Prevention & Control of Communicable Diseases During

and After The Flood; Kelantan Experience..

Dr Fauziah bt Mohd Nor

Public Health Physician

Senior Principle Assistant Director

CDC Unit, Kelantan State Health Department

10th

JOHOR SCIENTIFIC MEETING 2015

6 October 2015

Outline of Presentation

Introduction

Common Diseases Related to Flood

Risk factor of CD & Factors Favouring Diseases Outbreak

Kelantan Experience;•Prevention & Control Activities•Overview of Communicable Diseases Related to Flood.

Introduction

• Flood are the most common natural disaster inboth developed and developing countries, and theyare occasionally of devastating impact, as thefloods in China in 1959, Bangladesh in 1974 and thetsunami in Southeast Asia in December 2004 .

• Their impacts on health vary between populationsfor reasons relating to population vulnerability andtype of flood event (Epidemiologic Reiew.2005:36-46,http//epirev.oxfordjpurnals.org/)

• Flooding is associated with an increased risk ofinfection. However, this risk is low unless there issignificant population displacement or watersources are disrupted (WHO : 2007)

• Eg: Measles’ outbreak in Sudan 1980 - due to flood complicatedby population displacement & cholera outbreak (01, El Tor,Ogawa) in India 1998

Common Communicable Diseases related to flood

Flood could increase the transmission of:

• Water-borne diseases, such as typhoid fever, cholera, hepatitis A & Leptospirosis

• Leptospirosis –zoonotic diseases contracted through contact of skin and mucous membrane with water or environment contaminated with infected animal urine ;esp.rodent(rat)

• Flooding facilitated the spread by proliferation of rodents which shed large amounts of leptospires in the urine

• Outbreak of Leptospirosis occurred in Brazil (1983,1988 & 1996), India (1999) & Thailand (2000)

Common Communicable Diseases related to flood

Flood could increase the transmission of:

•Vector-borne diseases, such as malaria & dengue – stagnant water promote breeding sites for mosquitoes.

•Heavy dust- increased risk of respiratory infection

•Infected soil- increased risk of melioidosis

Key Factors in Prevention & Control of Communicable Diseases Post Flood;

•Factors causing them@ risk factor•Mode of Transmission•Management of Infectious/Communicable Diseases•Preventive intervention to control the spread of the Communicable diseases

Risk factors of Communicable Diseases

1. Presence of pathogens• Typhoid is endemic in Kelantan• Incidence of leptospirosis increases in Kelantan since 2014 (before flood)

2. Displacement of population Kelantan -312,000 people evacuated to gazetted evacuation centre

3. Change in environmentIncrease risk in transmission of diseases such as contamination of water due to cross contamination between water source & sewage line

4. Disruption of basic public utilities • include water pipe line, water source (open/tube well) or sewage system- causes FWBD.

5. Lack of basic health services- service disruption

6. Food Shortage- malnutrition and prone to infection

Factors Favouring Disease Outbreak

•Compromised sources of water

•Displacement of large numbers of people

•Temporary sheltering/evacuation centre in crowded conditions

•Inadequate sanitation

•Compromised waste management

•Potential food shortages•Malnutrition/malnourishment

•Level of immunity

•Ongoing outbreaks prior to flood

Kelantan Experience;

Prevention & Control of

Communicable Disease

During & After Flood…

Establishment of Health Team at Flood Operation Centre

• Flood operation centre at state level was immediately activated when flood involved two districts.

• Large Flood 2014 (Bah Kuning):• Kelantan has experienced a large flood from 18th

December 2014 till 5th January 2015.• Seven teams was formed under Flood Management Committee at state level and health team was one the committee members.

• Operation centre was running for 24 hours/day, and the staffs in charge had been scheduled according to shift system (8 hourly/per shift)

Oganization chart of Flood Operation Centre

Term of references of health team at State Level

• Epidemiology & surveillance of diseases• Establish disease surveillance system• Monitoring and Evaluation disease control activities; using designated form (Guidelines of Flood Management, KKM 2008)

• Ensure stockpile for disinfectant, abate, chlorine, PPE, and health education materials are adequate

• Monitoring of disease control activities at evacuation centres

• Necessities health staffs deployment either from local and outside Kelantan to utilised the services at evacuation centre and community (flood area).

• Monitoring of staff welfare in term of psychological preparedness in doing their routine activities

Task of Surveillance and Rapid Response Team (Health Team)• Rapid assessment of epidemic-prone infectious diseases at evacuation center and community affected flood.

• Enhance existing surveillance system• Daily monitoring of IID , ARI ( health clinic)• Daily monitoring of AGE cases in hospital ( A& E & wad)

• Lab surveillance for FWBD; stool sample taken for every 4th AGE cases at health clinic. 560 sample taken; no cholera & 4 +ve rotavirus.

• Daily monitoring of Leptospirosis cases and ICU cases for anticipation of severe cases.

• Establishing surveillance in evacuation center • Investigation and control of infectious diseases• Follow up on the implementation of sanitation and health measures

Prevention & Diseases Control Activities at Evacuation Centres Evacuation centres with > 1000

flood victims : static team should be placed for 24 hours

Evacuation centers with 500-1000 flood victims : mobile team should be placed for 8 working hours

Evacuation centers with < 500 flood victims : Daily visit by mobile team

Monitoring of disease at evacuation centres- data collection format

DaerahPusat Pemindahan

Banjir (Nama)

Jenis Penyakit Berjangkit

AGE ARIKonjunctivi

tisSkin

Infection

Demam(Tiada

SimptomLain)

HFMD Typhoid**Lain-lain

PenyakitBerjangkit

Leptospirosis

ChickenPox

Denggi

HarianKumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Harian

Kumulatif

Gua Musang

BALAIRAYA ARING 0 0 0 0 0 0 0 9 0 3 0 0 0 0 0 0 0 0 0 0 0 0

Kel(11/2)

0 539 0288

10 94 0

2030

0178

00 0 0 0 0 0 0 0 0 0 0 0

Task of Health Team During Flood (District)

• To ensure the evacuation centers are clean and healthy

• To keep updated regarding the number of the victims at the evacuation centers

• To detect the presence of LILATI & their breeding areas and subsequently act accordingly

• To ensure the safety and hygiene of the basic facilities such as toilets and disposal areas

• To investigate any reported communicable diseases among victims at the evacuation centers and to do the preventive measures

• To perform disease control measures at the evacuation centers such as disinfection of the premises

• To deliver the information regarding health education especially on infection control, self-hygiene and food safety

• To cooperate with other agencies to ensure the evacuation centers are always safe and clean

• To provide daily report regarding the activities of the health team team to the CPRC

Prevention & Control of Communicable diseases: Post Flood

• Increase Surveillance And Disease Control Activities • Identifying Common Health Risks • Risk Communication Of Related Diseases;

• Health education activities• Media ( radio, TV and press release)

• Improving Sanitation And Hygiene • Water Supply Chlorination • Food Safety Activities • Sanitation assessment at the flood affected areas especially

involving basic infrastructure such as safe water supply (GFS, private/regulated well), toilet, as well as water supply to the estate (bekalan air ladang)

• Implement remedial action on affected basic health infrastructure at the flood area

• Proper disposal of the flood wastes and carcess in order to prevent breeding places and environmental pollution.

Monitor The Health Status of Staff & Volunteers

• Distribution of health alert card

• Checklist monitoring the health status of staff and volunteers

Task of Health Team After Flood (District)

• To provide risk assessment regarding fWBD and assess the level of destruction of sanitation and its related facilities at the affected areas such as toilets, GFS and wells. Water samples taken will be analyzed within 24 hours and action is to be taken immediately

• To perform chlorination of the all water supplies (at least 0.5ppm)

• To restore the affected health-related basic facilities as soon as possible

• To assess the standard of safety and hygiene of food premises in order to restart the operation

• To assess the environmental hygiene in order to control the presence of LILATI

• To destroy all the dead animals and related biological wastage that can contribute to infections

• To involve with surveillance regarding the occurrence of communicable diseases among the victims such as leptospirosis, food water borne diseases and vector borne diseases.

• To deliver health education to the population at the affected areas.

• To do assessment on the evacuation centers to ensure they are clean and safe to be operated normally

New strategies: Flood Preparedness Dealing with Unexpected Events..

•Formation of Public Health Response Team-(PHRT) –lead by Public Heath Specialist• to increase the level of preparedness toward flood related diseases.

• the team will be equipted with transport, instruments eg; spray can,fogging machine, PPE,mobile tank, sleeping bag,life jacket & food ration.

• The team members will be trained for special survival and disaster preparedness course

Activities Number

Sanitation Inspection- No of villages visited- No house visited

1956 (100%)71,283 (100%)

Chlorination 42,725 (100%)

Premise disinfection 30,477

Vector borne control-Larvaciding-Fogging

3,0444,500

Lilati control 3,854

Health promotion- Talk- Individual advice &

demonstration- Public Announcement- Distribution of

flyer,bunting & banner

1265,38706,32960,918

Distribution of Hand Sanitizer

1,700(60ml),2,190(500ml)

Prevention And Control Activities during & After Flood 2014

Premis

No.

Inspection

done

Rating

<50%50-

75%

76-

100%

Restaurant 131 0 51 80

Food loft

(Gerai)111 0 43 68

Canteen/

kitchen370 0 63 307

Food

Factory77 9 5 63

Total 689 9 162 518

Food Safety ActivitiesFlood affected premises had to dispose all

food that being spoilt due to flood

Food premises being inspected for ensuring

that premises were able to operated without

compromised of food safety and quality

Involvement of Intra and Interstate Agencies including NGOs in Prevention & Control of CD.

• Deployment of health staff for heath team from other state -500 personel including from JKN Johor

• Management of domestic Sewage conducted by local authority and assisted by volunteers from other states & NGOs

Challenges: Control of Infectious Diseases During & After Flood in Kelantan

•Disrupted Water Supply

•Water Contamination

•Environmental Contamination•Domestic sewage, animal carcass

•Lack of stock pile for chlorine, disinfectant & hand sanitizer

•Inaccessible area due to disrupted road /transport issue- delayed in prevention activities

•Lack of Human resources • > 30% of Health staff- flood victim

Flood Related Communicable Diseases In Kelantan 2014/2015

0

200

400

600

800

1000

1200

1400

EW 46

EW 48

EW 50

EW 52

EW 1 EW 3 EW 5 EW 7

No

of

Cas

es

Epid Week

Flood2014 2015

Flood

AGE cases 3 fold increased (600-1200/week post flood compare 300 cases before flood)

Post Flood: consultation rate of AGE cases increased.

Trend Of Age Cases And Consultation Rate – Pre And Post Flood

One episode of FP ( evacuation centre) dan no cholera cases reported

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Kelantan 24. 7.4 56. 4.6 8.5 3.2 4.7 2.8 4.8 1.7 2.5 2.1

Malaysia 3.1 1.8 4.1 0.7 1.2 0.7 1.0 0.7 0.9 0.7 0.7 0.7

0

10

20

30

40

50

60

IR/1

00

.00

0 p

op

Years

Comparison of Typhoid Incidence in Kelantan & Malaysia;2003-2014

Typhoid fever still endemic in Kelantan and the incidence rate - highest in Malaysia.

Number Of Typhoid Cases; Kelantan,2003-2015 (EW 38)

361

110

888

74130

72 8346 72

31 42 35

130

0

100

200

300

400

500

600

700

800

900

1000

No

of

Cas

es

Typhoid cases increased in 2005 related to large flood in 2004

2015, typhoid cases also increased compared to cases in 2010-2014, most probably related to large flood 2014

0

2

4

6

8

10

12

14

16

36 39 42 45 48 51 2 5 8 11 14 17 20 23 26 29 32 35

No

of

case

s

Epid Week

2014

2015

FLOOD 2

014

Number of Typhoid Cases in Kelantan 2014/2015(EW38)

0

50

100

150

200

250

45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

No

of

case

s

Epid Week

20052004

Number of Typhoid Cases in Kelantan 2004/2005

FLOOD 2

004

Typhoid cases did not increased immediately after flood.2015; the number of typhoid cases started to increase in Epid Week 25, which was 6/12 after flood , the same situation occurred in 2005….4/12 after flood.

2015

Why Typhoid still ongoing ?... Endemic in Kelantan

• Healthy Carrier• Cases have not been clean-up• Personal Hygiene• Vaccination for food handler• Food Premises • Sanitation/Water supply

E

A H

A

A

H

H

E

Prevention & Control of Typhoid

Strengthen of The Typhoid Initiative program (2005) with focus on :

• Health Promotion

• Surveillance & field control

• Management of cases, contact & carrier

• Environmental sanitation

• Chlorination• Safe water supply

• Safe food practices

• Food premises inspection

• Anti typhoid vaccination for food handler

• Enforcement of Food Hygiene Regulation 2009

• Involvement of other agencies; eg Education department, Local Authority (PBT) etc.

No. o

f Cas

es

Epid Week

22

49

71 71

89 87

59

34

72

6067 65

4751

4144

29 2722

2934

16

32

42

27

40

22

34

2430

33

57

27

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

240

250

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

KEJADIAN LEPTOSPIROSIS MENGIKUT MINGGU EPID 2014(MINGGU UPDATE KEPUTUSAN)

Daftar Notifikasi 2015

Daftar Kes 2014

Daftar Kes 2015

Epidemic Level

Epidemic level

2015FL

OOD

201

4

Number of Leptospirosis Cases in Kelantan 2014 – 2015 (Epid Week 33)

• Leptospirosis in Kelantan start to increase at EW 34/2014.

• Leptospirosis cases increased by 3-fold after flood,thenreducing in trend but still above epidemic level (26 cases/week)

• Till EW 33- 1386 cases were reported compared to 447 Cases in 2014

Prevention & Control of Leptospirosis

Risk factor for leptospirosis In Kelantan ;

Poor environmental sanitation (presence of rats)

Occupation related to agricultural

Action focus on:

Health promotion

Advice on using PPE

Early detection &

treatment

Melioidosis

• Meliodoisis is not included as a notifiable disease under CDC Act 1988, administrative instruction to report began in January 2015.

• No significant increase of melioidosiscases related to flood in Kelantan

• Till EW 38; 17 cases of melioidosiswere reported whereby 8 cases were reported 2 month after flood and only 3 cases were related to flood

Dengue cases – Pre And Post Flood

23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

2014 & 2015 59 88 16 20 22 50 79 90 56 11 13 12 97 83 72 49 40 32 17 18 13 93 88 10 88 78 82 75 56 41 16 32 79 75 59 59 63 37 30 29 28 22 16 19 7 16 23 9 13 15 19 19 14 11 33 62 58 63 47 79 98 13 14 13

0

100

200

300

400

500

600

700

800

900

1,000

1,100

1,200

1,300

1,400

No

of

Ca

ses

Epid Weeks

• Dengue cases was not increased after flood 2014.

• The number of cases start to increase in EpidWeek 29, that was 2 weeks after Hari Raya AidilFitri.

• The increasing cases probably related to the influx of Kelantanase from Klang Valley to celebrate HariRaya in Kelantan.

FLOO

D 2

014

HARI RAYA

Number of Dengue Cases in Kelantan

2014 – 2015 (Epid Week 33)

2014

2015

Haze Post

Flood

Flooding areas were left with thick yellowish mud• It would dry up and became flying dust

Effect of dust• Eye irritation• Skin irritation• Respiratory effect (runny nose, cough, shortness of breath)

Advice to public • Reduce outdoor activities• Wearing face mask when doing cleaning activities • Drink plenty of water

Rate Of Acute Respiratory Infection – Pre And Post Flood

20152014

Increased trend Of ARI Post Flood, then reducing trend but increased at EW 29 & 30, most probably due to hot weather and dust…

FLOO

D 2

014

Proper placement of evacuation centre

Adequate sanitation

Adequate personal hygiene/using PPE

Vector/Lilatin control

Provision of clean water/Chlorination

Health education

Adequate and clean food

Factors that play key roles in controlling communicable diseases related to flood

Controlling communicable diseases related to flood; Adequate preparednessRisk assessment and hazard management

Conclusion

Strengthen the prevention & control activities Pre, During & Post Flood.

Thank you very much…