China is a one of the earthquake-prone countries that suffer a lot from earthquakes. Tangshan Earthquake in 1976 and Wenchuan Earthquake in 2008 were both disasters of great destructiveness and vast affected area, resulting in a great deal of difficulties in disaster relief and leaving very deep and far impact. The earthquakes not only caused casualties and property losses, but also brought big challenges to disease prevention and control after disasters happened. In order to further guide the work of disease control institutions at all levels, and to carry out plans pertinent to the disease prevention after earthquakes to ensure no outbreak of epidemics, with the help and support from the World Health Organization, the Chinese Center for Disease Control and Prevention has cooperated with West China University of Medical Sciences, Anhui Medical University and some provincial centers for disease control and prevention to develop this technical guide based on summarization of experience obtained from disease prevention and control in Tangshan Earthquake and Wenchuan Earthquake and lessons learned from other countries’ disease prevention and control work. According to the characteristics of public hygiene in earthquakes, this guide describes separately such core work at different stages as pre-disaster preparation, post-disaster emergency measures and restoration and reconstruction, so that disease control institutions at all levels can carry out their earthquake-related disease prevention and control work in a clear, active, scientific, orderly and efficient manner.
It contains the definition of seismic disaster and the five characteristics of seismic disaster, that is, emergent, cataclysmic, secondary-disaster prone, tremendously-impacted, and arduous restoration.
1. Direct hazards. Include: collapse of buildings, casualties, destruction of infrastructure like water, electricity, gas, road, etc., damages to energy supply, break of communication, impairment of social service facilities and destruction of ecological environment
2. Indirect hazards. Include: impacts on politics, economy, society and people.
3. Secondary disaster. Include: fires, explosion of chemicals, leak of chemicals and radioactive substance, floods, tsunami, traffic accidents, social disturbances, and so on.
1. Direct impacts on public health
(1) Large numbers of casualties. It mainly means mechanical injuries to bodies and deaths caused by collapse of buildings, landslide, etc;
(2) Outbreak of infectious disease. It is mainly caused by unclean water and food, massive human migration and gathering, imperfect sanitary facilities and changes in distribution of biological vector and human exposure;
(3) Accident injury. It is mainly caused by contingencies such as fires, heat stroke, CO intoxication, food poisoning, chemical poisoning, radioactive substance contamination, etc;
(4) Chronic non-communicable diseases. These are mainly attacks of cardia-cerebrovascular disease, hypertension, and diabetes and so on resulted from changes in living environment.
(5) Mental and psychic trauma. These are mainly contingent reaction in psychology caused by the emergent disaster and short-term psychological communication difficulty when living and surviving environment changed.
2 Damages to public medical facilities
(1)The capability of public medical facilities is under impact. On one hand, the hardware of public medical services has been impaired, including destruction of buildings, impairment of apparatus, damages of laboratories, and loss of data and technological documents; on the other hand, the medical services personnel have been affected, including individual and family members injuries and death, loss of family properties and depletion of personnel because of long-term overwork.
(2)Increase of need for medical services. A lot of wounded and sick people needing urgent medical care and a lot of mind-hurt people need consolation and communication, therefore, a great amount of medical personnel and materials like medical instrument and blood will be required in a short time.
(II) The stage of restoration and reconstruction: mainly indirect outcomes and long-term impacts caused by seismic disasters
1. Indirect impacts on public health
(1) Destruction of the public medical care system: including damages to normal public health services such as immunization, maternal and children health, mental health, and medicine and vaccine supply;
(2)The public normal life order has been changed, bodies’ resistance to diseases is lowered down, and people incurred mental and emotional disorder. All of these are prone to result in diseases;
(3)Destruction of the biological environment can lead to higher occurrence possibility of some infectious diseases.
2. Indirect impacts on public medical care system
(1) Infrastructure such as water, electricity, fuel, communication and drainage are destroyed, resulting in adverse effect on public medical care capability and work order;
(2) Traffics and communication are blocked, which have impact on timely supply of medical care services;
(3) Over attention and expectation from media and domestic and international communities increase pressure, intensiveness and difficulty of public medical care services.
The work cycle of disease control in seismic disaster is divided into three stages, that is, pre-disaster preparation, post-disaster response and restoration and reconstruction. Pre-disaster contains organization and preparation, risk assessment on public health, disaster avoidance and reduction, emergency plans, policy and capability establishment, etc. Post-disaster response contains emergency rescue and disease control. Restoration and reconstruction contains restoration of the capability of public medical care services and prevention and control of infectious diseases and chronic non-communicable diseases, etc.
This mainly means that imperfect dealing system and mechanism, insufficient reserve of materials and technology, unclear recognition of disaster-related public health risks and hazards. These can lead to disordered work in the short time after disaster.
This mainly pertains to lack of unified and efficient emergency command and management, impeded information channel, and slow response. Internal and external resources cannot be mobilized and allocated effectively.
This mainly indicates that in the short time after disaster, there exists a gap between demand and supply of public medical care services. Personnel, emergency equipment, transportation and professional facilities are also comparatively lacked.
This indicates that public facilities are destroyed so much in disasters that living condition is very hard at disease control work site due to lack of electricity, water, food, medicine and so on.
This implies that disasters have made huge impacts on public health and complicated situations are confronted after disasters with massive tasks and social pressure. Especially, the arduous task of ensuring no outbreak of epidemics after big disasters can bear little carelessness.
(i) Preparation for emergency measures in daily work shall be completed well.This includes organization and preparation, assessment on the risks of public hygiene, disaster avoidance and reduction, contingent plan, policy and capability, etc.
(ii)Establishment of unifying and coordinating mechanism and disaster emergency management system within health authorities shall be completed, including mechanism such as commanding and decision-making, organization and coordination, monitoring and warning, information collection and report, social mobilization and emergency guarantee (material distribution included), etc.
(iii) The key to winning the battle against disasters is the local strength in disease control, which means the local workforce of disease control are more familiar with local culture, customs, and geology, so that they can do a better job.
(iv)The aid to disease control workforce outside disaster area should be oriented at the needs of disaster area.The external aids can help disaster-affected areas return to normal quickly from disaster. However, if the aids do not match the local needs, or excessive aiding materials and staff are allocated, the disaster-affected area is prone to be put on new burdens, thus the work of disease prevention and control will be influenced.
(v) Appropriate guarantee measures shall be taken. The first is communication guarantee.Efforts shall be made to ensure successful communication among the main departments and organizations, such as commanding system, disease control institutions, hospitals, fire brigade, airport, stations, ports, all aid forces, by applying wired, wireless, satellite and labor communication, so that all forces of disease prevention and control can be commanded and coordinated with timely information from the disaster-affected area and understanding of their needs. The second is materials and equipment guarantee, including individual portable living equipment, individual safeguard equipment, office and communication equipment and on-site fast detection equipment. They can help smooth work on site. The third is logistic guarantee, including allocation of vehicles, life arrangement and receiving and distribution management of all kinds of disaster relief materials.
The fundamental purpose of pre-disaster preparation is to raise the capability to deal with disasters and carry out the work of post-disaster disease prevention and control.
Pre-disaster preparation for disease prevention and control primarily includes six key factors, that is, organization and preparation, risks assessment on public health, prevention and reduction of impacts on pubic health, preparation of human resources, emergency materials and on-the-spot treatment equipment.
The organization structure is logical structure that includes command department, coordination department and execution department. Great importance should be paid to EOC and provide sites for related personnel to develop planning, to conduct organizing, to obtain and distribute materials as well as to complete the six tasks including assessing on the condition of disasters and the needs, deciding handling measures, mobilizing all kinds of resources, starting action instructions, following the usage of resources and reporting the work development to superiors, aimed at providing policy guide and support and ensuring the key works and coordinating actions among institutions.
(1) Mechanism. It includes commanding and decision-making mechanism, organizing and coordinating mechanism, monitoring and warning mechanism, information collecting and reporting mechanism, social mobilizing mechanism, contingent guarantee mechanism (material distribution mechanism).
(2) System. It includes position responsibilities, supervision and assessment, encouragement and punishment, etc.
(1) Formulation of emergency plan and preparation. This includes overall analyses on risk factors of the system and the unit, types of possible emergency events and their hazardous degree; identification and elimination of hidden dangers’ type, number and distribution, forecasting of the types of possible emergencies and their hazardous degree; determination of risk sources for emergency events and risk assessment; determination of corresponding preventing measures based on the identified risk sources and existing problems; subjective evaluation on the unit’s emergency response capability; full reference to domestic and overseas emergencies’ lessons in the same industry and their experience.
(2) The contents of the plan. The contents of the plan are mainly organization and commanding system, responsibilities and division of work, information collection, analysis and report, measures and actions disease prevention and control after disasters (including drinking water health, food safety, environmental management and disinfection, infectious disease surveillance and control, control of vector organisms, injury prevention, health education, etc.), ways of communication and coordination, logistical support, safety and security, etc.
(3) Basic structure of the plan. The basic structure includes six parts: background, purpose, division of responsibilities, operation ways, coordination and cooperation and appendix. In the background part, the seismic disaster and its impacts, the necessity of the plan, etc are introduced; the overall policy, structure and purpose of the plan are explained in the operation ways parts; the coordination and cooperation part can make arrangement for the reporting procedure, communication channel and establishment of effective and appropriate coordinating mechanism. The appendix shows the flow chart of the procedure and separate completing plans made by different departments when supporting and practicing responsibilities.
Efforts shall be made to collect disaster information, identify the hazards and make analysis on vulnerability of community and population, water supply system and environmental hygiene, as well as on response capabilities and community risks. And risk management map shall be developed based on the analyses, at the same time, marking of the hazards and vulnerability on the maps and marking of risk distribution, information, materials and human resources shall be completed.
Upon community health education, organize and mobilize the community masses to clean living environment, change unhealthy habits and raise awareness of disease prevention.
The rules include setting up local standards for environmental health of some public facilities like water supply, toilet, disposal of refuse and sewage.
Within the frame of laws, participate actively in hygienic evaluation of local construction planning and facilities for seismic disaster prevention and mitigation. Guide the local setting up and construction to be conducted in a reasonable way.
Efforts shall be made to ensure no or less damages to the health departments’ facilities.
Expert team composed of some departments like public health, hospitals, transportation, communication and related majors in universities shall be established. Experts’ information shall be complete and training and assessment on experts’ professional quality, capability, work attitude, devotion and honesty and self-discipline shall be strengthened.
A professional team composed of epidemic professionals majored in infectious disease and food and chemical poisoning and nuclear radiation, laboratory professionals and logistics professionals shall be built. The professional team should be furnished with on-site work equipment and on-going training and rehearsal.
The training contains professional knowledge and on-site skills. The professional knowledge training includes related laws and regulations, information collection, assessment and report at the site of disaster and contingent investigation and treatment of emergently-prompted public hygienic event. The on-site skill training includes all first-aid medical knowledge, first-aid skill for saving fatal and critical patients, treating procedure for the group of the wounded and the sick, first-aid knowledge of infectious disease and common poisoning, self and mutual aid when natural disasters and accidents happen, mental quality training, how to contact and call police, how to get close to the wounded, etc. To ensure effectiveness of the training, there should be training plans and teaching books, trainees will be evaluated according to the stipulated evaluation standards and encouraging and punishing measures.
The purpose of the rehearsal is to test the plans, perfect preparation, exercise the team, gear the mechanism and communicate and educate the public. The forms of rehearsal can be the following five: seminars, desktop deduction, demonstration and presentation, specific function rehearsal and overall rehearsal.
The reserve includes buildings and locales, communication facilities and equipments, emergency energy equipment and materials, means of transportation, individual protection apparatus, team symbols, health education materials and lab quick-testing equipment. The principle for reserve should be in line with local conditions, ensuring safety, cost-effectiveness and application.
This includes assessments on disaster, needs after disaster and risks of public hygiene after disaster. Different tools are applied in alignment with different conditions.
Keep following and compiling technical documents of disease control in seismic disaster.
Disaster conditions shall be rapidly verified and evaluated, as well as immediately reported to relevant authorities; measures given in the plan shall be initiated to primarily define the emergency objectives; professional personnel and private entities shall be urgently mobilized for participating in the action; material allocation shall be arranged in an urgent manner for helping the fulfillment of determined objectives; a public health information communication platform shall be established for collecting public demands and giving relevant feedback; efforts shall be made to ensure the normal operation of the monitoring system and emergency laboratories and to verify their sound functions; works such as preparation of personal plan, upgrading of relevant contact data and roster shall be completed timely to facilitate subsequent utilization and inform of current tasks and problems to be solved; preparation for the state-and government- leadership’ on-the-spot relief assistant shall be done well; evaluation on health resource demands that have been satisfied and are required to be met shall be carried out; and energetic effort on logistics and psychological aids shall be made for rescue forces.
Emphasis shall be placed on internal resources and relevant external resources for disease control & prevention, including management on personnel such as local human resource, external assistance, supervisors and volunteers, material management, information management and logistics management.
According to the response, priority of contents to be assessed shall be determined, thus the assessment will be conducted based on available data as the response is giving. The principle is to ensure rapidness and conciseness rather than completeness and comprehensiveness.
The contents to be assessed shall include disaster situation, medical treatment capacity, risk sources, conditions of service objects and health service capacity.
The information collection system and a temporary information collection platform shall be established; while the tools for assessment include assessment forms.
Emergency disease surveillance shall be implemented by making use of those surviving surveillance resources and based on demands; and if necessary, syndromic surveillance for special groups shall be carried out.
Guidance and assistance shall be provided for searching, monitoring, publicizing, supervising and assessing the usable water supply. Simple, rapid and available means for observation and inspection as well as assessment parameters shall be adopted to preliminarily analyze risks of drinking water, determine criteria of emergency drinking water and give instruction opinions on potable water. In addition, guidance shall be given for taking necessary and feasible health measures to treat drinking water; and propaganda and education for clean and health drinking water shall be carried out.
Food risks shall be identified and eatable food types shall be determined; various food poisoning events shall be diagnosed and disposed in a timely manner; effort shall be made as much as possible to investigate the cause of food-poisoning for the purpose of preventing expansion and reoccurrence of food poisoning; management on food transportation, storage and processing shall be strengthen and propaganda and education for food-poisoning prevention shall be carried out.
Endeavors shall be made to participate and instruct the disposal of human and animal excreta, garbage and cadaver as well as the protection of water sources; methods that local natives are ready to accept shall be adopted for the purpose of guiding the people in the disaster areas to form a proper health habit.
methods such as making use of personal sense organs or technical measures shall be applied to monitor the activities of various vector organisms such as mice, mosquitoes and flies; guidance shall be given for private entities’ correct disinfection activities so as to control the breeding of vector organisms; health education shall be carried out for the purpose of instructing the public’ personal protection.
Rumors and misunderstanding of cadaver’s effect on transmission of infectious diseases shall be eliminated; according to the actual situation on the spot, assistance shall be provided to the relevant authorities for rapidly stipulating the process flow and precautions of cadaver disposal; resources required for cadaver disposal shall be estimated quickly; guidance shall be given for demonstrating humanistic care and respect during cadaver disposal; psychological assistance shall be offered for personnel engaging in cadaver disposal.
Thresholds for outbreaks of specific infectious diseases shall be assessed in case of emergency; abnormal signals shall be monitored and confirmed quickly; outbreaks of infectious diseases shall be verified and confirmed via laboratory if necessary; field investigation shall be conducted for identifying infectious sources and modes of transmission; during on-the-spot control, exposure and infection shall be prevented, and measures shall be taken for disease prevention and death prevention.
A detailed emergency vaccination plan shall be prepared; and strategy of community vaccination shall be determined; assessment on vaccination risks and logistic demands shall be conducted; training shall be offered for personnel to be engaged in vaccination work; emphasis shall be placed on selection of vaccination spots, injection safety, vaccine cold chain and emergency vaccine supply.
Risk sources such medical substances, radioactive substances, cancerogenous substance and teratogen (for example: asbestos in buildings) shall be identified; instruction on leakage inspection and exposure prevention shall be given; assistance shall be provided for leakage control and evacuation of affected persons; instruction on rescue and treatment as well as psychological consultation for persons exposed to risk sources shall be given.
Diagnosis in terms of health education sociology, epidemiology and behavioral science shall be carried out; propaganda shall be carried on via various modern communication means such as plane media (including propaganda column, picture poster and leaflet), radio and TV together with conventional forms such as giving lectures and oral communication, with propaganda emphasis placed on drinking water health, food safety, personal hygiene, prevention and protection from insect vector, disease knowledge and treatment guideline. Moreover, core information for media and public communication shall be determined, media propaganda columns shall be established positively and public health hotline shall be set.
Intervention objects shall be defined; intervention principles shall be followed; detailed work schemes shall be developed; mental health assessment shall be conducted; different field intervention measures for mental crisis shall be taken based on different mental health status; follow-up visits and assessment shall be carried out after intervention.
Efforts shall be made to participate in and guide the establishment and construction of hygienic facilities at concentrated settlement places; instructions on assessment, collection and transportation of human and animal excreta, domestic and industrial waste water and solid waste at the settlement places shall be given, and vector control and environment disinfection shall be implemented; temporary health and anti-epidemic stations shall be established for implementing common diseases, registration and report of infectious diseases, surveillance and guidance on drinking water, food and environment hygiene, and propaganda of health and disease prevention, even registration and report of syndromic surveillance if necessary.
Training shall be provided for working personnel who will participate in emergency treatment with carry-on safety manuals; safety risks that might be encountered and necessary precautions shall be informed in advance; required personal protective equipment including personal protective clothing, protective goggles, respirator, gloves and disinfectant shall be provided; if necessary, vaccine injection and preventive medication can be implemented.
The restoration and reconstruction stage means the stage when service system and capacity have not recovered yet. The work focus during this stage is to restore the working order of disease prevention and control, gradually enhance working capacity of disease prevention and control, and alleviate and lighten the public health risks that might be brought by earthquake disasters.
Medical capacity and demands of health organizations in the disaster areas, current situation and demands at settlement spots in other aspects such as medical and health services, drinking water and environment hygiene, food safety and nutrition, surveillance and control of vector organism and health education, and health service demands of special groups (including the disabled, children, the old aged, pregnant women and breast feeding women) shall be assessed continuously; and strategies for restoration and reconstruction shall also be adjusted from time to time. In addition, evaluation on restoration project effect shall be carried out for enhancing project efficiency.
According to the actual situation in the disaster areas, a network of infectious disease surveillance shall be planed and designed in a scientific way, for the purpose of ensuring epidemic surveillance and report system covering all temporary and permanent medical units and communities. Through the restoration and reconstruction of the surveillance and report network, the capacity of infectious disease surveillance and early-warning can be enhanced continuously and case clusters or outbreak symptoms can be found and identified base on establishment of a system for instruction, training and supervision of infectious disease epidemic reports and for analysis and discussion of epidemic situation.
Endeavor shall be made to elevate technical means for identification of infectious disease outbreak and identification capacity; procedures and norms for investigation and control of infectious disease outbreak shall be improved; recruitment of professional personnel shall be carried out and timely training on epidemiology shall be provided in a timely manner; technical equipment for diagnosis and examination capacity of key infectious disease in laboratories shall be enhanced; technical reserve and capacity for integrated utilization of various means such as controlling infection sources, cutting routes of transmission, vaccination and public education shall be intensified; risk assessment on infectious disease and risk source control shall be carried out continuously for decreasing the frequency of infectious disease outbreak.
Routine plans and schemes for surveillance and control of vector organisms shall be developed; simple methods available in local areas for density surveillance on mosquitoes, flies and mice shall be selected and according to surveillance results, disinfection strategies can be adjusted from time to time; efforts shall be made to participate in planning and hygienic evaluation of buildings, allowance shall be made for proper configuration and management of toilets and garbage, so as to reduce the breeding places and breeding of mosquitoes and flies; the patriotic heath activity shall be advocated and carried out and technical support shall be provided; instruction on personal protection from vector organisms shall be given to the public.
The nosocomial infection control shall be included in normal management and operation of organizations for nosocomial infection control shall be restored so as to carry out the routine nosocomial infection control; prevention and control of infectious disease in hospitals shall be strengthened, meanwhile the system of disinfection, separation and protection shall be strictly followed and medical waste and nosocomial sewage shall be treated according to relevant regulation; the comprehensive medical organizations shall be selected to establish infectious disease zones for giving medical treatment to infected patients in a concentrated way; the disinfectant rooms which could offer services to other medical organizations shall be provided or reconstructed in those comprehensive medical organizations; training on disinfection, separation and protection of medical staff shall be strengthened and health education for infected patients and caretakers shall be offered.
Efforts shall be made to instruct and participate in selection of permanent water sources and hygienic evaluation on facility construction; routine monitoring and assessment on key water supply facilities shall be carried out in a sustainable way; and popularization of knowledge about safe drinking water shall be promoted.
Assessment on environmental health situation shall be conducted; instructions on water source protection, disposal of domestic garbage and excreta, environmental cleaning, disinfection, insect elimination and deratization shall be given for doing this work well; propaganda shall be carried out in the public for mobilizing and guiding the private entities to participate in protection of environmental health.
Post-disaster food inspection and safety risk assessment for key objects such as catering industry, cooked food processing industry, settlement spots and canteens of external aid teams shall be carried out; participation in disposal of food-poisoning events shall be realized; and instructions on proper dining habits shall be given to the public.
Public health laboratories shall be reconstructed and restored gradually, for the purposes of conducting inspection of serious infectious diseases and inspection of drinking water and food and providing laboratory supports for post-disaster disease prevention and control.
TB prevention and control shall be recovered in disaster areas, for the purpose of ensuring the subsequent treatment and management of TB patients who were under treatment before disaster; newly infected TB patients shall be identified and reported in time so as to standardize medical treatment and management.
Comprehensive assessment on immunization planning shall be conducted regularly; management on immunization planning materials shall be restored; efforts shall be made to restore and reconstruct immunoprophylaxis and vaccination stations equipped with vaccination personnel, restore cold chain operation and promote quick restoration of children’s immunization services; surveillance on vaccine-preventable diseases shall be implemented and mass vaccination or strengthened immunization shall be organized and carried out in time.
Medical treatment of AIDS patients who have accepted antivirus treatment and methadone out-patients shall be given a priority; follow-up survey and intervention on existing persons infected with HIV and AIDS patients shall be carried out from time to time; construction and network direct report shall be restored.
A rapid assessment on material and child health resources and service object demands shall be conducted; reconstruction of a network system of basic maternal and child health service shall be completed as soon as possible and especially the restoration of basic maternal and child health care services shall be given a priority; personnel recruitment and training on medical knowledge and skills shall be carried out; materials for education on maternal and child health care shall be prepared for the purpose of carrying out public health education on maternal and child health; the information network of maternal and child health shall be recovered or reestablished.
Surveillance and assessment on nutrition status of key groups such as children, pregnant women shall be carried out so as to put forward appropriate measures for guarantee and intervention.
data of patients of chronic diseases such as hypertension and diabetes shall be sorted and registered; instructions on rational use of medicine shall be given to patients for cultivating a healthy lifestyle; services such as measuring of blood pressure and blood sugar shall be offered to key objects; Propaganda education on proper diet, mental health and abstention from smoking and alcohol shall be carried out for forming a supporting environment conducive to the healthy lifestyle.
（ii）Mental health care
In settlement places and schools, mass mental health education shall be carried out in forms of giving lessons, lectures, propaganda materials and entertainment; training shall be provided for teachers, medical staff and management personnel at settlement spots to enhance their capacity of identifying mental barriers; and those persons who need further mental intervention shall be treated by psychiatrists or accredited psychotherapists.
Public propaganda and education shall be carried out, for the purposes of strengthening the awareness of preventing various accident injury resulted from traffic accidents, heat stroke, dog bite, carbon monoxide poisoning and fire-fighting power utilization; safety measures such as advocating dog management, disinfectant management, high-temperature working management, care of the old aged and kids, safety railing along water body and warning setting on dangerous zones in buildings shall be taken.
A mechanism of health education at counties, towns, villages and concentrated settlement spots in disaster areas shall be established and improved; assessment shall be conducted to determine health problems to be solved in priority, targeted groups and core information for spreading.
Efforts shall be made to participate in hygienic evaluation on key public facilities and construction projects.
IX. Carrying out Study on Health Impact Caused by Earthquake and Post-disaster Health Emergency Assessment
Post-disaster public health risks shall be monitored and tracked for a long term; a scientific analysis of direct and indirect effects on public health in disaster areas caused by earthquake shall be carried out and relevant risk factors shall be identified; a comprehensive assessment and summary of experience and lessons about post-disaster emergency health rescue shall be conducted; and a further specific assessment and study shall also be carried out.