An unprecedented cholera outbreak affected Zimbabwe from August 2008 to July 2009 with 98,592 cases and 4,288 deaths, in 54 out of 62 districts. The main strategy used to overcome the outbreak was an integrated community-based interventions package. The present work is a case study to describe the strategy and lessons learned for future humanitarian crises and preparedness. The methodology was based on the review of epidemiological reports, assessment and surveys' reports, minutes of joint Health and Water Sanitation and Hygiene (WASH) Clusters' meetings, and direct observation as Health Cluster Coordinator. Epidemiological data showed an increasing number of cases in rural areas with community deaths representing 66% of the 1,948 deaths from 61,304 cases on 31 January 2009. Risk factors identified in communities were: lack of awareness about the disease, cultural and religious behaviors, lack of potable water with weak sanitation, lack and inappropriate use of water purification tablets, and lack of soap and water containers for effective behavior change. There also was late arrival to cholera to the few treatment centers by rural populations. In addition to treatment centers, a package of interventions was implemented by multi-sectoral stakeholders. The package included: health and WASH education tools and practice sessions for healthy and hygienic behavior change and for an effective use of oral rehydration salt as first aid measure; community-based surveillance with an early warning system and response teams; and distribution of containers and water purification tablets with drilling of water points. Epidemiological data showed a significant decrease of cholera cases where the full package was implemented. This work showed that an integrated package of interventions jointly targeting risk factors can be effective on public health threats in rural communities. Community-based preparedness and response should then take into account an integrated joint intervention package to mitigate public health threats.

The post-disaster response strategy in The Netherlands is unique in that it links scientific institutes, national government and local emergency response organizations. The lynch pin is the Centre for Environmental Health which was founded by the Ministry of Health to improve post-disaster care in The Netherlands. The recently refined Dutch strategy for post-disaster response will be presented and illustrated with a few examples from recent disasters. We will focus on both the role of the Centre and the role of public health Hazmat advisors who are part of the local emergency response organization. The latter advise on the health risks of exposure to CBRN agents. One of the main objectives of the Centre is to prepare guidelines and a structure to ensure transparent and authoritative advice is given to local governments and public health services on the need and value of post-disaster care. The Centre operates a front office, available 24/7, to deliver integrated advice on public health and psychosocial care to local emergency response organizations. A network of experts with a wide range of expertise is on stand-by, whereby the characteristics of the disaster determine which experts compile the advice. The Centre also works closely with several other advisory organizations within the national emergency response organization. Three kinds of advice are delivered. Firstly, as an immediate response (usually within an hour), advice is given on the registration of victims. Secondly, usually within 24 hours, advice is given on the need and value of a health outcome assessment (HOA). Thirdly, if a HOA is decided on, detailed advice is given on its implementation. Another objective of the Centre is strengthening the unique position of regional public health services to deal with post-disaster care. The Centre produces guidelines, tools and training on demand to achieve harmonization and uniformity among these services.

War, conflict, and complex emergencies are major contributors to the crisis of human suffering with impacts on health, public health infrastructure, food security, economic viability, community infrastructure, and social fabric as well as the environment. Conflict mitigation and resolution are essential to the recovery and restoration of the community and health. Public health can serve as a mechanism to mitigate the impacts of conflict, serve as a bridge to resolve conflict and provide community resilience. The role of health care professionals as a “Bridge to Peace” is a critical component of conflict resolution. Health as a Bridge for Peace was formally accepted by the 51st World Health Assembly in May 1998 as a feature of the “Health for All in the 21st Century” strategy and has been demonstrated across a wide range of conflicts. Public health has attributes that make it a valuable platform for conflict resolution: it is broad, population-based, affects all parties, benefits both individuals and society, valued by recipients, and supports Universal Values. Public heath can be utilized in pre-conflict, conflict, and post-conflict situations and has been used in more than 20 conflict scenarios with Humanitarian Cease-fires, Days of Tranquility, and Safe/Peace Corridors supporting programs such as childhood vaccination days in Afghanistan to Guinea Worm Eradication in East Africa.

Triage of disaster and trauma victims is challenging, especially when responders have limited resources and brief periods of time. Over-triage of victims results in the consumption of resources that would be better utilized on more critical patients, and under-triage can result in increased mortality and/or morbidity, as victims do not receive the appropriate care. In addition, the same patient may be triaged multiple times as they move through echelons of care. These different echelons may have different objectives in the triage process Over the years, multiple triage schemes have been proposed and used, both in exercises and real events. None of these schemes is based on well-defined research, due to the difficulty of carrying out a randomized control study in real events. There has been a concerted effort to apply research findings in a effort to more effectively use resources and thus, improve patient outcomes as well as apply information garnered from after action reports. This presentation reviews the current issues and state of triage for disasters and mass-casualty incidents, drawing on examples from prior events. The ultimate objective of this presentation is to help the responder to better understand the process of triage and apply it to their clinical practice, thereby delivering care in an effective and timely manner.

The history of triage started from the French battle field. In- hospital ED triage started in early 1960's from Baltimore. It is now an essential component of modern ED. Triage is not only to sort out patients as per their criticality, but it also serves the purpose of streamlining the patients so that the patient receives right treatment at the right time in the appropriate area. It helps to manage the ED overcrowding by better flow of patients. AKUH-ER experience of triage dates back to the year 2000, when triage was conducted by physicians and there used to be a manual documentation of patient's particulars such as complaints, vitals and BP. With the expansion of AKU-ED in 2008 responsibility of triage shifted to nursing services. Triage policy was drafted and implemented and for guidance and uniformity of care, triage protocols were developed. Another important development is replacement of register with triage data entry software. This help us to monitor some indicators like number of patients triaged, the time between triaging and actual bed assignment, triage categorization, length of stay, dispositions and return visits. The available information now helps us to make decisions based on evidence and also paves the way for future direction.

Speed and accuracy are major considerations in triage in emergency field settings. Traditional physical examination techniques often are limited in detecting the true nature and full extent of internal visceral injuries, for which delayed recognition and treatment may lead to catastrophic results. Ultrasound has a well-established role in the rapid initial assessment of intra-abdominal pathologies, including trauma, and contemporary portable ultrasound machines are available for use in the field. This presentation will introduce the basic principles of diagnostic ultrasound and its use in emergency settings. Common clinical applications and pathologies and potential limitations and pitfalls also will be discussed with image illustrations.

Most emergency medical response systems rely on paper triage tags and clipboards to share information during mass-causality incidents (MCIs). However, this procedure has proven labor-intensive, time-consuming, and susceptible to human error. Previous research about electronic triage depend on a small movable device, which can be costly. Therefore, an electronic triage system was developed to facilitate effective patient care during an emergency. In this paper, the design, development, and deployment of an electronic triage system for use by rescuers responding to MCIs and disasters will be discussed. The electronic triage software runs on a small, embedded system with limited memory and computational power that efficiently saves patient records. The software system is easy, user-friendly, can be used with any computer, laptop, or iPhone, and it is applicable in all hospitals. This system includes three interfaces: (1) electronic triage tags depending on the Simple Triage And Rapid Treatment (START) triage protocol; (2) the Sort Triage interface; and (3) the Evacuation interface, which includes hospital information such as the Hospital Treatment Capacity (HTC) and the Hospital Surgical Capacity (HSC). It also includes doctors information and hospitals and doctors can be alerted via e-mail. The system also has a database records file for patients that can be saved then immediately sent to hospitals and rescue centers. The electronic triage system will lay the foundation for reliable and continuously updated network coverage during a MCI. It also will help technologists develop future emergency response systems.

Emergency Services in catastrophic flooding in Poland (2010 experience) Przemyslaw Gula MD PhD, Edyta Szafran Institute for Emergency Medicine Flooding, Natural Disasters, Rescue Operations Between 17th May and 22nd June Poland faced one of the most catastrophic natural disasters in past 100 years history. The overall area of 779300 sq km. has been flooded. The flood affected several large municipalities. Nearly 270.000 people suffered the direct effects of the flood and 31000 were evacuated from their homes, 22 people were killed. Total number of 19000 buildings were destroyed or seriously damaged. Responding services were mainly the Fire and Rescue Service, Police, EMS, Military Units as well as supporting NGO's. The rescue and relief operation focused on evacuation, providing temporary shelter, water supply, establishing medical treatment and vaccination, providing public security. One of the challenges was the threat of evacuation of the hospitals in the affected areas. The total number of 80000 of rescue personnel and 15000 of military was involved in the rescue operation. The medical emergency operation included helicopter and boat evacuation, organization of field medical posts and secondary medical transfers. 43 helicopters and 1.000 vehicles were used. One of the problem was the collapse of the telephone network that affected the 112 Emergency Dispatch System. The out coming conclusions presented the high vulnerability of local medical systems on the effects of flooding. However the logistic support of Fire and Rescue and Military recourses can give quick compensation. The role of HEMS and SAR helicopters in providing evacuation and medical assistance is essential. Special emphasis should be made on providing the coordination of multiservice response and replacing the affected local communication systems. The main conclusion after flooding was the need of stronger integration of civil and military services, procedures, communication systems and compatibility of the equipment.

A Flood disaster struck the Islamic Republic of Pakistan in July 2010. It affected 3 million people and caused 1,400 deaths. Humanitarian Medical Assistance (HuMA) is a non-profit organization in Japan. The organization dispatched three personnel to Islamabad on 20 August in order to conduct an initial needs assessment. They discovered that medical assistance and supplies could not reach all of the victims, especially in the North. Their visits to the surrounding regions highlighted the Nowshera district of KPK province, which had not received enough assistance from the government or aid organizations despite the fact that there were thousands of Internally Displaced Persons (IDPs) with health issues such as diarrhea, eye and skin disease, and upper respiratory tract infection (URTI). On 03 September, the HuMA Disaster Relief Mission began with the purpose of providing medical treatment and promoting public health for the flood victims in the Nowshera District. Eleven medical providers and coordinators from HuMA operated field mobile clinics in the district in collaboration with a local counterpart non-governmental organization, Nippa Welfare Association (NWA). This project was supported financially by the grant funding from Japan Platform. Humanitarian Medical Assistance served seven sites in Nowshera Districts as mobile field clinics, and consulted 2,216 patients. Total distribution of disease was: (1) URTI = 18.1%; (2) skin disease = 17.9%; (3) musculoskeletal = 15.2%; and (4) others = 19.7%. The team considered continuous medical consultation in the Nowshera District after 2010. The HuMa medical activities ended at the end of September, and the organization donated multi-vitamin tablets, syrups, FE tablets, and anti-biotic cream in order to assist NWA's continuing assistance for the affected communities. The medical providers also left lists of medicines for local doctors and medical staff. Humanitarian Medical Assistance also provided basic supplies needed to prevent victims from experiencing further sanitation problems.

Floods are among the most common hazards in the world and can result in a devastating impact on human life and property. The impact of floods on humans can be traced directly to factors such as the location and topography of the area, as well as demographics and characteristics of the existing environment. Pakistan is currently facing the worst humanitarian crisis in history. It is faced with daunting challenges of reviving and reconstructing almost one fourth of the population. Latest government figures indicate that over 14 million people have been affected by the floods. More than 1.5 million cases of diarrheal diseases have been reported so far. Over 235,000 people have been treated at the diarrhea treatment centers set up in the aftermath of the floods. Floods are unique in their nature since every region is characterized by diverse factors. This paper examines closely the diarrheal outbreak in the flood-ravaged provinces of Pakistan. The study looks at the extent of spread of diarrhea across different time periods through a comparative analysis of different provinces affected. There are many direct factors that affect the severity and scale of floods and, in turn, impact human health like contaminated water, cramped living conditions and lack of sanitation facilities. The paper explores the pre-existing indirect factors responsible for the spread of outbreak in the provinces. These range from geography, socio-economic conditions, demographic features, topography, and community infrastructure. These factors play an extremely pivotal role in determining the nature of response required to control the diarrheal outbreak.

The impacts of disasters on the community are not necessarily determined by the scale of a disaster, but are influenced significantly by the preparedness of the community, including the health community. Resilience is a dynamic quality within a community that is developed and strengthened over time. Evidence of the Western Australian (WA) health system resilience was demonstrated on 22 March 2010 when two severe weather fronts crossed the Perth metropolitan area and severely impacted a significant number of hospitals, the State pathology service, radiological services in tertiary and secondary hospitals, as well as aged care, mental health and other key health facilities. This storm has resulted in more than 120,000 claims and the total estimated cost is expected to exceed 1 billion Australian dollars, making it the most costly disaster due to natural hazards in WA history. Damage to these facilities included: (1) flooding, ceiling collapse, and broken windows in intensive care units, emergency departments, and operating theatres; (2) loss of radiological services; (3) sewerage inflow into wards, resulting in evacuation of mental health inpatients; (4) infrastructure damage to aged care facilities requiring relocation of residents; and (5) extensive loss of electricity and communications throughout Perth, which impacted on home oxygen therapy clients. A public health response also was required due to sewerage overflow into Perth's main river systems. This presentation will provide an overview of the event, lessons learned and how these lessons learned will be used to further enhance the health community's resilience.

The winter of 2009 brought the worst disaster caused by a natural hazard in the history of the state of Arkansas. An ice storm spanned the entire northern half of the state, leaving thousands without electricity, heat, transportation, health care, and in some cases, shelter, food, and water. In one county alone, > 13,000 power poles were destroyed. The infrastructure was severely damaged. In the University's arena, a shelter was opened by the Red Cross in partnership with the Medical Reserve Corps (MRC) to accept special needs victims and provide urgent primary care for shelter residents. The majority of patients presenting to the MRC had more than two illnesses. Examples included diabetes, renal disease requiring dialysis, hypertensive crisis, injuries from the storm, MRSA, respiratory syncytial virus, and mental illness ranging from depression to schizophrenia. Because the Red Cross did not consider ice storms as a reasonable cause for medication/medication supplies, these items were not replaced; this had health consequences of under-managed illness. Oxygen converters were preferred over oxygen tanks; however, the arena was on a generator and not all plug-ins had electricity. An ambulance company loaned the MRC a glucometer so blood glucose levels could be monitored. Those with mental illness required significant time from MRC providers. Largely, the MRC was nurse-managed with physicians or nurse practitioners available for sick call twice a day. Relationships became strained when the state placed a hold on the arena to secure it for a regional shelter. This put the university's financial stability in peril due to breech of contract with vendors scheduled to use the arena. The partnership between these three organizations does remain intact with formal memorandums of agreement now existing. They continue to work together in the community and jointly respond to regional disasters.

On the evening of 07 December 2007, an ice storm occurred in the south central United States, causing severe power outages in Tulsa, Oklahoma, and leaving > 900,000 people without power for up to three weeks. Eighteen states contributed power workers to restore functioning power over a three-week period. Cleanup of debris from fallen trees took an additional five months. Hospitals and other healthcare facilities are considered to be critical infrastructure facilities in the community. During this storm, five of the six tertiary care hospitals lost power. In these hospitals, the internal telephone systems failed, internal suctioning systems failed, and the internal oxygen system failed. Water treatment plants were without power for 48 hours. Nursing home patients were discharged to homes or transferred to hospitals, as nursing homes tried to function without power for heating, patient monitoring devices, or cooking. Communication for these outlying care facilities was disrupted by the storm damage. Hospital emergency departments that had power became havens as they had heat, communication, water, and even warm food. Multiple patients with injuries due to cleaning up tree debris, falls, and carbon monoxide poisoning from ill-advised efforts to heat dwellings were seen in these emergency departments. Ambulance services had fuel shortages early in the course of the ice storm due to the inability to pump fuel (electrically operated pumps initially were non-functional). Three standards of care were altered for prehospital responders. This paper explains the efforts taken to mitigate future calamities, based on the lessons learned from this event.

Socioeconomic impact of “Hurricane Karl” on health facilities in Veracruz, Mexico with a population of 7 million 600 thousand in September 2010 Summary Hurricane Karl, thirteenth tropical cyclone of the season in the Atlantic hurricane of 2010, originated in the Caribbean Sea and slammed into the Yucatan Peninsula as a strong tropical storm, to emerge into the Gulf of Mexico where it gradually reorganized to achieve Category 3 (major hurricane) on the Saffir-Simpson scale and hit the east coast of Mexico on September 17th of 2010. Preparations On September 16th, the Federal Government, Federal Electricity Commission, Laguna Verde Nuclear Power Plants, The Ministry of National Defense, The Ministry of Marine Affairs and human elements and materials deployed for relief to the population. The health sector also was prepared to take appropriate measures under the concept of Safe Hospital PAHO / WHO. Impact In the state of Veracruz (more than 7 million 600 thousand habitants), Hurricane Karl arrived around 11:30 am on September 17th to 15 km north of the port of Veracruz reaching a capacity of 195 km per hour. Torrential rains flooded the streets of the phenomenon and avenues of the historic center of the port, the water reached 40 centimeters to 1 meter in height, to the south of the state and surrounding areas reached 2 meters in height. Caused serious damage since its inception in health infrastructure, such as suspension of public services, damage to the distribution system of drinking water, broken windows and flooding of a hospital as well as several units of Family Medicine.