ENVIRONMENTAL HEALTH "No amount of medical knowledge will lessen the accountability

for nurses to do what nurses do; that is, to manage the environment to promote
positive life processes." Sister Calista Roy, Commentary on Notes on Nursing, 1992
To enable the public health nurse to use the environment to assist the community in
improving its state of wellness, it is necessary to study the various relationships
between the components of the environment and human health. This chapter discusses
the geophysical, social, biological, and built environments of people that affect
their health.In 1998, the Department of Health (DOH), in its Implementing Rules and
Regulations of Chapter XX (Pollution of the Environment) of the Code of Sanitation
of the Philippines, defined environmental health as:The characteristics of
environmental conditions that affect the quality of health. It is the aspect of
public health that is concerned with those forms of life, substances, forces, and
conditions in the surroundings or person that may exert an influence on human
health and well-being.In 1993, the World Health Organization (WHO) described
environmental health through a consultation in Sofia, Bulgaria:Environmental Health
comprises of those aspects of human health, including quality of life, that are
determined by physical, chemical, biological, social, and psychosocial factors in
the environment. It also refers to the theory and practice of assessing,
correcting, controlling, and preventing those factors in the environment that can
potentially affect adversely the health of present and future generations.Note that
environmental health could refer either to the components of the environment that
affect human health or to the components of human health that are affected by the
environment. To provide emphasis that an individual is the client of the public
health nurse (i.e., instead of the environment), this chapter shall take this
definition: Environmental health is the component of the individual's well-being
that is determined by interactions with the physical, chemical, biological, social,
and psychosocial factors external to him or her.As the government takes the
responsibility for providing an environment that supports the right of people to
lead healthy lives, it will seek the various expertise of its members including
that of the public health nurses. The Philippine government takes this course of
action through Executive Order No. 489: Institutionalizing the Inter-Agency
Committee on Environmental Health (IACEH). The member agencies are represented by
the various secretaries and directors of the executive branch of the government,
headed by the Secretary of the DOH as chairperson, and the Secretary of the
Department of Environment and Natural Resources (DENR) as vice chairperson.The
various roles of IACEH specified by law include the task of coordinating,
monitoring, and evaluating environmental health programs initiated by the
government and private agencies to achieve environmental protection for health
promotion. To perform these roles, the National Environmental Health Action Plan
(NEHAP) had been developed.NEHAP identified seven components of environmental
health that will be assigned to the leadership of the members of the IACEH, namely,
solid waste, water, air, toxic and hazardous waste, occupational health, food
safety, and sanitation (SWATOFS). In July 2010, this has been expanded to include
climate change.

ENVIRONMENTAL HEALTH RECORDS MANAGEMENTIn the Philippines, the maintenance of

environmental health records is one of the responsibilities given to city,
municipal, and provincial health nurses. The current data management system being
used by the DOH is the Field Health Service Information System (FHSIS). Data
collection begins with the midwife and the barangay health workers. In the 2008
version of the FHSIS, the midwife is tasked to maintain a monthly record of the
environmental health program accomplishments in the "Summary Table" form. The eight
environmental health indicators that need to be monitored are as follows:
1
2 Households with access to improved or safe water - stratified to Levels
I, II, and III
3 Households with sanitary toilets
4 Households with satisfactory disposal of solid waste
5 Households with complete basic sanitation facilities
 6 Food establishments
7 Food establishments with sanitary permits
8 Food handlers
9 Food handlers with health certificates

At the end of each year, the midwife would have already completed the 12-month
columns of the summary table. On the second week of January of the following year,
the midwife must submit her Annual Barangay Health Station Report "A-BHS" form to
the city/municipal health nurse. The city/ municipal health nurse then consolidates
all A-BHS forms into an annual report of the city/ municipality using the "A1" form
that is due by the third week of January. The provincial health nurse performs the
same task and submits a consolidated "A1" report form of all the cities and
municipalities of the province to the DOH Regional FHSIS Coordinator on the fourth
week of January. The consolidated regional annual reports are submitted to the DOH
National Office on the second week of March that year.

The public health nurse must therefore be abreast with the definition of these
records that must be maintained. The 2008 version of the FHSIS presents the
following definitions:
•
• Households with access to improved or safe water supply - refers to
those covered by or have access to any of the three levels of safe water sources
that conforms to the national standards for drinking water.
• Level I (point source) - refers to a protected well (shallow or deep
well), improved dug well, developed spring, or rainwater cistern with an outlet but
without a distribution system. A Level I facility is generally adaptable for rural
areas where the houses are thinly scattered. It would normally serve 15-25
households and its outreach must not be more than 250 meters from the farthest
user. The yield or discharge is generally from 40 to 140 liters/minute.
The point of consumption of Level I systems is at the source itself, placing the
water reservoir at higher risk of contamination. In the FHSIS, if the Level I
reservoir (e.g. a protected rainwater cistern) is piped into the tap of households,
they are then considered to have a Level III access as the risk of reservoir
contamination is minimized.
•
• Level II (communal faucet system or standpost) - refers to a system
composed of a source, a reservoir, a piped distribution network, and a communal
faucet located not more than 25 meters from the farthest house. It is generally
suitable for rural and urban areas where houses are clustered densely enough to
justify a simple piped water system. For reporting purposes in the FHSIS, Level II
system may also include a communal faucet where a group of households get their
water supply even if the said faucet is connected to a Level III source. The
typical Level II system is designed to deliver 40-80 liters per capita per day to
an average of 100 households, with one faucet per 4-6 households.
The piped distribution network takes the point of consumption away from the
reservoir, thus decreasing the risk of pollution coming from the consumers.
Contamination of water from Level II sources would more likely take place during
its transport and storage in the individual households.
•
• Level III (waterworks system) - refers to a system with a source,
transmission pipes, a reservoir, and a piped distribution network for household
taps. It is generally suited for densely populated areas. This level of facility
requires minimum treatment of disinfection. Examples of this include water
districts with individual household connections. For reporting purposes, a Level
III system may also include a Level I system with piped distribution for household
taps, serving a group of housing dwellings such as apartments or condominiums.
• Households with sanitary toilets - refer to households with their own
flush toilets connected to septic tanks and/or sewerage system or any other
approved treatment system, sanitary pit latrine, or ventilated improved pit
latrine. The national target for this component is 91% (96% for urban and 86% for
rural areas).
• Households with complete basic sanitation facilities - refers to those
that satisfy the presence of the following basic sanitation elements, namely,
1 access to safe water,
2 availability of a sanitary toilet, and
3 satisfactory system of garbage disposal.

• Food establishments - refer to those where food or drinks are

manufactured, processed, stored, sold, or served, including those that are located
in vessels.
• Sanitary permit - the written certification of the city or municipal
health officer or sanitary engineer that the establishment complies with the
existing minimum sanitation requirements upon inspection conducted in accordance
with Presidential Decrees Nos. 522 and 856 and local ordinances.
• Food handlers - refer to persons who handle, store, prepare, or serve
any food item, drink, or ice, or who come in contact with any eating or cooking
utensil or food vending machine.
As food handlers are taken as any human source of food contamination other than the
consumer, the interest of public health nurses as collators and consumers of FHSIS
data is to compare the number of food handlers with the number of those who have
active health certificates.
•
• Health certificate - a written certification, using the prescribed
form, and issued by the municipal or city health officer to a person after passing
the required physical and medical examinations and immunizations.
SOLID WASTE MANAGEMENTThe Philippine Development Plan (PDP) for the year 2011-2016
aspires to get a 50% increase of the solid waste diversion (SWD) rate of 33% level
in the year 2010. SWD refers to activities that reduce, and possibly eliminate, the
potentially recyclable materials in the waste stream before they end up as added
undesirable matter on the land known as land pollution. This act to reduce the
contamination of land supports the work of the public health nurse in enabling the
community to increase its level of wellness, as it necessarily protects some of the
health-supporting functions of land, such as:
1
2 Platform for human activities: Polluted soil may be contaminated with
disease-causing parasites and microbes.
3 Agricultural production: Alteration of soil composition can make the
land unsuitable for growing crops and threaten food security. Hazardous materials
such as cadmium, lead, and mercury from disposed batteries and mine tailings can
accumulate in the land and be present in the harvested products.
4 Habitat of members of the food chain: As hazardous materials accumulate
in the soil; they affect the lower life-forms in a process called
"bioaccumulation." As these creatures in the bottom of the food chain are consumed
by the more superior creatures, hazardous chemicals increase in concentrations in
the food chain in a process called "biomagnification." At the top of the food
chain, the human is at risk of consuming the hazardous materials.
5 Filter for surface water: Natural bodies of water and storm water
percolate through the layers of the soil until it finds its way to the groundwater.
Soil saturated with pollution not only acts as a poor filter but may also
contaminate the seeping water. The nurse in communities that rely on ground water
must be interested in the routine testing of these sources.

Through the definitions used by Republic Act 9003 otherwise known as the
"Ecological Solid Waste Management Act of 2000" and the DOH Manual on Healthcare
Waste Management of 2011, a way by which solid wastes may be classified is as
follows:
•
• Municipal waste refers to all discarded nonhazardous household
commercial and institutional waste, street sweepings, and construction debris.
• Health care waste (or biomedical wastes) refers to the refuse that is
generated in the diagnosis, treatment, or immunization of human beings or animals
together with those related to the production or research of the same. This can be
classified as follows:
•
1 "Infectious wastes" refer to those suspected to contain bacterial,
viral, parasitic, or fungal pathogens in sufficient concentration so as to cause a
disease in susceptible hosts. These include, but are not limited to, laboratory
cultures, contaminated wastes from clients with infectious disease, and any other
dressing, swabs, instruments, or materials that have been in contact with infected
persons or animals.
2 "Pathological wastes" refer to tissues, organs, body parts, human
fetuses, animal carcasses, and blood and body fluids. Within this category,
recognizable human and animal body parts are also called anatomical waste. This
category should be considered as a subcategory of infectious waste, even though it
may also include healthy body parts.
3 "Pharmaceutical wastes" include pharmaceutical products such as drugs,
vaccines, and sera that are no longer required and need to be disposed of
appropriately for any reason. This category also includes discarded items used in
handling of pharmaceuticals such as bottles or boxes with residues, gloves, masks,
connecting tubes, and drug vials.
4 "Chemical wastes" include the varied states of chemical matter from
clinical or laboratory activities, environmental work, housekeeping, and
disinfecting procedures. This subcategory has any of the five properties of
hazardous wastes and is therefore termed as "hazardous chemical wastes."
5 "Sharps" include biomedical wastes that could cause cuts or puncture
wounds. These include, but are not limited to, needles, broken glass, and scalpel
blades.
6 "Radioactive wastes" include sealed radiation sources typically used in
cancer treatments, liquid, and gaseous materials contaminated with radioactivity,
and excreta of patients who underwent radionuclide diagnostic and therapeutic
applications, together with the related paraphernalia and tap water washings.

• Industrial waste refers to the refuse that arise from production and
from agricultural, and mining industries. Aside from rubbish, industrial wastes can
be mixed with contaminated soil, ashes, and hazardous wastes.
• Hazardous wastes are substances that pose either an immediate or long-
term substantial danger to human because of possessing any of the following
properties:
1
2 Toxic
3 Corrosive such as acids of pH <2, and bases of pH >12
4 Flammable
5 Reactive such as those that can cause explosions
6 Genotoxic such as cytostatic drugs.
•
R.A. 9003 also defines solid waste management as the discipline associated with the
control of generation, storage, collection, transfer and transport, processing, and
disposal of solid wastes in a manner that is in accordance with the best principles
of public health, economics, engineering, conservation, aesthetics, and other
environmental considerations, and that is also responsive to public attitudes. It
is the discipline that governs over the solid waste stream.

The pathway of municipal solid waste (solid waste stream) begins with waste
generation. At this stage, waste reduction can be done through the reuse of
materials. Materials that cannot be used should be segregated in trash bins with
color-coded and labeled linings, so that each form of waste item could be managed
accordingly. In the third edition of the Manual on Healthcare Waste Management,
published by the DOH in December 2011, the following color coding of hospital waste
bins were prescribed:
•
• Black or colorless: Nonhazardous and nonbiodegradable wastes
• Green: Nonhazardous biodegradable wastes
• Yellow with biohazard symbol: Pathological/ anatomical wastes.
• Yellow with black band: Pharmaceutical, cytotoxic, or chemical wastes
(labeled separately)
• Yellow bag that can be autoclaved: Infectious wastes
• Orange with radioactive symbol: Radioactive wastes
The segregated wastes are collected and transported accordingly. Recyclable wastes
such as metals, plastics, paper, and glass can be sent to a materials recovery
facility to generate recycled raw materials for producers. Biodegradable and
organic wastes can be sent to a composting unit for processing and subsequent
agricultural use. Only residual wastes (if any) should be dumped into the sanitary
landfill.

There are various waste processors that could be utilized by institutions,

organizations, and local government units (LGUs) including shredders, biological
reactors, and thermal processors. Individuals responsible for community surveys
should note that the law excludes incineration from the acceptable processes, as it
is known to emit toxic and poisonous fumes. Public health officers should also keep
in mind that the Implementing Rules and Regulations of Republic Act 9003 has
declared the following as some of the prohibited acts:
•
• Open burning of solid wastes
• Open dumping
• Burying in flood-prone areas
• Squatting in landfills
• Operation of landfills on any aquifer, groundwater reservoir, or
watershed
• Construction of any establishment within 200 meters from a dump or
landfill
WATER SANITATIONIncrease in access to safe water supply is one of the crucial steps
to the achievement of the health-related Millennium Development Goals (MDGs).
According to the PDP of 2011-2016, the percentage of households in the Philippines
with access to safe water in the year 2007 was 82.9%. By 2016, the PDP aims to
increase this ratio to 86.6%.The DOH had identified three levels of access to safe
water supply and had set the standards of the quality of drinking water through the
DOH Administrative Order No. 2007-0012, otherwise known as the Philippine National
Standards for Drinking Water of 2007.The general requirements of safe drinking
water cover the following:
1 Microbial quality tested through the parameters of total coliform,
fecal coliform, and heterotrophic plate count.
2 Chemical and physical quality tested through the parameters of pH,
chemical-specific levels, color, odor, turbidity, hardness, and total dissolved
solids.
3 Radiological quality tested through the parameters of gross alpha
activity, gross beta, and radon.

DOH A.O. 2007-0012 directs all drinking water processors from large water systems
to water refilling stations to create a water safety plan. The three key components
of water safety plans include:
1
2 System assessment - to determine if the drinking water supply chain as
a whole can deliver water of quality that meets health-based targets.
3 Operational monitoring - to identify control measures in a drinking
water system that will collectively control identified risks and ensure that the
health-based targets are met, and to rapidly detect any deviation from the required
performance.
4 Management plans - to describe actions to be taken during normal
operations or incident conditions.

The national law on water quality management is Republic Act 9275, otherwise known
as the Philippine Clean Water Act of 2004. It directed the DENR to act as the lead
agency in the implementation and enforcement of this law. It also directed the DOH
to be primarily responsible for the promulgation, revision, and enforcement of
drinking water quality standards.

Other than the concern on the standards of the quality of drinking water, DOH has
also produced the Implementing Rules and Regulations of the Code of Sanitation of
the Philippines Chapter II: Water Supply. Some of the provisions include:
1
2 Washing and bathing within a radius of 25 meters from any well or other
source of drinking water is prohibited.
3 No artesians, deep, or shallow well shall be constructed within 25
meters from any source of pollution (including septic tanks and sewerage systems).
Drilling a well within a 50-meters distance from a cemetery is also prohibited.
4 No radioactive source or material shall be stored within a radius of 25
meters from any well or source of drinking water unless the radioactive source is
adequately and safely enclosed by proper shielding.
5 No dwellings shall be constructed within the catchment area of a
protected spring water source, and it shall be off limits to people and animals.

Emergency water treatment

Water that needs treatment during emergencies is the one that is used for drinking
and preparing foods. This is estimated to amount to about 5 liters per person per
day. In 2011, the WHO published the Technical Notes on Drinking Water, Sanitation,
and Hygiene in Emergencies created by the Water, Engineering, and Development
Center (WEDC). It provides the following prescriptions for emergency treatment of
drinking water:

Pretreatment Processes:
•
• Aeration is done to remove volatile substances, reduce carbon dioxide
content, and oxidize dissolved minerals in preparation for sedimentation and
filtration. A method for aeration is to rapidly shake a container that is partially
full of water for about 5 minutes.
• Settlement is done by allowing water to stand undisturbed in the dark
for a day. This process causes death to more than 50% of most harmful bacteria and
settling of suspended solids. Repetition of settlement in another container or pot
increases the effectiveness of the process, as water is made to settle for longer
periods.
• Filtration is done by utilizing filters to block particles while
allowing water to pass through. Filters include clean cloth, sand, and ceramics.
Disinfection Processes:
•
• Boiling, despite being energy consuming, is considered as a very
effective method for water disinfection. The water should be brought to a "rolling
boil" and kept in that state for at least 1 minute at sea level. At higher
altitudes, the water should be kept in a rolling boil state for at least 3 minutes.
This process causes the water to change taste. This can be improved by performing
aeration after the water has been cooled.
• Chemical disinfection can be done using various chemicals but the most
widely used remains to be chlorine as it can kill all viruses and bacteria.
However, some species of protozoa and helminths have been seen to be resistant to
chlorination. Chlorine is available in various size and strength; thus, it is
important to follow the manufacturer's instructions on their use.
• Solardisinfection (SODIS) follows the principle that ultraviolet rays
from the sun destroy harmful organisms in water. This can be done by filling
transparent plastic containers 1 to 2 liters in size with clear water, and exposing
them to direct sunlight for about 5 hours. If the skies are cloudy, the bottles are
exposed for two consecutive days.
Water Storage and Consumption
•
• Wide-necked containers with tight-fitting lids are best for water
storage as they are easy to clean between use.
• Hands and utensils may come in contact with water, therefore educating
people about proper washing techniques is of high importance.
AIR PURITYPublic health nurses must be sensitive to the various sources of air
pollution in their community. The DENR, in its Administrative Order 2000-81,
defines an air pollutant as any matter in the atmosphere other than the natural
concentrations of oxygen, nitrogen, water vapor, carbon dioxide, and inert gases
that may be detrimental to health or the environment.The first 11 kilometers of the
atmosphere from the earth is the troposphere where we live in. In this layer, the
temperature profile is warmest at sea level and coolest at higher altitudes. Public
health nurses serving mountainous communities should keep in mind that these
communities are generally exposed to cooler weather. Having in mind that as the air
gets cooler, the less water vapor it is able to carry, the public health nurse
should be sensitive to the rise of respiratory infections in these communities, as
the moist "mucociliary blanket" protection of the airways could be interrupted by
the dry air.The troposphere near sea level has a typical composition of gases that
support healthy human life. In general, it is thought to be 78% nitrogen, 21%
oxygen, and 1% other gases (such as carbon dioxide, argon, and water vapors). As
the altitude increases, oxygen per-centages decrease.The typical composition of air
can be disturbed by pollutants. Pollutants can be suspended in particulate matter
or the gases themselves. Particulate matter that is of public health concern is
approximately 10 pm in size (PM 10) as they can be suspended in air. Gases that
exceed their normal concentrations are considered as pollutants to healthy air.The
DENR A.O.2000-81: Implementing Rules and Regulations for R.A. 8746 identified some
of the pollutants that should concern communities such as ozone-depleting
substances, chlorofluorocarbons, particulate matter that refer to any material that
exists in a finely divided form as a liquid or solid other than water, greenhouse
gases that can potentially induce global warming such as carbon dioxide, methane,
and oxides of nitrogen, chlorofluorocarbons, and fuel components such as aromatics,
benzene, and sulfur.Then, there is the stratosphere where the ozone layer is found.
The stratosphere has an inverted vertical-temperature profile, that is, it gets
warmer as you increase altitude. Public health nurses of communities with airports
know that this is the layer where most airplanes fly and emit most of the products
of jet fuel combustion. A.O.2000-81 defines an emission as any measurable pollutant
gas or unwanted sound from a known source, which is passed into the atmosphere.As
public health nurses identify possible sources of air pollution, they should be
aware of the two major sources identified by the Clean Air Act, namely, mobile and
stationary sources.
• Mobile source - refers to any vehicle/machine propelled by or through
oxidation or reduction reactions, including combustion of carbon-based or other
fuel, constructed and operated principally for the conveyance of persons or the
transportation of property or goods, that emit air pollutants as a reaction
product.
• Stationary source - refers to any building or fixed structure,
facility, or installation that emits or may emit any air pollutant.
Other than air pollution, contamination with microorganisms is a public health
concern in terms of clean air. Infections with microbes generally follow the
principles of particulate matter invasion of the respiratory tract, in that the
smaller the particle is, the more efficient it becomes in reaching the lower
airways. The American Conference of Governmental Industrial Hygienists has defined
a criteria depending on the efficiency of various particle sizes in entering the
respiratory tract as
1
2 Inhalable particulate matter starting at 100-µm diameter.
3 Thoracic particulate matter starting at 10-µm diameter.
4 Respirable particulate matter starting at 4-µm diameter.

The Pollution Prevention and Abatement Handbook by the World Bank says that the
particles most likely to cause adverse health effects are the fine particulates
PM10 and PM2.5—particles smaller than 10 and 2.5 pm. Prevention of exposure to such
is facilitated by the use of high-efficiency particulate filters such as that of
used in the branded N-95 Mask.

In the Philippines, the Air Quality Management Section of the DENR Environmental
Management Bureau (DENR-EMB) monitors air quality. It maintains 42 air quality—
monitoring stations nationwide, which measure the total suspended particulates
(TSP). Healthy air has a TSP that does not exceed 90 µm/m3. The direction of air
quality monitoring is toward building technical capacity to monitor PM10 and PM2.5.
DENR-EMB acts as the chairperson of the air management, whereas the Department of
Transportation and Communication (DOTC) acts as the vice chairperson.

Several programs have been initiated to address air pollution:

•
• Bantay Tsimineya Program that monitors point-source air pollution from
industries.
• Bantay Tambutso Program and Standard Setting that adopted Euro-II
emission standards for motorized vehicles. This program penalizes vehicle owners
who fail to meet the set-standards.
• Improved Fuel Quality Program that phased out leaded gasoline, and
regulated the sulfur, benzene, and aromatic content of fuels.
• National Research and Development Program for the Prevention and
Control of Air Pollution whose development was directed by DENR Administrative
order 2000-81 to the DENR-EMB, in coordination with the Department of Science and
Technology (DOST).
Public health nurses serve as an expert resource not only for the mayors and
governors of their respective localities but also for the "Airshed" to whom the
city or municipality belongs. An airshed refers to an area with a common weather or
meteorological condition and a common source of air pollution. The DENR Secretary,
on the recommendation of the Environmental Management Bureau, has the legal mandate
to divide the geopolitical regions of the country into airsheds for a more
effective air quality management. The designation of airsheds shall be revised as
additional data, needs, or situations arise. Each airshed is tasked to develop and
implement a common action plan.

Other than outdoor settings, indoor air pollution in-built spaces intended for
public use is a concern of community health providers. Public health nurses,
together with the city or municipal health officer, are at a key position to make
recommendations to the LGU regarding the air safety in built public establishments.
In the evaluation of such areas, Rule 1000 can be used as a guide.

Rule XXIX, Section 1 of DENR A.O.2000-81 "Ban on Smoking" had already directed the
LGUs to:

“...implement or enforce a ban on smoking inside a public building or an enclosed

public place including public vehicles and other means of transport or in any
enclosed area outside of one's private residence, private place of work or any duly
designated smoking area which shall be enclosed.”

The public health nurse is tasked to be both a nurse who advocates for the client
community, and a government officer who must assure that the rights of the people
are protected. People's right to clean air has been clearly defined by the Republic
Act 8749 also known as the "Philippine Clean Air Act of 1999." Pursuant to the
principles of the said law, following rights of citizens are sought to be
recognized:
1
2 The right to breathe clean air.
3 The right to utilize and enjoy all-natural resources according to the
principle of sustainable development.
4 The right to participate in the formulation, planning, implementation,
and monitoring of environmental policies and programs and in the decision-making
process.
5 The right to participate in the decision-making process concerning
development policies, plans, and programs projects or activities that may have
adverse impact on the environment and public health.
6 The right to be informed of the nature and extent of the potential
hazard of any activity, undertaking, or project and to be served timely notice of
any significant rise in the level of pollution and the accidental or deliberate
release into the atmosphere of harmful or hazardous substances.
7 The right of access to public records which a citizen may need to
exercise his or her rights effectively under this Act.
8 The right to bring action in court or quasi-judicial bodies to enjoin
all activities in violation of environmental laws and regulations, to compel the
rehabilitation and cleanup of affected area, and to seek the imposition of penal
sanctions against violators of environmental laws.
9 The right to bring action in court for compensation of personal damages
resulting from the adverse environmental and public health impact of a project or
activity.
TOXIC AND HAZARDOUS WASTE CONTROLThe government accounts the chemicals that it
monitors in the Philippine Inventory of Chemicals and Chemical Substances (PICCS).
To date, there are 44,600 substances in the list, five of which are controlled
chemicals, namely, asbestos, cyanide, mercury, polychlorinated biphenyls, and
ozone-depleting substances.The country has several poison control centers
nationwide, headed by the National Poison Management and Control Center (NPMCC)
based in the Philippine General Hospital (PGH). In 2009, the centers reported a
total of 1,286 poisoning cases. The top causes of poisons are the following:
jewelry cleaners (high in cyanide), pesticides, button batteries, Watusi
firecracker, Jatropha seeds, multivitamins, malathion and xylene, camphor with
methyl ASA, and turpentine.
Air quality indices
24-hours average total suspended particulates (TSP) (ug/m3)
Good
0-80
Fair
81-230
Unhealthy for sensitive groups
231-349
Very unhealthy
350-599
Acutely unhealthy
600-899
Emergency
900 and above
24-hours PM10 - (ug/m3)
Good
0-54
Fair
55-154
Unhealthy for sensitive groups
155-254
Very unhealthy
255-354
Acutely unhealthy
355-424
Emergency
425-504
TSP and PM10 specific statements for the general public
(1) Unhealthy for sensitive groups. People with respiratory disease, such as
asthma, should limit outdoor exertion.
(2) Very unhealthy pedestrians should avoid heavy traffic areas. People with heart
or respiratory disease, such as asthma, should stay indoors and rest as much as
possible. Unnecessary trips should be postponed. People should voluntarily restrict
the use of vehicles.
(3) Acutely unhealthy People should limit outdoor exertion. People with heart or
respiratory disease, such as asthma, should stay indoors and rest as much as
possible. Unnecessary trips should be postponed. Motor vehicle use may be
restricted. Industrial activities may be curtailed.
(4) Emergency Everyone should remain indoors, keeping windows and doors closed
unless heat stress is possible. Motor vehicle use should be prohibited except for
emergency situations. Industrial activities, except that which are vital for public
safety and health, should be curtailed.
8-hours carbon monoxide
Good
0.0-4.4
Fair
4.5-9.4
Unhealthy for sensitive groups
9.5-12.4
Very unhealthy
12.5-15.4
Acutely unhealthy
15.5-30.4
Emergency
30.5-40.4
(1) Unhealthy for sensitive groups People with cardiovascular disease, such as
angina, should limit heavy exertion and avoid sources of CO, such as heavy traffic.
(2) Very unhealthy People should stay indoors and rest as much as possible.
Unnecessary trips should be postponed. People should voluntarily restrict the use
of vehicles and avoid sources of CO, such as heavy traffic. Smokers should refrain
from smoking.
(3) Acutely unhealthy People with cardiovascular disease, such as angina, should
avoid exertion and sources of CO, such as heavy traffic, and should stay indoors
and rest as much as possible. Unnecessary trips should be postponed. Motor vehicle
use may be restricted. Industrial activities may be curtailed.
(4) Emergency Everyone should avoid exertion and sources of CO, such as heavy
traffic, and should stay indoors and rest as much as possible.
24-hours sulfur dioxide (ppm)
Good
0.000-0.034
Fair
0.035-0.144
Unhealthy for sensitive groups
0.145-0.224
Very unhealthy
0.225-0.304
Acutely unhealthy
0.305-0.604
Emergency
0.605-0.804
8-hours ozone (ppm)
Good
0.000-0.064
Fair
0.065-0.084
Unhealthy for sensitive groups
0.085-0.104
Very unhealthy
0.105-0.124
Acutely unhealthy
0.125-0.374
1-hour nitrogen dioxide (ppm)
Acutely unhealthy
0.65-1.24
Emergency
1.25-1.64

The DENR accounts for the ratio of hazardous waste treatment plants and hazardous
waste-generating facilities. In 2010, there were 108 privately owned hazardous
waste treatment facilities serving 11,162 hazardous waste-generating facilities.

Primary health care facilities should be capable of following the WHO

recommendations on essential symptomatic and supportive treatment of acute
poisoning. Health care workers and trained volunteers should wear personal
protective equipment (PPE) to evacuate victims from the contaminated environment.
In the event of skin contamination, the clothing is removed and the skin is washed
with the appropriate fluid. Interventions that may be considered thereafter include
gastric aspiration and lavage of adults, induced emesis of children, administration
of a high dose of activated charcoal into the stomach, and administration of
protective agents such as:
•
• Atropine for carbamate and organophosphate pesticides
• Methylene blue for chlorates and nitrites
• Acetylcysteine or methionine for paracetamol overdose
• Hydroxocobalamin or sodium thiosulfate for cyanide in silver cleaners
Referral to higher institutions allows the safe toxicological analysis and
subsequent administration of specific antidotes, anticonvulsants, antiarrhythmics,
and analgesics. The Toxic and Environmental Health Working Group is headed by the
DENR (chairperson) and the Department of Agriculture (vice chairperson).
Air quality indices
24-hours average total suspended particulates (TSP) (ug/m3)
Good 0-80
Fair 81-230
Unhealthy for sensitive groups 231-349
Very unhealthy 350-599
Acutely unhealthy 600-899
Emergency 900 and above
24-hours PM10 - (ug/m3)
Good 0-54
Fair 55-154
Unhealthy for sensitive groups 155-254
Very unhealthy 255-354
Acutely unhealthy 355-424
Emergency 425-504
TSP and PM10 specific statements for the general public
(1) Unhealthy for sensitive groups. People with respiratory disease, such as
asthma, should limit outdoor exertion.
(2) Very unhealthy pedestrians should avoid heavy traffic areas. People with heart
or respiratory disease, such as asthma, should stay indoors and rest as much as
possible. Unnecessary trips should be postponed. People should voluntarily restrict
the use of vehicles.
(3) Acutely unhealthy People should limit outdoor exertion. People with heart or
respiratory disease, such as asthma, should stay indoors and rest as much as
possible. Unnecessary trips should be postponed. Motor vehicle use may be
restricted. Industrial activities may be curtailed.
(4) Emergency Everyone should remain indoors, keeping windows and doors closed
unless heat stress is possible. Motor vehicle use should be prohibited except for
emergency situations. Industrial activities, except that which are vital for public
safety and health, should be curtailed.
8-hours carbon monoxide
Good 0.0-4.4
Fair 4.5-9.4
Unhealthy for sensitive groups 9.5-12.4
Very unhealthy 12.5-15.4
Acutely unhealthy 15.5-30.4
Emergency 30.5-40.4
(1) Unhealthy for sensitive groups People with cardiovascular disease, such as
angina, should limit heavy exertion and avoid sources of CO, such as heavy traffic.
(2) Very unhealthy People should stay indoors and rest as much as possible.
Unnecessary trips should be postponed. People should voluntarily restrict the use
of vehicles and avoid sources of CO, such as heavy traffic. Smokers should refrain
from smoking.
(3) Acutely unhealthy People with cardiovascular disease, such as angina, should
avoid exertion and sources of CO, such as heavy traffic, and should stay indoors
and rest as much as possible. Unnecessary trips should be postponed. Motor vehicle
use may be restricted. Industrial activities may be curtailed.
(4) Emergency Everyone should avoid exertion and sources of CO, such as heavy
traffic, and should stay indoors and rest as much as possible.
24-hours sulfur dioxide (ppm)
Good 0.000-0.034
Fair 0.035-0.144
Unhealthy for sensitive groups 0.145-0.224
Very unhealthy 0.225-0.304
Acutely unhealthy 0.305-0.604
Emergency 0.605-0.804
8-hours ozone (ppm)
Good 0.000-0.064
Fair 0.065-0.084
Unhealthy for sensitive groups 0.085-0.104
Very unhealthy 0.105-0.124
Acutely unhealthy 0.125-0.374
1-hour nitrogen dioxide (ppm)
Acutely unhealthy 0.65-1.24
Emergency 1.25-1.64
FOOD SAFETYThe NEHAP defined food safety as the assurance that food will not cause
any harm to the consumer when it is prepared and eaten according to its intended
use. To gear toward the food safety, the DOH formed an interagency committee that
is led by the Food and Drug Administration (FDA). In 2009, Republic Act 9711 was
enacted and is now known as the Food and Drug Administration Act, which
strengthened the FDA in safeguarding the safety and quality of processed foods,
drugs, diagnostic reagents, medical devices, cosmetics, and household substances.
The DOH has published the Implementing Rules and Regulations to define the
sanitation requirements for the operation of a food establishment.The food
establishment must have a sanitary permit from the city or municipality that has
jurisdiction over the business. In the case of food-establishments on-board sea-
crafts, the application must be filed in the vessel's port of origin. The permit
must be posted in a conspicuous place in the establishment, available for
inspection by health and other regulatory personnel.The implementing rules state
that no person shall be employed in any food establishment without a health
certificate properly issued by the city/municipal health officer. This must be
clipped on the upper left front portion of the garment of the employee while
working. No person shall be allowed to work on food handling if afflicted with a
communicable disease, including boils, infected wounds, respiratory infections,
diarrhea, and gastro-intestinal upset.Particular guidelines on sources,
transportation, preparation, storage, and serving have been set by the implementing
rules and regulations. All of which are geared toward the preservation of the
quality and cleanliness of food, as well as the safety of the service and
consumption of the same.The food preparation and storage rooms should never be used
or be directly connected to a sleeping apartment or a toilet. No animals can be
kept in the food areas. The display of any live animal in the food area is strictly
prohibited. Floors, walls, and ceilings must be made of materials that can be
cleansed. The rules have set standards for the adequacy of lighting, sufficiency of
ventilation, and minimum space requirements. It requires hand washing basins,
appropriate toilet facilities, water supply, and refuse management systems.Utensils
must be scraped of all food particles and be washed in warm water (49 °C) with
soap. If running water is not available, the wash water shall be changed
frequently. The utensils are then subjected to one of the following bactericidal
treatments:
1
2 Immersion for at least 30 seconds in clean hot water (77 °C).
3 Immersion for at least 1 minute in lukewarm water containing 55-100 ppm
of chlorine solution.
4 Exposure to steam for at least 15 minutes to 77 °C, or for 5 minutes to
at least 200 °C.

It shall be the duty of the Sanitation Inspector of the city, municipality, or

province to perform an inspection and evaluation of the compliance of food
establishments to the set standards at a frequency specified by the implementing
rules and regulations.

Ambulant food vendors shall sell only bottled drinks, and prepacked food. They are
prohibited from selling food that requires the use of utensils.

As monitored by the FHSIS, all food handlers must maintain an updated health
certificate. The public health nurses are at an advantageous position to
participate in the monitoring and implementation of the ordinance on food handlers
as they are given the task to collate and report data in the FHSIS system.
SANITATIONThe Philippines Sanitation Sourcebook and Decision Aid developed by the
DENR, the DOH, and the Local Water Utilities Administration (LWUA) in 2005 limited
the definition of sanitation to "the hygienic and proper management, collection,
disposal, or reuse of human excreta (feces and urine) and community liquid wastes
to safeguard the health of individuals and communities". This is proof of the
development of the arts and sciences involved in the various fields of sanitation,
that is, a singular code on sanitation such as the Presidential Decree 856: the
Code on Sanitation of the Philippines of 1976 may need to be revisited and updated
to provide a more comprehensive coverage to this growing discipline.The government
keeps track on the proportion of the population that does not have the approved
types of sanitation facilities. One may observe fluctuations in the figures through
the years as the problem of service coverage is aggravated by the effect of
disasters that damage existing sanitary facilities. The DOH is the chair of the
sanitation sector, whereas the Department of Interior and Local Government serves
as the vice chair. It is to the nation's advantage that the public health nurses
working for or with the DOH become well-abreast with the various concepts on
sanitation. For example, microorganisms in human excreta and agricultural run-off
may contaminate water systems and cause an epidemic.In 2005, the Sanitation and
Hygiene Promotion Programming Guidelines developed the F-Diagram that proposed the
6 Fs that form part of the means to transmit microorganisms in fecal materials to a
new host, namely, feces, fingers, fluids, flies, fields/ floors, and food. It
featured the primary and secondary barriers that public health practice could
implement to prevent the transmission of the pathogens. Primary barriers are the
structures and facilities that prevent the fecal contamination of fingers, fluids,
flies, and fields/floors. Secondary barriers are practices that prevent
contaminated fingers, fluids, flies, fields/floors from coming in contact with food
or the new host. Secondary barriers include, but are not limited to, handwashing
practices, insect and vermin control, water treatment, and proper food handling.
The following text focuses on the primary barriers.Sanitation facilities generally
have four components, namely, toilet, collection, treatment, and disposal/reuse.
The toilet could either be a receptacle (bowl) where the user sits down or a
squatting plate. Collection systems, also known as sewerage systems, transport the
wastewater for treatment or disposal. Treatment is the process of reducing liquid
and solid waste to nonpolluting matter. Disposal or reuse finally releases the
treated waste to the environment. The disposal can mean discharge to water bodies
such as rivers, application to soils, or release to the atmosphere in the form of
gas. Ecological sanitation moves for the reuse instead of the disposal of treated
wastewater as they can be safely used for irrigation of agricultural and landscaped
plants and firefighting.A general classification of sanitation systems could be
done according to water reliance. Water-reliant systems make use of water to flush
and transport the waste material to the collection system, thus requiring a
continuous supply of water. Communities or resettlement areas that do not have
access to continuous water supply may have problems in compliance to the use of
these facilities.On the other hand, nonwater-reliant systems make use of "dry"
storage for urine and feces. It is important to note, however, that a small amount
of water may be used to cleanse the parts of the dry system, such as that of
vacuum-flush toilets of buses and airplanes. These toilet systems treat or store
the materials on-site as they are not connected to sewerage systems. A toilet
system that is not connected to a sewerage system is called a privy.The
Implementing Rules and Regulations of the Sanitation Code of the Philippines
developed by the DOH describes three components of a sanitary privy, namely, an
earthen pit, a floor covering the pit, and a water-sealed bowl. Wooden floors and
seat risers are not to be used anymore. The flooring should cover the pit tightly
and joined to the bowl with a water-tight and insert-proof joint. The pit should be
at least 1 m² wide.The following are some of the sanitation facilities that a nurse
or sanitation officer may encounter in the community:
•
• Box-and-can privy (or bucket latrine): Fecal matter is collected in a
can or bucket, which is periodically removed for emptying and cleaning.
• Pit latrine (or pit privy): Fecal matter is eliminated into a hole in
the ground that leads to a dug pit. Generally, a latrine refers to toilet
facilities without a bowl. It can be equipped with either a squatting plate or a
riser with a seat. The pit reduces the volume of its contents as the liquid
infiltrates the surrounding soil.
• Antipolo toilet: It is made up of an elevated pit privy that has a
covered latrine. The elevation ensures that the bottom of the pit is at least 1.5
meters above the water table.
• Septic privy: Fecal matter is collected in a built septic tank that is
not connected to a sewerage system. The septic tank contains water but there is no
drop pipe from the latrine that is dipped into the water.
• Aqua privy: Fecal matter is eliminated into a water-sealed drop pipe
that leads from the latrine to a small water-filled septic tank located directly
below the squatting plate. The drop pipe extends below the septic tank water level
to form a simple water seal. An effluent pipe is installed in the septic tank to
prevent the overflow of water through the squatting plate. Water loss is then
replaced by adding water with each toilet use. A ventilation pipe with a fly screen
on top is part of the design of the housing of this facility.
 • Overhung latrine: Fecal material is directly eliminated into a body of
water such as a flowing river that is underneath the facility. Public health
organizations such as the WHO recognize the acceptability of the use of such in
disaster situations like heavy flooding when the body of water is deemed polluted.
The chosen body of water should be large and freely flowing. The public health
nurse should coordinate with downstream communities on releasing advisory that the
body of water is polluted.
• Ventilated-improved pit (VIP) latrine: It is a pit latrine with a
screened air vent installed directly over the pit. The ambient air that enters the
pit hole pushes the foul air onto the air vent. The screen on top of the vent
prevents entry of insects attracted by the smell. Filled pits are then covered with
soil for composting, and the facility is redirected or relocated to another pit.
• Concrete vault privy: Fecal matter is collected in a pit privy lined
with concrete in such a manner so as to make it water tight.
• Chemical privy: Fecal matter is collected into a tank that contains a
caustic chemical solution, which in turn controls and facilitates the waste
decomposition.
• Compost privy: Fecal matter is collected into a pit with urine and anal
cleansing materials with the addition of organic garbage such as leaves and grass
to allow biological decomposition and production of agricultural or fishpond
compost (or nightsoil).
• Pour-flush latrine: It has a bowl with a water-seal trap similar to the
conventional tank-flush toilet except that it requires only a small volume of water
for flushing. Feces at the water-sealed trap are washed-off by small quantities of
water hand-poured from a container.
• Tank-flush toilet: Feces are excreted into a bowl with a water-sealed
trap. The water tank that receives a limited amount of water empties into the bowl
for flushing of fecal materials through the water-sealed trap and into the sewerage
system. The trap retains an amount of the flush to maintain the water seal.
• Urine diversion dehydration toilet (UDDT): It is a waterless toilet
system that allows the separate collection and on-site storage or treatment of
urine and feces. The site could be made up of a urine separation toilet with the
urine side leading to a collecting container for agricultural use and the fecal
side leading to a ventilated vault. The fecal vault is kept "dry" and, the feces
are left to dehydrate for agricultural use.
In 2010, the DOH published the Philippine Sustainable Sanitation Roadmap and
defined the three sanitation facilities that are considered sanitary under the DOH
and the National Statistics Office (NSO) definitions:
1
2 Water-sealed toilet connected to a sewer or septic tank, used
exclusively by the household.
3 Water-sealed toilet connected to other depository type, used
exclusively by the household.
4 Closed pit used exclusively by the household.

The same considers the following as unsanitary facilities:

1
2 Water-sealed toilet connected to a sewer or septic tank, shared with
other households.
3 Water-sealed toilet connected to other depository type, shared with
other households.
4 Closed pit, shared with other households.
5 Open pit.
6 Hanging toilet.
7 Other unsanitary types of practice.
8 Open defecation.
VERMIN AND VECTOR CONTROLThe DOH had also prepared the Implementing Rules and
Regulations of Chapter XVI Vermin Control of the Code of Sanitation of the
Philippines (P.D. 856). This document defined the following terms:
 1
2 Vermin: A group of insects or small animals such as flies, mosquitoes,
cockroaches, fleas, lice, bedbugs, mice, and rats, which are vectors of diseases.
3 Insects: Flies, mosquitoes, cockroaches, bedbugs, fleas, lice, ticks,
ants, and other arthropods.
4 Pest: Any destructive or unwanted insect or other small animals (rats,
mice, etc.) that cause annoyance, discomfort, nuisance, or transmission of disease
to humans and damage to structures.
5 Rodent: Small mammals such as rats and mice, characterized by
constantly growing incisor teeth used for gnawing or nibbling.
6 Vector: Any organism that transmits infection by inoculation into the
skin or mucous membrane by biting; or by deposit of infective materials on skin,
food, or other objects; or by biological reproduction within the organism.

The DOH identified the strategies of a vermin abatement program, namely:

1
2 It must be community-wide and community-participated.
3 It must be technically coordinated.
4 It must be continuing.
5 It must be basically a partnership between the private and government
sectors.
6 It should preferably utilize indigenous technology and resources to
attain self-reliance.

The DOH outlined the various vermin control and disinfestation methods, which
include:
•
• Environmental sanitation control: The maintenance of cleanliness of the
immediate premises and proper building construction and maintenance so as to
prevent access of pests into human dwellings. Clean-up drives are aimed at altering
or eliminating the breeding sites of the vectors.
• Naturalistic control: A pest control method that utilizes nature and
nature's systems without disturbing the balance of nature.
• Biological and genetic control: A method that utilizes living
predators, parasites, and other natural enemies of the pest species to reduce or
eliminate the pest populations. It is aimed at killing the larvae without polluting
the environment.
• Mechanical and physical control: A method that utilizes mechanical
devices such as rodent traps, fly traps, mosquito traps, air curtain, and
ultraviolet light.
• Chemical control: A method that utilizes rodenticides, insecticides,
larvicides, and pesticides.
• Integrated control: A method that controls pests through the use of
different methods and procedures that are used to complement each other. These
procedures may include the use of pesticides, environmental sanitation measures,
and natural, as well as mechanical and biological control methods.
BUILT ENVIRONMENTS The built environment refers to the man-made structures that
provide a setting for human activities. In the Philippines, Presidential Decree
Number 1096 (P.D. 1096), also known as the National Building Code of the
Philippines, governs the design of built environments. In 2004, the Department of
Public Works and Highways developed the Revised Implementing Rules and Regulations
of the National Building Code of the Philippines. Some of the provisions enacted to
protect public health are as follows:
•
• Minimum air space shall be provided as follows:
•
• School rooms - 3.00 m3 with 1.00 m2 of floor area per person.
• Workshops, factories, and offices -12.00 m3 of air space per person.
• Habitable rooms - 14.00 m3 of air space per person.
 •
• Minimum sizes of rooms and their least horizontal dimensions shall be
as follows:
•
• Rooms for human habitations - 6.00 m2 with a least horizontal dimension
of 2.00 m.
• Kitchen - 3.00 m2 with a least horizontal dimension of 1.50 m.
• Bath and toilet - 1.20 m2 with a least horizontal dimension of 900 mm.
•
• Ceiling height of habitable rooms:
•
• Rooms provided with artificial ventilation shall have ceiling heights
not less than 2.40 m (8 ft) measured from the floor to the ceiling.
• Rooms with natural ventilation shall have ceiling heights of not less
than 2.70 m (9 ft).
• Mezzanine floors shall have a clear ceiling height not less than 1.80 m
above and below it.
•
• Minimum window sizes:
•
• Rooms intended for any use, not provided with artificial ventilation
system, shall be provided with a window or windows with a total free area of
openings equal to at least 10% of the floor area of the room, provided that such
opening shall be not less than 1.00 m2.
• Toilet and bathrooms, laundry rooms, and similar rooms shall be
provided with window or windows with an area not less than 1 /20 of the floor area
of such rooms, provided that such opening shall not be less than 240 mm2.
• Such window or windows shall open directly to a court, yard, public
street or alley, or open watercourse.
INTRODUCTIONCommunities throughout the world experience an emergency or disaster
incident of one kind or another on an almost daily basis. The media may only
mention these events or may report on them in great detail, depending on the number
of deaths or injured, the degree of devastation or damage to the area involved, and
the extent of normal activity disruption in the community that the event has
brought about. The increasing severity of recent disasters is multifaceted and is
generally attributable to a number of societal and environmental changes.

The health of a community can be affected significantly by disasters. Tropical

Storm (TS) Ondoy (international code name Ketsana), which hit 26 provinces in the
Philippines in September 2009, is an example of how communities and health
facilities are directly affected as a result of a disaster. TS Ondoy brought heavy
rains that caused widespread flooding in almost all parts of Metro Manila and
Central and Southern Luzon. The floods also affected some parts of Visayas and
Mindanao. Landslides occurred in the Cordillera Administrative Region. A total of
993,227 families/4,901,234 persons were affected. The storm left in its wake 1,030
casualties: 464 dead, 529 injured, and 37 missing persons. The estimated cost of
damage was about Php 11 billion, including damage to health facilities. The total
number of houses damaged was 185,004.

During TS Ondoy, as is typical in widespread notable disasters, medical and nursing

personnel, medicines, and needed supplies were unavailable, scarce, or depleted
because of the increased demand. Damaged health facilities had to evacuate
patients. Evacuation centers and temporary health care services were established in
schools, churches, and a variety of other facilities. Because many houses were
completely destroyed, many evacuees had to stay in the evacuation centers for
weeks, resulting in a high incidence of acute respiratory and gastroenteritis cases
because of overcrowding and lack of sanitary facilities in evacuation centers. The
extensive flooding resulted in panic for food, water, and rescue in the seriously
affected areas. First responders and rescue teams were overwhelmed in their
attempts to assist the victims.

Because of its geographical location, the Philippines frequently experiences

natural disasters such as typhoons, floods, and earthquakes. Industrial accidents
may also lead to disasters, such as mining disasters. Further, in recent years,
terrorist attacks have become more common. Terrorist attacks occur all over the
world on an almost daily basis, and concerns about potential terrorist attacks have
increased the focus on what needs to be done in terms of prevention, preparedness,
response, and recovery—not only in the event of terrorist attacks but also in the
event of disasters of all kinds.

Nurses are uniquely positioned to provide valuable information for the development
of plans for disaster prevention, preparedness, response, and recovery for
communities. Nurses, as team members, can cooperate with health and social
representatives, government bodies, community groups, and volunteer agencies in
disaster planning and preparedness programs (i.e., drills). Nurses can utilize
their knowledge of nursing, public health, and cultural-familial structures, as
well as clinical skills and abilities, in order to actively assist or participate
in all aspects and stages of an emergency or disaster, regardless of the setting in
which the event may occur. Nurses have a significant role in meeting the health
care needs of the community, not only on a day-to-day basis but also in relation to
disasters.

Disaster definitionsAn emergency is any event endangering the life or health of a

significant number of people and demanding immediate action. An emergency situation
may result from a natural, man-made, technological, or societal hazard.A disaster
is any event that causes a level of destruction, death, or injury that affects the
abilities of the community to respond to the incident using available resources.
Emergencies differ from disasters in that the agency, community, family, or
individual can manage an emergency using his or her own resources. But a disaster
event, depending on the characteristics of the disaster, may be beyond the ability
of the community to respond and recover from the incident using their own
resources. Disasters frequently require assistance from outside the immediate
community, both to manage resulting issues and to recover completely.Some disasters
(e.g. a house fire) may affect only a few persons, whereas others (e.g. a
hurricane) can impact thousands. A mass casualty event is one in which 100 or more
individuals are involved; a multiple casualty event is one in which more than 2 but
fewer than 100 individuals are involved. Casualties can be classified as a direct
victim, an indirect victim, a displaced person, or a refugee. A direct victim is an
individual who is immediately affected by the event; the indirect victim may be a
family member or friend of the victim or a first responder. Displaced persons and
refugees are special categories of direct victims. Displaced persons are those who
have to evacuate their home, school, or business as a result of a disaster, and
refugees are a group of people who have fled their home or even their country as a
result of famine, drought, natural disaster, war, or civil unrest.

TYPES OF DISASTERSDisasters may result from natural, biological, technological, or

societal hazards. A natural hazard is a physical force, such as a typhoon, flood,
landslide, earthquake, and volcanic activity. A biological hazard is a process or
phenomenon of organic origin or conveyed by biological vectors, including exposure
to pathogenic microorganisms, toxins, and bioactive substances. Examples are
disease outbreaks and red tide poisoning. A technological hazard arises from
technological or industrial conditions, including accidents, dangerous procedures,
and infrastructure failures. A societal hazard results from the interaction of
varying political, social, or economic factors, which may have a negative impact on
the community. Examples are stampedes, armed conflicts, terrorist activities, and
riots.A NA-TECH (natural-technological) disaster is a natural disaster that creates
or results in a widespread technological problem. An example of a NA-TECH disaster
is an earthquake that causes the structural collapse of roadways or bridges that,
in turn, brought down electrical wires and caused subsequent fires. Another example
is a chemical spill resulting from a flood. Types of natural disasters and man-made
disasters, particularly those that are experienced in the Philippines.

Injury or death from a disaster may be direct or indirect. For example, injuries
from typhoons occur because people fail to evacuate or take shelter, do not take
precautions in securing their property, and do not follow guidelines on food and
water safety or injury prevention during recovery.

Drowning, electrocution, lacerations or punctures from flying debris, and blunt

trauma from falling trees or other objects are some of the morbidity concerns.
Heart attacks and stress-related disorders also occur. Injuries also may occur from
activities in the recovery phase, for example, from use of equipment for recovery
and reconstruction or from bites from animals, snakes, or insects.

Acts of terrorism have become a frequent occurrence in different countries, which

have resulted in considerable loss of lives and destruction of property. The United
Nations has exerted efforts to define terrorism, but a definition acceptable to all
member states is yet to be formulated. In a resolution, the UN Security Council,
although not directly defining terrorism, described terrorism as, "criminal acts,
including against civilians, committed with the intent to cause death or serious
bodily injury, or taking of hostages, with the purpose to provoke a state of terror
in the general public or in a group of persons or particular persons, intimidate a
population or compel a government or an international organization to do or to
abstain from doing any act".

Threats of terrorism, assassinations, kidnappings, hijackings, bomb scares and

bombings, computer-based attacks, and use of chemical, biological, nuclear, and
radiological weapons are considered acts of terrorism. From a global perspective,
examples of terrorist acts are the September 11, 2001 terrorist attacks in the
United States, which caused unprecedented destruction and death; the nerve gas
(sarin) attack in the Tokyo subway in March 1995, which killed 12 and injured more
than 6,000 people; the bombing of the commuter train in Spain in March 2004, which
killed 191 people; the suicide bombing in the London subway in July 2005, which
killed 52 commuters and 4 terrorists; and the shooting and bombing attacks in
Mumbai's financial district in November 2008, which killed more than 170 people. In
the Philippines, notable terrorist acts include the ferry bombing in Ozamis City on
February 25, 2000, which claimed 39 lives; the so-called Rizal Day bombings on
December 30, 2000 where 22 people perished; and the Superferry bombing at Manila
Bay on February 27, 2004 that killed 116 people.

Concerns now are increasingly focused on weapons of mass destruction. Weapons of

mass destruction refer to any weapon that is designed or intended to cause death or
serious bodily injury through the release, dissemination, or impact of toxic or
poisonous chemicals, or its precursors; any weapon involving a disease organism; or
any weapon that is designed to release radiation or radioactivity at a level
dangerous to human life.

Biological weapons of mass destruction

Biological organism
Lethality
Prevention
Treatment
Potential for use
Smallpox (incubation 1-5 days)
High
Vaccine
Symptomatic; secondary infections
One person could possibly cause a national epidemic
Anthrax (incubation 2-60 days)
Very high
Vaccine
Antibiotics early; if late, nothing
Likely agent; resistant to weather; can be stored
Plague (Yersinia pestis) (incubation 1-3 days)
Very high; 100% if untreated
No vaccine
Antibiotics
Not considered a likely agent; difficult to turn into a weapon
Botulism
High
Vaccine being tested
Antitoxin; requires intensive supportive care
Not considered a likely weapon
Tularemia
Moderate
Vaccine being studied
Antibiotics
Difficult to stabilize for use as a weapon
Ebola
Very high
No vaccine
Minimal
Not considered a likely weapon; difficult to acquire; poorly understood
Brucellosis (incubation 5-21 days)
Low
No vaccine
Antibiotics; begin upon suspicion of disease
Not considered a likely weapon; low lethality
Q fever (Coxiella burnetii) (incubation 14-26 days)
Low
Vaccine
Antibiotics; begin in incubation period
Not considered a likely weapon; low lethality
Other potentials: Viral Venezuelan equine encephalitis, cholera, salmonella,
influenza, and staphylococcal enterotoxin B
-
-
-
-
Biological weapons of mass destruction
Biological organism Lethality Prevention Treatment Potential for use
Smallpox (incubation 1-5 days) High Vaccine Symptomatic; secondary
infections One person could possibly cause a national epidemic
Anthrax (incubation 2-60 days) Very high Vaccine Antibiotics early; if
late, nothing Likely agent; resistant to weather; can be stored
Plague (Yersinia pestis) (incubation 1-3 days) Very high; 100% if untreated No
vaccine Antibiotics Not considered a likely agent; difficult to turn into a
weapon
Botulism High Vaccine being tested Antitoxin; requires intensive supportive
care Not considered a likely weapon
Tularemia Moderate Vaccine being studied Antibiotics Difficult to stabilize
for use as a weapon
Ebola Very high No vaccine Minimal Not considered a likely weapon; difficult
to acquire; poorly understood
Brucellosis (incubation 5-21 days) Low No vaccine Antibiotics; begin upon
suspicion of disease Not considered a likely weapon; low lethality
Q fever (Coxiella burnetii) (incubation 14-26 days) Low Vaccine Antibiotics;
begin in incubation period Not considered a likely weapon; low lethality
Other potentials: Viral Venezuelan equine encephalitis, cholera, salmonella,
influenza, and staphylococcal enterotoxin B - - - -
Chemical agents of mass destruction
Chemical agent Lethality Treatment Impact
Sarin (nerve agent) High Move to fresh air; wash skin; drugs limited
effectiveness Likely nerve agent; chemicals needed to produce are banned by
International Chemical Weapons Convention
VX (nerve agent) Very high Move to fresh air; wash skin; drugs limited
effectiveness Not likely weapon; difficult to manufacture
Tabun (nerve agent) High Move to fresh air; wash skin; drugs limited
effectiveness Easy to manufacture nerve agent; likely agent to be used
Chlorine (pulmonary agent) Low Move to fresh air; wash skin; no antidote
Readily available; likely agent because of availability; breaks down with
water
Hydrogen cyanide (blood agent) Low to moderate Move to fresh air; wash skin;
some drugs mitigate effects Industrial product; some chemicals used to produce
are banned; likely agent because of availability
CHARACTERISTICS OF DISASTERSSeveral characteristics have been used to describe
disasters. These characteristics are interdependent and therefore important to
consider in plans for managing any disaster event. Each is discussed briefly in the
following text. FrequencyFrequency refers to how often a disaster occurs. Some
disasters occur relatively often in certain parts of the world. Terrorist
activities are occurring on an almost daily basis in Iraq, Pakistan, and elsewhere
in the world. Other examples are tropical cyclones, which occur with variable
frequency between the months of June and November. However, because of climate
change, the occurrence of typhoons has become more variable than in previous years.
Earthquakes occur periodically throughout the world. The Philippines runs along the
so-called Ring of Fire, which encircles the Pacific Ocean and is known for frequent
earthquakes and volcanic eruptions. The Philippine Institute of Volcanology and
Seismology (PHILVOCS) records daily earthquakes occurring in different parts of the
country with variable intensity, with only a very small proportion of the quakes
felt by people. The most destructive earthquake in recorded history occurred almost
three decades ago on July 16, 1990 affecting Northern and Central Luzon. The quake
had an intensity of 7.8 on the Richter scale. More than 1,600 people lost their
lives in the earthquake.Other disasters, such as volcanic eruptions, are far less
frequent and are geographically limited to certain regions of the country. PHIVOLCS
has listed 23 active volcanoes in the country. Mayon in the province of Albay, Taal
in the province of Batangas, and Kanlaon in the province of Negros Oriental are the
top three most active volcanoes.The eruption of Mount Pinatubo (located at the
boundaries of Pampanga, Tarlac, and Zambales) in June, 1991 is the second largest
volcanic eruption of the 20th century. PHIVOLCS, together with the US Geological
Survey, was able to forecast the eruption, saving at least 5,000 lives. Mount
Pinatubo released a large amount of gas cloud into the atmosphere, causing global
temperature to drop by 0.5 °C from 1991 to 1993 (USGS, 2005).

Predictability
Predictability relates to the ability to tell when and if a disaster event will
occur. Some disasters, such as floods, may be predicted based on the expected
volume of rainfall, sometimes in conjunction with tide changes. Weather forecasters
can predict when conditions are right for the development of typhoons and with the
monsoon rains. These generally occur between June and November, but climate change
has made their occurrence more variable. Because of advances in technology, weather
forecasters can predict hurricanes with increasing accuracy. Other disasters (e.g.
fires and industrial explosions) may not be predictable at all.

Preventability

Preventability is a characteristic indicating that actions can be taken to avoid a

disaster. Some disasters (e.g. typhoons and earthquakes) are not preventable,
whereas others can be easily controlled if not prevented entirely. For example,
flooding can be controlled or prevented through proper refuse disposal, maintenance
of waterways, control of indiscriminate logging, and construction of infrastructure
for flood control.

Primary prevention is aimed at preventing the occurrence of a disaster or limiting

consequences when the event itself cannot be prevented. Primary prevention occurs
in the nondisaster and the predisaster stage refers to the period immediately
before the disaster or when a disaster is pending. Preventive actions during the
nondisaster stage include assessing communities to determine potential disaster
hazards, developing disaster plans at local and national levels, conducting drills
to test the plan, training volunteers and health care providers, and providing
educational programs of all kinds.

The disaster plan is initiated predisaster or when a disaster is imminent. Primary

prevention actions during this stage include notifying the appropriate officials,
warning the population, and advising what response to take (e.g. shelter in place
or evacuate).

Secondary prevention strategies are implemented once the disaster occurs. Secondary
prevention actions include search, rescue, and triage of victims and assessment of
the destruction and devastation of the area involved.

Tertiary prevention focuses on recovery of the community, that is, restoring the
community to its previous level of functioning and its residents to their maximum
functioning. Tertiary prevention is aimed at preventing a recurrence or minimizing
the effects of future disasters.

Nurses are involved in all stages of prevention and related activities. In order to
respond effectively, personally, and professionally during different types of
disasters, nurses need to know the:
1
2 Kind of disasters that threaten the communities,
3 Injuries to expect from different disaster scenarios
4 Evacuation route,
5 Location of shelters or evacuation centers
6 Warning systems.

Nurses must also be able to educate others about disasters and how to prepare for
and respond to them. Finally, nurses must be updated on the latest recommendations
and advances in lifesaving measures (e.g. basic first aid, cardiopulmonary
resuscitation, and use of automated external defibrillators).

Imminence

Imminence is the speed of onset of an impending disaster and relates to the extent
of forewarning possible and the anticipated duration of the incident. Weather
forecasters can tell when a weather disturbance may be developing days ahead of its
expected arrival and can give the approximate time of arrival, the general
direction it will take, and the location for its landing and forward movement.
Weather disturbances like typhoons, however, are subject to other weather variables
and can change direction and intensity several times before actual landfall.

In the Philippines, the imminence of weather disturbances, typhoons in particular,

is announced to the public in terms of Public Storm Warning Signals (PSWS). The
PSWS is raised to warn the public of an incoming weather disturbance. The
Philippine Atmospheric, Geophysical and Astronomical Services Administration
(PAGASA), a service institute under the Department of Science and Technology
(DOST), issues the PSWS.

Some disastrous incidents (e.g. terrorist attacks) have no warning time.

Bioterrorist attacks are generally silent, and the first awareness may be days or
even weeks after exposure. For example, individuals exposed to a pathologic agent
(e.g. anthrax, smallpox) may arrive at health care facilities at various times and
to various providers, making diagnosis and early treatment difficult. Nurses and
medical personnel need to know the signs and symptoms of biological, chemical,
radiation, and nuclear exposure in order to identify the nature of the threat and
then to treat and control the spread of both biological and chemical agents.

Scope and number of casualties

The scope of a disaster indicates the range of its effect. The scope is described
in terms of the geographic area involved and in terms of the number of individuals
affected, injured, or killed. From a health care perspective, the location, type,
and timing of a disaster event are predictors of the types of injuries and
illnesses that might occur. For example, several factors brought about contrasting
effects of TS Ondoy in 2009 and TS Sendong (international code name Washi) in 2011.

The casualty count of TS Ondoy totaled to 1,030, with 464 deaths. The widespread
flooding caused by TS Ondoy in 2009 happened in Luzon during the daytime. In
addition to the fact that flood waters started to rise during the daytime, floods
occur frequently in many areas in Luzon like Metro Manila and Central Luzon. People
were more conscious of tropical cyclones causing floods.

In contrast, the casualties that resulted from TS Sendong were far greater, with a
total number of reported casualties of 7,520: 1,268 persons reported dead, 6,071
persons injured, and 181 missing. The last time Cagayan de Oro City and its
surrounding areas had a flood was 75 years before 2011. Most of the casualties
resulted from flash floods brought about by heavy rainfall in the evening of
December 16 which continued until the early morning of December 17, when people
were mostly asleep.

Tropical cyclones generally affect a large geographic area. Despite this, they may
cause few if any deaths if sufficient preventive measures are taken.

Intensity

Intensity is the characteristic describing the level of destruction and devastation

of the disaster event. Tropical cyclones that affect the country are categorized
according to intensity in terms of wind speed near the center of the cyclone.
Factors contributing to the amount of damage from a disaster event such as a
typhoon are the distance from the zone of maximum winds, degree of exposure of the
location to the disaster, building standards, vegetation type, and resultant
flooding. For instance, the casualties and damage to property (estimated at more
than Php 2 billion) are the result of a combination of factors. The intense
rainfall in the upstream portion of the Cagayan De Oro River resulted in the
swelling of the river and created a strong current that uprooted trees along the
river banks. The muddy water full of sediment and debris flowed downstream. Heavy
rainfall was coupled with the occurrence of a high tide that restricted the flow of
flood waters.
DISASTER MANAGEMENTWhen one is aware of the types and characteristics of disasters,
the question then becomes: What can be done to prevent, prepare for, respond to,
and recover from disasters? Disaster management requires an interdisciplinary,
collaborative team effort and involves a network of agencies and individuals to
develop a disaster plan that covers the multiple elements necessary for an
effective plan. Communities can respond more quickly, more effectively, and with
less confusion if the efforts needed in the event of a disaster have been
anticipated and plans for meeting them have been identified. The result of planning
is that more lives are saved and less property is damaged. Planning ensures that
resources are available and that roles and responsibilities of all personnel and
agencies, both official and unofficial, are delineated.Nurses need to know their
personal, professional, and community responsibilities. They should realize that
conflicts may arise between their personal and professional responsibilities if
these have not been considered and planned for in advance. In addition, nurses may
be direct or indirect victims and may even be displaced persons themselves as a
result of a disaster event. Recognizing this possibility, nurses need to plan,
prepare, practice, and teach their family and significant others how to respond.
During a disaster, a nurse might face an ethical dilemma because of competing
responsibilities to family, employer, and patients, for example, a nurse who is a
single parent with young children and has a limited support system may be forced to
decide between his or her responsibility to care for his or her children or a
mandate to report to work to care for patients. Choosing may result in loss of
employment or danger to the children. Potential conflicts such as this should be
considered, discussed, and decisions be made in conjunction with the employer
before a disaster event. Disaster management stagesPrevention stageThe first stage
in disaster management occurs before a disaster is imminent and is known as the
nondisaster stage. Potential disaster risks should be identified and risk maps
created. For example, geohazard maps are used in identifying areas prone to natural
dangers like landslides, flooding, and ground subsidence or sinking. The maps are
used in preparing government authorities and the people for possible disasters. The
Department of Environment and Natural Resources (DENR) spearheaded the creation of
the geohazard maps through its Mines and Geosciences Bureau. The population
demographics and vulnerabilities, as well as the community's capabilities, should
be analyzed. Primary prevention measures include educating the public regarding
what actions to take to prepare for disasters at the individual, family, and
community levels. Further, based on the assessment of potential risks, the
community must develop a plan for meeting the potential disasters identified.With
regard to bioterrorist attacks, prevention means that health care providers need to
be knowledgeable about the biological and chemical agents that might be used. In
addition, health care providers need to know the signs and symptoms of the various
biological and chemical agents that have been recognized as potential threats. As
mentioned, unlike other disasters, biochemical terrorist threats may be identified
only when events raise the suspicions of health care providers, rather than first
responders at a particular site.

Early identification of ill or exposed persons, rapid implementation of preventive

therapy, special infection control considerations, and collaboration or
communication with the public are essential in controlling the spread of cases.
Hospitals need to identify rooms that can be converted into isolation units to meet
the demand. Nurses need to be instructed in decontamination and be reminded of
isolation techniques that might be needed, depending on the biological agent.
Volunteers and professionals must remain current in first aid, cardiopulmonary
resuscitation, and advanced lifesaving procedures.

Preparedness and planning stage

Individual and family preparedness includes training in first aid, assembling a

disaster emergency kit, establishing a predetermined meeting place away from home,
and making a family communication plan.

Although there will be some variation according to the individual community's

needs, all community disaster plans should address the following elements:
authority, communication, control, logistical coordination of personnel, supplies
and equipment, evacuation, rescue, and care of the dead. The plan should indicate
who has the power to declare that there is a disaster and who has the power to
initiate the disaster plan.

Authority should be designated by the title of the person; it should not specify a
person by name. There should also be backup positions identified in the event the
first individual is not available. Every individual should be equally informed
about the role and responsibilities that go with this authority. A clear chain of
authority for carrying out the plan is critical for successful implementation of
the plan. Authority may change, depending on whether the disaster is natural or
man-made as a result of some criminal action, and the change of authority should be
addressed in the plan.

Communication is recognized as a very significant problem during disasters.

Misinformation and misinterpretation can occur when communication is ineffective.
Reliance on telephone systems or cell phones should not be the sole planned means
of communicating because these may not work or the systems might be overloaded. The
communication section of the disaster plan should address how the authority figure
will be notified of the disaster, how the emergency management team members will be
notified, how the community residents will be warned about the incident, and what
actions will be required. This section needs to address how communication between
relief workers and authorities will be maintained. Also, it should include
information on the role of the media in keeping people informed and in letting
people know what assistance and supplies are needed. In case of electric power
interruptions, the use of battery-operated portable radios is advised so residents
may listen for instructions and updates about the disaster. One of the most
important elements to consider in communication is the early warning stage. This
generally impacts on how the community will respond to warnings of possible
disaster, which eventually will be very crucial in preventing the loss of lives.

The analysis of the population during the nondisaster stage should identify groups
that need special attention as to the process of notification. These people include
those who speak different languages, are homeless or poor, are without television
or other means of communication, and are in institutions such as prisons, custodial
care facilities, day care settings, or schools. Effective communication during a
disaster must be credible, current, and authoritative and must give some indication
of future events.
The logistical section should specify where supplies and equipment are located or
where additional supplies and equipment can be obtained from, where these will be
stored or found, and how these will be transported to the disaster site. Essential
human resources (e.g. emergency and disaster specialists, officials of governmental
and voluntary agencies, engineers, weather specialists, and community leaders)
should be identified and tracked where they will be located. The plan should
include information about transportation for evacuation and rescue (particularly
taking into account vulnerable groups), documentation and record keeping, and plans
for evaluation of the success or failure of the plan.

A disaster plan is a dynamic entity. Planning is a continuous process, and plans

change with circumstances and when gaps are identified during drills or from
previous disaster incidents. The plan should set realistic expectations of effects
and needs, should be brief and concise, and should establish priorities and
timelines for actions.

For a plan to be effective, it must be tested by having different disaster scenario

drills. The more times realistic scenarios are created to test the plan in actual
practice sessions, the more problems with the plan will be identified, and
solutions for those problems can be found. Without practice drills, plans may have
many unrecognized faults and, as a result, many more individuals may be harmed and
communities damaged when an actual disaster occurs.

Response stage

This stage begins immediately after the disaster incident occurs. The community
preparedness plans that have been developed are initiated. If a disaster occurs,
people should remain calm and exert patience, follow the advice of local emergency
officials, and listen to the radio or television for news and instructions. If
people nearby are injured, one should give first aid, seek help, and check the area
for dangerous hazards. Those at home should shut off any damaged utilities, confine
or secure pets, call family contact(s), and check on neighbors, especially the
elderly or disabled.

The plan may call for people to shelter in place or to evacuate, or for search and
rescue to begin. If the only response needed is shelter in place, then people need
to know what to do if they are at home, at work, at school, or in their vehicle.

Evacuation

Each community should have established evacuation routes for the residents to use
if evacuation from the area is necessary. In some instances, mandatory evacuation
may be implemented. However, there are always some individuals who will not leave
their home for any numbers of reasons (e.g. fear of vandalism, denial of the
potential extent of the disaster, pride in their home and belongings). Education of
residents as to the potential damage, deaths, and injuries that will be incurred
from the potential disasters that may affect their community needs to be done in
the preparedness stage and not when evacuation is ordered. In some extreme cases,
it may be necessary for hospitals and other facilities, such as nursing homes, to
evacuate patients. This requires significant advance planning, as health
practitioners must determine how to move seriously, and even critically ill people
and coordinate transportation and placement for their disposition to safe
facilities.

Search and rescue

Before search and rescue should begin, safety must be considered. In some
instances, if a criminal action is suspected, law officials will be among the first
to respond in order to secure the area and possibly gather evidence. While the area
is being checked and then cleared of potential threats, a staging area can be set
up at or near the site of the incident to direct on-site activities. Search and
rescue of victims can begin once clearance is given, a disaster triage area is
established, and an emergency treatment area is set up to provide first aid until
transportation for victims to hospitals or health care facilities for treatment can
be coordinated.

Staging area

The staging area is the on-site incident command station. Disaster responders
should report to this area to "check in" so that everyone is accounted for and can
be given an assignment. This will allow for the most effective use of the skills
and abilities of those responding. No one should go to the disaster site unless
directed to do so by the staging area commander. The staging area is also where the
authority rests for decisions as to additional resources to be called to the area
to manage the disaster incident. Resources may include construction equipment to
move building materials, rescue dogs to locate humans who are buried in the debris,
or more fire, police, or medical personnel.

Disaster triage

Triage at the site and again at the treatment area is very different from triage
that is routinely conducted in the emergency department. The focus of disaster
triage is to do as little as possible, for the greatest number, in the shortest
period of time. One triage system that is used by first responders is the START
triage system. START stands for "simple triage and rapid treatment." This system
describes what to do when first arriving at a multicasualty or mass casualty
incident. Disaster triage of an injured person should occur in less than 1 minute.
This system also describes how to enlist people with minor injuries to assist. As a
decision is made regarding the status of an individual, the person is tagged with a
colored triage tag. Depending on what type of tag is available, the tags may simply
be pieces of colored paper.

Green on the triage tag is for the walking wounded or those with minor injuries
(e.g. cuts and abrasions) who can wait several hours before they receive treatment;
yellow is for those with systemic but not yet life-threatening complications who
can wait 45 to 60 minutes (e.g. simple fractures); red is considered top priority
or immediate and is for those with life-threatening conditions but who can be
stabilized and have a high probability of survival (e.g. amputations); black is for
the deceased or for those whose injuries are so extensive that nothing can be done
to save them (e.g. multiple severe injuries).

A new classification of victim, those who are contaminated, will require a hazmat
(for "hazardous materials") tag. To assess an individual within the 1-minute
guideline, the system uses three characteristics. First, respirations are checked;
if they are over 30 per minute, the individual is tagged red or immediate. If the
individual has fewer than 30 respirations per minute, then the assessor moves to
the second step—perfusion. Pinching the nail bed and observing the reaction are
done to check perfusion; color should return to normal within 2 seconds. The third
step is checking mental status. The assessor should ask the individual simple
questions (e.g. Who are you?). By doing these steps, the individual responsible for
triage can very quickly assess an individual and decide which color tag fits his or
her condition. Further, the steps are easy to remember by thinking "30—2—can do,"
where "30" is the number of respirations, "2" is the number of seconds needed to
check for perfusion, and "can do" relates to checking mental status.

Following triage, victims are then moved to the treatment area where their
condition is checked again. First aid may be provided there, until transportation
is available. Ambulances, helicopters, buses, or all three may be used to transport
the victims to various hospitals or health care facilities. Some victims, such as
those in the surrounding area that may have been affected by the incident, may even
go by private vehicle to a hospital or medical facility. This process may go on for
days as it did in the September 11 incidents, the 2005 tsunami in South Asia, and
Hurricanes Katrina and Rita in the United States. Search and rescue eventually will
be called off, and the recovery stage will begin.

While search and rescue is going on, other agencies (e.g. public health agencies)
are checking for threats such as contaminated water, vectors, and air quality. They
also disseminate data on what has been found and relate health information to
officials, the media, and the public as appropriate. Designated agencies measure
the occurrence and distribution of health-related events associated with the
disaster, describe factors contributing to health-related effects, and assess the
needs of populations and facilities. They will allocate resources and work to
prevent further adverse health problems that may result from the disaster. For
example, following disasters, especially those that require evacuation,
immunization is provided, particularly to the young children in temporary shelters
or evacuation centers.

Although triage of individuals exposed to chemical warfare agents is basically the

same as for any multiple or mass casualty incident, it poses special challenges.
For these events, the triage area is set up in the "hot zone" to assist in
determining priorities for resuscitation, decontamination, pharmacological therapy,
and site evacuation. Only specially trained emergency personnel who are familiar
with chemical agents and the use of personal protection equipment should triage
chemical agent victims. The same triage categories can be assigned to these
victims.

Psychological triage presents the challenge of determining who most needs help and
deciding what interventions will help. Mental health disorders related to disasters
can include anxiety disorders, exacerbation of existing substance abuse problems,
somatic complaints, depression, and, later, posttraumatic stress disorder (PTSD).
Research has identified four keys to gauging the mental health impact of such
events, any two of which may result in severe, lasting, and pervasive psychological
effects. The key factors are as follows:
•
• Extreme and widespread property damage.
• Serious and ongoing financial problems.
• High prevalence of trauma in the form of injuries, threat to life, and
loss of life.
• When human intent caused the disaster. In addition, panic during the
disaster, horror, separation from family, and relocation or displacement are
factors that may play a part in psychological impairment. Nurses need to evaluate
an individual's danger to self or others. Nurses need to know the symptoms to look
for and know what resources are available for people who need help.
Recovery stage

The recovery stage begins when the danger from the disaster has passed and
concerned local and national agencies are present in the area to help victims
rebuild their lives and help the community restore public services. Cleanup of the
damage and repair of homes and businesses begin. Evaluation and revision of the
disaster plans based on lessons learned from the experience are made. Understanding
the financial impact on the community and agencies involved is essential in
developing future public health policy. Research is needed on all aspects of
prevention, preparedness, response, and recovery stages of disasters. Research is
also needed on the education and training needs of first responders, health care
providers, and community populations. Nurse researchers, in partnership with
researchers from other disciplines, can play a significant role in these research
endeavors.

Governmental responsibilities

The government is responsible for the safety and welfare of its citizens.
Emergencies and disaster incidents are handled at the lowest possible
organizational and jurisdictional level. Police, fire, public health, public works,
and medical emergency services are the first responders responsible for incident
management at the local level. Local officials and agencies are responsible for
preparing their citizens for all kinds of emergencies and disasters and, where and
when possible, for testing disaster plans with mock drills.

The local government manages events during an incident by carrying out evacuation,
search, and rescue and maintaining public health and public works responsibilities.
Local communities should have contingency operation plans for multiple disaster
situations and for various aspects of the plan. For example, landline telephone
service and cell phone service may not work because of being restricted for
emergency use only or damage to the infrastructure; therefore, other forms of
communication should be available.

For a biological or chemical terrorist incident, the process is very different.

First responders generally are not involved. Rather, nurses and doctors in health
care facilities may be the first to suspect that a biological or chemical agent has
been released into the community.

In an incident other than a biological, chemical, radiation, or nuclear event, in

most cases, it is the fire or police department that gets the initial message. The
emergency telephone number for the Philippines is 117, also called Patrol 117,
which is under the management of the Department of Interior and Local Government
(DILG). Executive Order No. 226, s. 2003 institutionalized Patrol 117 as the
nationwide emergency hotline number for police assistance, fire protection,
Philippine Red Cross (PRC), among others.

Public health system

The public health system's mission is the promotion of health, prevention of

disease, and protection from threats to health. The public health system is a broad
term used to describe all of the governmental and nongovernmental organizations and
agencies that contribute to the improvement of the health of populations. Public
health agencies are the primary agencies for the health and medical response to
disaster incidents and therefore are a part of the initial response activities.

Public health officials provide advice and assistance to other public officials
related to environmental and health matters. Preparedness includes vigilance and
reporting of suspicious illnesses (e.g. signs and symptoms of biological agents,
food-borne diseases, and communicable diseases) in the community by physicians and
nurses in local health care facilities or private offices and clinics. Public
health officials then have the responsibility of detecting outbreaks, determining
the cause of illness, identifying the risk factors for the population, implementing
interventions to control the outbreak, and informing the public of the health risks
and preventive measures that need to be taken. These relate both directly and
indirectly to the essential public health services.

The Philippine Red Cross

When it was officially founded in 1947, the PRC carried out two main functions:
blood provision and disaster-related services. Embodying the fundamental principles
of the International Red Cross and Red Crescent Movement (i.e., humanity,
impartiality, neutrality, independence, voluntary service, unity and universality),
the present-day Red Cross offers she major services:
1
2 National Blood Services - provision of safe blood for medical purposes.
3 Safety Services - conduct of training in first aid, basic life support,
water safety, accident prevention, and other basic rescue courses.
4 Social Services - among its wide range of services, social services
relevant to disaster and postdisaster situations include:
•
• Guidance and counseling.
• Psychosocial support program or critical incident stress management -
helps in stress during disasters.
• Tracing service - assists in locating displaced or missing person (s)
during a disaster that occurred either in the Philippines or in a foreign country
where normal channels of communication have become difficult for the families
concerned.
• Referral service.
• Early livelihood recovery program -supports restoration of livelihood
after a disaster.
• Hot meals - facilitates a feeding program to prevent malnutrition among
calamity victims, especially children.
5
6 Volunteer services - provides training courses for volunteers.
7 Community health and nursing services - offers training programs in
Basic Health Education Program and Primary Health Care (Community-Based Health
Program) for professional nurses and student nurses.
8 Disaster management services - involves disaster relief operations and
services of identifying hazard-prone areas and making vulnerability assessment of
these areas. The PRC offers several courses on Disaster Management, including
Community-Based Disaster Management Training. Specific disaster management services
offered include:
•
• Relief operations
• Deployment of disaster response teams
• Organization of barangay disaster action team
• Pre-position of relief supplies

The PRC is one of the major nongovernmental agencies that work hand-in-hand with
government agencies in disaster risk reduction. This purpose of the PRC is
specifically stated in R.A. 10072 or the Philippine Red Cross Act.
THE NATIONAL DISASTER RISK REDUCTION AND MANAGEMENT PLANSigned into law in 2010,
R.A. 10121, also known as the Philippine Disaster Risk Reduction and Management
Act, brought about a paradigm shift from disaster preparedness and response to
disaster risk reduction and management (DRRM). It also mentioned disasters brought
about by climate change. The law specified the policy of developing and
implementing a National Disaster Risk Reduction and Management Plan (NDRRMP)The
NDRRM framework envisions a country that has "safer, adaptive and disaster-
resilient Filipino communities toward sustainable development." The goal is to
shift from being reactive to proactive in DRRM. This means the focus is on:
1
2 Building individual, collective, and institutional capacities to adjust
to situations (increased resilience)
3 Decreasing vulnerabilities. Filipinos will continue to be subjected to
risk factors (hazards), but in due time, resources will be invested more on
disaster prevention, mitigation, preparedness, and climate change adaptation,
rather than on response and rehabilitation and recovery.
The NDRRMP aims to:
•
• Strengthen the capacity of the government—national and local— together
with partner stakeholders.
• Build the disaster resilience of communities.
• Institutionalize arrangements and measures for reducing disaster risks.
The plan has four priority areas:
•
• Disaster prevention and mitigation by reducing vulnerabilities and
exposure and enhancing capabilities of communities. Examples of activities that
prevent and mitigate disasters are hazard and risk mapping (geohazard mapping),
construction of dams or embankments that eliminate flood risks, regulations that do
not permit any settlement in high-risk zones, improved environmental policies, and
increased public awareness.
• Disaster preparedness - the capacity to effectively anticipate, respond
to, and recover from the impacts of hazardous events or conditions. This includes
such activities as contingency planning, stockpiling of equipment and supplies,
development of arrangements for coordination, evacuation drills, and associated
training.
• Disaster response - the provision of emergency services and public
assistance during or immediately after a disaster in order to save lives, reduce
health impacts, ensure public safety, and meet the basic subsistence needs of the
people affected. It is sometimes called "disaster relief."
• Rehabilitation and recovery - measures that ensure the ability of
affected communities to restore their normal level of functioning by rebuilding
livelihood and damaged infrastructure and increasing the communities'
organizational capacity.

R.A. 10121 has designated the Office of Civil Defense, an attached bureau of the
Department of National Defense, as the operating arm and the Secretariat of the
NDRRMC. A focal agency has been assigned to each of the four priority areas, and
the heads of these agencies shall serve as Vice Chairperson in the NDRRMC.

The other member of the Cabinet of the President, including the Secretary of
Health, together with the heads of various government offices and representatives
of civil society organizations, complete the composition of the NDRRMC.

The NDRRMC provides national leadership. Disaster Risk Reduction and Management
Councils exist at the regional, provincial, city, and municipal levels. The NDRRMP
is the document formulated and implemented by the Office of Civil Defense, the
agency that sets out goals and specific objectives for reducing disaster risks
together with related actions to accomplish these objectives.

A Community-Based Disaster Risk Reduction and Management (CBDRRM) describes the

process of DRRM in which at-risk communities are actively engaged in the
identification, analysis, treatment, monitoring, and evaluation of disaster risks
in order to reduce their vulnerabilities and enhance their capacities. In the
CBDRRM, the people are at the heart of decision-making and implementation of DRRM
activities.

The local DRRM offices at the provincial, city, and municipal levels and the
Barangay Development Councils are responsible for developing the local DRRM plan of
their respective LGUs.

Incident Command System

The Incident Command System (ICS) is a standardized, on-scene, all-hazard incident
management concept. It allows its users to adopt an integrated organizational
structure to match the complexities and demands of single or multiple incidents
without being hindered by jurisdictional boundaries. ICS is a nonpermanent
organization and is activated only in response to disasters or emergencies. The
establishment of an ICS was also provided for by the Implementing Rules and
Regulations of R.A. 10121.

Whenever possible, the local DRRMCs manage incidents with their own emergency teams
and material resources. The following criteria are used in defining which level of
DRRMC should take charge of a particular incident:
•
• The Barangay Development Committee (BDC), if a barangay is affected.
• The city/municipal DRRMC, if two or more barangays are affected.
• The provincial DRRMC, if two or more cities/municipalities are
affected.
• The regional DRRMC, if two or more provinces within the region are
affected.
• The NDRRMC, if two or more regions are affected.
The NDRRMC and intermediary local DRRMCs shall always act as support to local
government units (LGUs) that have the primary responsibility as first disaster
responders to any incident occurring within their jurisdictions.

The DRRMC, through its chairperson or responsible official, provides the Incident
Commander the mission and authority to achieve the overall priorities of the on-
scene disaster response operations, namely, life safety, incident stabilization,
and property/ environmental conservation and protection.

The Incident Command is responsible for the overall management of the incident. It
is headed by the Incident Commander and made up of the Command Staff and the
General Staff. The command function may be done either as a Single Incident Command
or as a Unified Command. The Single Incident Command may be applied when the
incident occurs within a single jurisdiction and there is no functional agency
overlap. The Unified Command for incident management may be applied when a disaster
or emergency affects several areas or jurisdictions or requires multiagency
engagement. Here, agencies work together through the designated members of the
Unified Command to establish a common set of objectives and strategies and a single
Incident Action Plan.

The Command Staff, composed of people who report directly to the Incident
Commander, usually includes:
•
• The Public Information Officer who is responsible for providing the
public, media, and/or other agencies with required information related to the
incident. Even a Unified Command has a single Public Information Officer.
• The Safety Officer who monitors operations related to the incident and
advises the Incident Command on matters of operational safety, including the health
and safety of responding personnel. The Safety Officer is responsible for the safe
conduct of the incident management and has the authority to stop any unsafe act.
• The Liaison Officer who takes charge of coordinating with
representatives from cooperating and assisting agencies or organizations.
The General Staff is responsible for the functional aspects of the incident command
structure. It usually consists of the operations, planning, logistics, and finance/
administration.

The DRRMC Emergency Operations Center (EOC), which is generally located away from
the disaster site, supports the Incident Commander by making executive/policy
decisions, coordinating interagency relations, mobilizing and tracking resources,
collecting, analyzing, and disseminating information, and continuously providing
alert advisories/ bulletins and monitoring of the obtaining situation. The EOC does
not command the on-scene level of the incident. The Incident Command takes charge
of the operations at the scene.

RESPONSES TO A DISASTERCommunity responses to a disasterThe classic four phases of

a community's reaction to a disaster are the heroic phase, honeymoon phase,
disillusionment phase, and reconstruction phase.Heroic phaseDuring the heroic
phase, nearly everyone feels the need to rush to help people survive the disaster.
Medical personnel may work hours without sleep, under very dangerous and life-
threatening conditions, in order to take care of their patients. Medical personnel
may help out in areas in which they are not familiar and have no experience.
Disaster medical assistance teams, consisting of professionals and paraprofessional
medical personnel, provide emergency relief during a disaster and may travel long
distances to help out in a disaster. This was illustrated by the people who
volunteered to help in the immediate aftermaths of the Luzon earthquake of 1990 and
TS Ondoy.Honeymoon phaseIndividuals who have survived the disaster gather together
with others who have simultaneously experienced the same event; this is known as
the honeymoon phase. People begin to tell their stories and review over and over
again what has occurred. Bonds are formed among victims and health care workers.
Gratitude is expressed for being alive.Disillusionment phaseWhen time has elapsed
and a delay in receiving help or failure to receive the promised aid has not
occurred, feelings of despair arise. Medical personnel and other first responders
may begin to experience depression due to exhaustion from many long days of long
hours. Depression may set in as a result of knowledge of what has happened to the
community, friends, and family. People realize the way things were before the
disaster is not the way things are now and may never be the same again. They
recognize that many things are different and much needs to be done to adjust to the
current situation.Reconstruction phaseOnce the community has restored some of the
buildings, businesses, homes, and services, and some sense of normalcy is
returning, feelings of despair will subside. Counseling support for victims and
helpers may need to be initiated to help people to recover more fully. During this
phase, people begin to look to the future. Common individual reactions to a
disasterThe reactions by individuals to a disaster vary. Some of the more commonly
encountered emotional, cognitive, physical, and interpersonal reactions to a
disaster that may be experienced. It should be noted that both victims and helpers
are under stress as a result of a disaster, thus disaster planning becomes futile
if it fails to account for possible intra- and intergroup conflicts.

Posttraumatic stress disorder

The reactions mentioned usually resolve in 1 to 3 months after the disaster event
but, in some cases, may lead to PTSD. PTSD is a psychiatric disorder that can occur
following an individual's experiencing or witnessing a life-threatening event, such
as a disaster. Men and women, adults and children, and all socioeconomic groups can
experience PTSD. People who have PTSD often relive the experience through
nightmares and flashbacks. The social and psychological symptoms can be severe
enough, and last long enough, to significantly impair a person's daily life. If
PTSD occurs in conjunction with related disorders (e.g. depression, substance
abuse, and other problems of physical and mental health), the situation becomes
more complicated. Individuals experiencing PTSD require medical attention.

Research is needed on all aspects of prevention, preparedness, response, and

recovery stages of disasters. Research is also needed on the education and training
needs of first responders, health care providers, and community populations. Nurse
researchers, in partnership with researchers from other disciplines, can play a
significant role in conducting research on disaster management.