al (2014) applied the constructive relationship management model which was found to be an appropriate strategy for mobilizing and integrating the knowledge and skills needed for comprehensive science and 64 supplement-flood disaster.pmd 64 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT components of organisational structure, operational processes, reconstruction goals and implementation areas. organizations to develop a dualintervention model of capacity-building for public mental health preparedness and community resilience.The collaborative model was found to be an effective approach for promoting public health preparedness and community resilience. Crowd psychology should be considered in handling patients at relief centers. The attitude of the victims should be taken into consideration. Safety should be observed. Carter H et al (2015) applied crowd psychology to develop recommendations for the management of mass decontamination of a major incident. This approach emphasized that crowd events are characteristically intergroup encounters, in which the behavior of one group can affect the perceptions and behavior of another. In this partnership, the sending of expert team enabled the crowd psychology especially at relief centres be studied and relevant strategies outlined. In our experience, we spent a shorter time in Kelantan as there was already an overflow of volunteers. We then shifted focus to Pahang. This enabled us to channel our resources more effectively where they were needed most or at places where help was still required. We found that needs such as clean water was of utmost importance. Water filter of purification system was essential. Through this partnership, water tanks and water purification system costing RM 32,100 were donated. Conclusion Smart partnership via collaboration among EDHKL, Projek BAH and National Welfare Foundation enabled a good synergy of assistance. The assistance provided much needed help effectively. It is hoped that future co-operation could be formed to provide similar services in times of need. Resources can be sought from external agencies via this model of smart partnership whereby parties with different resources can join hand and contribute respective strengths. Acknowledgement The authors would like to acknowledge the Director General of Health Malaysia for his permission for this article to be published. References 1. Steven R. Covey. 7 Habits of Highly Effective People. Simon & Shuster 2013. 2. Kim H(1), Ahn ME(2), Lee KH(3), Kim YC(4), Hong ES(5).Disaster medical assistance in super typhoon Haiyan: Collaboration with the local medical team that resulted in great synergy. Ulus Travma Acil Cerrahi Derg. 2015 Mar;21(2):143-8. doi: 10.5505/tjtes.2015.54770. Partnership of various organizations would improve community resilience as well. McCabe et al (2014) described the collaboration of academic-governmentfaith as partnership for community resilience. Johns Hopkins Preparedness and Emergency Response Research Center partnered with local health departments and faith-based 65 supplement-flood disaster.pmd 65 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 3. Kuziemsky CE(1), O'Sullivan TL(2).A model for common ground development to support collaborative health communities. Soc Sci Med. 2015 Mar;128:231-8. doi: 10.1016/j.socscimed.2015.01.032. Epub 2015 Jan 20. 4. Kotarba JA(1), Croisant SA(2), Elferink C(3), Scott LE(4).COLLABORATING WITH THE COMMUNITY: THE EXTRATERRITORIAL TRANSLATIONAL RESEARCHTEAM. J Transl Med Epidemiol. 2014 Dec 5;2(2):1038. 5. Lu Y(1), Xu J.NGO collaboration in community post-disaster reconstruction: field research following the 2008 Wenchuan earthquake in China. Disasters. 2015 Apr;39(2):25878. doi: 10.1111/disa.12098. Epub 2014 Nov 28. 6. Errett NA(1), Frattaroli S(1), Resnick BA(1), Barnett DJ(2), Rutkow L(1).Interlocal collaboration and emergency preparedness: a qualitative analysis ofthe impact of the Urban Area Security Initiative program. Am J Disaster Med. 2014 Fall;9(4):297-308. doi: 10.5055/ajdm.2014.0181. 7. Carter H, Drury J, Rubin GJ, Williams R, Amlôt R. Applying crowd psychology to develop recommendations for the management of mass decontamination. Health Secur. 2015 Jan-Feb;13(1):45-53. 8. McCabe OL(1), Semon NL(2), Lating JM(3), Everly GS Jr(4), Perry CJ(5), Moore SS(6), Mosley AM(7), Thompson CB(8), Links JM(2).An academic-government-faith partnership to build disaster mental health preparedness and community resilience. Public Health Rep. 2014;129 Suppl 4:96-106. 66 supplement-flood disaster.pmd 66 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT lesser but nonetheless, as serious as it was of longer duration. minimise adverse health impact. We had learnt from the history of previous floods, local or international, of major public health impacts resulting from damage to homes and subsequent displacement of occupants which led to compromised personal hygiene, contamination of water sources, disruption of sewage service and solid-waste collection, injuries sustained during clean up, stress-related mental health and substance abuse problems, and even deaths due mainly to accidental drowning(4). The responsibility to manage health and medical emergency response was delegated to Health District of Kemaman, as one of the team of District Disaster Management and Relief Committee (DDMRC). This article describes Kemaman’s flood disaster plan and shares its experience in operationalising the plan for the benefit of those who are involved in flood management, whether locally or other parts of the world. Realising the magnitude of such potential devastations, a team from the Kemaman Health District Office, led by the Medical Health Officer, deliberated and came out with a comprehensive Flood Management Plan. The plan was developed and completed in April 2014, before the 2014 floods which came at the end of the year. Experience from the previous flood in 2013 had been a great help in strengthening the plan. Methodology This is a case study, using secondary data from its documented records and interviews with those who were directly involved in the management of flood. Data and reports during the 2014 flood were retrieved and analysed descriptively. Senior officers of the District Health Department such as the District Health Officer, epidemiological officers, medical officers, and Health District staff who experienced the flood were interviewed. This plan was created based on the Risk Control Management model which comprised of risk analysis, maintenance improvement, preparedness and disaster response (Figure1). It is a comprehensive plan, catering for the pre, during and post-flood periods. Flood Management Plan In Kemaman 2014 Handling flood disaster is not an easy task. It is a big responsibility which requires outstanding performance to 68 supplement-flood disaster.pmd 68 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 1 : Risk Management Operation (Adapted from Eikenberg, 1998) Risk Analysis Risk analysis involves hazard determination, vulnerability analysis and risk determination. The aim of this step is to identify potential risks, either those that lead to flood itself or harms that can occur during the disaster. This is crucial in order to plan for counter-measures to overcome or reduce the flood hazard. DIS had earlier taken steps to expand the river capacity by upgrading trench and drainage system of the area to make sure Kemaman could cope with large amounts of water in the face of torrential rains. Vulnerability analysis is identifying persons, places or things that are more susceptible to hazard when disaster comes. Health Clinics which are located in the risky (prone to flood) areas were determined, and preparation were made to mitigate the risks. This included relocation of valuable portable assets such as ultrasound machine, x-ray machine, vaccine refrigerator, laboratory equipment and documents such as patients’ records and medications to safer places. These had to be planned and executed before the floods, including transporting them to other locations. Health clinics must Heavy rainfall, poor and insufficient drainage, low river holding capacity and back water phenomenon are potential hazards that can lead to flood formation. Thus, indicators for these components such as weather forecast and sea level conditions were gathered and monitored through a Flood System Surveillance system (Infobanjir) as well as direct information from the Drainage and Irrigation Department (DIS). 69 supplement-flood disaster.pmd 69 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT develop alternative plans to continue with their services if they are affected by flood. Of equal importance are risk determination on communication system, transportation issues, power supply, food and medical supplies. The plan also covered identification of vulnerable patients such as elderly and bed-ridden persons, pregnant mothers who were close to their due dates, patients with chronic illnesses who required uninterrupted care or medications such as those with end stage renal failure, diabetes mellitus, hypertension and psychiatric patients and those on anti-coagulants. All health clinics had to list and identify their vulnerable patients, and planned for their relocation before an impending flood. Maintenance Improvement Having been made aware of the possible risks explained above, the next step was to work towards maintenance improvement, which can be categorised as structural and non-structural. Structural maintenance improvement Structural maintenance improvements include preparation of medications and food supplies, as well as establishing sufficient crucial utilities such as water, electrical and communication facilities. Medications to be used by visiting medical team to relief centres were reviewed to ensure their availability and adequacy. These medications were pre-packed and put in specific containers. Storage was upgraded and updated to ensure they are easy located when needed. Risk determination is listing all possible risks associated with flood which could impact on the flood victims. The impacts could be directly through contact with flood water, or indirectly through damage caused to natural and human-built environment. The impact of floods on the human habitat is related directly to the location and topography of the area, as well as human demographics and characteristics of the environment. Contingency plan for power supply shortage include getting in place electrical generator for hospitals and relief centres to when the need arise. This part of the plan is essential as some patients in hospitals are dependent on life-saving machine such as ventilators in the Intensive Care Unit (ICU) and haemodialysis machines in the other critical units. For the same reason, the National Power Supplier (Tenaga Nasional Berhad) had made earlier efforts to upgrade their substations to a higher level at flood risk areas. For example, contamination of water sources, disruption of sewage service and solid-waste collection during flood would increase the probability of communicable diseases transmission such as leptospirosis, typhoid, cholera and meliodosis. Thus, preparation had to be made to ensure health promotion and education is conducted in flood relief centres. Besides, all flood relief centres must undergo cleanliness and sanitation assessment to ensure safe water supply, adequate and functioning sanitation facilities as well as checks on food preparation and handling practices. 70 supplement-flood disaster.pmd 70 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT each health clinic. Their names were listed together with contact numbers. There were two teams (Table 2), one to deliver medical care, and the other, public health service. In order to strength the teams, continual medical education and updates were given to them prior to the flood. Non-structural maintenance improvement Non-structural improvements include the management and updating the staff list, and recruiting possible non-governmental bodies that could be called upon when they were needed. Designated medical and health teams were recruited from Table 2: Staffs of medical and health team Medical Team Health Team Medical & Health Officer PPKP Medical assistant PKA Staff Nurse Driver PPK PRA Driver No 1 2 3 4 5 Medical team would function in mobile and static clinics in the relief centres, while the health teams would do environmental assessments and preventive measures such as fogging and checking for other vectors. These training were not limited to the health staff alone, but extended to staff from other agencies, such as District Office, Fire Service and Public Defence Department as well as community leaders. This simulation ensured that all members in the rescue team were wellprepared and able to perform well during a disaster. On the other hand, participants from the community had a better understanding of the evacuation plan. In addition, training for food handlers during disaster, handling boat and psychological first aid team were carried out. Preparedness Based on previous evidences, it is proposed that good preparedness plan is mandatory to be prepared in any areas that are likely to experience disasters (57). Preparedness is defined as “activities and measures taken in advance to ensure effective response to the impact of hazards”(8). The purpose of Kemaman Health District Office’s preparedness plan was to reduce the risk through early warning systems and measures which can be taken to mitigate the effect of a flood disaster. Logistic A list of transportation assets from the health team and other agencies were made in ready for mobilisation during flood disaster. These include ambulance, 4x4 wheel drive, boats and lorries. Access to flooded areas and relief centres had already been established. Training Acknowledging the challenges that would be encountered, table top training and simulation exercises for the rescue team and evacuation plan were carried out. Food Supply Food supplies were sent prior to the flood to the relief centres. Taking cognisance of 71 supplement-flood disaster.pmd 71 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Disaster Response The flood disaster in Kemaman in the year 2014 started on 16th December 2014 until 4th January 2015. Disaster Operational Room for Kemaman Health District Office was activated on 16th December as soon as floods were reported in upstream areas of the Kemaman River. At the beginning, two flood relief centres were opened with 65 casualties recorded. The flood operation office was headed by the Kemaman District Health Officer. The role of the control room include – coordination of health teams (mobile, static and emergency relief teams from nine community health centres, one district hospital and medical volunteers), stock indenting and management for medication and food supply for health staffs and volunteers, distribution of flood disaster equipment (technical and nontechnical), coordinating safe transport and vehicles for the use of mobile teams and medical emergency relief teams as well as arrangement for the relief of health staff affected by flood. It also functioned as a call centre for medical emergency needs from the Kemaman District Disaster Operational Room or the Head of Flood Relief Centres as well as calls from individuals requiring medical aid. the 2013 experience on supply-shortage due to inaccessibility, more food stock were allotted in the centres with the help of the Social Welfare Department. A newly prepared helipad ensured adequate and continual supply to all the relief centres, as more pre-packed foods were stored near to it. In all health facilities, food supply had been distributed early and can only be used during the flood emergency. Inspection And Examination Of Relief Centres Pre-Flood All gazetted relief centres were inspected and examined for safe water supplies, toilets, place for food preparations and waste disposal systems. Suggestions were given to authorities to improve the facilities if needed. Health education and promotion with regards to hand hygiene, dangers of flood and standing waters, common disease outbreaks in the postflood period such as typhoid and diarrhoea, safe food preparation and drinking boiled water were given to the community as soon as relief centres were opened. Posters and pamphlets were also distributed prior to event. Warning System And Evacuation Memo was circulated to the communities in potential flood areas which consist of a list of gazetted relief centers where the flood victims could go according to designated areas to avoid over-crowding if left to choice. Warning sirens were installed in mosques to announce updates on flood situation, as early information to the communities and for early evacuation to non-flooded area. Kemaman District Health Office Disaster Operational Room (DOR) The daily activities of Kemaman District Health Office Disaster Operational Room (DOR) were as follows: 1. Risk Based Surveillance The main activity of DOR is performing risk evaluation based on situational analysis from daily surveillance assessments. The risk analysis was performed daily based on weather 72 supplement-flood disaster.pmd 72 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT forecast (rainfall, river water level and sea tides), manpower availability, medication supply, number of flood victims and flood relief centres as well as updates on roads and routes accessibility. The data source of risk surveillance include the weather forecast from the national Meteorology Department, daily health report from medical teams, latest updates on flood relief effort from Kemaman District DOR (number of flood victims and food relief centres) as well as information from the local people. Updates were given during daily morning briefing held at the District Health Office DOR, attended by the control room personnel and representatives from the medical team, health team as well as volunteers. the same time attempting to minimise team exhaustion. During the peak disaster, 38 medical teams (mobile and static teams) consisting of medical officers, paramedics, nurses and drivers were deployed in one day to all flood relief centres, providing medical aid and relief. Unresolved medical emergencies were informed directly to DOR to arrange for emergency evacuation and hospital referral via inter-agency collaboration. All medical teams were equipped with a standard set of medical equipment as well as medications which was developed based on the medication needs during the flood disaster of 2013. It consisted of medications for symptomatic relief of common ailments, medications for common chronic diseases and injections. The medication supply was constantly evaluated and medication boxes were continuously refilled by the pharmacy teams at DOR. Medications required that were not available will be obtained from the district hospital and transported to the patient as arranged by DOR. 2. Medical and Health Teams Coordination and Response Planning of mobile teams and static health team routing and shift schedule were done daily under the control of the Chief Medical Officer of DOR. The mobile health teams were scheduled to visit and provide medical care and treatment to all flood relief centres with victims less than 1000 people on a daily basis whereas static medical teams were rostered to provide 24-hour medical treatment at static clinics in major flood relief centres with flood victims of more than 1000 people. The number of teams was decided based on the daily updates on the number of flood victims as well flood relief centres. There were 29 medical teams registered as flood relief medical teams during the flood preparedness plan. However, team deployment was being reorganised by the Chief Medical Officer of DOR as nearly 30% of health staff were also flood victims. Duty rosters were updated daily to cater for needs, while at Medical and health team activities were reported daily to DOR based on a standard reporting format which includes types of diseases treated (communicable or non-communicable diseases), disease outbreak occurrence, hospital referral or death. This report became the source for daily risk surveillance, providing information for the next disease control activity plan to prevent disease outbreak. For example, water source testing and treatment was performed at flood relief centres when cases of acute gastroenteritis were noted to be rising. 73 supplement-flood disaster.pmd 73 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 3. Transportation and Logistics Coordination Transportation as well as driver requirements were controlled centrally by the DOR commandant. Vehicles available include ambulances and 4-wheel drives (FWD) which were provided by the community health centres, district hospital, dental office as well as volunteers from the community. Need for truck or boat to access certain areas for emergency relief were requested through the Kemaman District DOR. However, standard safety measures were of utmost priority in providing relief and only gazetted boats equipped with safety life jackets were utilised at every level of operation. 4. Inter-agency Coordination Based on risk surveillance, the most challenging period during the disaster was from 24th to 28th December 2015. The rain was ferocious and the river water level kept rising above its danger limit. In addition, sea tide was also recorded to be at its highest level, rendering the city of Kemaman paralysed and at great risk. Electricity and several telecommunication service provisions were cut off. The number of flood victims increased dramatically. Flood centres were concentrated in the city area with 10 major centres being opened and each requiring 24-hour medical cover. The majority of housing areas in the city were submerged by the flood and most major roads were totally cut off. Communication was badly affected as several telecommunications were cut off at several severely impacted areas, especially in the upstream region of Kemaman. Attempts to enter those areas were made daily based on risk surveillance updates obtained from the Kemaman District DOR. Therefore, any emergency medical need must reach Kemaman Health District Office DOR in a timely manner. For example, an antenatal mother who experienced premature contraction at Felda Seberang Tayor was successfully evacuated using a 5 tonne army truck, the only vehicle that could access her area, after it was informed to the Kemaman District DOR by the local people via text message. Medications supplies needed by the medical teams were delivered successfully to ensure continuity in medical relief provision service. Issues of road accessibility continued to become a challenge as the main road to get to the upstream region was severely damaged, cutting off the access to several flood relief centres. One of the major relief centres, the Sekolah Kebangsaan Bukit Mentok, which was accommodating up to 1,900 flood victims, was only accessible by boat or air transport. During this period, the number of medical teams available was not able to cater for the needs at the relief centres as both the flood victims and flood relief centres kept on rising. Call for help was sent out by the head of Kemaman Health District Office DOR 3 days prior to the situation, based on the weather forecast and the worsening flood trend. It became the centre for receiving medical volunteers from government and non-government organisations. These volunteers were incorporated into the local medical relief teams schedule and 74 supplement-flood disaster.pmd 74 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Malaysia (ATM), Majlis Keselamatan Negara (MKN) and MIMPA. Their efforts their help had been commendable. During the period, 38 medical teams were deployed to all flood relief centres daily using transportation arranged by DOR in collaboration with other agencies such as had been truly commendable and greatly contributed to the successful management of medical emergency evacuation and relief work during the flood disaster in Kemaman in 2014. Pejabat Daerah Kemaman, Jabatan Bomba Kemaman, Jabatan Pertahanan Awam Malaysia (JPAM), Angkatan Tentera Figure 2: The Kemaman District Health Office’s Disaster Operational Room Activities 1. Post Flood Activities Post-flood period is as crucial as the after effects of flood could be as devastating as the flood itself. Again, risk analysis and assessment had to be repeated. Some potential disease transmission did exist, and affected communities remained under close surveillance. Kemaman Health District Office continued to be vigilant in the post-flood period. The activities carried out were as follows: Evaluation of damage and loss in affected health facilities Health facilities which were affected by flood were assessed on loss and damage of assets, infrastructures and building. Any stolen or damaged asset had to be reported within 24 hours of detection. Health facilities with minimal damage had to restart operating as soon as possible, or at least within three days after the flood subsided in order to provide continuous health care to the communities. 75 supplement-flood disaster.pmd 75 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 2. Prevention of post flood diseases Flood waters and standing waters posed various risks. These include infectious diseases, chemical hazards, and injuries. Larviciding, fogging and environmental assessment were continued by health team in the relief centres and post-flood areas. Food premises and factories were visited by the inspectorate unit for food sampling and monitoring of food safety compliance. Health education and promotion continued with emphasis on post-flood management measures. 3. Surveillance of outbreaks and other health related illness post flood. Disease surveillance and analysis were carried out continuously to monitor for any disease outbreak for early and rapid response. Additionally, psychological assessment for flood victims was made through psychological first aid teams which were led by trained Family Medicine Specialist. Health education regarding post-traumatic stress disorder and depression were highlighted to the flood victims and identified cases were referred to the psychiatrists for further management. The surveillance for diseases is presented in Figure 3 and 4. Figure 3: The number of cases of notifiable diseases during 2014 flood . 76 supplement-flood disaster.pmd 76 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 4: Total number of patients seen during 2014 flood 77 supplement-flood disaster.pmd 77 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Discussion comprehensive and well-structured plans, it was impossible to sustain the “business”. As proven by the census (Figure 1), there were no outbreak of common communicable diseases such as typhoid, cholera, leptospirosis, and dengue during/post flood occurred. Floods are a common disaster and have led to extensive morbidity and mortality throughout the world (9). The health impacts of flood are wide ranging, from immediate to medium and long term (2). However in the 2014 flood, these impacts were minimised in Kemaman due to its outstanding flood hazard management plan. Nevertheless, attempt should be made to determine the long term impacts of flood to the victims such as disability, mental health problems, social disruptions and other health relate diseases. A study had shown the prevalence of psychological distress in survivors could be as high as 53% two years post-flood and it could also exacerbate their physical illness(1). Even though a Psychological First Aid Team (PFAT) was established, the role was limited to during and immediately after the flood period. This kind of support should be extended longer to ensure a comprehensive risk management process (4). According to Matthew (10), effective health response to disasters will depend on three important lines of action: disaster preparedness; emergency relief; and management of disasters . In our setting, these entire components were executed and supplemented with risk analysis (Figure 1). Based on this assessment, simple steps like developing facility specific preparedness plans which detail out standard operating procedures during floods and identify clear lines of command had strengthened the response to the flood (11). Thus, it is proven that early detection of an impending flood and the availability of counter-measures to deal with them can significantly reduce the health consequences (9,11). The strong partnership of the District Health Office and other stakeholders as well as NGOs expedited social mobilization. Every team managed to play their respective roles during the flood and was successful in reducing human vulnerabilities in social, economic, health, and cultural aspects. It allowed for the use of both structural, for example canalization of rivers, helipad construction; and non-structural flood management, for example flood forecasting and warning system, removal of medical assets from risky area. This collaboration had managed to reduce the susceptibility to flood hazards among stakeholders and victims. Chan (3) advocated on the need Daily activities during the flood which included risk-based surveillance, coordinating medical and health team response, transport, logistic and interagency coordination enabled the activities to run smoothly and carried out as planned, alleviating the hazard and health impacts. The long duration of flood (more than 2 weeks) was a great challenge, while maintaining service and activities during the flood period was demanding. Without proper 78 supplement-flood disaster.pmd 78 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Acknowledgement The authors would like to acknowledge the Director General of Health Malaysia for his permission for this article to be published. for multi-agency collaboration for disaster management, and suggested it as one of the most important component in flood disaster risk management. This was tested and noted to be true in the Kemaman flood in 2014. References: 1. Alderman K, Turner LR, Tong S. Floods and human health: a systematic Environment international. review. 2012;47:37-47. The benefit of inter-agency approach extends to capacity building for stakeholders as well as the victims. Simulation exercise on flood scenario increased the awareness and alertness of the victims to be quickly mobilised during flood situation. Mobilisation of health staff and medical team, boat handler competency, and food handling at the distribution centre had improved significantly and proceeded smoothly during the real disaster event, which could have contributed to saving many lives. 2. Du W, FitzGerald GJ, Clark M, Hou X-Y. Health impacts of floods. Prehospital and 4. Keim ME. Building human resilience: the role of public health preparedn ess and response as an adaptation to climate change. American Journal Of Preventive Medicine. 2008;35(5):50816. 5. Haines A, Kovats RS, CampbellLendrum D, Corvalán C. Climate change and human health: Impacts, vulnerability and public health. Public Health. 2006;120(7):585-96. 6. Ziegler AD, Lim H, Tantasarin C, Jachowski NR, Wasson R. Floods, false hope, and the future. Hydrological Processes. 2012;26(11):1748-50. 79 79 medicine. 3. Chan NW. Impacts of Disasters and Disaster Risk Management in Malaysia: The Case of Floods. Resilience and Recovery in Asian Disasters: Springer; 2015. p. 239-65. Conclusions The experience of Kemaman Health District in the 2014 flood had enriched us greatly in executing a Flood Disaster Plan and flood hazard management. This real life participation and experience is invaluable to many who were involved, and made us resilient to respond to future flood disasters, including providing help to other parts of the country. Early risk assessment, good preparedness and contingency plan had ensured continuous public health care delivery to the community. It helps to reduce the negative impacts of flood disaster. High level of commitment and inter-agency collaboration are crucial elements in successfully managing a flood disaster. supplement-flood disaster.pmd disaster 2010;25(03):265-72. 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 7. Plate EJ. Flood risk and flood management. Journal of Hydrology. 2002;267(1):2-11. 8. Nation U. UNISDR Terminology on Disaster Risk Reduction 2004. 9. Ahern M, Kovats RS, Wilkinson P, Few R, Matthies F. Global health impacts of floods: epidemiologic evidence. Epidemiologic reviews. 2005;27(1):3646. 10. Mathew D. Information technology and public health management of disasters—a model for South Asian countries. Prehospital and disaster medicine. 2005;20(01):54-60. 11. Phalkey R, Dash SR, Mukhopadhyay A, Runge-Ranzinger S, Marx M. Prepared to react? Assessing the functional capacity of the primary health care system in rural Orissa, India to respond to the devastating flood of September 2008. Global health action. 2012;5. 80 supplement-flood disaster.pmd 80 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Communicable Disease Control in The 2014 Pahang Flood Sapian M, Sharifah Mahani SMA, Akmalina H, Shahidan H, Aznita Iryany MN, Hafeez I Pahang State Health Department ABSTRACT Pahang, an east coast state in Peninsular Malaysia encountered its worst flood on 22nd December 2014 to 18th January 2015. Medical and health teams were mobilized to carry out preventive and control measures at Disaster Relief Centres and flood affected areas. This study describes the pattern of communicable disease occurrence, as well as preventive and control measures taken during the flood period. Data from the Disaster Operation Room of Pahang State Health Department and CDCIS E-Notification system were reviewed. Ten districts in Pahang were affected by the flood. A total of 81,927 people were evacuated, of which 5,974 (7.3%) were found to have communicable diseases. Five most common diseases encountered were Acute Respiratory Infection (64.9%), skin infection (16.3%), fever (11.9%), Acute Gastroenteritis (4.4%) and conjunctivitis (0.8%). Five food poisoning outbreaks and one HFMD outbreak were reported. Overall, there was no significant increase in the number of notifiable communicable disease related to the flood except for leptospirosis, melioidosis and food poisoning. However not all of the leptospirosis (5%) and melioidosis (56%) cases were directly caused by flood. Communicable diseases were well under control during the flood period and this was attributed to due diligence by all health districts in carrying out their flood preparedness plan effectively. Keywords: Pahang, Flood, Preventive and Control 1.0 Preparedness INTRODUCTION Plan, Communicable and 2013 in terms of the number of districts affected and extent of infrastructure damage. This recent flood started from 22nd December 2014 till 18th January 2015 and involved ten districts. Flood is a yearly occurrence in the east coast of Malaysia where the state of Pahang is located. Flood phenomenon is due to climatological factors like temperature, rainfall, evaporation, wind movement and the natural topography of the place.1 Those affected by the flood are normally placed at Disaster Relief Centres (DRCs). These relief centres are located in designated public places such as schools and community halls. These facilities are equipped with basic amenities The 2014 flood in Pahang was the worst, compared to the previous floods in 1926, 1971, 2001, 2007 81 supplement-flood disaster.pmd 81 Disease, 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT the transmission of food and water-borne diseases such as typhoid fever, cholera, hepatitis A, dysentry, food poisoning and acute gastroenteritis, as well as vectorborne diseases like dengue and malaria, and other diseases like leptospirosis and melioidosis. such as portable water supply, electricity and sanitary latrines. However, during the floods, these places may experience environmental risk factors such as overcrowding, sanitation issues and issues related to food handling and preparation. Further, foods for the flood victims housed in these relief centres are prepared by volunteers, some of whom had never been briefed on proper food handling practices. Since flood is a yearly event and usually occur at the end of the year in Pahang, all government agencies at the state and district level start their preparation early. The Natural Disaster Management and Relief Committee (NDMRC) at the state and district level are headed by State Secretary and District Officer respectively. Inter-agency collaboration and communication are important to ensure smooth and efficient execution of the state and district disaster preparedness plan. For the PSHD, DHOs and hospitals have their own preparedness plan which includes assisting the District Officer in identifying suitable places for DRC, providing logistics support, medical and health teams during the flood (refer to Annex 1 for Summary of The State Preparedness Plan). Health education materials are also produced adequately to be disseminated during all phases of flood to increase awareness among the public on steps to be taken to prevent diseases related to flood. Medical and health teams from District Health Offices (DHO) are responsible for monitoring flood victims’ health status and health related activities at DRCs and flood affected areas. Medical teams comprising doctors and paramedics are tasked to provide medical treatment and psychological support to flood victims. Health teams carry out preventive and control measures for disease outbreaks such as ensuring food safety, water quality, vector control and proper refuse disposal. Flood situations increase the risk of infection and communicable disease transmission. Standing water cause by heavy rainfall or overflow of rivers can act as breeding grounds for mosquitoes, putting affected population and rescuers at risk to infections transmitted by mosquitoes. Overcrowding at DRC facilitates the transmission of diseases like acute respiratory infections (ARI), skin infections and conjunctivitis.2 Hence, floods potentially increase This study describes the pattern of communicable disease occurrence, as well as preventive and control measures taken during the flood period. 82 supplement-flood disaster.pmd 82 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 2.0 METHODOLOGY other diseases. Data on notifiable communicable diseases for the whole state during the flood period were taken from the Ministry of Health’s web-based Communicable Disease Control Information System (CDCIS), namely E-Notification and EDengue. This is a retrospective review of communicable diseases data and activities during the 2014 Pahang flood. The flood period was divided into three phases, preflood period (23rd November 2014 - 21st December 2014), during the flood (22nd December 2014 18th January 2015) and postflood period (19th January 2015 18th February 2015). Following the epidemiological week (epid week) reporting system for disease surveillance in the country, the period of study was from epid week 48/2014 to epid week 7/2015. Melioidosis is not a gazetted notifiable disease by law in Malaysia. However, it was made compulsory to notify this disease administratively by the Ministry of Health (MOH), Malaysia in 2015. In Pahang, melioidosis is not uncommon. Hence, all medical practitioners in Pahang had been instructed to notify melioidosis administratively since 2011 and this is captured in the Pahang Melioidosis Registry. Additional information on leptospirosis and melioidosis were also obtained from daily returns which were specifically collected during the flood period by the Pahang State Communicable Disease Control (CDC) unit. Data on flood victims from DRCs, medical and health teams reports, disease surveillance data, preventive and control activities at DRCs and flood affected areas were gathered from daily returns submitted to the PSHD Disaster Operation Room (DOR). Some victims complained of only fever without other symptoms. As such, data on fever alone were captured to differentiate it from 83 supplement-flood disaster.pmd 83 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 3.0 RESULT 3.1 Flood Victims and Disaster Relief Centres (DRC) Table 1: Flood victims and DRC's during 2014/2015 flood by districts in Pahang District Number of Number of Number of Mean duration of DRC Families Flood DRCs’ operation Affected Victims (days) Kuantan 61 6,326 23,549 4 Jerantut 59 1,161 4,418 10 Lipis 34 1,173 4,442 7 Pekan 85 3,912 15,298 12 Rompin 6 122 471 2 Maran 44 1,629 6,788 10 Temerloh 77 5,978 22,865 11 Bera 19 869 3,327 10 Raub 16 200 668 1 Bentong 2 20 101 1 Total Pahang 403 21,390 81,927 8 Source: State Disaster Operation Control Centre (SDOCC) Table 2: Medical and Health Team by districts in Pahang during 2014/2015 flood District Pre-flood During flood Medical Health Medical Health Within Within Within District Outside Within District Outside NGO/ district district district within state, district within state, other MOH/ (team) state KKM (team) (team) (team) state agency (team) *MAF (team) (team) (person) (team) Kuantan Rompin Maran Jerantut Lipis Pekan Temerloh Bera Raub Bentong C.Highlands Total Pahang 16 9 12 11 12 8 8 13 6 6 4 13 8 9 9 9 12 11 6 12 4 4 24 9 12 11 12 11 8 13 6 6 4 10 2 13 5 1 - 3 6 3/2 20 - 13 8 9 9 10 12 11 6 12 4 4 1 1 6 13 1 - 2 6 21 6 - 10 51 12 73 60 - 105 97 112 31 34 98 22 35 206 MAF - Malaysian Armed Forces 84 supplement-flood disaster.pmd 84 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 3.2. Communicable Diseases And Outbreak Reported Figure 1: Type of notifiable communicable diseases related to flood during flood period by epid week in Pahang Figure 2: Leptospirosis and melioidosis during flood period by epid week in Pahang 85 supplement-flood disaster.pmd 85 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Table 3: Type of communicable diseases at DRC’s by districts during flood period Communicable Diseases District AGE ARI Conjunctivitis Skin Fever HF Infection MD Typhoid Total Food Lepto- Chicken Dengue Cases Poisoning spirosis Pox Kuantan 39 655 11 36 0 0 0 27 1 0 0 688 Jerantut 73 640 2 93 111 0 0 22 0 0 0 775 Lipis 7 285 4 120 0 0 0 0 0 1 0 369 Pekan 66 1384 24 321 272 0 0 0 0 5 0 1882 Rompin 1 38 0 10 5 0 0 0 0 0 0 47 Maran 24 123 1 270 224 3 0 0 0 2 1 643 Temerloh 26 107 5 100 62 0 0 39 0 0 0 339 Bera Raub 24 0 643 1 2 0 26 0 38 1 0 0 0 0 0 0 0 0 0 0 0 0 628 2 Bentong 0 0 0 0 0 0 0 0 0 0 0 0 Total Pahang 260 3876 49 976 713 3 0 88 1 8 1 5974 86 supplement-flood disaster.pmd 86 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 3: Distribution of communicable diseases among flood victims at the DRC’s by day. Figure 4: Type of communicable diseases during flood period at DRC’s by day 87 supplement-flood disaster.pmd 87 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Figure 5: Distribution of communicable diseases at the DRC’s by day. 88 supplement-flood disaster.pmd 88 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Table 4: Outbreak of communicable diseases reported during flood period 26.12.201 4 Type of Disease Outbreak Food Poisoning Kuantan 27.12.201 4 Food Poisoning 13 Outside food is suspected Jerantut 28.12.201 4 Food Poisoning 22 Outside food is suspected Temerloh 29.12.201 4 Food Poisoning 20 Food is undercooked Temerloh 31.12.201 4 Food Poisoning 19 Poor food handling Maran 5.1.2015 HFMD 2 Involved siblings (contracted the disease before moving to DRC) Locality District DRC Youth Complex (Wisma Belia) DRC Pahang Sport Complex (SUKPA) DRC Advanced Technology Training Centre (ADTEC) DRC National-type Tamil Primary School Mentakab (SJKT Mentakab) DRC Malaysia Civil Defence Department (JPAM) DRC UMNO Hall Pekan Tajau Kuantan 3.3 Date Of Outbreak Number Comments of Case 14 Outside food is suspected Prevention and Control Activities Table 5: Dengue Control Activities at DRC’s and flood affected areas No. of No. of No. of No. of Total pesticide used DRC/ DRC/ container container (1/kg) flood flood inspected positive Larvicide Adulticide area area inspected positive During 1225 11 20216 29 524.84 36.42 flood Post2482 7 8636 11 11.31 14.6 flood 89 supplement-flood disaster.pmd 89 8/6/2015, 2:32 PM No. of DRC/ flood area fogged 224 1286 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Table 6: Flies Control Activities at DRC’s and flood affected areas No. of locality No. of locality No. of control No. of inspected for positive for activities premises disinfected Maggot Adult Maggot Adult Larvicide Adulticide During flood 3343 3116 133 1344 866 394 1628 Post-flood 1156 1308 0 10 340 218 1953 Table 7: Rats & Cockroaches Control Activities at DRC’s and flood affected areas No. of locality inspected for Rats Cockroaches Rats 2643 1064 During flood Post- flood No. of locality positive for 2538 1064 Cockroaches No. of locality disinfected 7 0 1254 506 4 0 Table 8: Safe water supply monitoring activities at DRC's and flood affected area Pipe Water Supply Well No. of pH Chlorine NTU E.coli No. of No. of Samples violation violation violation violation Well Well (Colilert inspected Chlorinated test) During 840 0 81 59 0 13 13 flood Post120 0 0 0 0 96 96 flood Table 9: Environmental sanitation monitoring activities at flood affected area Environmental Cleanliness Villages Postflood 108 Sanitation Inspected Unsatisfactory Unsatisfactory Unsatisfactory Unsatisfactory solid houses houses water toilets waste sewerage disposal 2394 314 90 269 90 supplement-flood disaster.pmd 90 8/6/2015, 2:32 PM 214 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Table 10: Food Safety & Quality Activities for Food Handlers at DRC's Briefing on Food Handling Anti-typhoid vaccine given No. of Briefing No. of Food conducted Handlers involved Before 14 574 329 Flood During flood 815 5168 689 TOTAL 829 5742 1018 Table 11: Health Education Activities During Flood Period in Pahang No. of health education session Lecture Individual Demon- Small Public Radio counseling stration group announ- announdiscussion cement cement During flood Post- flood No. of materials distributed Gotong- Pamphlet Poster Bunting Banner royong 523 16492 8585 2914 650 176 78 46197 3779 1 3152 2514 205 0 0 15 1403 4 DISCUSSION 43 The major causes of communicable disease outbreaks in disasters can be categorized into four areas; infections due to contaminated food and water, respiratory infections, vector and insect borne diseases, and infections due to wounds and Various studies had shown that following a disaster, there was increased incidence of communicable diseases in the disaster affected areas. This was contributed by over-population, 91 91 3 population movements and economic and displacement, environmental devastation, poverty, lack of sanitary water, poor waste management, lack of shelter, malnutrition as a consequence of food shortages, and poor access to health care.3-7 The 2014 flood was the worst in Pahang affecting 81,927 people in ten districts. It lasted for 28 days from 22nd December 2014 till 18th January 2015. The victims and districts involved were higher compared to previous flood disasters in Pahang. supplement-flood disaster.pmd 267 1024 105 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT injuries.8 The most common causes of morbidity and mortality in this situation were diarrheal disease and acute respiratory infections.9 duration of DRCs’ operation, the number of communicable diseases reported from this district was only 5.7% (339 cases). This was explained by the fact that medical and health activities were not in full swing as many of the staff were themselves affected by flood. In addition, a number of DRCs were inaccessible to the teams for a few days during the flood. In Pahang, 177 medical teams were mobilized to render medical aid to flood victims in 403 DRCs. Only 7.3% (5,974) of the flood victims from DRCs throughout Pahang were detected to have communicable diseases. Five most common diseases were ARI (3876 cases, 64.9%), skin infection (976 cases, 16.3%), fever (713 cases, 11.9%), AGE (260 cases, 4.4%) and conjunctivitis (49 cases, 0.8%). The pattern of communicable diseases seen during the flood disaster was similar to the Johor flood in 2006-2007 as reported by Badrul Hisham, A.S., et al. (2009).10 The risk of ARI increased due to over-crowding, poor ventilation and poor nutrition at DRCs during disaster.11 The number of communicable diseases reported daily at the DRC corresponded to the number of flood victims present the centres. Only 91 cases (1.5%) of all communicable diseases seen at DRC were notifiable, of which 88 cases were due to food poisoning and three cases were Hand, Foot and Mouth Disease (HFMD). Six outbreaks reported from DRCs during the flood period, five for food poisoning and one for HFMD outbreak. All the outbreaks were under control and all were treated as outpatients. For food poisoning, three of the five episodes were caused by consuming foods prepared and brought in from outside the DRC. The time these foods were prepared and how they were prepared were not known. For the remaining two episodes, poor food handling by food handlers at the DRC was identified as the cause for the outbreak. Most food handlers at DRC were volunteers and some had not been identified Pekan district reported the highest number of communicable disease cases with 1,882 cases (31.5% of total case), of which 73.5% were ARI cases. This could be due to Pekan having the highest number of DRCs and longest DRC mean duration of operation. Although Temerloh district was the worst hit district with the second highest number of DRCs and victims as well as mean 92 supplement-flood disaster.pmd 92 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT and designated as food handlers prior to the flood as flood was not predicted to occur at their areas. All designated food handlers were briefed on proper food handling and preparation before the flood. leptospirosis, melioidosis and food poisoning during the flood period as compared to pre and post flood. During flood, the incidence of leptospirosis and melioidosis were expected to increase especially after heavy rainfall as it facilitates the spread of Leptospires1 and Bulkholderia pseudomallei bacteria, agents causing leptospirosis and melioidosis. Although leptospirosis and melioidosis cases reported were higher during the flood, further investigations showed that not all leptospirosis (only 5% of cases) and melioidosis (56% of cases) were directly caused by flood. The cases reported during the flood was higher due to increase awareness and notifications by the medical practitioners following instruction from the Crisis Preparedness and Response Centre (CPRC), MOH to be on high alert for leptospirosis and melioidosis which were expected to increase during flood. A hundred and fifty five (155) health teams were formed during the flood period throughout Pahang. One of the tasks was to supervise and monitor food preparation at the DRC. However, some teams allocated to look after certain DRCs were unable to do so initially as they had to monitor a few other new DRCs at the same time. The number of DRCs that were opened overwhelmed the number of health teams, especially during the peak period. The formation of adequate health teams was also hampered by the fact that some health personnel were flood victims themselves, especially in Temerloh district. The situation improved after mobilization of an additional 34 health teams from outside the district and state. The HFMD outbreak reported during the flood occurred in one family. The cases developed HFMD symptoms at home prior to being evacuated to the DRC. In the DRC, the cases were isolated in a room to prevent transmission to other flood victims. Vector borne disease was expected to increase during flood as a result of increase potential breeding sites and expansion in the number and range of vector habitats. However, the expected increase in dengue cases was not observed during the flood period. This could be due to intensive and integrated control activities done. Overall, there was no significant increase in the number of notifiable communicable diseases related to the flood except for 93 supplement-flood disaster.pmd 93 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Prevention Activities and Control Prevention and control activities were carried out by the state and district public health teams prior to the flood, during and post flood. These activities contributed to the low occurrence of communicable diseases and outbreak related to flood. ii. Drinking Water Quality Control (KMAM) and Rural Water Supply & Environmental Sanitation (BAKAS) Activities Ensuring uninterrupted provision of safe drinking water is the most important preventive measure to be implemented following a flood, to reduce the risk of outbreaks of water-borne diseases.2,12 During the flood, 960 water samples were taken from the pipe water supplied by the Pahang Water Authority (PAIP). The sampling points include treatment plant outlet, reticulations and also at the DRCs. Only 8.4% and 6.1% violation on residual chlorine and turbidity were found respectively. All violations were reported to PAIP and remedial measures were taken immediately. There was no report of food water borne cases from the area. A total of 109 wells were also inspected and chlorinated. i. Vector Control Activities Vector prevention and control activities started prior to the flood. Flood prone areas were visited whereby search and destroy activities were carried out. Pamphlets and poster were distributed. During the flood, a total of 1225 inspections were carried out at the DRCs, of which only 11 (0.9%) were found to be positive for Aedes breeding. This was detected at the early phase of flood period. Fogging and larviciding were carried out and no breeding were detected after that. The activities continued during the post flood period. Apart from mosquitoes, prevention and control activities for other pests such as cockroaches, flies and rodents were also conducted at the DRCs and flood affected areas. More than 4,000 localities were inspected for the presence of maggots and flies. Larvaciding, adulticiding and disinfection were carried out accordingly at the premises. To ensure environmental cleanliness, 2394 houses were inspected of which 314 were found to be unsatisfactory. It was also found that 269 latrines, 90 domestic water sewerage system and 214 solid waste disposal systems were in substandard conditions. Remedial actions were taken immediately by the health teams. These include 94 supplement-flood disaster.pmd 94 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT gotong-royong disinfections, activities and health. A total of 60 mobile toilets were also dispatched to the areas which were badly affected. carried out. The three most frequent activities were individual counseling (47.1%), demonstration on proper hand washing (24.5%) and small group discussion (8.3%). A total of 52,821 educational materials on various health topics related to flood were distributed during the flood. The topics include hand hygiene, steps taken to avoid disease during flood, food and water borne diseases, vector borne diseases, leptospirosis, melioidosis and cough etiquette. iii. Food Quality and Safety Activities Before the flood, briefings on hygienic and sanitary food handling were given to volunteers identified and designated to help in preparing food at the DRCs. Anti-typhoid vaccinations were administered to 1018 food handlers. However, not all food handlers were given the briefing and anti-typhoid vaccination as some of them were recruited at the last minute due to sudden occurrence of floods at areas not identified as potential flood areas earlier. However, these DRCs were inspected and food preparations were supervised for every meal. Besides DRCs, 397 food premises in flood affected area were also inspected to ensure the quality and safety of the food sold. Another 122 inspections were carried out at the point of sale such as supermarkets, hypermarkets and sundry shops to ensure food that were affected during flood were not sold to the public. During the operation, food items worth RM 1,360,723.58 were sealed. These health education activities carried out during the flood period had probably increased public awareness and empower them to take actions which prevent them from contracting communicable diseases. 5.0 CONCLUSION There was no increase in the prevalence of communicable disease during the recent flood, except for leptospirosis, melioidosis and food poisoning. However, the increase was not directly caused by the flood. A few factors contributed to the success in keeping communicable diseases under control in the 2014 flood. Firstly, all districts had succeeded in carrying out their preparedness plan (pre, during and post flood period). This was further enhanced by good inter-agency collaboration during the flood period. In addition, DRCs were equipped iv. Health Education Activities During the flood period, 35,305 health education sessions were 95 supplement-flood disaster.pmd 95 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT DRCs are equipped with facilities and personnel who have been briefed on proper food handling and preparation. Further, they are being supervised by health teams. with basic amenities such as treated water supply, sanitary latrines, uninterrupted electrical supply and supervised food preparation. Moreover, population displacement and movement of victims which usually lead to increase in prevalence of communicable diseases and outbreak did not occur in Pahang since the flood period was short in duration, causing less impact on health. 6.0 iii) RECOMMENDATIONS i) ii) To further improve the management of communicable diseases related to flood, Flood Preparedness Plan has to be reviewed. Alternative plan has to be made to cater for situations where health staff themselves are affected by the flood. Contingency plan utilizing staff from unaffected neighbouring districts within the state and outside the state should be put in place so that this could be activated at short notice to ensure prompt and smooth running of preventive and control activities. To prevent food poisoning outbreaks occurring during the flood period, it is recommended that foods for evacuees in DRCS should not be prepared and brought from outside as there is no proper control on their quality. All Health Alert Cards (HAC) were distributed to monitor the health status of MOH staff and volunteers, especially on Typhoid, Leptospirosis and Melioidosis. However these cards were distributed a little late, and some well passed the incubation period for these diseases. In future, HACs should be made available distributed to the exposed staff and volunteers early. ACKNOWLEGEMENT We would like to thank the Director General of Health Malaysia for giving the permission to publish this report. We also would like to express our gratitude to those who were involved directly or indirectly in this study. REFERENCES 1. Balek, J. (1983). Hydrology and water resources in tropical regions. Developments in water science. Vol.18 2. World Health Organization (2005) Flooding and communicable diseases fact sheet: Risk assessment and preventive measures cited 7 April 2015). Available from http://www.who.int/diseasecontrol_eme 96 supplement-flood disaster.pmd 96 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT rgencies/publications/who_cds_2005.35/ en/ OR www.who.int/hac/techguidance/ems/ flood_cds/en/ Mohd Yusof, M., Adam, A.M. (2009). Spectrum of flood-related diseases encountered during flood disaster in Johore, Malaysia. Journal of Community 3. Connolly, M.A., Gayer, M., Ryan, M.J., Salama, P., Spiegel, P., Heymann, D.L. (2004). Communicable diseases in complex emergencies: impact and challenges. Lancet. 364(9449):1974–83. [PubMed: 15567014] 4. Jensen, P.K., Meyrowitsch, D.W., Konradsen, F. (2010).Water and sanitation in disaster situations] Ugeskr Laeger. 172(2):109–12. [PubMed: 20074486] 5. Ivers, L.C., Ryan, E.T. (2006). Infectious diseases of severe weatherrelated and flood-related natural disasters. Curr Opin Infect Dis. 19(5):408–14. [PubMed: 16940862] 6. Wilder-Smith, A. (2005).Tsunami in South Asia: what is the risk of postdisaster infectious disease outbreaks? Ann Acad Med Singapore. 34(10):625– 31. [PubMed: 16382248] 7. Lashley, F.R. (2003) Factors contributing to the occurrence of emerging infectious diseases. Biol Res Nurs. 4(4):258–67. [PubMed: 12698918] 8. Ligon, B.L. (2006). Infectious diseases that pose specific challenges after natural disasters: a review. Semin Pediatr Infect Dis. 17(1):36– 45.[PubMed: 16522504] 9. Waring, .S.C., Brown, B.J. (2005). The threat of communicable diseases following natural disasters: a public health response. Disaster Manage Response. 3(2):41–7.[PubMed: 15829908] 10. Badrul Hisham, A.S., Shaharom Nor Azian, C.M.D. , Marzukhi, M.I., Norli, R., Fatimah, O., Kee, K.F, Arbaiah, O., 11. Isidore, K.K., Syed, A., Taro, K., Karen, H., Hitoshi, O. (2012). Infectious diseases following natural diasasters: prevention and control measures. Expert Health,Vol.15,15-23 Rev. Anti Infect. Ther. 10(1), 95-104 12. Najmeh, J., Armindokht, S., Mehrdad, (2011). Prevention of M. & Amir, L. communicable diseases after disaster: A review. Journal of Research in Medical Sciences 97 supplement-flood disaster.pmd 97 8/6/2015, 2:32 PM supplement-flood disaster.pmd 98 Food quality and safety CDC Preparedness notification, e-measles, MyTB, e-Dengue, e-wabak Early warning signs (warning and epidemic level) and response Plan of action for disaster/flood available Stock piling of supplies, operation room (Pahang CPRC) standby Rapid assessment team (RAT) and rapid respond team (RRT) Training of staffs and simulation exercise Epidemiology of notifiable disease by enotification, e-measles, MyTB, e-wabak Early warning signs (warning and epidemic level) and response Plan of action for disaster/flood available Stock piling of supplies, operation room (Pahang CPRC) standby Rapid assessment team (RAT) and rapid respond team (RRT) 98 8/6/2015, 2:32 PM Data collection & monitoring briefing, vaccination of food handlers Food premises inspection, food sampling, food safety Epidemiology of notifiable disease by e- disease (ILI, sARI, AGE) Training of staffs and simulation exercise Surveillance of ILI, sARI, AGE, Dengue PRE FLOOD DISTRICT Surveillance and trending of infectious STATE Pahang Annex 1: Summary of Preparedness Plan for Communicable Disease Surveillance, Control and Prevention in 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT supplement-flood disaster.pmd 99 99 8/6/2015, 2:32 PM CDC Response collaboration Inter-agencies Identify, mobilize, apply, and activate medical and health resources. Resources include medical and health personnel, equipment and supplies required for district. Identify, mobilize, apply, and activate medical and health resources. Resources include medical and health personnel, equipment and supplies required for state DURING FLOOD outbreak Meeting and update of communicable disease & areas materials Inter-agencies meeting at state level Distribution of health education material to flood prone Inspection of identified DRC Provision of latrines, databases of the population Management) by PAIP (Pengurusan Air Pahang or the Pahang Water Preparation and distribution of health education List of identified DRC sanitation Health Promotion Data collection & monitoring Data collection & monitoring e-Vekpro) Water sampling & monitoring of water treatment plant and control activities, management of Dengue outbreak Epidemiology of notifiable disease (eDengue, Case notification and investigation, ACD/PCD, preventive DISTRICT Monitoring of E-Dengue Environment and Water quality and safety Vector control STATE 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT supplement-flood disaster.pmd 100 Food quality and safety notifiable diseases, lab surveillance, TBIS, vector/Vekpro, clinic-based continue and inclusive of evacuation centres & flood areas Early Warning And Response (EWAR) RRT activated/standby for any outbreak verification, confirmation and data collection for outbreak investigation. Disease outbreak(medical & investigation) team Surveillance activities enhanced and upgraded Epidemiology of notifiable disease especially diseases related to flood such as Typhoid, Leptospirosis and Melioidosis Early Warning And Response (EWAR) Laboratory preparedness for testing of samples for causative agent identification Data collection & monitoring enhanced Data collection & Surveillance, Epidemiology of CPRC room activated 100 8/6/2015, 2:32 PM inspection, food sampling inclusive of evacuation Data collection & monitoring food premises evacuation centres Typhoid vaccination given to all food handlers at for lab testing for causative agent identification ACD/PCD, isolation of cases, swab/samples taking activated Operation room activated DISTRICT and district. STATE 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT supplement-flood disaster.pmd 101 Data collection & monitoring enhanced Need assessment of resources including human resource Distribution of HE materials and media statements Water quality and safety Environment and sanitation Health Promotion CDC Response 101 8/6/2015, 2:32 PM verification, confirmation and data collection Report writing & lessons learned Epidemiology of notifiable disease (enotification,e-measles, MyTB, e-wabak) diseases related to flood Weekly epidemiologic meeting focusing on RRT activated/standby for any outbreak Controlling Centre Daily meetings at the district Disaster Operation area Distribution of HE material at DRC and flood affected Larvaciding, temporary toilets & mobile toilets provision points on-site testing besides the routine water sampling Water sampling & monitoring inclusive of DRC, additional investigation of cases, ACD/PCD, source reduction inclusive of DRC, centres, holding samples DISTRICT Surveillance (ILI, sARI, AGE) POST FLOOD Controlling Centre for problem solving, updates & collaboration coordination of resources Daily meeting at the state Disaster Operation Inter-agencies focusing on topics related to flood Data collection & monitoring enhanced Vector control STATE 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT supplement-flood disaster.pmd 102 Need assessment Environment and 102 8/6/2015, 2:32 PM Documentation, report writing & dissemination Inter-agencies collaboration Provision of health material on post flood diseases Health Promotion sanitation Data collection & monitoring of any violation Data collection & monitoring Vector control Water quality and safety Data collection & monitoring Food quality and safety Report writing respond team (RRT) Rapid assessment team (RAT) and rapid level) and response Early warning signs (warning and epidemic STATE Documentation , report writing & dissemination Health education continued Inspection of latrine & rebuilding new ones & chlorination of wells Water sampling & monitoring of any violation, inspection affected areas ACD/PCD, source reduction inclusive of DRC & flood services Food sampling, Inspection of food premises that resume DISTRICT 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Pakat Pasca Banjir Kelantan 2014: Pendekatan Komunikasi Kesihatan Kepada Mangsa Banjir Menangani Risiko Penyakit Berjangkit Kamarul S1, Zanariah Z2, Affendi I2,M Nasir A1&Norrafizah J1 1 Institut Penyelidikan Tingkahlaku Kesihatan 2 Bahagian Pendidikan Kesihatan ABSTRACT Health Education Special Task Force Team (PAKAT) has been mobilized by the Health Education Division to empower the flood victims in Kelantan in preventing infection of post-flood communicable diseases. The objective of presentation is to share an experience in delivering PAKAT health message to the target group.The PAKAT team consists of 40 Health Education Officers from all the states in Malaysia. Those officers divided in four groups and they were sent to the affected localities by stages. There were 7 regions with 58 localities visited throughout the entire operating team. PAKAT was divided into twoapproach; to provide the knowledge and perception as well as skills to the flood victims. The main method used by PAKATwas delivering health messages via house to house. A total of 14,151 leaflets, posters and bunting had been distributed or displayed, 5584 individual advice was implemented, 720 demonstration, 527 small group discussions were conducted, 1678 public announcements and 6 public talks.PAKAT teams managed to move along the current operation covering seven districts in Kelantan which were Gua Musang (8 Localities), Kuala Krai (17 localities), Tumpat (13 Localities), Machang (3 Localities), Pasir Mas (6 Localities), Kota Bharu (4 Localities) and Tanah merah (7 Localities). The PAKAT has successfully promoted and educated specific and tailored health messages among community affected with flood disaster using multiple health communication methods and approaches. Keywords: PAKAT, flood disaster 2014, Kelantan ABSTRAK Pasukan Khas Pendidikan Kesihatan (PAKAT) ditubuhkan oleh Bahagian Pendidikan Kesihatan, Kementerian Kesihatan Malaysia (KKM) bertujuan untuk menggerakkan komuniti di kawasan bencana banjir di Kelantan. Strategi PAKAT pasca banjir adalah menggunakan pendekatan komunikasi bagi menyampaikan mesej kesihatan kepada mangsa banjir untuk mengelak daripada wabak penyakit berjangkit pasca banjir. PAKAT pasca banjir Kelantan dianggotai oleh seramai 40 orang Pegawai Pendidikan Kesihatan dari seluruh negara. Semua pegawai dipecahkan kepada 4 pasukan dan setiap pasukan dihantar secara berperingkat ke lokaliti yang telah dikenal pasti. Operasi PAKAT pasca banjir bergerak selama sebulan. PAKAT pasca banjir melakukan lawatan dari rumah ke rumah untuk menyampaikan mesej kesihatan dengan menerapkan ilmu pengetahuan dan perkongsian tentang penyakit berjangkit, serta meningkatkan kemahiran cara mencegah penyakit kepada mangsa banjir. Pasukan PAKAT pasca banjir berjaya digerakkan ke semua tujuh jajahan Kelantan iaitu Gua Musang (8 Lokaliti), Kuala Krai (17 lokaliti), Tumpat (13 Lokaliti), Machang (3 Lokaliti), Pasir Mas (6 Lokaliti), Kota Bharu (4 Lokaliti) dan Tanah Merah (7 Lokaliti). 103 supplement-flood disaster.pmd 103 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Sebanyak 14,151 risalah, poster dan bunting telah diedar dan digantung di lokasi yang strategik. Sebanyak 5,584 nasihat individu, 720 tunjuk cara, 527 perbincangan kumpulan kecil, 1,678 hebahan awam dan 6 ceramah telah dilaksanakan. PAKAT pasca banjir telah berjaya melaksanakan promosi dan pendidikan kesihatan kepada mangsa banjir dengan menggunakan pelbagai kaedah dan pendekatan bagi memastikan penyakit berjangkit tidak merebak di kawasan yang terjejas akibat banjir. Kata kunci: PAKAT, Banjir Kelantan PENDAHULUAN Pasukan Khas Pendidikan Kesihatan (PAKAT) adalah gerak kerja (task force) yang menggembling tenaga Pegawai Pendidikan Kesihatan atau Health Education Officer (HEO) dalam melaksanakan mobilisasi komuniti. Pasukan PAKAT digerakkan pada Ogos 2014 atas inisiatif Bahagian Pendidikan Kesihatan Kementerian Kesihatan Malaysia (BPKKKM). Penubuhan PAKAT pada asalnya bertujuan untuk memobilisasi komuniti di lokaliti panas (hotspots) denggi di negeri Selangor. Pada Disember 2014, banjir besar melanda beberapa negeri di Semenjung Malaysia terutama di pantai timur. Kelantan adalah salah satu negeri yang terjejas teruk di mana seramai 339,703 orang penduduk terpaksa dipindahkan (Sumber: Jabatan Kebajikan Masyarakat 2015). Pada 29 Disember Crisis 2014, satu mesyuarat kerjasama BPKKKM dengan Persatuan Promosi Kesihatan Malaysia (MAHEO). Penulisan ini dilakukan bertujuan untuk berkongsi pengalaman pasukan PAKAT Pasca Banjir Kelantan dalam melaksanakan aktiviti promosi dan pendidikan kesihatan untuk mencegah penyakit berjangkit. Ia juga sebagai salah satu platform bagi menambah baik garis panduan pengurusan komunikasi risiko semasa banjir serta pelaksanaan PAKAT Pasca Banjir pada masa akan datang. MATERIAL DAN METODOLOGI Tempoh operasi PAKAT Pasukan PAKAT pasca banjir beroperasi selama sebulan bermula dari 1 Januari hingga 30 Januari 2015. Petugas PAKAT Petugas terdiri daripada Pegawai Pendidikan Kesihatan dan dibantu oleh anggota sokongan dari BPK, Institut Penyelidikan Tingkahlaku Kesihatan (IPTK) dan Unit Promosi Kesihatan (UPK) negeri di seluruh negara. Preparedness and Response Centre (CPRC) banjir yang dipengerusikan oleh Ketua Pengarah Kesihatan Malaysia telah mencapai kata sepakat untuk mengaktifkan semula PAKAT. PAKAT kali ini dikenali sebagai PAKAT Pasca Banjir kerana tumpuan diberi untuk menyalurkan maklumat kesihatan kepada mangsa banjir bagi menangani masalah kesihatan selepas banjir di pusat pemindahan serta daerah terjejas teruk akibat banjir. PAKAT Pasca Banjir adalah hasil Bahan Bercetak Pendidikan Kesihatan BPK membekalkan pasukan PAKAT Pasca Banjir dengan bahan bercetak pendidikan KKM sedia ada yang berkaitan dengan penyakit berjangkit pasca banjir seperti risalah, poster dan kain rentang. 104 supplement-flood disaster.pmd 104 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Strategi operasi PAKAT BPK KKM telah menghantar surat arahan bertugas bagi mengumpul petugas PAKAT Pasca Panjir dan keperluan logistik seperti kenderaan, khemah dan peralatan memasak minima. Petugas PAKAT Pasca Banjir telah dibahagikan kepada 4 pasukan yang mengandungi antara 15 hingga 16 orang petugas. Setiap pasukan PAKAT Pasca Banjir telah menerima jadual pergerakan secara berperingkat dan senarai asas keperluan diri minima yang perlu dibawa bersama termasuk sarung tangan getah, penutup muka dan but getah. Berdasarkan jadual yang ditetapkan, pasukan PAKAT Pasca Banjir diarah berkumpul di BPK bagi mendengar taklimat penting daripada ketua PAKAT Pasca Banjir BPK KKM sebelum bergerak ke Kelantan. Sesi taklimat tersebut merangkumi maklumat keselamatan ketika bertugas, mesej kesihatan, kaedah penyampaian mesej, maklumat ringkas lokasi yang akan dilawati, pegawai bertugas dan tempat untuk melapor diri. Sebelum berlepas, BPK telah menyerahkan bahan pendidikan kesihatan dan keperluan asas penjagaan kebersihan hasil pemberian MAHEO untuk mangsa banjir seperti gel pencuci tangan, cecair mandian berubat dan cecair pembasmi kuman. Setibanya di Kelantan, pasukan PAKAT Pasca Banjir telah diberi taklimat penuh berkaitan situasi terkini lokasi bencana berdasarkan penilaian situasi dan keperluan yang telah dilakukan oleh pihak UPK Jabatan Kesihatan Negeri Kelantan (JKNK). Pasukan PAKAT Pasca Banjir kemudian dibahagikan kepada 3 kumpulan kecil terdiri daripada 5 hingga 6 orang petugas dan disediakan jadual logistik bagi memudahkan pergerakan semasa di lapangan. Sesi taklimat di lapangan dan post mortem juga diadakan setiap hari sebelum dan selepas aktiviti PAKAT Pasca Banjir dijalankan di lokaliti terpilih. Pendekatan PAKAT Petugas PAKAT Pasca Banjir bertanggungjawab menyampaikan mesej kesihatan dengan menerapkan ilmu pengetahuan dan persepsi terhadap penyakit berjangkit, serta membina kemahiran pencegahan penyakit berjangkit kepada mangsa banjir. Pendidikan kesihatan diberikan bagi membantu individu dan masyarakat mengambil tindakan yang bersesuaian dalam menangani ancaman penyakit akibat banjir. Petugas telah mengambil pendekatan secara individu, kumpulan kecil dan beramai-ramai (mass) mengikut kesesuaian keadaan dan emosi mangsa banjir di lokasi. Rajah 1 menghuraikan pendekatan dan kaedah komunikasi berkesan seperti nasihat individu, tunjuk cara, perbincangan kumpulan kecil, hebahan awam, ceramah dan edaran bahan pendidikan kesihatan yang digunakan oleh petugas PAKAT Pasca Banjir dalam memastikan mesej kesihatan sampai kepada mangsa banjir. 105 supplement-flood disaster.pmd 105 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Rajah 1: Pendekatan dan Kaedah PAKAT Pasca Banjir Pendekatan & Kaedah Kemahiran Pengetahuan & Persepsi Kumpulan Kumpulan Individu Poster Risalah Ceramah Bunting Demonstrasi Lawatan rumah ke rumah Lawatan ke pusat pemindahan Hebahan awam Advokasi melalui pemimpin Demonstrasi Perbincangan Kumpulan Kecil Demonstrasi Lawatan rumah ke rumah Lawatan ke pusat pemindahan Perbincangan Kumpulan Kecil Mesej kesihatan PAKAT Terdapat 9 mesej kesihatan utama yang disampaikan kepada mangsa banjir mengikut kesesuaian mangsa yang ditemui di lokasi. Adaptasi mesej dilakukan tanpa menghilangkan kepentingan mesej kesihatan yang disampaikan bagi menghormati keadaan dan emosi mangsa. Sebagai contoh, mangsa banjir dinasihatkan agar minum banyak air mineral atau air suling dalam botol yang dibekalkan jika tiada kemudahan untuk memasak air minuman dan mesej kesihatan tentang penggunaan cecair pembasmi kuman ketika 106 Risalah Tunjuk cara Nasihat individu membersihkan rumah dan atau peralatan di mana hanya akan diberikan kepada mangsa banjir yang masih mempunyai rumah dan atau peralatan. Mangsa banjir turut diberi penjelasan kukuh tentang kewajaran mengapa setiap tindakan harus dilakukan dengan betul berdasarkan mesej kesihatan yang disampaikan (WHO 2015 & Morgan O, 2004). Dengan cara ini, petugas PAKAT Pasca Banjir dapat mendekati mangsa dengan mudah bagi menyalurkan mesej-mesej kesihatan berikut dengan berkesan: 106 supplement-flood disaster.pmd Individu 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Kebersihan tangan (membasuh tangan menggunakan guna sabun atau gel pencuci tangan); Minum air yang telah dimasak sempurna; Elak makan ulam-ulaman; Guna cecair pembasmi kuman ketika bersih rumah dan peralatan; Memakai sarung tangan dan kasut keselamatan; Dapatkan rawatan segera jika sakit atau demam; Guna penutup muka; Buang sampah domestik dengan cara yang betul; Menanam bangkai binatang dengan cara yang betul. HASIL Seramai 61 orang pegawai telah menyertai PAKAT Pasca Banjir yang terdiri daripada 40 orang Pegawai Pendidikan Kesihatan dan dibantu oleh 4 orang Juru Audiovisual, 8 orang Pembantu Kesihatan Awam, seorang Pembantu Rendah Awam dan 8 orang Pemandu. UPK negeri yang turut serta adalah Negeri Sembilan, Melaka, Selangor, Kedah, Kelantan dan dibantu oleh BPK serta IPTK. Pasukan pertama telah digerakkan pada 1 hingga 4 Januari 2015 dan pasukan terakhir pada 19 hingga 25 Januari 2015 seperti Jadual 1. Jadual 1: Jadual Operasi pasukan dan jumlah kekuatan PAKAT Pasca Bbanjir Kelantan JUMLAH KEKUATAN PAKAT PASUKAN TARIKH OPERASI KELANTAN (orang) Satu 1- 4 Januari 2015 40 HEO & Dua 5-11 Januari 2015 21 anggota sokongan Tiga 12-18 Januari 2015 Empat 19-25 Januari 2015 Aktiviti pendidikan kesihatan menggunakan pendekatan secara individu, berkumpulan dan beramairamai telah dilaksanakan di 7 jajahan Kelantan; Gua Musang (8 lokaliti), Kuala Krai (17 lokaliti), Tumpat (13 lokaliti), Machang (3 lokaliti), Pasir Mas (6 lokaliti), Kota Bharu (4 lokaliti) dan Tanah Merah (7 lokaliti). Hasil daripada aktiviti tersebut sebanyak 12,730 risalah telah diedar, 187 poster berjaya ditampal, 1,234 bunting juga telah digantung di pusat-pusat pemindahan banjir dan klinik kesihatan serta sebanyak 1,678 hebahan awam berjaya dilakukan oleh Unit Bergerak Promosi Kesihatan (Jadual 2). Seramai 190 orang telah menghadiri ceramah, 3,925 individu mengikuti perbincangan kumpulan kecil, 2,885 orang mengikuti tunjuk cara dan 5,584 orang diberi nasihat individu. 107 supplement-flood disaster.pmd 107 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Jadual 2: Aktiviti dan jumlah Pendidikan Kesihatan yang dilaksanakan oleh pasukan PAKAT Pasca Banjir Kelantan Aktiviti Ceramah Poster Perbincangan Kumpulan Kecil Tunjuk Cara Bunting Hebahan Awam Nasihat Individu Risalah Pasukan Pasukan Pasukan Pasukan Jumlah 2 3 4 1 2 8 0 27 0 101 4 51 6 187 56 257 140 77 527 171 2 55 2 188 2429 42 499 410 4314 1431 52 570 178 5941 1553 28 554 130 2089 720 1,234 1,678 5,584 12,730 Gambar 1: Aktiviti-aktiviti yang dilakukan petugas PAKAT Pasca Banjir (Gambar ehsan: Petugas PAKAT Pasca Banjir). 108 supplement-flood disaster.pmd 108 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT Gambar 2: Cabaran yang dihadapi oleh petugas PAKAT Pasca Banjir ketika menjalankan tugas (Gambar ehsan: Petugas PAKAT Pasca Banjir) 109 supplement-flood disaster.pmd 109 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT PERBINCANGAN Hasil kajian yang dilakukan oleh Pusat Kajian Kawalan Banjir, Fakulti Kejuruteraan Awam Universiti Teknologi MARA (UiTM) mendapati terdapat peningkatan curahan hujan yang tinggi direkodkan di stesen Gunung Gagau di Gua Musang pada 21 Disember 2014 (302mm), 22 Disember 2014 (478mm) dan 23 Disember 2014 (515 mm). Keadaan ini menyebabkan terjadinya bencana banjir kuning besar di Kelantan (Berita Harian 2015). serta seterusnya, memperkasa mangsa banjir untuk melakukan tindakan yang disarankan. Model Kepercayaan Kesihatan (Health Belief Model[HBM]) perceived severity, merangkumi perceived susceptibility, perceived benefits, perceived barrier, cues to action dan self-efficacy (Rosenstock et al 1988) digunakan dalam menyampaikan 9 mesej kesihatan pasca banjir. Penggunaan teori HBM ini telah membantu petugas PAKAT Pasca Banjir mendekati dan menyakinkan mangsa banjir untuk bertindak mengikut tingkah laku dan amalan penjagaan kebersihan serta kesihatan yang betul bagi mengelak risiko jangkitan penyakit berjangkit. Pasukan PAKAT telah digerakkan ke lokasi bencana terpilih di Kelantan selama sebulan bertujuan memberikan promosi dan pendidikan kesihatan kepada mangsa banjir bagi mencegah wabak penyakit berjangkit bawaan air seperti demam tifiod, kolera, leptospirosis dan hepatitis A serta penyakit berjangkit bawaan vektor seperti demam denggi dan demam denggi berdarah (WHO 2015, Gayer M & Connolly MA 2005). Bermula pada 1 hingga 18 Januari 2015, dilaporkan terdapat 458 kes Leptospirosis telah berlaku di lokaliti terjejas banjir di Kelantan, namun tiada wabak diisytiharkan (KKM 2015). Ini menunjukkan bahawa, inisiatif PAKAT Pasca Banjir dalam menyampaikan mesej kesihatan kepada mangsa banjir telah dapat membantu mencegah berlakunya wabak penyakit berjangkit pasca banjir. Bagi menjayakan misi tersebut, pasukan PAKAT Pasca Banjir telah menumpukan operasi gerakan dengan mengadakan lawatan dari rumah ke rumah atau lawatan ke tapak asal rumah mangsa atau lawatan ke khemah kediaman mangsa bagi menemui mangsa banjir. Berdasarkan analisa awal situasi yang dijalankan oleh UPK JKNK, didapati nasihat individu, perbincangan kumpulan kecil dan tunjuk cara adalah antara kaedah yang paling sesuai dalam menyampaikan mesej kesihatan berkaitan tingkah laku kesihatan yang perlu dilakukan untuk mengelak wabak penyakit berjangkit. Kaedah nasihat individu merupakan kaedah utama yang dilaksanakan dalam menyampaikan mesej kesihatan. Kaedah ini sangat praktikal dan efektif kerana lebih bersifat personalized yakni individu didapati lebih mudah menerima mesej kesihatan yang ingin disampaikan. Kaedah perbincangan kumpulan kecil pula dilaksanakan di kalangan mangsa yang tinggal Penyampaian mesej kesihatan PAKAT Pasca Banjir telah menekankan penggunaan teori dalam merancang pendekatan dan kaedah penyampaian mesej kesihatan kepada mangsa banjir bagi memastikan keberkesanan mesej dan perubahan tingkahlaku berlaku 110 supplement-flood disaster.pmd 110 8/6/2015, 2:32 PM 2015, SPECIAL EDITION, JOURNAL OF HEALTH MANAGEMENT bersama atau duduk berkumpul dalam kumpulan kecil seperti di wakaf, rumah dan khemah. Kaedah ini sangat praktikal dan menjimatkan masa kerana banyak mesej kesihatan dapat disampaikan kepada mangsa banjir dalam jumlah yang ramai (Declan T Bradley 2014). Di samping itu, kaedah tunjuk cara telah dilaksanakan bertujuan untuk memberi kemahiran kepada mangsa banjir tentang cara membasuh tangan yang betul, cara membasuh rumah menggunakan pembasmi kuman serta pemakaian topeng muka yang betul. Kaedah ini membantu mangsa banjir daripada terdedah kepada risiko penyakit berjangkit ketika banjir. Aktiviti hebahan awam menggunakan alat pembesar suara yang dipasang pada kenderaan jabatan juga antara kaedah yang dilaksanakan bagi memberi maklumat secara umum kepada mangsa banjir. Kaedah ini sangat praktikal dilakukan di kawasan bencana yang mampu diakses oleh kenderaan dan mempunyai ramai mangsa yang tinggal berselerak pada skala yang lua. Ini kerana, hebahan dapat didengari oleh ramai mangsa banjir pada satu-satu masa. Pemberian risalah kepada mangsa banjir bertujuan untuk dijadikan bahan rujukan selepas semua aktiviti di atas dilaksanakan ke atas mereka. Walaupun objektif utama PAKAT Pasca Banjir adalah untuk menyampaikan mesej kesihatan dengan menerapkan ilmu pengetahuan dan persepsi terhadap penyakit berjangkit serta membina kemahiran pencegahan penyakit kepada mangsa banjir, setiap petugas telah diberi peringatan awal semasa taklimat agar mengambil kira keadaan dan emosi mangsa ketika menjalankan tugas. Petugas PAKAT Pasca Banjir mengambil inisiatif memulakan interaksi dengan bertanya khabar, menyampaikan sumbangan barangan MAHEO dan memberi kata semangat kepada mangsa banjir untuk mewujudkan kemesraan sebelum menyampaikan mesej kesihatan. Setiap perjumpaan bersama mangsa banjir diakhiri dengan kata-kata semangat dan peringatan agar sentiasa menjaga kesihatan seperti disarankan demi diri sendiri dan keluarga untuk kelangsungan hidup. Hasil daripada pemerhatian yang dijalankan, mangsa banjir menerima baik kehadiran petugas PAKAT Pasca Banjir dan mesej kesihatan dapat disampaikan dengan baik. KESIMPULAN PAKAT Pasca Banjir telah berjaya melakukan promosi dan memberi pendidikan kesihatan kepada mangsa banjir di tujuh jajahan Kelantan dalam masa sebulan. Pelbagai pendekatan dan kaedah telah digunakan oleh PAKAT dalam menyampaikan mesej kesihatan kepada mangsa banjir. Pendekatan PAKAT yang memberi tumpuan kepada lawatan dari rumah ke rumah atau lawatan ke tapak asal rumah mangsa atau lawatan ke khemah kediaman mangsa menunjukkan komitmen pasukan untuk memastikan mesej kesihatan disampaikan terus kepada mangsa banjir secara bersemuka supaya mereka mendapat maklumat tepat mengenai amalan yang harus dilakukan untuk mengelak risiko wabak penyakit berjangkit. 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