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					STATE LEVEL DISASTER MANAGEMENT PLAN


                    YEAR: 2008




HEALTH & FAMILY WELFARE DEPARTMENT
              GUJARAT




                          Epidemic Cell 
Commissionerate of Health, Medical Services & Medical Education (Health
                        Section) Gandhinagar.
                                      INTRODUCTION
The increasing incidences of disasters across the globe are creating a devastating
impact on lives, property and livelihood of people. Disaster preparedness entails
varied forms of actions on various fronts. One such measure is the formulation of
disaster preparedness plans not only at the national, state and the district level but
also percolating to the community level.
Concept & Significance:
Disaster preparedness involve two key elements namely, the event and people
vulnerable to it. Hence preparedness assume significance, to strengthen the abilities,
capacities to predict, and wherever feasible, prevent disasters, reduce the impact
and facilitate response and handle the consequences of disasters at various level.
The significance of disaster preparedness activities arises on an analysis of whether
the people are aware of their vulnerability to disaster, the inherent risks and possible
ways of reducing risk.
Disaster preparedness is a multifaceted activity and has to pay attention to
economic, social, political, technological and psychological variables.
A Disaster Preparedness Plan is a plan of action that indicates the objectives to
be fulfilled; the preparedness and mitigation measur4es to be taken before, during
and post-disaster phases and enables the authorities to take prompt action in
disaster situations.
Planning results in allocation of clear responsibilities and consequently improves
coordination between various agencies for bringing most benefits to a wide range of
beneficiaries at an affordable cost.
    Classification Of Disasters
1) Natural – Floods, Drought, cyclones, Volcanic eruptions etc.
2) Man made or Induced:-
  a) Intentional like warfare, civil strife, riots
  b) Unintentional: - Accidents, (Bhopal gas leak) or Chernobyl nuclear plant
                  disaster.
Acute: -        Aero plane crash, Explosion etc.
Chronic: -      Deforestation (green house effect)
Rapid Onset: - Little or no advance warning like Earthquake, Flash floods,
                 cyclone
Slow onset: - Al least – some advance warning like in floods, drought, epidemic,
                civil strife.

Major Public Health Problems of Disaster
1.    Injuries, deaths, disabilities,
2.    Effect on communicable disease patterns and environmental hazards.
3.    Damage or strain on health facilities, services
      a)      Shelter
      b)      Water supply
      c)      Food stock/PDS
      d)      Sanitation
      e)      Sewage
4.    Effect on human behavior
5.    Severe nutritional consequences

 The above effects are more seen in India and other developing countries because of
following factors.
       a) Border line economic status.
Disaster-2008_Action Plan-08               2
      b) Vulnerable population with no or inadequate adjustable capacity.
      c) Large density of population.
What is Disaster Management?
  • Disaster management means a continuous and integrated process of
      planning and implementation of measures with a view to
      1Mitigrating or reducing the risks of disasters.
      2 Mitigating the severity or consequence of disaster.
      3 Capacity – building.
      4 Emergency preparedness.
      5 Assessing the effects of disasters.
      6 Providing emergency relief and rescue, and
      7 Post disaster rehabilitation and reconstruction

Seven Fundamental Terms in Risk Management


                           A Logical Framework of Terminology

Hazard                                      Risks
Any potential threat to public safety and / The potential consequences of hazard
or public health                            interacting with community

Emergency                                   Vulnerabilities
Any actual threat to public safety and / or Factors which determine the type and
public health                               severity of those consequences.


Disaster                                Readiness for Response
A civil emergency in which the          A determinant of the severity and
humanitarian needs are beyond local     manageability of those consequences
capacity to meet those needs i.e. the
response and recovery operation must be
managed at the national and/or
international level

Community is people, property, services, livelihoods and environment i.e. the
elements exposed to hazards

COMMUNITY RISKS are proportional to

HAZARDS x VULNERABILITIES
__________________________
READINESS FOR RESPONSE

WARNING: this is not a mathematical formula!

Risk & Risk Management
RISKS are the anticipated consequences (e.g. losses or damage) that can be
predicted to result from a particular hazard affecting a particular place at a particular
time.


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RISK MANAGEMENT is a comprehensive strategy for reducing hazards and
consequences to public health and safety of communities by:
Preventing exposure to hazards (target = hazards)
Reducing vulnerabilities (target group = community)
Developing response and recovery capacities (target group = community and
response agencies)

Risk Management Demonstration
   1. The facilitator will use a simple demonstration to illustrate the key terms in risk
      management
   2. One of the participants will be asked to repeat the demonstration and the
      others should comment on his / her presentation.

A Community Consists of 5 Elements:
   1. the people
   2. their property (infrastructure, possessions and assets; public, private and
      cultural)
   3. their services (government and non-government, commercial and voluntary)
   4. their livelihoods (urban and rural, formal and informal)
   5. their environment (air, water and soil; urban and rural, built and natural)

There are 4 classes of hazard:
         1. Natural hazards
         2. Technological hazards
         3. Biological hazards
         4. Societal hazards

Indicators of Vulnerabilities
Each element of community can be described in terms of its vulnerabilities:

            •    people
            •    property
            •    services
            •    livelihoods
            •    environment

Capacities are to be strengthened for following aspects.
  • Policy, guidelines, legal framework, protocols
  • Risk assessment
  • Emergency response and emergency recovery planning
  • Emergency response and recovery operations
  • Capacity development and training – resources, skills, knowledge

Health services in disasters are crucial for
  • Management of mass casualty
  • mental health
  • environmental health
  • reproductive health
  • management of the dead and missing
  • emergency feeding
  • Communicable disease surveillance and response.

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Response and Recovery Needs
Readiness is needed for:
   find and rescue victims
   evacuate victims to safe place
   provide first aid and medical transport
   treat the injured
   provide emergency shelter, sanitation, food and water
   provide care for the dead and manage the missing
   re-establish security
   re-establish essential services (water, energy, communications)
   repair essential infrastructure
   plan for recovery and reconstruction

Management of Emergencies
To protect public safety and public health, a community and its emergency services
need:
          • Capacity to reduce risks
          • Capacity to respond
          • Capacity to recover

Supported by policy, guidelines, legislation, plans, resources and personal
capabilities
Risk Management Process
Risk assessment
Risk communication
Risk reduction
Risk monitoring

Risk Assessment Process
   Prepares hazard profiles.
   Maps the distribution of those hazards.
   Identifies the elements of the community exposed to those hazards
     (vulnerabilities).
   Predicts the consequences of a hazard interacting with that community at a
     certain time (e.g. in a certain season).
   Analyses each of the 5 elements of community in terms of that hazard to
     identify the factors which will lead to each consequence i.e. determines the
     vulnerabilities of each element.
   Assesses risk reduction capacities within communities..
   The information from a Risk Assessment is used to undertake interventions to
     reduce risks by reducing exposure to hazards, reducing vulnerabilities and
     building capacities.




Disaster-2008_Action Plan-08              5
  STATE LEVEL DISASTER MANAGEMENT PLAN

                               Earth-quake
INTRODUCTION

        Earthquake can be defined as shaking caused by waves moving on and
below the earth‘s surface, which results in surface faulting, tremors vibration,
landslides, aftershocks and/or tsunamis. Latur earthquake and most recently Kutch,
Gujarat earthquake are example of earthquake calamities. This tragedies are
unpredictable or there is very little time available, to scramble resources and
equipment for tackling and managing such disasters and their aftermath. Health
relief services in the wake of other natural calamities like heavy rain, floods, draught,
cyclone and manmade disaster etc. to prevent post calamity disease outbreaks.

Zoning Map for earthquake
      Gujarat falls under three seismic zones, high risk zone (Zone V) comprising of
Kutch and adjoining area, moderate risk zone (zone IV), Jamnagar, Rajkot, Patan,
Surendranagar and Banaskantha. Low risk zone (zone III) all other districts.




                Seismic Zoning in Gujarat




             Zone-5

             Zone-4

             Zone-3




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                      Earth Quake Prone Area




                               Grade5 Zone


                                             Grade 4
                                                       Grade 3
                                              Zone      Zone




          EARTH QUAKE FAULT LINES IN GUJARAT




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                       Seismological Monitoring in Gujarat
                       Seismological Monitoring in Gujarat




         Network of Forty Strong Motion Accelerographs




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                        VSAT connectivity of 22 stations at
                           Central Recording Station
                               ISR Gandhinagar




        Central Recording Station at
        ISR-Gandhinagar




                                       Earthquake Recording Stations in Gujarat (by ISR)




                  Terrorism Prone Areas In Gujarat




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                         FLOOD AFFECTED AREAS
                                August 2006




                Areas Prone For Communal Violence




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                               Tsunami waves in Dec.2004




                                 Tidal Wave in Tasunami


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                               Mechanism Of Tsunami


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       Characteristics of Disasters
Characteristics            Flood        Earth-         Drought         Epidemic           Complex
                                        Quake                                            Emergency

       Cause             Natural   or   Natural        Natural   or    Natural      or Manmade

                       manmade                        manmade         manmade

  Speed of onset          Slow     or   Sudden          Slow            Slow        or Slow
                         sudden                                        sudden
      Deaths              Few            Many          Many              May        be May         be

                                                                        many             many
Disease outbreaks       Possible        Possible      Possible            (by            Common
                                                                      definition)

  Food shortage         Common           Rare         Overwhelming         Rare          Common

                                          Not
       Mass             Common                          Common             Not           Common
                                        common
  displacement                                                           common
 Injury potential       May be high      High             Low              Low           May be high

       Scope             Wide      or    Wide             Wide         Wide         or      Wide
                         focal                                         focal
     Duration            Long      or    Short            Long         Short        or      Long
                         short                                         long



Health consequences of disaster

Main Causes of Mortality and Morbidity

Direct Impact
1.     Earthquake cause high mortality resulting from trauma, asphyxia, dust
       inhalation (acute respiratory distress) or exposure to the environment i.e.
       hypothermia.
2.     Surgical needs are important in the first week. The pattern of injury is likely to
       be large numbers of injured with minor cuts and bruises, a smaller group
       suffering from simple fractures and a minority with serious multiple fractures
       or internal injuries and crush syndrome requiring surgery and other intensive
       treatment.
3.     Burns and electric shocks are also observed.


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Indirect Impact
4.    Damages to health facilities can be massive and lead to an interruption in
      basic health care services
5.    There is also likely to be massive damages to essential services such as
      water and sewerage systems, power lines, telecommunications, roads and
      airports.
6.    Pending assessment, anticipated needs would be: search and rescue,
      emergency medical assistance including the management of crush syndrome
      and management of homeless populations.
7.    Survival in entrapment is rarely longer than 48 hours, 85 – 95 % of people
      rescued alive from collapsed buildings are found in the first 24-48 hours after
      the earthquake.
8.    The demand for health services is concentrated within the first 24 hours of the
      event. Most injured people appear at medical facilities during the first 3 – 5
      days, after which consultation patterns, return almost to normal.
9.    Patients may appear in two waves: first causalities from the immediate area
      around the medical facility arrive, then, as relief is organized in more distant
      areas, referred cases follow, victims of secondary hazards (post –
      earthquakes, aftershocks and fires) may arrive at later stage.
10.   This has obvious implications on the type of assistance, which can be offered
      in a timely and efficient fashion. Camp / field hospitals and rescue teams
      usually arrive too late to have a life saving impact.
11.   Disasters may affect the psychological and social behavior of the stricken
      community. Generalized panic, paralyzing trauma, or antisocial behavior
      rarely occurs after major disasters, and survivors rapidly recover from their
      initial shock. However anxiety, neuroses and depression may occur after
      either sudden or slow onset emergencies.

Various phases of disaster management (The disaster cycle)
      There are five different phases of sudden impact disasters, interdisaster,
predisaster, impact, emergency and rehabilitation.i For each phase, new knowledge
exists about how to design appropriate prevention measures for different types of
natural disasters. These phases may last from just a few seconds to months or
years, with one phase merging into the next.

The Non-disaster or Interdisaster Phase
       This is the phase for preparedness. Before the disaster strikes the officials
should have in place disaster prevention measures and should conduct disaster
training and education programs for the community. Several activities should be
undertaken in this phase:
        Mapping the potential locations for disasters and associated risks
        Vulnerability analysis
        Taking an inventory of existing resources
        Planning appropriate preventive, preparedness and mitigation measures
        Conducting education and training of health personnel and the community.

The Predisaster or Warning Phase
       Before a disaster strikes, officials should issue timely warnings, take
protective actions, and possibly evacuate the population. The effectiveness of
protective actions will depend largely on the level of preparedness of the population,


Disaster-2008_Action Plan-08              14
particularly at the community level. During this phase, several essential emergency-
management activities should be undertaken:
         Issuing early warnings on the basis of predictions of the impending
            disaster
         Implementing protective measures-evacuation, preparing temporary
            shelters (Safe water supply, sanitation facilities in the shelter places)

The Impact Phase
       When disaster strikes, destruction, injuries, and death occur. It may last for a
few seconds (earthquakes). The impact on human health varies according to the
nature of the disaster itself, population density, predisaster health and nutritional
status, climate, and the organization of health services.

The Emergency Phase (also called the Relief or Isolation Phase)
        The emergency phase starts immediately after impact and is the time for
providing relief and assistance to the victims. This phase requires actions that are
necessary to save lives, including:
    Search and rescue operations
         First aid
         Emergency medical assistance
         Restoration of emergency communications and transportation network
         Public health surveillance
         In some cases, evacuation from areas still vulnerable to the hazard.
        In the immediate post impact period the local community is isolated and the
survivors themselves accomplish many of the most pressing rescue tasks, by using
locally available resources.
        The existence of district-and community –preparedness plans greatly
increases the self-reliance and effectiveness of assistance, contributing to the
reduction of disaster-related mortality and morbidity.

The Reconstruction or Rehabilitation Phase
       As the emergency or relief phase ends, restoration of predisaster conditions
begins including
        chlorination of water
        Vaccination
        Surveillance
        Plantation of the easy growing crops like, potato
        Electricity supply
       The reconstruction phase, which should lead to the restoration of predisaster
conditions, includes reestablishing normal health services and assessing, repairing,
and reconstructing damaged facilities and buildings. This phase is also the time for
thinking about the lessons learned from the recent disaster that could assist in
improving current emergency-preparedness plans. This phase actually represents
the beginning of a new inter-disaster phase. The time span for reconstruction or
recovery is often difficult t define. It may start fairly early, even during the emergency
period, and may last for many years.




Disaster-2008_Action Plan-08                15
                       OVER VIEW OF PLAN
                                         Vision:
     To provide an authentic and accurate database, documented and rehearsed
       in a manner,
       That it can be activated in the shortest possible time
        With simple and minimal orders and procedures
        Ensuring active participation and synchronization of the State and districts
        And the other important health sectors such as the GOI units, and private
           and trust hospitals.
        This would be done in such a way that there is optimal utilization of men,
           material, and resources with no gaps or overlaps.
        In order to minimize loss of lives, prevent disabilities, and further
           complications of emergencies.
        At the same time ensure the fastest restoration of routine health services.
(Involvement of PHCs, Community participation should be included?)

1. The objectives of the health sector plan
     a. To develop an effective emergency medical services (EMS) system to
         minimize loss of lives, and prevent disabilities, and further complications.
     b. To develop an effective Public health system for emergencies which works
         in synchronization with the medical services to deal with:
                   Prevention of outbreaks
                   Management of outbreaks
     c. Ensure the fastest restoration of routine health services through
         preparedness at all levels.
     d. To make available effective support and resources to all the concerned
         individuals, groups and disaster preparedness departments.
     e. To develop capacities of health personnel at all levels in developing
         compatible skills for disaster preparedness and management.
     f. To disseminate/communicate factual information in a timely, accurate and
         tactful manner while maintaining necessary confidentiality.
     g. To develop immediate and long-term support plans for vulnerable people
         in/during disasters.
     h. To create awareness among the people about hazard occurrence and
         increase their participation in preparedness, prevention, development,
         relief, rehabilitation and reconstruction process.
     i. To ensure active participation by the government administration,
         communities, NGOs, and volunteers at all levels making optimal utilization
         of human and material resources at the time of disaster.

2. Perspective and Strategy
       The formal plan for managing disaster related health issues has the following
salient features:

Building on existing resources:
       The plan uses the existing resources of the department of health and family
welfare of GOG for disaster preparedness and response. At the same time it adds to


Disaster-2008_Action Plan-08             16
its resources by building on the resources of the other health sectors such as the
IMA, NGO/Trust hospitals, and other GOI units.
Effective Training and Capacity building:
       With coordination and collaboration with GSDMA, and other local resource
persons and agencies training modules will be developed for various cadres of
health personnel. The training will focus on building the capacities of the health
personnel for developing appropriate skills for emergency response. The training will
be implemented through the SIHFW.

The effective use of GSWAN for EHIS and GIS

Specific role of the Medical College Hospitals

Support from GSDMA:
       The health sector contingency plan will be facilitated by the GSDMA, which is
coordinating disaster preparedness and response of all the important departments.
The implementation of Emergency Medical Services in coordination of the At the site
of disaster, the first response will be

Specific Plans for each District:
      Each district will be given guidelines to prepare a contingency plan for
emergencies based on the vulnerability analysis of their district.

Mitigation measures against the earthquake include
 Long term management of economic and urban development in seismic areas.
 Earthquake - proof building codes and by-laws.
 Fiscal incentives and control for proper building practices.
 Earthquake-proof essential systems (including hospitals)
 Strong public capacities for search and rescue and mass casualty management.
 Improved public awareness of earthquake risks through education and drills.

PREPAREDNESS FOR RAPID RESPONSE IN EVENT OF EARTHQUAKE

Rapid Assessment Protocol
      This rapid assessment protocol is divided into three parts;
1. Assessment purpose
2. The importance of preparedness
   2.1. Organizational preparedness
   2.2. Preparedness for rapid assessment
3. Strategy to organize rapid response
   3.1. Setting priorities for rapid assessment
   3.2. Assessing impact on health.
   3.3. Assessing impact on health services

1. Assessment purpose
       The sudden onset characteristic of many natural disasters often disrupts key
communications, transportation systems and social structure.
A rapid assessment should be initiated as soon as possible after a natural disaster
to;
     Assess its impacts on health.
     Assess immediate impact on health services.
     Assess the extent of damage to other sectors relevant to health operations
Disaster-2008_Action Plan-08              17
2. The importance of preparedness
        When they occur, sudden onset natural disasters put additional stress on
existing health services. Although international response to such emergencies is
often necessary, it is extremely important that disaster- prone communities be ready
to respond, by formulating their own disaster-preparedness plans in advance.

2.1 Organizational preparedness
        A rapid health assessment should help decision-makers respond more
effectively following a natural disaster. However, in order that a prompt response
follows, the measures listed below should have been implemented by the MOH
during the preparedness phase.

(A) The following structures for emergency health response should be in
    place:

 Formal structures at all levels with clear responsibilities for emergency health
  action (e.g. 1. emergency health committees at community 2. District 3. Regional
  and central levels).
      1.     Community level
      2.     District level
      3.     State level
      4.     Central level
 Prepare a clear chain of command from central to peripheral levels for
  emergency health management.
 Arrange working links at all level between the MOH, national relief organizations,
  WHO, UNICEF, UNHCR, UNDP, WFP, NGO‘s, community organizations and
  bilateral agencies.

(B) Emergency Plans should be prepared for likely natural disasters

Because of communities are at risk of some type of natural disasters, simple
contingency plans should be prepared, which outline the administrative and
technical responsibilities / procedures for emergency health response.

Administrative aspects of emergency planning:

       The following administrative actions should be taken in advance to enable a
prompt health response to a natural disaster.

1. Compile and update information for improving response.
 List and map health facilities by level of care /bed capacity/specialized services
 Maintain an inventory of community organizations and NGO‘s working in health
    and areas of expertise.
 In areas at increased risk of specific natural disasters, have detailed maps
    showing airfields, access roads, health facilities and major water sources.

2. Clarify areas of responsibility and accountability.
 Clarify responsibility for emergency of health action at each administrative level.
 Clarify agency responsibilities for, interagency co-ordination, leading the rapid
    assessment, clearance/storage/transport of relief items, directing health response
    and other critical activities such as providing travel permits.

Disaster-2008_Action Plan-08              18
3. Standardize approaches to international health assistance:
 Clarify reporting channels / lines of accountability for international agencies and
    NGOs.
 Develop standard procedure for requesting external health assistance in the
    event of natural disasters.
 Develop guidelines for emergency drugs and other health relief items, and
    circulate these to international assistance agencies to avoid inappropriate
    donations.
 Establish standard working procedures for the importation and expedited
    clearance of health relief items/drugs.
 What is likely health impact?
       1.     Treatment to injured.
       2.     Surveillance a). Disease Surveillance
                             b). Entomological Surveillance
 Likely effects on health facilities and services in the high –risk areas.
       1.     Structural damage
       2.     Severed communications.
       3.     Water supply
       4.     Power failure

3. Strategies to organize medical relief

     Response required in earthquake can be seen in terms of stages. These are
     described below.

(a) Stage – 1 (Day 1 & 2)
         In a catastrophic natural disaster, local priorities are to be simultaneously
assessed and rapidly respond to the health crisis, which is likely to follow.
         Essential medical measures: Local resources are spontaneously and often
effectively reassigned / adjusted.
         During this period, when outside resources have not yet arrived, the highest
health priority is emergency medical response, by available local and neighboring
areas.

(b) Stage – 2 (Days 3 & 4)
         Immediate medical life-saving measures become less important at the stage,
as most critical patients have already received initial medical attention in accessible
areas. (However, mass media and public attention may continue to focus on the
relatively small numbers of victims discovered after the first day.)
Determine and strengthen:
  Emergency medical response in less accessible areas.
  Shortages in primary health care resources.
  Strengthen local temporary hospitals.
  Shift severally injured cases for the treatment.
  Secondary health care needs, shelter, food and water to dislocated populations.
  Need for national and international resources (To re-established essential health
    services, restock medical supplies and orthopedic equipment)




Disaster-2008_Action Plan-08               19
 (c) Stage – 3 (Days 5 & 6)
          Restoring normal primary health care and adequate shelter become high
  priorities, along with the most effective use of national and international resources.
          Therefore, a rapid response should focus increasingly on needs for:
   Environmental health, food and public health services.
   Special protection and shelter of vulnerable groups. (e.g. the homeless
      population.)
   Re-establishing the primary health care systems and restoration of health
      facilities.

 (d) Stage – 4 (After day six)
        After day six, relief plans should be implemented and a fully functional
  disaster operation ideally in place, with resources for all components.
        From the stage on, health assessment should:
   Be based on an established surveillance system ;
   Incorporate information on both disease surveillance and the health care system;
   Focus on health trends as they relate to the relief operation itself.

 2.2 Assessing Health Impact

 (a) Background Information
         Estimating the health impact of a disaster on a population ideally requires
 some (1) basic demographic information (Such as age and sex distribution of the
 population) and (2) good knowledge of the affected area (Such as the (i) mapped (ii)
 location of health facilities (iii) water sources and (iv)high risk communities) Such
 information is often available from government departments, academic institutions or
 relief agencies.

 (b) Injuries
  Primary injury patterns and their importance vary according to the type of
     disaster.


E.g. Earthquakes are often associated with large numbers of traumatic injuries.


 Special priorities for rapid assessment of injuries:
  Secondary injuries which occur in the post-impact of a disaster (Such as the
   numbers /kinds of injuries associated with clean up and rescue operations, and
   as people return to their homes). At –risk groups includes residence, relief and
   rescue workers, volunteers and others in the affected area.
  Injuries from secondary effects of the disasters (Such as fires and toxic releases).

 Information to collect:

   Because injury patterns vary in different types of sudden impact disasters, it is
   essential in advance to determine which categories of information are absolutely
   necessary for decision-making purposes.

  Estimate the number of persons injured.
  Assess the severity of injuries.

 Disaster-2008_Action Plan-08              20
 Types of injuries.
 Sites of injuries.
 Approximate age/sex distribution of affected persons.

Strategies for Collecting Information
         Potential sources of information include any place the injured have gone to
seek care. In responding to an earthquake for example, the number of seriously
injured patients is of much greater operational importance than the number of
ambulatory patients. Therefore priority should be given to second and third level
facilities, where most of the seriously injured will seek help.

During immediate stages;
       Hospitals (Which may have usable emergency room and in-patients records)
including mobile hospitals.

During later stages;
 Pharmacies
 Community Health Centers
 Evacuation Centers
 Local Officials/leaders
 Non Government Relief Organizations

(c) Other Illness

     Communicable disease outbreaks are quite rare in the days immediately
     following a sudden impact natural disaster. However, With continued lack of
     utilities (Such as water supplies and sewage treatment), disrupted health
     services and environmental conditions, there is an increase risk of
     communicable disease out breaks.

      Because only those pathogens present in the affected area are likely to cause
outbreaks, a rapid assessment should;
 Identify pathogens already present, or likely to be introduced from outside the
   affected area. Careful consideration should be given to identifying those
   communicable diseases of increased risk in the disaster-affected area.
 Determine control needs: Mass immunization campaigns are often requested
   following a disaster, but are frequently unnecessary and counterproductive
   because they divert resources from more essential services. However, attention
   should be paid to determining the immunization needs of children in densely
   populated areas against measles, pertussis, diphtheria and polio.

2.3 Assess Impact on Health Services

(a) Medical Services :
       Natural disasters may damage health care facilities and disrupt services. The
structural integrity of hospitals and clinics may be affected. Further more, the quality
and availability of medical care may be severely affected by;
 Lack of electricity and water
 Damage to supplies and equipment
 Disrupted communications and supply lines
 Injuries and deaths of staff.

Disaster-2008_Action Plan-08               21
       Therefore, a rapid assessment should provide essential information for
determining the extent of damage, and the location of undamaged / functioning
services in relation to health needs.
What information to collect?

Immediately post-impact or when constrained by limited time:
  Number, location and type of facilities (Preferably mapped before the disaster)
  Structural integrity of health care facilities.
  Level of functioning of health care facilities.
  Current capacity of health facilities.
  Functioning electricity and water supplies (Yes/No), gaps in coverage by key
   personnel.
  Acute gaps in key emergency supplies /medicines.

At a later Stage or if time permits:
 Number/types of medicines available, vaccines, blood, laboratory supplies, etc.
 Number and types of injuries / illnesses reported at facilities.
 Needs for evacuation of injured / ill persons to other types of facilities needs for
   specialized care (e.g. burn treatment);
 Number and functions of medical field operation (e.g. type of injuries treated and
   resources needed);
 Key emergency supplies most urgently needed.

(b) Environmental Health Services

Due to the significant effects of environmental factors on health after a sudden
impact disaster, early attention should be given to assessing the status of health
related services, such as water supply, sanitation/vector control measures, shelter
and transport.

What information to collect?

1. Water supply
       The two priorities to assess are quantity and quality of untreated water
supplies (In earthquakes for instance, a major problem is adequate quantity if supply
lines are cut).

Particular attention should be paid to;
 Structural or functional damage to water supplies
 Size and location of populations with adequate sources of water supply – to
   identify groups at increased risk of communicable disease
 Actual or potentially contaminated water sources and populations exposed to
   such sources.

2. Sanitation and vector control

 Structural integrity of sewage treatment systems,
 Signs of functional damage (Such as overflowing of septic pits)




Disaster-2008_Action Plan-08             22
GUIDELINES FOR SURVEILLANCE OF EPIDEMIC PRONE DISEASES IN
AFFECTED AREAS IN GUJARAT

INTRODUCTION

       Surveillance of diseases is the continuing scrutiny of all aspects of the
occurrence and spread of a disease that are pertinent to effective control.
Sudden impact natural disasters like earthquakes are rarely followed by
communicable disease outbreaks. However, continued lack of water supply and
proper disposal of excreta, disrupted health services and environmental conditions,
there is always an increased risk of communicable disease outbreaks.
       A core group of senior officers have to take up comprehensive responsibility
to plan, organize, supervise and monitor the state level management cell which
should include medical experts, epidemiologists and Entomologists.

OBJECTIVES
1.     Immediate provision of essential medical care
2.     Strengthening of epidemiological surveillance of selected epidemic prone
       Communicable diseases to generate early warning signals of potential
       outbreaks.
3.      To undertake epidemiological investigation of potential outbreak, if any, and
to take rapid appropriate action for the containment of impending outbreak.

METHODOLOGY
A.      Essential medical care:
1.      Provision of medical expert teams
2.      Ambulance hospitals
3.      Local temporary hospitals
4.      Transport of injured to well equipped hospitals, provision of drugs/ equipment/
skilled medical and paramedical.

B. Diseases/syndromes/events to be covered:
     Acute diarrhoeal diseases including cholera
     Acute Respiratory infection (ARI) including pneumonia
     Measles
     Meningococcal meningitis
     Jaundice
     Plague
     Leptospirosis
     Diphtheria
     Poliomyelitis
     Malaria
     Monitoring of drinking water quality

Data collection, compilation and analysis
       All the reporting units would collate and analyse data locally for timely action
and transmit it to Surveillance Unit where it would be further compiled, analysed and
information thus generated will be transmitted accordingly.
Reporting Units:
       All the reporting units in the district are to be identified which may be field
camps, mobile health units, dispensaries besides subcentres, PHCs, new PHCs,
CHCs, District Hospitals etc.
Disaster-2008_Action Plan-08              23
Frequency of reporting:
       Frequency should be daily from ―reporting units including "field camps" to
Surveillance Unit and weekly from there onwards. The data should reach
Surveillance Unit by 9.00-p.m. everyday.

Flow of information:
All reporting units'           Surveillance unit        State authorities
                                                        NICD, Delhi
                               of Health, Medical
                               Services and Medical
                               Education, Gandhinagar

Formats:
As per Annexure A and B

Action and Feedback:
       Action and feedback would be the responsibility of District Health authorities
with all the help/supervision from Surveillance Unit. If needed, help may be sought
from other agencies/institutions. Apex institutes e.g. NICD, WHO etc.

HOUSE FLY CONTROL MEASURES

ENVIRONMENTAL SANITATION AND HYGIENE

1 Source reduction
a.    Proper disposal of human and animal excreta
b.    Collection, transport, storage and disposal of garbage
c.    Avoiding soil mixed with organic matter nearer to the house Elimination of
source that attracts flies from other areas.

2 Fly Control
a.     Environmental sanitation and hygiene – Long term measures
b.     Insecticidal control
c.     Biological control – Predators like spiders, parasitoids like wasps and
       Microorganisms
d.     Other methods of control like Trapping methods
e.     Knowledge on susceptibility to insecticides is essential before the use of
Insecticides.

3 Insecticidal control
-    Larvicides – Borax (Sodium Borate) Solution @ 1.4 Kg/m3
-    Adulticides
a.   Residual treatment with OP Compounds, Carbomates and Pyrethroids
     i.     Malathion @ 1-2 gm/m2
     ii.    Fenthion 0.5-1% ready to use emulsion @ 20 liters/100m2
b.   Impregnated strips, chords etc.
c.   Toxic baits – Baygon bait @ 60gm/100m2
d.   Space sprays directly on adult flies with pyrethrum extract (0.1%)


Disaster-2008_Action Plan-08                       24
ANNEXURE - A

Daily Reporting Form

Surveillance of Epidemic-Prone Communicable Diseases

Name of the Reporting Unit........................... Population (Approx) ……....................

Date       /     /

Sr.    Diseases                               Number Reported            Cumulative Since
No                                            Cases     Deaths           Cases      Deaths
1      Acute     Diarrhoeal diseases
       including Cholera
2      ARI including Pneumonia
3      Measles
4      Meningitis
5      Jaundice
6      Leptospirosis
7      Diphtheria
8      Malaria
9      Poliomyelitis
10     Plague




Name and Signature




Disaster-2008_Action Plan-08                   25
ANNEXURE - B

Weekly Reporting Form

Surveillance of Epidemic-Prone Communicable Diseases

Name of the Reporting Unit ....................              Population(Approx) ..........................

Week ending..........................................

Sr.      Diseases                                        Number Reported           Cumulative Since
No.                                                      Cases    Deaths           Cases      Deaths
1        Acute     Diarrhoeal diseases
         including Cholera
2        ARI including Pneumonia
3        Measles
4        Meningitis
5        Jaundice
6        Leptospirosis
7        Diphtheria
8        Malaria
9        Poliomyelitis
10       Plague




Name and Signature




Disaster-2008_Action Plan-08                            26
The Operational Plan

Important Steps:

All these steps will be followed for health sector preparedness for disasters.

1. Preparing an accurate and authentic database for use in planning:

    a. Vulnerability mapping of Gujarat for the State and Districts/Corporation
       areas
              Vulnerability for specific disasters – marking out disaster zones of
       earthquake. Gujarat falls under three seismic zones, high risk zone (Zone V)
       comprising of Kutch and adjoins area, moderate risk zone (zone IV),
       Jamnagar, Rajkot, Patan, Surendranagar and Banaskantha. Low risk zone
       (zone III) all other districts.

        b. Resource mapping for each district/corporation
           Resource mapping will include mapping of health facilities, specialties,
        manpower and equipment (Annexure-I to VI)

               i.   Of government infrastructure- for identifying shortfalls in
                    equipments/training/manpower for up-gradation.
              ii.   GOI units.
             iii.   Of other resources-private, trust hospitals, Grant-in-aid institutions.

2. Plan for effective management of resources

   Detailed planning for the optimum utilization of available resources will be done
   for the State/District/Corporation levels. The following specific plans will be
   prepared.
             i. Manpower planning for - EMS, various components of public health
                (Disease surveillance, Maternal care, Child care)
            ii. Logistics and infrastructure- ambulances, equipments and medical
                supplies
Network of the supply systems, CMSO and the district infrastructure-SUMA

3. Setting up Mechanisms for quick response - Preplanning a proper
   sequence of response actions.
i.    Establishing a District and State response machinery
             For monitoring, supervision and co-ordination function during disaster,
      the nodal officers at various levels will be identified. Additional Chief Secretary
      Health and Family Welfare is overall in charge for monitoring and co-
      coordinating health sector disaster situation.
             Commissioner of Health organizes immediate field operations with the
      help of Additional Directors and State epidemic cell that is the nodal officer for
      Disaster management. At District level Chief District Health officer and
      Superintendent of District hospital are Responsible for implementing various
      curative, preventive activities through the Superintendents of CHC/Sub-
      divisional Hospitals or Medical Officers, PHC of the affected areas. Deputy
      Director, Epidemic cell at State level and Chief District Health officer at District


Disaster-2008_Action Plan-08                 27
        level are the Nodal Officers to implement public Health measures during
        Disasters.
ii.     Control Rooms.

Manpower at the control rooms with specified responsibilities

Role- Peace time: Creating appropriate a data base –EHIS
      Information available at control room (Vulnerability mapping, resource
mapping, contact numbers, history of disasters, EHIS of the area)

Emergency time: Coordination (inter and intra), ensuring communication of the right
info at the right time within districts, state.

State Control Room
       Nodal Officer will be in central command and control at all times. A round the
clock control room will be started from precautionary stage at Commissionerate at
Gandhinagar, manned by a medical officer and supportive staff. Important phone
numbers are given as annex:
Important phone numbers:

Name of Officer                 Office            Fax              Residence
Deputy Director Epidemic        079 -23253336     079-23253343     079-23254831
                                                                   M:9825342899
Additional Director, Health     079-              079-23221854     079-26733659
Services                        23221854          23253299
Commissioner,         Health,   079-23253279,     079-23223982     079-23221291
Medical, Medical Education      23253271
Secretary, Health & Family      079-23220069      079-23224409     9825037403
Welfare

       Task forces will be formed in the Commissionerate of Health, Medical
Services & Medical Education (HS) Gandhinagar with a view to respond to state
control room (relief) state control (relief) will inform state control room (Epidemic
Division) which is turn activate various task forces as required.
 Task forces shall be following nature and members:
(1)    Health& Medical Services.
          i.  Medical Officer
         ii.  Staff Nurse ANM/FHW
        iii.  Paramedical
        iv.   Field staff like BEE, Supervisors, MPW etc.
         v.   Driver, Cl-IV
       5 such task forces will be formed in each district by CDHO will be activate by
Additional Director (Health)

(2)     Specialist services task force :
               This will formed are each in 6 of the Regional Deputy Director zones
        with specialists from district hospitals and CHCs along with paramedicals, one
        senior CHC superintendent will be designated team leader and he will
        organized co-ordination and team working in predisaster phase will be
        activated by Additional Director (Medical Services).

Disaster-2008_Action Plan-08              28
(3)     Multi-specialty task forces :
                These will be formed in all of 6 Govt. Medial Colleges and 4 of
        Municipal /Trust Medial Colleges. The team leader will be Associate
        Professor/Sr. Asstt. Professor of surgery with members from all essential
        medical specialists of ranks of Asstt. Professor along with requisite staff of
        junior doctors–e.g. lecturers and resident doctors and with requisite
        paramedical staff.
        These will be constituted by respective dean of the medical colleges and will
        be activated by the Additional Director (Medical Education).
        These task forces will be equipped with essential medical supplies other
        logistics vehicles and if possible with special communication systems.
        Two medical officers of Gandhinagar District Panchayat will be posted in state
        control room as task force co-ordinator from health department.
        Similarly two medical officers will be posted in control room (Health
        department) as task force co-ordinator.

Regional Deputy Director’s Control Room
Similarly round the clock control rooms will be established at all six Regional Deputy
Director‘s offices. These will co-ordinate with various districts under them and nodal
officers control room.

           Sr.     Zone          STD            Phone No.    Phone    No.
           No.                   Code           office       Residence
           1       Ahmedabad     079            22680112     26853837
           2       Gandhinagar   079            23222788
           3       Vadodara      0265           2432381      22310623
           4       Surat         0261           23479175     22655833
           5       Rajkot        0281           22440599     24767610
           6       Bhavnagar     0278           22427330     22423123

District Level Command and Control
       The overall implementation of the action plan will be the responsibility of
designated district level command. In districts with medical college, the
Superintendent of Govt. Medical College will undertake this responsibility. He will
also supervise and coordinate other medical institutions of Govt. local body/Private
sector. The Chief District Medical Officer / Civil Surgeon for implementation will
assist him in district level hospital, CHC‘s and grant-in-aid institutions. In districts
without Govt. medical colleges, the Civil Surgeons will be in overall charge. A
detailed list of designated officers for each district is given as annex.




Disaster-2008_Action Plan-08               29
Sr        District             Hospital     Designation     STD     Phone      Phone
No                                                          code    Office    Residence
1     Ahmedabad           Civil Hospital   Medi. Supdt.    079     2681379    22685033
                                                                   2123721
      Assisted by         Civil Hospt. Sola Civil          079     27474355   27457138
                                             Surgeon               27474359
2     Vadodara            S.S.G. Hospital Medi. Supdt.     0265    22425751   27483003
      Assisted by         Jamnabai           Civil         0265    22462134   22424003
                          Hospt.             Surgeon               22461400
3     Surat               New Civil Hosp. Medi. Supdt      0261    22244985   22241574
      Assisted by         Old          Civil Civil         0261    22479311
                          Hospital           Surgeon               22479610
4     Jamnagar            Irwin      Group Medi. Supdt     0288    22554629   22513157
                          Hospital                                 22550226
      Assisted by         Govt. Hospital     Civil         02833   2235170    2234724
                          Jamkhambhaliy Surgeon
                          a
5     Rajkot              General            Medi. Supdt   0281    22479315   22476685
                          Hospital
      Assisted by         P.K         Govt. Civil          0281    2227136
                          Hospt., Rajkot     Surgeon
6     Bhavnagar           Sir T. Hospital    Med. Supdt.   0278
      Assisted by         Govt. Hospital Civil             02848   2243075    222529
                          Palitana           Surgeon
7     Amreli              General            Civil         02792   2222587    2223416
                          Hospital           Surgeon               2222173
8     Ahwa                General            Civil         02631   2220205    2220397
                          Hospital           Surgeon               2220240
9     Kutch               G. K. General Civil              02832   2250150    2250554
                          Hospital, Bhuj     Surgeon
                          Campus             Campus        02832   2220852    -
                          Director     New Director
                          Dist.Hospital
10    Bharuch             General            Civil         02642   2243515    2264200
                          Hospital           Surgeon               2230307
11    Dahod               Govt. Hospital     Civil         02673   2246548    2221284
                                             Surgeon
12    Godhra              Gen.Hospital       Civil         02672   2242559    2242227
                                             Surgeon
13    Gandhinagar         General            Civil         079     23222733   27473374
                          Hospital           Surgeon               23221932
14    Himatnagar          Sir       Pratap Civil           02772   2246618    2240033
                          Hospt.             Surgeon               2241892
15    Junagadh            Civil Hospital     Civil         0285    2620090    2650302
                                             Surgeon
16    Mehsana             General            Civil         02762   221217     253475
                          Hospital           Surgeon
17    Kheda               General            Civil         0268    2529074    2550073
                          Hospital Nadiad Surgeon
18    Navsari             Govt. Hospital     Civil         02742   2257001    258195
Disaster-2008_Action Plan-08                 30
                                           Surgeon
Sr        District             Hospital    Designation    STD        Phone      Phone
No                                                        code       Office    Residence
19    Banaskantha         General          Civil         02742     2253083    2252475
                          Hospital         Surgeon                 2253758
                          Palanpur
20    Patan               Govt. Hospital Civil           02766     2233311    2230778
                                         Surgeon
21    Porbandar           Govt. Hospital Civil           0286      2242910    2242882
                                         Surgeon                   2240923
22    Narmada             Govt. Hospital Civil           02640     2220030    2220287
                          Rajpipla       Surgeon
23    Surendranag         General        Civil           02752     2222052    2233541
      ar                  Hospital       Surgeon
24    Valsad              General        Civil           02632     2251744    2253310
                          Hospital       Surgeon
25    Anand               Govt. Hospital Civil           02697     2224645    2224775
                          Petlad         Surgeon

District level advisory committee: (Medical Relief)
        A District level Advisory Committee will be formed with following members to
assist and coordinate. The committee chairman will be the administrative head of the
district, while members will be all important officials from departments of health,
police, fire, transport, army and other local bodies and voluntary organizations. All
sub-sectors of health such as the major dist hospitals, teaching hospitals, army and
other GOI hospitals and private hospitals if any should be represented in the
committee.


District level

      A District Level Coordination and Review Committee is constituted and
headed by the Collector as Chairman in which all other related agencies and
departments participate.

1.      District Magistrate & Collector                         Chairman
2.      District Development Officer                            Co-Chairman
3.      Chief District Health Officer                           Member-secretary
4.      Civil Surgeon/Supdt. Other Govt. Hospital               Member
5.      Supdt. of Local body Hospt/specialty Hospt.             Member
6.      District Superintendent of Police                       Member
7.      R.D.C.                                                  Member
8.      Local I.M.A. President                                  Member
9.      Civil Defense Commandant                                Member
10.     Chief Fire Dept.                                        Member
11.     Representative of Local bodies                          Member
12.     Voluntary organization                                  Member
13.     R.T.O.                                                  Member
14.     D.E.O.                                                  Member
15.     R & B Dept. Ex. Engineer                                Member
16.     Local Army Est. Representative                          Member
17.     Representative of Nodal officer                         Member
Disaster-2008_Action Plan-08                31
i.       Communications network
         The present communication facilities available with the State and districts will be
         assessed and a plan with the following objectives will be made:
                 Ensure that all district control rooms are connected with the State
                   control room with communication systems, which are not affected by
                   natural disasters (HAM radios).
                 The communication network of each district control room is easily
                   accessible to the local agencies and individuals.
      4. Allocation of responsibilities
             To the participant levels within the health department and other health
      sectors.

      Making teams for:

ii.       Mass casualty management
          This plan deals with both pre-hospital and hospital emergency medical services.
          The main features will be TRIAGE at the site and the hospital, plan for referral
          services,

      Mass casualty management has Two Components

      (i) Prehospital Management

             First aid Parties
             First Aid Posts(staticand mobile)
             Ambulance service
             Mobile Surgical Units.

      (ii) Hospital
            Emergency Hospital Services (including I.C.U./C.C.U. facilities)
            Emergency Transfusion Services
            Emergency investigation facilities
                 o X-Ray
                 o Laboratory investigations.
                 o E.C.G. facilities.

      PREHOSPITAL MANAGEMENT

      Objective
            To render first aid to victims at the spot of disaster, their transportation to
      nearby hospital as a part of life saving measures.

      Responsibility
             With guidance from District Command, Chief District Health Officer will be the
      officer commanding Casualty services. RMO of the emergency hospital & CHC
      Superintendent of the town will assist him. He (CDHO) will function in this capacity
      also under guidance.



      Disaster-2008_Action Plan-08                32
   First Aid Party

Objective:
       The Functions of the First Aid Party is to render First, Aid to casualties at the
place of incident and transport the casualties on stretchers to nearby first-aid post.

Task of First Aid Party
1)    Will rush and render first aid and provide transport by stretchers.
2)    Party will consist of one Driver and four first aid trained workers / volunteers.
      The leader will be a health worker/fire brigade person.
3)    One car will be provided for 3 such parties.
4)    3 such parties will be constituted for 10,000 population for towns upto l lac,
      population. For additional, 3 parties per 20,000 population.
5)    These will be located at Civil Defense Depots.
6)    Medical officer in charge will train personnel and young volunteers from
      different sectors.
7)    Officer will send the party to scene in charge of Civil Defense, will report to
      incident officer/ warden and start work.
8)    Party will have equipments specified in appendix 16 of Union War Book.

   First Aid Posts

Objective
Primarily First Aid posts are meant for treating the lightly wounded casualties those
not requiring hospitalization 'thus relieving congestion at. the hospitals.
They are also responsible for screening casualties sent by First Aid Parties, to sort
out those who need immediate hospitalization. Cases demanding urgent medical
attention may be sent direct to the hospital without delay.
First aid post may be static or mobile. A mobile First Aid Post is meant to rush
medical aid to the site of incident for the treatment of casualties on the spot.
   Structure and Operational Management

        1)      Control:      A medical officer will be in charge.
        2)      Location:     it will be housed in existing govt. local body charitable or
                private dispensary.
        3)      Scale:        1 such post for a population of 25,000.
        4)      Lay-out:      it will have 3 rooms – reception, treatment and waiting
                room.
        5)      Personnel : Medical officer         1 + 2 relief
                              Nurse                 1+ 2    ―
                              First aider           3+6 ―
                              Messenger             1+1 ―
                              Clerk                 1
                              Sanitary worker       1
        6)      Stores: As per annexure 2

      All 63 dispensaries located in large cities at present will serve as First Aid
Posts. Notably the dispensaries as follows:



Disaster-2008_Action Plan-08                 33
City/Town               Dispensary to Act as First Aid Post.
Ahmedabad               Dariyakhan Gummat, A colony; E-colony, Nr.Ambar cinema,
                        Srangpur; G-colony, Sukramnagar, Rakhial; F-colony, Shah
                        Alam Tolnaka; New Mental, Meghaninagar; Bechardas Disp.
                        Delhi Chakla; Sadvichar Eye Hospt. Naroda; Polytechnic-
                        Ambawadi;Govt. Quarter, Vastrapur; Shastrinagar, Naranpura;
                        Bombay Housing, Police line, Gomtipur; Gaukwad Haveli Police
                        line; Sardarnagar disp.; Kubernager disp.; SRP Group.2 disp.
                        Saijpur Bogha.
Vadodara                Fatehgunj Disp;Mohammadvadi Disp; SRP Group 1; SRP Group
                        - 2.
Bharuch                 Kevadia Colony
Bhuj                    Dispensary Bhuj.
Gandhinagar             Dispensaries of Sectors 16,20,22,28,& 30.
Rajkot                  Suchak dispensary, Dr.Radhakrishnan Road; SRP Disp Group
                        13.
Bhavnagar               Jashwantsinhji disp; Benba disp; Umarjanbai disp,Haluria
                        chowk; Jawansinhji disp;Refugee camp dispensary.
Junagadh                New disp, Jaymala chowk; Police training college.
                        Porbandar Plot disp; Gaikwad dispensary.

This is only guidance list. District Command shall plan others as per need.

Responsibilities:

All First Aid posts will be manned round the clock. The Medical Officer will maintain
record of the bed state of the dependent hospital daily. Casualties arriving in the First
Aid Post will be disposed off as under:

a) Casualties with sever injuries requiring hospitalization will be transferred by
   ambulances to the casualty receiving hospital.
b) Casualties with moderate injuries not requiring immediate hospitalization will be
   treated at the First Aid Post and then sent home with directions to report at the
   post as required.
 First Aid Post (Mobile)
Objective:
       A mobile First Aid post consists of a complete. First Aid Medical Unit mounted
on wheels ready to proceed to the scene of a major accident and to set up and
provide treatment there.
Organization

a) It is a complete first aid unit on wheels, ready to proceed to scene, set up and
   provides treatment.
b) A big truck or a van will be the motor vehicle.
c) One unit shall be set up per 3 lac population. If less, then minimum 1 unit will be
   set up.

Disaster-2008_Action Plan-08                34
Each mobile post will carry the same equipment as the Static First Aid Post.

Responsibility:

All relevant action stated above for First Aid Post (static) will be applicable to the
Mobile First Aid Post.

   Mobile surgical units

Objective:

Mobile surgical units are small surgical teams mounted on wheels on location near
the disaster site with essential instruments for performing life saving emergency
surgery. The units should function in conjunction with the First Aid Post. One unit
shall be set up per 3 to 5 lac population. If less, then minimum 1 unit will be set up.

Staff:
       Each Mobile/Surgical unit may have 3 doctors including one Anesthetist. It will
also have one fully trained Nurse, One Operation Theatre Assistant, two First Aid
Assistants and one driver.

Stores and Equipments:

The scale of equipment is placed at Annexure II.

Ambulance Services

Objective:
       An efficient ambulance service is an essential part of the casualty service for
the transportation of casualties from the scene of disaster to First Aid Posts and
Hospitals.


Vehicles:

          INFORMATION ABOUT VEHICLE.

                                                    Other
           Sr.N                    Ambulan          than
                         Place                                   Remarks
            o.                       ce            Ambulan
                                                     ce
                    District
             1      Head              873            144
                    Quarter
                    At
             2                        425            690
                    CHC/PHC


                   Total…             1298           834




Disaster-2008_Action Plan-08              35
      Ambulances and vehicles available with health dept. as shown below shall be
deployed immediately.
# Type of institution                 Total                  Ambulances
                                      Vehicles(working)
1 Hospitals under medical section     226                    132
2 PHC‘S                               994                    -
3 Mobile clinics                      60                     -
4 ESIS Hospitals                      31                     31

Vehicles shall also be obtained from following institutions of Health Department.
      1.     285 CHC‘s
      2.     8 Medical colleges
      3.     140 Grant -in- aid institutions.
      4.     98 PP Units
      5.     11Jeevan Raksha Kendras
      6.     16 General Nursing Schools
      7.     1 SIH&FW and associated training centers
      8.     124 TB Centers
      9.     5 Mental hospitals
      10.    6 RDD Offices
      11.    Dental College
      12.    35 Leprosy units

Stores and equipment:
The scale of equipment is given in Annexure III

SCALES FOR PREHOSPITAL FACILITIES

 Population Coverage                              => 3 - 5 lakhs
 No. of first-aid parties                         => 40
 No. of First Aid Posts.                          => 7
                            Mobile - 1
                            Static - 6
 No. of mobile surgical units                     => 1
 No. of Ambulances                                => 6
 No. of Emergency Hospital Beds                   => 100 - 150

Actions during Precautionary Stage:
1) CDHO will alert all first aid leaders to stand by.
2) Officer in charge of civil defense in consultation with CDHO and Med. Supt./Supt.
   shall keep stores and reserves ready. He will identify vehicle and driver to be sent
   with each party.
3) Buildings for First aid post (static) shall be ear-marked, personnel, stores,
   signposts kept ready and meetings arranged with members
4) Vehicles for first aid post (mobile) earmarked, personnel, stores kept ready, and
   meetings arranged with members.
5) Mobile surgical units set up.
6) Vehicles requisitioned, stretcher fitments kept ready, drivers made familiar with all
   locations.

Disaster-2008_Action Plan-08               36
Actions during War Stage
1) First aid party
              All members will report to civil defense depot
              Rosters of 8 hour duty prepared
              Vehicles allotted, their fuel, oil, maintenance ensured with the help of
               Collector
2) First aid posts (static)
              Ear-marked buildings taken over
              Personnel, stores and equipment kept ready
              Day and night visible signposts set up
              M.O. shall keep information of all vacant beds of attached hospital
              Severe casualty transferred to casualty hospital
              Moderate injuries attended & sent home with follow-up reporting
               advice.
                    Trivial injuries attended and sent home
                    Record of all casualties maintained
                    Casualty identity label if not given previously, is given
3) First aid posts (mobile): As Above.
4) Mobile surgical units:
              Ear marked vehicles requisitioned.
              Personnel to report to duty at short notice.
5) Ambulance services:
              Available ambulances and other vehicles requisitioned
              Equipped with stretcher, stores, staffed.
              Fuel, oil, maintenance provisions made
Details of number of first aid parties, first aid posts (static and mobile) , mobile
surgical units, ambulances and total vehicles required for 11 vulnerable towns of
Gujarat is listed in TABLE A.
       District Commands of non-vulnerable towns will work out their requirements
as per plan.




Disaster-2008_Action Plan-08              37
             Actions during Bioterrorism attack
           Terrorism Prone Areas In Gujarat




MANAGEMENT OF BIOLOGICAL WARFARE AGENTS.
Introduction:
    • Biological weapons are any infectious agents such as bacteria or virus, which
      are used intentionally to inflict harm upon others. This definition is often
      expanded to include biologically derived toxins and poisons.
    • Biological warfare agents includes both living microorganisms (like bacteria,
      protozoa, rickettsia, viruses and fungi) and toxins (chemicals) produced by
      microorganisms, plants or animals.
    • Importance of Biological weapons :
    • Biological weapons are immensely destructive. In the right environment they
      can multiply, and so self-perpetuate. And they can naturally mutate,
      frustrating treatment and protective measures. Chemical weapons, for all
      their horrors, become less lethal as they are dispersed and diluted. But even
      tiniest quantities of diseases organism can be lethal. e.g. Bottulinum toxin has
      been described as 3 million times more potent than the chemical nerve agents
      sarin.
    • In race of creating new and new weapons biological warfare has been one of
      the most distressing problem for tackling crisis or disaster it leads to,

Common Biological agents
  • Anthrax
  • Cryptococcosis
  • Escherichia coli toxins
  • Haemophilus influenza endotoxins
  • Brucellosis
  • Coccidioidomycosis
  • Psittacosis
  • Yersina pestis
  • Tuaremia
Disaster-2008_Action Plan-08              38
    •   Malaria
    •   Cholera
    •   Typhoid
    •   Bubonic plague
    •   Cobra venom
    •   Shell fish toxin
    •   Botulinal toxin
    •   Saxitoxin
    •   Ricin
    •   Smallpox
    •   Shigella flexneri
    •   S. Dysenteriae
    •   Salmonella
    •   Histoplasma capsulatum
    •   Pneumonic plague
    •   Rockymountain spotted fever
    •   Dengue fever
    •   Diphtheria
    •   Meliodosis
    •   Glanders
    •   Tuberculosis
    •   Infectious hepatitis
    •   Encephalitides
    •   Blastomycosis
    •   Nocardiosis
    •   Yellow fever
    •   Typhus
    •   Tricothrcene
    •   Alfatoxin
    •   Q fever

1) Mapping of area under risk in each district:-
   I.     Likely area to be affected can be charted on map
  II. This gives an idea of likely population can be affected
 III. Type of population & density of population
 IV. Type of houses e.g. Kaccha, Pakka, and Multistoried etc.
  V. Other structures like industries, ports, air-ports, temples, mosques etc.
 VI. Factories etc.
2) Vulnerability Analysis:-
      Based on types of bioterrorism attack vulnerability can be analyzed. In gas
      leakage the wind direction may decide the likely population. In a case of drought,
      biological disaster children and females are more vulnerable. Amongst the
      various constituents of population financial status may have to be considered.

3) Public Health Problems to be kept in mind in situation of Terrorism:
   1. Injuries, deaths, disabilities,
   2. Effect on communicable disease patterns and environmental hazards.
   3. Damage or strain on health facilities, services
       a) Shelter                     b) Water supply
       c) Food stock/PDS              d) Sanitation
       e) Sewage
   4. Effect on human behavior
Disaster-2008_Action Plan-08               39
    5. Severe nutritional consequences
    The above effects are more vulnerable in Gujarat because of
        a) Good economic status
        b) Vulnerable population with no or inadequate adjustable capacity
        c) Large density of population
        d) Large costal area (About 1600 Kms.)
        e) International boarder with politically disputed country.
         f) Big industrial set ups.
4) Formation of Crisis Management Group (C.M.G.)
        Each Ministry (Nodal) has established crisis management groups which is
        responsible for
                 a) Dealing with crisis situation
                 b) Reporting of all developments
FORMATION OF CRISIS MANAGEMENT COMMITTEE
                 Chairman              - Cabinet Secretary
                 Members               - Secretary – Nodal Ministry
                                                     Support Ministry
                 Convener              - Officer of the cabinet secretariat
                 Co-opted member - Secretary of Other             Nodal Ministries,
                                           Heads of departments (Directly responsible)

State Crisis Management Committee
    Chairman                  - Chief Secretary
    Members                   - Secretaries,
                                  Heads of Departments
Responsible Ministries in Terrorism Attacks & Disaster conditions.
    • Air accidents                   Civil aviation Ministry
    • Civil Strife                    Home Ministry
    • Railway accidents               Railway Ministry
    • Chemical                        Ministry of Environment.
    • Biological                      Ministry of Health
    • Nuclear accidents               Dept. of atomic energy
    • Natural Disaster                Ministry of agriculture
 5) Planning of Control Room:-
    Established control rooms at district and state level nodal ministry are reactivated
    in crisis situation. Sr. officer of the branch should be the in-charge of control
    room. It must works for 24 hrs and must have adequate communication facilities
    If so needed, hot line facility to be created.
6) Inventory of existing resources
    Proper inventory of money, Material and manpower
    Planning of their distribution in advance
    Advance Preparedness and alternative plan village wise/PHC wise
    Rough distribution plan for external help.

7) Planning for appropriate method of Prevention.
1) Prevention of population from Disaster by shifting them to safer places.
2) Teach them to run away from wind direction in a case of gas leakage.
3) Preventive steps to avoid diseases.
    • Prevention may take several forms. In the case of biological warfare
       international disarmament and inspection regimes may deter production and
       dissemination of biological agent.

Disaster-2008_Action Plan-08               40
    •  Intelligence assets may indicate potential threats and allow for prevention
      action to be undertaken.
   • Vaccination programme may provide substantial protection against naturally
      occurring agents and limited or no protection against genetically engineered
      variants designed to defect such vaccines.
Preparedness:-
  In a case of early warning received: Prepare to store food and water, Prepare for
  a shift camp for a safer abode.
  Triage
      Triage is a brief clinical assessment that determines the time and sequence in
  which patients should be seen in the ED or, if in the field, the speed of transport
  and choice of hospital destination. These decisions generally are based on a
  short evaluation of the patient and an assessment of vital signs. The patient‘s
  overall appearance, history of illness and/or injury, and mental status also are
  important in the triage decision.

   PREHOSPITAL TRIAGE:
   • In addition to estimating a patient's severity of illness and/or injury within the
     ED, triage also occurs in the field prior to a patient's arrival at the ED. With
     some 911 systems, a degree of triage occurs at the dispatch level. For
     example, based on assigned protocols, dispatchers may routinely send an
     ambulance (with or without lights and sirens) to the scene of ill or injured
     patients. Once an ambulance has arrived at the scene, the paramedics or
     emergency medical technicians (EMTs) reassess the patient and place him or
     her in a higher or lower triage category.




Trauma triage:
   • Nationally validated criteria are used to triage injured patients. These triage
     decisions influence to which hospital patients are transported. Many
     emergency medical service (EMS) districts have well-defined triage criteria
Disaster-2008_Action Plan-08              41
         that determine which accident victims need the services of a trauma center
         and which can be cared for at a local facility. Each EMS jurisdiction may use
         different criteria, but most use a combination of the following:
         • Mechanism of injury
         • Anatomic criteria
         • Medical criteria
         Patients generally are tagged. Tags are color-coded as follows:
    • Red       -         Emergent
    • Yellow -            Urgent
    • Green -             Nonurgent
    • Black -             Dead or very severely injured and not expected to survive
         Patients who are severely injured and not expected to survive are the most
    difficult to assign because of the obvious ominous implications. Note that patients
    placed in this category clearly are so severely injured that no degree of medical
    help relieves them.




Disaster-2008_Action Plan-08              42
Treatment
    DISEASE          VACCINE                CHEMO-THERAPY (Rx)                  CHEMO-PROPHY-LAXIS                      COMMENTS

     Anthrax Bioport       Vaccine     Ciprofloxacin 400 mg ivq 8-12 Ciprofloxacin 500 mg PO bid x Potential alternatea for Rx:
             (Licensed) 0.5 ml SC          hours.                            4 weeks if unvaccinated, begin gentamycin
             @ 0,2,4, week, 6,12,18 Doxycycline                              initial doses of vaccine.       Erythromycin-    cin,   and
             months then annual 200 mg iv, then100 mg iv q 8-12 hours.            Doxycyclin 100 mg PO bid x chloramph- ancol
             boosters.              Penicillin 2 million units iv q 2 hourly 4 weeks + vaccination.          PCN for sensitive organisms
                                                                                                             only.

  CHOLERA Whethayerst                   Oral rehydration therapy during            --                       Vaccine not recommended
          Vaccine 2 doses 0.5            period of high fluid loss                                           For routine protection in
          ml IM or SC @ 0,7,30          Tetracycline 500 mg q 6 hx 3 d.                                     endemic areas ( 50%
          days then boosters q 6        Doxycycline 300 mg once, or 100                                     efficacy,      short       term)
          months.                        mg q 12 hourly x 3 d.                                               alternates         for       Rx:
                                        Ciprofloxacn 500 mg q 12 h x 3 d                                    Erythromycin
                                         Nofloxacin 400 mg 12 h X 3 d.                                       Trymethoprim and Sulfameth
                                                                                                             oxazole and Furazolidine
                                                                                                             Quinolones for tetra/doxy
                                                                                                             resistant strains.
     Q Fever IND 610 – inactived Tetracycline 500 mg PO q 6 h x 5-7 d        Tetracycline starts 8-12 d post Currently testing vaccine to
            whole cell vaccine Doxycycline 100 mg PO q 12 h x 5-7 d.         exposure x 5d Dpxycyclin        determine the necessity of
            given as single 0.5 ml                                           Start 8-12 post exposure x 5 d. skin testing prior to use.
            SC injection.
Decontamination
   • Unlike chemical weapons, which disperse over time biological agents may
      grow and multiply over time. Anthrax can remain active in the soil for at least
      40 years and is highly resistant to eradication.
   • In biological warfare agents not only above said measures are needed but
      patient isolation precautions are also necessary. This is unique to biological
      warfare. There are certain standard precautions and particular precaution as
      per the route of entry and mode of excretion of particular organism.
Decontamination in case of Bomb Explosion
   • Remove all Clothing (Put in a Plastic Bag)
   • Wash with Soap and Water
   • Remove Contact Lenses
   • Flush Eyes with Lots of Water
   • Wash Face and Hair
   • Change Into Uncontaminated Clothes
   • Proceed to a Medical Facility
Standard precautions:
   • Hard washing after patient contact.
   • Use of gloves when touching body fluids, secretions, excretions and
      contaminated items.
   • Use of Masks, Eye Protectors, Gowns.
   • Handle contaminated patient care equipment and linen in manner that
      prevents the transfer of microorganisms to people or equipment.
   • Use mouthpiece or ventilators as an alternative to mouth –mouth resuscitation
      when practiced.
   • Isolation of patient.
Airborne precautions:.
    Place the patient in a private room that has negative air pressure, at least 6
      air changes / hour and appropriate filtration of air before it is discharged from
      the room.
    Use of respiratory protection when entering the room. Limit the movement of
      patient. If mobile use mask for the patient.
Droplet precautions:
    Isolate patient or keep at least 3 feet distance between patients.
    Use masks if working within 3 feet of patients.
    Limit movements of patient or else use masks for them.
Contact precautions:
    Standard precautions plus.
    Isolate the patient.
    Use gloves.
    Use gowns when entering the room or the patient has an infected or open
      would or Diarrhoea.
    Limit the movement of patient.
    Daily cleaning of items used by the patients.
    Use disposable and if not possible ensure proper disinfection.




Disaster-2008_Action Plan-08              44
What to Do During Explosion
  • Leave the Area / Building
  • If there is a Fire:
         – Stay Low
         – Exit Quickly
         – Cover Your Nose and Mouth
  • If Trapped:
         – Tap on a Pipe
         – Use a Whistle if Available

What to Do During a Chemical or Biological Attack
   Listen to Your Radio
   If Remaining at Home Turn Off HVAC
   Seal a Room (10 Sq. Ft. /Person = 5 Hours)
   If Caught Outside:
         – Get Up Wind
         – Find a Shelter
         – Listen to Your Radio

What to Do During Nuclear Attack
  • Find a Shelter
  • Listen to the Radio
  • Fallout Could be Present for Up To 1 Month and Wind Will Carry it Hundreds
      of Miles from the Center (80% - 1 Day / 99% - 2 weeks)
  • Evacuate to an Unaffected Area Within a Few Days
  • Water and Food May be Scarce




Mitigation:
   Surveillance of Population for
   a) Various kinds of communicable diseases
   b) Nutritional problems
   c) Area specific diseases
Education & Training
Training to masses
Training to those involved in disaster management
Response System
   On occurrence of crisis Action plans are put into action. If situation have wider
   ramifications state Government contact nodal ministry for help. Concerned nodal
   ministry activates the control room and crisis group meeting is held, contacts
   cabinet secretary, if feels necessary. Cabinet secretary if feels necessary calls a
   meeting of crisis management committee




Disaster-2008_Action Plan-08              45
    Response System

                                      On crisis development


                                     Activation of Action Plan


                                   Rapid assessment of situation


                                      Control room activated


                               If need arises state crisis management
                                         Committee meeting


                           Chief Secretary Contacts Nodal Ministry


                                     Secretary Nodal Ministry


                                 Crisis Management group (CMG)


                                     Contact Cabinet Secretary


                                         Calls Meeting of
                                      CRISIS MANAGEMENT
                                          COMMITTEE




Disaster-2008_Action Plan-08                   46
                                         Minister
                Secy. Health                            Comm. Health
                               Addl. Director, Health

                                                                     RRT
                                                                     Expertise
                                State epidemic cell
                                                        Medical college
                 RDD
                                                                 Sr. M.O.
                                                                 2 Supervisors
                CDMO                     CDHO                    4 workers

                                                                T.R.T.
                                         BHO
                   CHC
                                    MO PHC
                                                             Informer
                                                             Volunteers
                                  Village level              Health workers
                                                             Local bodies




Disaster-2008_Action Plan-08        47
Job Responsibilities:

                               •   Twenty to fifty Community Volunteers are
                                   selected and five sub groups are made from
                                   them as below.
    COMMUNITY                  •   Early warning group, First aid group & medical
                                   group.
                               •   Based on sub groups, they will perform given
                                   job responsibilities.

                               •   Rescue
                               •   First aid
    HEALTH WORKER              •   Referral
                               •   Reporting
                               •   Co-ordination

                               •   Evaluation of extent of disaster
                               •   Reporting to Epidemic Cell, C.D.M.O., C.H.C.,
                                   and T.R.T.
    MEDICAL OFFICER            •   Medical Management
                               •   Postmortems
                               •   Referral
                               •   Follow up

                               •   Prepare hospital for care of referred pts.
                               •   Medical Management
    C.H.C.-                    •   Surgical Intervention
    SUPERINTENDENTS            •   Referral to higher centre
                               •   X-ray, lab., Investigation
                               •   Reporting-C.D.H.O., C.D.M.O., R.D.D.


                               •   Evaluation & assessment
                               •   Reporting
    C.D.H.O.                   •   Resource mobilization – T.R.T., R.R.T.
                               •   Technical Guidance
                               •   On site supervision
                               •   Co-ordination

                               •   Hospital Preparedness
                               •   Co-ordination
    C.D.M.O.                   •   Preparing C.H.C. for       Medical    &      Surgical
                                   Management
                               •   Resource Mobilization
                               •   Reporting




Disaster-2008_Action Plan-08            48
Job Responsibilities:

                               •   Resource Mobilization
                               •   Co-ordination
                               •   Manpower Management
                               •   Supply of Equipment, Instruments, Logistics,
    R.D.D.                         Ambulances & drugs. Make shift hospital
                               •   On site, Hospital Supervision & Monitoring
                               •   Reporting

                               •   Over All Supervision & Control
                               •   Reporting to Additional Director, Commissioner,
                                   Secretary Health, Minister
    Epidemic Cell              •   Manpower Mobilization
                               •   Mobilization Funds & Resources
                               •   Reporting to Government & higher authority
                               •   Records preparation, analysis & maintenance.

                               •   Stream line activities of N.G.O.s who flock to
                                   site in large No. ( Dedicated, Determined, Self
                                   less lot )
    O.S.D.                     •   Service utilization by proper inventory,
                                   distribution & co-ordination
                               •   Reporting
                               •   Co-ordination with other agencies
                               •   Evaluation & assessment of services
                               •   Public relation, press briefing

                               •   Over all Command.
                               •   Reporting to Government.
                               •   Manpower Mobilization.
                               •   Management and control of large scale disaster.
    Additional Director        •   Management of Drugs, Antidotes, Logistics,
                                   Equipments,         Instruments,       Vaccines,
                                   Ambulance, Funds.
                               •   Inter sectoral co-ordination & co-operation.




Disaster-2008_Action Plan-08            49
Testing the plan including mock drills.
Monitoring and evaluation of actions taken during relief and rehabilitation.

Sr.   Phase               Task Force Team             Action
No
.
1     Predisaster- Additional Director (Health)       Preparedness in respective
      Phase      - Additional Director (Medical       branches mainly in Public,
                   Services)                          health, Medical and Medical
                 - Additional Director Medical        Education.
                   Education)
                 - Additional Director (Vital
                   Statistical)
                 - Director (State Institute of
                   Health & Family Welfare,
                   Sola)
                 - Director, Central Medical
                   Store Organization.
2     Impact and - Medical Teams – (M.O.)             -   First Aid
      Rescue        - Rapid Response Team             -   First Aid Post
                    - Specialist Team                 -   Mobile Hospital
                  - Volunteers, NGOs, IMA,            -   Base Hospital
                    Red Cross.                        -   Referral Services
3     Recovery    - Medical Teams – M.O.              -   Follow up for injuries
                                                      -   Survey of damages
                                                      -   Psychological disorders
5     Rehabilitation      -    Medical Team           -   Home visit, guidance
                          -    Specialist Team        -   Reconstructions surgery
                                                      -   Rehabilitation
                                                      -   Physiotherapy




Disaster-2008_Action Plan-08                     50
ACTION PLAN FOR AVIAN-INFLUENZA
Five strategic principles for pandemic preparedness-
   • Reducing risk of human infections by separating humans from poultry during
       winter seasons through health education, & mass media communication.
   • Early detection of pandemic influenza by alerting health agencies of state and
       surveillance.
   • Enhanced emergency preparedness and response in all PHCs, CHCs and
       District hospitals for the patients of Avian Influenza.
   • Fostering collaboration with neighbor states, central and international health
       authorities
   • Rehabilitation support in post-pandemic phase




                                  Surveillance
                                   and control
              Integrated
                                                          Stockpiling
             command &
                                                          and logistics
             coordination            Strategies
                                   for pandemic
                                      influenza
                                  preparedness
                Risk                                     Emergency
            communication                                 Response:
            and education                                public health
                                    Emergency
                                    Response:
                                    community

                Source: Ministry of Public Health, Thailand

 Early preparedness of planning and coordination for year 2007:
   • Chief District Health Officers & EMO of all districts Panchayat were instructed
       to watch for any massive deaths among the visiting birds in the Wet-Land
       areas during present winter in the respective districts on 5th Jan 2007.
   • ‗Tabletop exercise to critically review contingency plan & to develop SOPs for
       Avian Influenza‘ held at NICD-Delhi, on 10th 11th January 2007 was given to
       officials concerned.
   • Discussion to be done on the preventive strategies and as per GOI guidelines
       (Department of Animal Husbandry, Dairying & Fisheries, Ministry of
       Agriculture, GOI, Letter No. 50-213/2006-LDT(AQ) dated 12th August 2006)
       for year 2007 with local officers of Animal Husbandry department.
   • Instructions to be given to Local Health Workers regarding,
    Enumeration of all poultry farm workers
    Clinical surveillance for the presence of symptoms of Avian Flu in community.
    Collection of Serum Samples of suspected cases & sent to NICD Delhi.

Disaster-2008_Action Plan-08             51
     Enumeration of all back-yard poultries in villages, as most of them have
      started after last year episode.
     To keep watch over any sudden deaths among birds of poultry farms.
     To make necessary arrangements for the admission of suspected cases at
      CHC Vyara & Govt. Medical College Surat.
     Vaccination for all imported and local chickens
     Import control of chickens from affected area.
     Regulation of local farms (including tightened biosecurity measures)
     Rest days in Chicken Market.
     Strict implementations of Hygiene requirements on wholesale markets and
      retail outlets
     Enhanced surveillance of wild birds in Bird Sanctuaries by Animal Husbandry
      Department.
     Segregation of waterfowl and land based poultry
     Enhanced inspection of farms and markets
     Volunteer databases and training programs for both health and non-
      healthcare workers
     Staff / hospital bed mobilization plans
     Strengthened external communication: Close contact with WHO and
      health authorities of places affected by avian influenza.

Situation analysis, risk assessment

 When large outbreaks of highly pandemic H5N1 avian influenza occurs in
 birds.
 An immediate priority is to halt further spread of epidemics in poultry populations.
 Vaccination of persons at high risk of exposure to infected poultry, using existing
    vaccine.
 Workers involved in the culling of poultry flocks must be protected by, proper
    clothing and equipments. Anti viral drugs as a prophylactic measures.

When case of avian influenza in human occurs
 Information on the extent of influenza infection in animal as well as humans.
 Thorough investigation of each case.
 Aggressive management of human cases with anti viral drugs and isolation.
 Prophylactic to all contacts.
 Adequate surveillance system.
Ensuring state preparedness through development and implementation of the
pandemic preparedness plan with full involvement of all relevant sectors.

(3) All-round measures targeting sources of virus and carriers
     Enhanced surveillance of wild birds
     Segregation of waterfowl and land based poultry
     Enhanced inspection of farms and markets
     The surveillance network (local and global)
     Investigation and control measures
     Laboratory support
     Infection control measures
     Antiviral stockpiling
     Vaccination
Disaster-2008_Action Plan-08              52
       Port health measures
       Risk communication and public education
       Dedicated website to provide information and updates (www.gswan.com)
       Mass media publicity
       Leaflets and posters


Emergency Response
Three-tiered response system

    Alert Response Level
    Confirmation of AI outbreaks in poultry populations outside India & Gujarat; or
    Confirmation of AI in India & Gujarat in imported birds in quarantine, in wild birds,
    in recreational parks, in pet bird shops or in the natural environment; or
    Confirmation of human case(s) of avian influenza outside India & Gujarat
    • Inter-departmental Action Coordinating Committee to coordinate actions
        between Health, Animal Husbandry & Poultry farm Owners.
    • Enhance surveillance in districts close to Maharastra and districts having
        Water lands, migratory birds and poultry business.
    • External liaison with other states and agencies. (NGOs, private hospitals,
        seaports, airports etc.)
    • Risk communication and public education by media.


Serious Response Level
    Confirmation of AI outbreaks in the environment of or among poultry
      population in retail markets, wholesale markets, farms in Gujarat due to a
      strain with known human health impact; or
    Confirmation of human case(s) of avian influenza in Gujarat without evidence
      of efficient human-to-human transmission


    Emergency Response Level
    • Enhance surveillance & Epidemiological investigation to identify source
      of infection & mode of transmission.
    • Contact tracing, medical surveillance of close contacts
    • Enforce quarantine measures as appropriate.
    • To find out evidence of efficient human-to-human transmission of new Sub-
      type of influenza overseas or in India
    • Essential public and medical services by Support from hospitals and
      laboratories
    • We can plan to reduce local poultry population by way of voluntary surrender
      of poultry farm licenses and license conditions, and Culling operation
      to minimize the risks and ensure that all poultry can be speedily culled in
      times of emergency.
    • Separation of Human from Poultry
    • Requiring a minimum distance (say, one meter) to be kept between live
      poultry cages and customers at retail outlets.
    • Segregation of live poultry from customers by means of acrylic panels;

Disaster-2008_Action Plan-08               53
    •  Reduce the scale of live chicken trade by voluntary surrendering of
       licenses/tenancies scheme & by vigilant supervision on poultry hygiene.
    Long term plan –
    Developing a Poultry Slaughtering & Processing Plant
    – To put together poultry slaughtering activities at the Plant
    – To invite expression of interest shortly to ascertain market interest and views
      on operational arrangements and business models, before the open tendering
      for developing the Plant in late 2007
               Majority of the Plant products would be chilled chickens and/or ancillary
      chicken related products. It would be up to the Plant operator to decide
      whether or not to provide freshly slaughtered chickens depending on technical
      feasibility and market demand
    – Planning workshops- Adoption of table top exercises in workshops/ training
    – Reporting of cases through Short Messaging System
    – Strong private sector participation in all levels of the program
    – Business Continuity Planning – involvement and support of the Business
               Sector
    – Training of field personnel, epidemiologists, hospitals, Speakers‘ Bureau
Formulation and maintenance of medical contingency plan
Since diagnostic and curative services are mainly provided district hospitals, taluka
hospitals, and community health centers, Deputy Director, (epidemic) is appointed as
state nodal officer by        Commissioner, Health, Medical Services and Medical
Education and Research to formulate the medical contingency plan.
Responsibilities of state nodal officer
1. To formulate and maintain the medical contingency plan.
2 To keep liaison with Deputy Assistant Director General (EMR), DGHS, Nirman
     Bhavan, New Delhi, and state administration.
3 Suggest amendments / additions to State Ministry of Health & Family Welfare.
4 To send Daily / Weekly reports as necessary.
State Committee
State nodal officer suggests that a Committee be set up immediately for smooth
implementation of action plan as under:
Commissioner, Health, Medical, Medical Education and Research Chairman
Additional Director, Medical services                                  Member
Additional Director, Medical Education and Research                    Member
Additional Director, Health                                            Member
Additional Director, Family Welfare                                    Member
Additional Director, State Aids Control Society                        Member
Director, CMSO                                                         Member
Director, SIH&FW                                                       Member
Director, ESIS                                                         Member
Project Manager, Gujarat healthcare (ORET) project                     Member
Representative of Director of Civil Defense / Home Secretary           Member
R.D.D., Gandhinagar Zone                                               Member
R.D.D. Ahmedabad                                                       Member
Deans & Superintendents of Medical Colleges / Hospitals                Member
Any other invitee as deemed necessary                                  Member
Deputy Director (epidemic)                                       Member-secretary



Disaster-2008_Action Plan-08               54
   Working Committee
   Following members will assist the State Nodal Officer for ease of implementation:
   1. Assistant Director
   2. R.D.D. Gandhinagar Zone
   3. C.D.M.O. Gandhinagar
   4. State Epidemiologist
   Planning Team
   Senior staff of health services
Designation                            Office             Fax              Residence
Deputy Director Epidemic               23253336           23253343         23254831
Additional Director, Health            23253298-99        23253298         9825749149
Additional Director, Medical Services 079-23220418 079-23220418 26401053
Commissioner, Health, Medical, 079-23253271 079-23223982 9825037421
Medical Education.                                                         23221291
Principal Secretary, Health & F.W.     079-23220069 079-23224409 9879550221

  Areas of Action:
  Action plans are made for the following in vulnerable towns and cities:
  1. Casualty Services
  2. Emergency Services
  3. Blood Transfusion Services
  4. Emergency Environment Health Measures
  5. Evacuation
  6. Medical Stores And Equipment
  7. Manpower Requirement
  8. Mass Casualty Care

  Central Command and control
  Nodal Officer will be in central command and control at all times. A round the clock
  control room will be started from precautionary stage at Commissionerate at
  Gandhinagar, manned by a medical officer and supportive staff.
  Important phone numbers:

  Name of Officer          Designation         Office              Fax        Residence
  Dr.S.J.Gandhi                                23253336
                           Deputy Director Epidemic                23253343   23254831
  Dr.B.K.Patel                                 23253298-
                           Additional Director, Health             23253298   9825749149
                                               99
  Dr.K.A.Mithawala Additional        Director, 079-                079-       23222132
                    Medical Services           23220418            23220418
  Dr.Amarjit Singh, Commissioner,     Health, 079-                 079-       9825037421
  IAS               Medical,         Medical 23253271              23223982   23221291
                    Education
  Rita Teotia , IAS Additional     Secretary, 079-                 079-
                    Health       &       F.W. 23220069             23224409
                    Department.




  Disaster-2008_Action Plan-08                  55
Regional Deputy Director’s Control Room

Similarly round the clock control rooms will be established at all six Regional
Deputy Director’s offices. These will co-ordinate with various districts under
them and nodal officers control room. The following six R.D.D’s will arrange
this.
  Sr.
  No      Zone       Name of R.D.D      STD      Phone No.       Phone No.
                                        code       office        Residence
 1 Gandhinagar Dr.K B Patel            079      23259113      9826018419
 2 Ahmedabad Dr.Avasiya                079      2680112       26853737
                                       0265     2464381       9327012931
 3 Vadodara        Dr. Kanchhal
                                                2462528
                                       0261     2479175       9826027044
 4 Surat           Dr.Limdad
                                                2460260
                                       0278     2427330       9825372119
 5 Bhavnagar       Dr.N F Dafda
                                                2424535
                                       0281     2440599       2476610
 6 Rajkot          Dr.S.C.Vashishtha
                                                2459488


DISTRICT LEVEL ADVISORY COMMITTEE: (Medical Relief)

A District level Advisory Committee will be formed with following members to assist
and coordinate.

1.    District Magistrate & Collector                      Chairman
2.    District Development Officer                         Member
3.    District Veterinary Officer                          Member
4.    District Agriculture Officer                         Member
5.    Medical Supdt./Civil Surgeon                         Member-secretary
6.    Civil Surgeon/Supdt. Other Govt. hospital            Member
7.    Supdt. Of Local body Hospt/specialty Hospital        Member
8.    Chief District Health Officer                        Member
9.    Epidemic Medical Officer                             Member
10.   District Superintendent of Police                    Member
11.   R.D.C.                                               Member
12.   Local I.M.A. President                               Member
13.   Civil Defense Commandant                             Member
14.   Chief Fire Dept.                                     Member
15.   Representative of Local bodies                       Member
16.   Voluntary organization                               Member
17.   R.T.O.                                               Member
18.   D.E.O.                                               Member
19.   R & B Dept. Ex. Engineer                             Member
20.   Local Army Est. Representative                       Member
21.   Representative of Nodal office (State Headquarter)   Member




Disaster-2008_Action Plan-08             56
District Level Command and Control
The overall implementation of the action plan will be the responsibility of designated
district level command. In districts with medical college, the Superintendent of Govt.
Medical College will undertake this responsibility.      He will also supervise and
coordinate other medical institutions of Govt. local body/Private sector. The district
Civil Surgeon for implementation will assist him in district level hospital, CHC‘s and
grant-in-aid institutions.     In districts without Govt. medical colleges, the Civil
Surgeons will be in overall charge. The following Chief District Medical Officers are
designated as District Command for Medical Relief.




Disaster-2008_Action Plan-08               57
        District wise Civil Surgeons (CDMO) Contact Numbers.
Sr.   District              Name of Officer           Phone (O)      Phone (R)      Address
                                                      27474355
1     Ahmedabad (Sola)      I/c fDr.Jagdish Chavda                   27457138       Civil Hospital, Sola, Ahmedabad
                                                      27474359
2     Amreli                Dr.B.B.Patel              02792-222587   223416         General Hospital, Amreli
                                                      02642-243515
3     Bharuch               Dr.H.S.Raval                             02642-264200   General Hospital, Bharuch
                                                      241759
                                                                                    General Hospital, Palanpur Dist.
4     Banaskantha           Dr.S.J.Mayatra            -              -
                                                                                    Banaskantha
                                                      0278-2427330
5     Bhavnagar             -                                        -              General Hospital, Bhavnagar
                                                      2424535
6     Dang-ahwa             Dr.Thakkar (I/c.)         02631-220205   220294         General Hospital, Ahwa Dist.Dang
7     Junagadh              Dr.G.K.Gadhesariya        0285-2620090   2650302        General Hospital, Junagadh
      Jamnagar                                                                      General Hospital,       Jamkhabhaliya
8                           Dr.H.P.Devmurari (I/c.)   -              9824162964
      (Jamkhambhaliya)                                                              Dist.Jamnagar
9     Gandhinagar           Dr.N.B.Dholakiya          079-23222733   27473374       General Hospital, Gandhinagar
10    Kheda (Nadiad)        Dr.F.J.Gohel              0268-2529074   2550073        General Hospital, Kheda
                                                                                    General      Hospital,           Bhuj
11    Kutch-Bhuj            Dr.N.K.Bheda              02832-250150   250554
                                                                                    Dist.Kachchh
12    Mehsana               Dr.G.C.Patel              02762-21217    253475         General Hospital, Mehsana
      Panchmahal                                                                    General Hospital,       Godhara Dist.
13                          Dr.L.M.Chandarana         02672-242559   242287
      (Godhara)                                                                     Panchmahl
14    Rajkot                Dr.Manjari Mankad         0281-2459488   2455541        General Hospital, Rajkot
      Sabarkantha                                                                   General Hospital,        Himmatnagar
15                          Dr.V.S.Ninama             02772-246618   240033
      (Himmatnagar)                                                                 Dist.Sabarkantha
16    Surat                 -                         0261-2479311   2771055        General Hospital, Surat
17    Surendranagar         Dr.D.K.Vadher             02752-222052   233541         General Hospital, Surendranagar
18    Vadodara              Dr.Pragna A. Joshi        0265-251744    251046         General Hospital, Vadodara
19    Valsad                Dr.M.G.Damor              02632-251044   2523110        General Hospital, Valsad
20    Patan                 -                         02766-233311   230778         General Hospital, Patan
                                                                                    General Hospital,        Petlad Dist.
21    Anand (Petlad)        Dr.R.M.Mehta              02697-224645   224775
                                                                                    Anand
22    Dahod                 Dr.R.M.Patel              02673-246548   221284         General Hospital, Dahod
                                                                                    General     Hospital,        Rajpipla
23    Narmada (Rajpipla)    Dr.R.D.Patel              02640-220030   220286
                                                                                    Dist.Narmada
24    Porbandar             Dr.M.A.Maheswari          0286-2242910   2242882        General Hospital, Porbandar
25    Navsari               Dr.S.D.Limbad             02637-257001   258195         General Hospital, Navsari




        Disaster-2008_Action Plan-08                       58
                                   District Nodal Officer (CDHO)
                                                                               Telephone Number
Sr.                          District    Nodal      Officer(IDSP)
          District                                                  STD Code                      Mobile No.
No.                          (CDHO)
                                                                               Office

1         Ahmedabad          Dr. R R Vaidya [I/C]                   079        25507076           9879772257

2         Amreli             Dr. G.C.Patel                          02792      222197             9898072049

3         Bharuch            Dr. B. D. Vegda                        02642      243660             9825589561

4         Banaskantha        Dr. R. P. Sahay                        02742      242365             9825874289

5         Bhavnagar          Dr. Agrawal (i/C)                      0278       2423665,243951

6         Dang-ahwa          Dr. M. R. Chaudhari                    02631      220344             9426770602

7         Junagadh           Dr. Pankaj Kumar Pandey                0285       2653131

8         Jamnagar           Dr. K. P. Patel                        0288       2671097            9925046770

9         Gandhinagar        Dr. D. K. Raval                        079        23256942           9825361595

10        Kheda              Dr. N. J. Patel                        0268       2556273            9427083910

11        Kutch-Bhuj         Dr. D. K.. Dabhi                       02832      252207             9909949303

12        Mehsana            Dr. Nayan.N.Jani                       02762      222324             9426540991

13        Panchmahal         Dr. Prakash. Vaghela                   02672      253367             9824321989

14        Rajkot             Dr. A. S. Sanghvi                      0281       2443235            9825934229

15        Sabarkantha        Dr. S. S. Chauhan                      02772      246422             9826380760

16        Surat              Dr. V.R.Gupta                          0261       2430589            9426469040

17        Surendranagar      Dr. B.R.Solanki                        02752      283706,285383

18        Vadodara           Dr. B.P.Itare                          0265       2432383            9426323116

19        Valsad             Dr. M. K. Gajera                       02632      253080             9824021907

20        Patan              Dr. T. K. Soni                         02766      220592             9879790593

21        Anand              Dr. W. Q. Sheikh                       02692      254277             9824427315

22        Dahod              Dr.Miss. D.B. Rathod                   2673       243357             9228426304

23        Narmada            Dr.S.P.Singh                           02640      222081/82/83/84    9427063669

24        Porbandar          Dr. A.G.Lakhani                        0286       2211083

25        Navsari            Dr. V. K. Mahajan                      02637      280143             9879363606




    Disaster-2008_Action Plan-08                           59
      District wise List of Epidemic Medical Officers (EMO)

                               District Surveillance                Telephone
     Sr.                                                  STD        Number
             District                 Officer                                      Mobile No.
     No.                                                  Code
                                       (EMO)
                                                                       Office

 1         Ahmedabad       Dr. P. L. Dave               079      25501204          9879560297

 2         Amreli          Dr. A.K Singh                02792    223585            9904286861

 3         Anand           Dr. S. P. Singh              02642    243660            9427063669

 4         Banaskantha     Dr. N. K. Garg               02742    252243            9825842597

 5         Bharuch         Dr. V. P. Upadhyay           0278     2423665

 6         Bhavnagar       Dr. B. N. Vyas               02631    220344            9427282332

 7         Dahod           Dr. D. N. Patel              0285     2627097           9426431704

 8         Dang            Mr. M. N. Chauhan            0288     2671097           9427155305

 9         Gandhinagar     Dr. N. G. Shah               079      23256942          9909942242


 10        Jamnagar        Dr. A.K.Chaudhary            0268     2556273           9426222846


 11        Junagadh        Dr. K.P.Kapadia              02832    252207            9998885342

 12        Kutchh          Dr. R. S. Kashyap            02762    222324            9909949305

 13        Kheda           Dr. A. Y. Thakar             02672    241804            9825797006

 14        Mahesana        Dr. R. N. Patel              0281     2443235           9909966911

 15        Narmada         Dr. C. S. Mandloi            02772    246422            9427108943

 16        Navsari         Dr. M. R. Deliwala           0261     2430589           9825593338

 17        Panchmahal      Dr. B. K. Patel              02752    283706            9825789014

 18        Patan           Dr. M. A. Patel              0265     2432383           9825561863

 19        Porbandar       Dr. N.K.Khudkhudiya          02632    253080            9979437863

 20        Rajkot          Dr. N. M. Rathod             02766    220592            9825211895

 21        Sabarkantha     Dr. Bhati                    02692    254277            9427364801

 22        Surat           Dr. P. Y. Shah               2673     2242430           9426184463

 23        Surendranagar   Dr. Arvind Singh             02640    222081/82/83/84   9426944188

 24        Vadodara        Dr. V. K. Bidla              0286     2211083           9824516862

 25        Valsad          Dr. P.H.Patel                02637    280143




Disaster-2008_Action Plan-08                       60
Avian Influenza
       A fact sheet on Avian Influenza released by WHO on 15th January 2004 was
        circulated to medical colleges, district hospitals, regional deputy directors,
        chief district health officers, chief district medical officers and municipal
        corporations
       Directorate of Animal Husbandry, Gujarat state constituted The State Animal
        Diseases Emergency Committee and meeting of committee was held on 30-
        1-04 to discuss and decide line of action for the control and prevention of bird
        flue. In this meeting The Finance Adviser, Finance Department, The
        Additional Director Animal Husbandry, The Joint Director of Animal
        Husbandry and Animal Vaccine Institute, Deputy Director of Animal
        Husbandry (sheep development), Deputy Director (Epidemic) were
        participated.
       As the country is threatened with the outbreak of Avian Influenza, Govt. of
        Gujarat has taken proactive and necessary steps like, awareness campaign
        amongst poultry breeders regarding various poultry diseases by calling
        meeting with the poultry industries for monitoring/surveillance of the poultry
        diseases and issued guidelines and questionnaires for reporting the disease.

       During the year 2005 Director, Animal Husbandry Department circulated a
        letter regarding alert against possible outbreak of bird flue and guideline for
        taking serum samples of diseased birds. Same letter was circulated by Health
        Department to C.D.H.O.s and R.D.Ds. and alerted regarding early warning
        signals of bird flue.


       Updated information of Avian Influenza released by WHO on 14 th October
        2005 regarding Avian Influenza frequently asked question was circulated
        to all health functionaries in the state wide our Gujarati letter Þ_.³Õíçí/ÚÍó
        Îáð/±õÇ.±õá.Ëí./ 5488-5550/05, Öë.17-10-2005

       Updated information of Avian Influenza released by WHO was put on website
        www.gujhealth.gov.in by Govt. of Gujarat for awareness and alertness
        amongst the health functionaries.


       Action Plan for Health & Medical Relief in Avian Influenza was prepared
        by Health and Family Welfare Department in the month of January 2006 &
        updated in Jan.2007.




Disaster-2008_Action Plan-08               61
                  BIRD FLU PRONE AREA




                                                                            Uchhchhal




Action taken by State Epidemic Cell, Commissionerate of Health, Medical
Services & Medical Education (H.S.) Gandhinagar.

          The Maharastra Govt. sent the samples for the investigation to the High
Security Animal laboratory, Bhopal as soon as they came to know about the mass
death of chicken in the poultry farms in Navapur, Dist .Nandurbar. As soon as the
report of Avian Influenza (Bird Flu) came positive the Govt. of Gujarat has taken
nessacerry steps for the prevention of the diseases in the villages with in the radius
of 10 Km.at the interstate border of Gujarat and Maharastra.
          As soon as press reports about selling of the sick & diseased chicken in
border districts of Gujarat i.e. Navapur-Uchhchhal were noticed, followings actions
were taken---

1     Dr.S .J. Gandhi, Deputy Director epidemic Gandhinagar, Dr. Verma, ADHO,
      Surat and RRT from Govt.Medical College (Dr.Pradeep kumar PSM,Dr.Tanuja
      Chakrabarti, Microbiology)-Surat visited the affected area of Uchhchhal-
      Navapur on 12th Feb.06 under the direct instruction by Commissioner Health.
2     To prevent the possibility of spread of Bird-Flu A meeting was held with local
      Animal husbandry Deptt; Local Health Officers and given instruction to take
      necessary actions for the medical examination of the poultry farm workers.
3     A meeting was also arranged with the owners of the poultry farms and the
      situation was reviewed


Disaster-2008_Action Plan-08              62
4     Deptt. of Animal Husbandry was instructed to send the collected 13 samples &
      two dead bodies of birds to the High Security Animal Disease Laboratory,
      Bhopal immediately.
5     A report from epidemic branch was submitted to the Principal Secretary, Health
      & Family-Welfare, Secretary, Animal Husbandry Deptt. by a letter No.462006-b
      dated 14-2-06.
6     Commissioner, Health & District Development Officer,Surat were also duly
      informed.

       A fact sheet on Avian Influenza released by WHO on 15th January 2004 was
        circulated to medical colleges, district hospitals, regional deputy directors,
        chief district health officers, chief district medical officers and municipal
        corporations           wide         Gujarati         letter        Þ_.³Õíçí/ÚÍó
        Îáð/±ÃÜÇõÖí/ÕÃáë_/çðÇÞë±ù/481-551, Öë.29-1-2004
       Updated information of Avian Influenza released by WHO was put on website
        www.gujhealth.gov.in by Govt. of Gujarat for awareness and alertness
        amongst the health functionaries.
       Directorate of Animal Husbandry, Gujarat state constituted The State Animal
        Diseases Emergency Committee and meeting of committee was held on 30-
        1-04 and also recently on 7-02-06 to discuss and decide line of action for the
        control and prevention of bird flue. In these meetings various departmental
        heads actively participated. An action plan for the prevention of Avian
        Influenza (Bird Flu), was prepared and sent to the Govt.of India and Principal
        secretary health & Family welfare ,Govt. of Gujarat on 01-02-06
       Asstt.Director epidemic visited Uchhchhal and surroundings villages on 18 th
        Feb.06 with a team from National Institute of Communicable Diseases, Delhi.
       Necessary preventive measures for suspected Bird flu cases were taken
        immediately under the supervision of Deputy Director Epidemic and
        Asstt.Director epidemic, Gandhinagar,who continuously camped at Uchhchhal
       24 hours control room has been started at the epidemic branch at the office of
        Health Commissionerate, Gandhinagar.
       Principal Secretary, Health, visited the affected area of Vyara taluka got the
        information & given necessary instructions to the collector and other officers
        for the prevention of suspected Bird-Flu.
       Hon'ble health Minister and Commissioner, Health visited the affected area on
        19th Feb.06.A meeting was held under the chairman ship of Hon'ble Health
        minister in the presence of Collector, DDO Surat and other officers from
        health department. Hon. Health Minister provided guidance according to
        action plan made by the state as per GOI guideline for prevention for
        suspected Bird-Flu. Collector arranged the joint meeting of Health and other
        relevant department to take steps on a war footing basis to prevent likely
        outbreak of Bird-flu.
       Commissioner, Health has given instruction in detail for watch to the collector
        Surat by a letter dated 18-02-06.
       Collector, Surat issued a notification on 19-2-06 to prohibit entry of the
        chicken in the district from the Maharastra border area to prevent infection of
        suspected Bird-Flu in the 10 km.surrounding area of Uchhchhal village as
        precautionary measures.
        24 hours control room started in CHC Uchhchhal and Vyara.

Disaster-2008_Action Plan-08               63
      Arrangement is made by starting an isolation ward of 20 beds with ICU and a
       team of specialist at Vyara and 30 bed isolation ward at Govt.Medical College,
       Surat.
      Surveillance activity and Prophylaxis Treatment for Contacts.
              13 M.O. and 61 paramedical staff, 16 vehicles and 4 ambulance van
       are doing house to house surveillance activity in 44 villages of Uchhchhal
       taluka in the radius of 10 Kms area. Till date not a single case of Bird-flu is
       detected amongst human beings.
              88731 houses, 436282 populations are covered in rounds. Among
       them 1219 fever cases, 614 of common cold, 974 of Headache, 112 of watery
       diarrhoea and 10 cases of conjunctivitis were found and treated them on the
       spot.
              24467 contact persons were examined and given treatment who were
       working in the poultry farms & with the H/O close contact with birds.
              Commissioner health instructed to all Deans of Govt.Medical colleges
       to keep RRT( Expert Medical Team) stand by a letter dated 21st Feb.06
              Following items are supplied by GOI
                1 Tab.Temiflu---11900
                2 Masks---1000
                3 PPE Kit---1075
              State Govt. supplied 1500 PPE-kit
     To prevent panic community participation and co-operation regarding sanitary
       aware ness is made and this activity is in progress.
     76 serum samples from the suspected Bird-flu cases were sent to NICD-Delhi
       & NIV-Pune.
     No death has been recorded up till this date today in the state of Gujarat due to
       human cases of Avian Influenza
     The following officers visited the affected area on 21st Feb.06 got the
       information & satisfied with action taken & given necessary guidance.
          1 Additional Director General of Health Services NICD-Delhi,
          2 Join Secretary, Animal Husbandry & Agriculture Department
          3 Commissioner Health, Gujarat.
     A letter No.EPC/Bird flu/2006 dated 2-3-06 was issued by the Collector-Surat
      to the District Supply Officer, Deputy Collector-vyara,Deputy DDO,Surat and
      Director Animal Husbandry,Gandhinagar informing about the visit on 28-2-06 &
      1-3-06 and instruction by the Joint Secretary Animal Husbandry Dept.Govt.of
      India.
     A review meeting of Taskforce for Avianflu,Vyara Dist.Surat, was held on 2-3-
      06 suggesting to close the control room at Vyara and control room at
      Uchhchhal should be continued for few more days to monitor the health status
      of the cullers under the supervision of the PSM Dept.Medical College-
      Surat,State Epidemiologist. It is also suggested that the team of 1 Physician,1
      Anesthetic from Medical College,Surat to continue for one week as a stand by
      for the requirement at CHC-Vyara.
     Deputy Director Epidemic has informed by a letter dated 2-3-06, to the
      Director, Animal Husbandry, Gujarat and CDHO, CDMO of all districts to keep
      watch for at least ten days for the development of Bird flu symptoms in the
      persons of their district, who had worked in the poultry farm in Navapur &
      Uchhchhal taluka.
Disaster-2008_Action Plan-08              64
                           NUCLEAR DISASTER MANAGEMENT




Disaster-2008_Action Plan-08           65
WHAT TO DO IF A NUCLEAR DISASTER IS IMMINENT OR OCCURE!

      This guide is for families preparing for imminent terrorist or strategic
nuclear attacks with expected severe destruction followed by widespread
radioactive fallout downwind.

IF ONLY A 'Dirty Bomb' Attack
You can expect localized and downwind contamination from the explosion and
dispersed radioactive materials.
 If you are near enough to see or hear any local bomb blast, assume that it includes
radiological or chemical agents.
 You should move away from the blast area as quickly as possible. If the wind is
blowing toward you from the direction of the blast, travel in a direction that is
crosswise or perpendicular to the wind as you move away from the blast area.
 If possible cover your face with a dust mask or cloth to avoid inhaling potentially
radioactive dust.
Upon reaching a safe location, remove your outer clothing outside and shower as
soon as possible.
 Refer to local news sources for additional instructions about sheltering or
evacuation. The government is better prepared to direct and assist the public in a
'dirty bomb' incident, unlike an actual nuclear weapon attack.
      If an actual nuclear weapon attack occur than following steps should be
        taken………………………….
1 - STAY OR GO?
You must decide FIRST if you need to prepare where you are, or attempt
evacuation.
      The nature of the threat, your prior preparations, and your confidence in your
sources of information should direct your decision.
       If you are considering evacuation, your decision requires a very high
confidence that it is worth the risk.
       You do not want to get stuck between your current location and your hoped
for destination, as there will probably be no easy getting back.
      If you fail to get to your destination, you may be exposed without shelter, in a
dangerous situation with little effective law enforcement, perhaps among panicked
hordes of refugees.
        Whatever supplies you have may be limited then to what you can carry on
foot. IF you are in a big city or near a military target, AND you have relatives or
friends in the country that you know are awaiting you, AND the roads between you
and them are clear, AND the authorities are not yet restricting traffic, AND you have
the means and fuel, evacuation may be a viable option for a limited time.
        DO NOT attempt evacuation if all of the above is not clearly known, or if the
situation is deteriorating too quickly to make the complete trip. You do not want to
get stuck and/or become a refugee being herded along with panicked masses.


Disaster-2008_Action Plan-08              66
        If evacuation is truly a viable option, do not wait - GO NOW! Do so with
as many of the supplies listed on the last page as possible. Better to be two days too
early in arriving than two hours too late and getting snagged mid-way, potentially
exposing your family to a worse fate than having stayed where you were. Because of
the very real danger of getting caught in an evacuation stampede that stalls, almost
all families will be better off making the best of it wherever they currently are.
2 - WHAT YOU NEED TO DO FIRST
       Because time is of the essence, you need to first delegate and assign to
different adult family members specific tasks so they can all be accomplished at
the same time.
       Your first priorities to assure your family survival are Shelter, Water, and
Food/Supplies. While some are working on the water storage and shelter at home,
others need to be acquiring, as much as possible, the food and supplies.
3 - FOOD/SUPPLIES
        Because much of the food and supplies may quickly become unavailable, you
need to assign someone NOW to immediately go to the stores with that list!
Get cash from the bank and ATM's first, but try and use credit cards at the stores, if
at all possible, to preserve your cash.
4 - WATER
      With one or more adults now heading to the stores with the list, those
remaining need to begin storing water IMMEDIATELY! Lack of clean water will
devastate your family much more quickly and more severely than any lack of food.
Without water for both drinking and continued good sanitary practices in food
preparation and for bathroom excursions (which will inevitably be much less sanitary
than normal), debilitating sickness could rampage through your household with little
hope of prompt medical attention. That is a highly likely but, avoidable, disaster,
ONLY IF you have enough water.
      Every possible container needs to be filled with water It will be very hard
to have stored too much water. When the electricity/pumps go down or everybody in
your community is doing the same thing, thus dropping the water pressure, what
you've got is all you might be getting for a very long time. Empty bottles (1-3 liter)
are ideal for water storage, also filling up the bathtub and washing machine.
Anything and everything that hold water needs to be filled up quickly RIGHT NOW!!
       If you can't get any more new cans, you could clean out an existing garbage
can and scrub it throughout with bleach, then put in a new garbage bag liner and fill it
with water. Choose well where you fill up cans with water because they won't easily
be moved once full and many of them together could be too heavy for some upper
floor locations. Ideally, they need to be very near where your shelter will be
constructed and can actually add to its shielding properties, as you'll see below. BE
ASSURED, YOU CANNOT STORE AND HAVE TOO MUCH WATER! Do not
hesitate; fill up every possible container.



Disaster-2008_Action Plan-08               67
5 - SHELTER
       The principles of radiation protection are simple - with many options and
resources families can use to prepare or improvise a very effective shelter. You must
throw off the self-defeating myths of nuclear un-survivability that may needlessly seal
the fate of less informed families.
       Radioactive fallout is the particulate matter (dust) produced by a nuclear
explosion and carried high up into the air by the mushroom cloud. It drifts on the
wind and most of it settles back to earth downwind of the explosion. The heaviest,
most dangerous, and most noticeable fallout, will 'fall out' first close to ground zero.
        It may begin arriving minutes after an explosion. While the smaller and lighter
dust-like particles will typically be arriving hours later, as they drift much farther
downwind, often for hundreds of miles. As it settles, whether you can see it or not,
fallout will accumulate and blow around everywhere just like dust or light snow does
on the ground and roofs.
       Wind and rain can concentrate the fallout into localized 'hot spots' of much
more intense radiation with no visible indication of its presence.
       This radioactive fallout 'dust' is dangerous because it is emitting penetrating
radiation energy (similar to x-ray's). This radiation (not the fallout dust) can go right
through walls, roofs and protective clothing. Even if you manage not to inhale or
ingest the dust, and keep it off your skin, hair, and clothes, and even if none gets
inside your house, the radiation penetrating your home is still extremely dangerous,
and can injure or kill you inside.
        Radioactive fallout from a nuclear explosion, though very dangerous initially,
loses its intensity quickly because it is giving off so much energy. For example,
fallout emitting gamma ray radiation at a rate of 500 R/hr (fatal with one hour of
exposure) shortly after an explosion, weakens to only 1/10th as strong 7 hours later.
Two days later, it's only 1/100th as strong, or as deadly, as it was initially.
      That is really very good news, because our families can readily survive it
IF we get them into a proper shelter to safely wait it out as it becomes less
dangerous with every passing hour.
       What stops radiation, and thus shields your family, is simply putting mass
between them and the radiation source. Like police body armor stopping bullets,
mass stops (absorbs) radiation. The thicker the mass, the more radiation it stops.
Also, the denser (heavier) the mass used, the more effective it is with every inch
more you add to your fallout shelter.
         The thickness in inches needed to cut the radiation down to only 1/10th of its
initial intensity for different common materials is: Steel 3.3", concrete 11", earth 16",
water 24", wood 38", etc. The thickness required to stop 99% of the radiation is: 5" of
steel, 16" of solid brick or hollow concrete blocks filled with mortar or sand, 2 feet of
packed earth or 3 feet if loose, 3 feet of water. You may not have enough steel
available, but anything you do have will have mass and can be used to add to your
shielding - it just takes more thickness of lighter wood, for example, than heavier
earth, to absorb and stop the same amount of radiation.

Disaster-2008_Action Plan-08               68
      Increasing the distance between your family and the radiation outside also
reduces the radiation intensity.
The goals of your family fallout shelter are:
       To maximize the distance away from the fallout 'dusting' outside on the
        ground and roof
       To place sufficient mass between your family and the fallout to absorb
        the deadly radiation
       To make the shelter tolerable to stay in while the radiation subsides with
        every passing hour
   While a fallout shelter can be built anywhere, you should see what your best
options are at home or nearby. Some structures already provide significant shielding
or partial shielding that can be enhanced for adequate protection. If you do not
have a basement available, you can still use the techniques shown below in
any above ground structure, but you'll need to use more mass to achieve the
same level of shielding.
    You may consider using other solid structures nearby, especially those
with below ground spaces, such as commercial buildings, schools, churches,
below ground parking garages, large and long culverts, tunnels, etc.. Some of
these may require permissions and/or the acquiring of additional materials to
minimize any fallout drifting or blowing into them, if open ended. Buildings with a
half-dozen or more floors, where there is not a concern of blast damage, may
provide good radiation protection in the center of the middle floors. This is because
of both the distance and the shielding the multiple floors provide from the fallout on
the ground and roof.
Bottom Line: choose a structure nearby with both the greatest mass and distance
already in place between the outside, where the fallout would settle, and the shelter
inside.




Disaster-2008_Action Plan-08              69
If you have a basement in your home,
or at a nearby relatives' or friends'
house that you can use, your best
option is probably to fortify and use it,
unless you have ready access to a
better/deeper structure nearby.
For     an     expedient     last-minute
basement shelter, push a heavy table
that you can get under into the corner
that has the soil highest on the
outside. The ground level outside
ideally needs to be above the top of
the inside shelter. If no heavy table is
available, you can take internal doors
off their hinges and lay them on
supports to create your 'table'. Then
pile any available mass on and
around it such as books, wood,
cordwood, bricks, sandbags, heavy
furniture, full file cabinets, full water
containers, your food stocks, and
boxes and pillow cases full of
anything heavy, like earth. Everything
you could pile up and around it has
mass that will help absorb and stop
more radiation from penetrating
inside - the heavier the better.
However, be sure to reinforce your
table and supports so you do not
overload it and risk collapse.




Disaster-2008_Action Plan-08                70
Leave a small crawl-through
entrance and more mass there that
can be easily pulled in after you to
seal it up. Have at least two gaps or
4-6" square air spaces, one high at
one end and one low at the other.
Use more if crowded and/or hotter
climate. A small piece of cardboard
can help fan fresh air in if the
natural rising warmer air convection
current needs an assist moving the
air along. This incoming air won't
need to be filtered if the basement
has been reasonably sealed up,
however any windows or other
openings will require some solid
mass coverage to assure they stay
sealed and to provide additional
shielding     protection    for   the
basement. More details on this in
the next (#6) section.
With more time, materials, and
carpentry or masonry skills, you
could even construct a more formal
fallout shelter, such as the lean-to
shown to the right, but you will
need to assure structural integrity is
achieved and adequate mass is
utilized.


Disaster-2008_Action Plan-08             71
An     effective    fallout      shelter
constructed in a basement may
reduce your radiation exposure
100-200 fold. Thus, if the initial
radiation intensity outside was 500
R/hr (fatal in one hour), the
basement shelter occupants might
only experience 5 R/hr or even
less, which is survivable, as the
radiation     intensity     will     be
decreasing with every passing
hour.



Adding mass on the floor above
your chosen basement corner, and
outside against the walls opposite
your shelter, can dramatically
increase your shielding protection.
Every inch thicker adds up to more
effective    life-saving  radiation
shielding.
As cramped as that crawl space
fallout shelter might seem, the vital
shielding provided by simply moving
some mass into place could be the
difference between exposure to a
lethal dose of radiation and the
survival of your family.
The majority of people requiring any
sheltering at all will be many miles
downwind, and they will not need to
stay sheltered for weeks on end. In
fact, most people will only need to
stay sheltered full-time for a few
days before they can start coming
out briefly to attend to quick
essential chores. Later, they can
begin spending ever more time out
of the shelter daily, only coming
back in to sleep. As miserable as it
might seem now, you and your
family can easily endure that,
especially    compared      to   the
alternative.


Disaster-2008_Action Plan-08               72
It's really not so difficult to build an effective family fallout shelter, not to get it
done...
6 - ESSENTIAL DETAILS
   If you've accomplished the above; securing your supplies, stored water, and built
your family fallout shelter, you need to expand your knowledge.
       Government information and guidance is a vital resource in your response to
        a nuclear crisis, but for many reasons it may be late, incomplete, misleading
        or simply in error. While evacuation might be prudent for individuals who act
        quickly in response to a threat, governments will be slow to call for mass
        evacuations because of their potential for panic and gridlock. If you want to
        assure that you have adequate food and supplies for your family you must act
        BEFORE the panic without first waiting for government instructions that may
        never come or as urgently as warranted. You alone are ultimately
        responsible for your family.


       Filtering the air coming into your basement shelter won't be required.
        Air does not become radioactive, and if your basement is reasonably snug,
    there won't be any wind blowing through it to carry the radioactive fallout dust
    inside. Simply sealing any basement windows and other openings prevents
    significant fallout from getting inside. To improve both the radiation shielding
    inside the basement, and to protect the windows from being broken and letting
    fallout blow in later, you should cover them all with wood, and then with sandbags
    or solid masonry blocks or earth, etc. on the outside and inside too, if possible. If
    the basement air gets seriously stale later on, you could re-open a door into the
    upper floors of the still closed house, or secure a common furnace air filter over
    an outside air opening leading into your basement.
       Regarding fallout contamination, any food or water stored in sealed
        containers, that can later have any fallout dust brushed or rinsed off the
        outside of the container, will then be safe to use. As long as the fallout dust
        does not get inside the container, then whatever radiation penetrated the
        food/water container from the outside does not harm the contents. If you
        suspect that your clothes have fallout on them, remove your outer clothing
        before you come inside and leave them outside. Have water and baby
        shampoo near the entrance (hose and containers) to wash and thoroughly
        rinse any exposed skin and hair. Exposure to fallout radiation does not
        make you radioactive, but you need to assure that you don't bring any
        inside. If any are stricken with radiation sickness, typically nausea, it is when
        mild (<100 Rads) 100% recoverable and cannot be passed on to others.
        Before fallout arrives, you might also try to cover up items you want to protect
        outside for easier rinsing off of the fallout dust later when it's safe to come out
        and do so.
       If close to a target, your first indication of a nuclear detonation may be with its
        characteristic blinding bright flash. The first effects you may have to deal with
        before radioactive fallout arrives, depending on your proximity to it, are blast
Disaster-2008_Action Plan-08                73
        and thermal energy. Promptly employing the old "Duck & Cover" strategy will
        save many from avoidable flying debris injuries and minimize thermal burns.
        Those very close will experience tornado strength winds and should quickly
        dive behind any solid object or into any available depression, culvert, etc. A
        very large 500 kiloton blast, 2.2 miles away, will arrive about 8 seconds after
        the detonation flash with a very strong three second wind blast. That delay is
        much greater further away. That is a lot of time to take cover IF alert and you
        should stay down for up to 2 minutes. If not near any target 'ground zero' you
        will only, like the vast majority, have to deal with the fallout later.
       When fallout is first anticipated, but has not yet arrived, anyone not already
        sheltered should begin using a dust protector filter mask. Everyone should
        begin taking Potassium Iodide (KI) or Potassium Iodate (KIO3) tablets for
        thyroid protection against cancer causing radioactive iodine, a major
        product of nuclear weapons explosions. If no tablets available, you can
        topically (on the skin) apply an iodine solution, like tincture of iodine or
        Betadine, for a similar protective effect. (WARNING: Iodine solutions are
        NEVER to be ingested or swallowed.) For adults, paint 8 ml of a 2 percent
        tincture of Iodine on the abdomen or forearm each day, ideally at least 2
        hours prior to possible exposure. For children 3 to 18, but under 150 pounds,
        only half that amount painted on daily, or 4 ml. For children under 3 but older
        than a month, half again, or 2 ml. For newborns to 1 month old, half it again,
        or just 1 ml. (One measuring teaspoon is about 5 ml, if you don't have a
        medicine dropper graduated in ml.) If your iodine is stronger than 2%, reduce
        the dosage accordingly. Absorption through the skin is not as reliable a dosing
        method as using the tablets, but tests show that it will still be very effective for
        most. Do not use if allergic to iodine. If at all possible, inquire of your doctor
        NOW if there is any reason why anybody in your household should not use KI
        or KIO3 tablets, or iodine solutions on their skin, in a future nuclear
        emergency, just to be sure.
       When you know that the time to take protective action is approaching, turn off
        all the utilities into the house, check that everything is sealed up and locked
        down, and head for the shelter. You should also check that you have near
        your shelter additional tools, crow bars, and car jacks for digging out later, if
        required, and fire extinguishers handy, too. Also, any building supplies, tools,
        sheet plastic, staple guns, etc. for sealing any holes from damage. Your
        basement should already be very well sealed against fallout drifting inside.
        Now, you'll need to seal around the last door you use to enter with duct tape
        all around the edges, especially if it's a direct to the outside door.
       You don't need to risk fire, burns, and asphyxiation trying to cook anything in
        the cramped shelter space, if you have pre-positioned in your shelter enough
        canned goods, can opener, and other non-perishable foods, that are ready-to-
        eat without preparation. More food, along with water, can be located right
        outside your crawl space entrance that you can pull in quickly as needed
        when safe to do so.
       For lighting needs within the shelter have many small LED flashlights or LED
        head-lamps to stretch your battery life. Try not to have to use candles if at


Disaster-2008_Action Plan-08                 74
        all possible. Bring in some books for yourself and games for the children.
        Maybe throw in a small/thin mattress, some cushions, blankets, pillows, etc.
       Toilet use will be via the 5 gallon bucket with a seat borrowed from one of the
        house bathrooms, if you did not purchase a separate one. Garbage bag
        liners, preferably sized for it, should always be used and a full-size and bag
        lined garbage can should be positioned very close to the shelter entrance for
        depositing these in when it is safe to do so quickly. Hanging a sheet or
        blanket will help provide a little privacy as shelter occupants 'take their
        turn'. The toilet needs to have its new 'deposits' sealed up tight with the
        plastic liner after each use. Use a very secure top on the bucket and position
        it near the wall with the outgoing upper air vent.
       Pets, and what to do about them, is a tough call. Letting dogs run free is not a
        humane option, both for their potential to die a miserable death from radiation
        exposure outside and/or to be a danger to others, especially if they get
        diseased and/or run in the inevitable packs of multitudes of other abandoned
        pets. Caring for them is ideal, if truly realistic and not a drain on limited
        resources, while 'putting them down' might eventually become a painful, but
        necessary reality if the disruption of services and food supplies was very long
        term.
       Boiling or bleach water treatments will be used for cleaning your stored water
        later for drinking. (This is for killing bacteria, not for radiation contamination,
        which is never a concern for any stored and covered water containers or even
        sealed food.) Tap water recently put into clean containers won't likely need to
        be purified before using. To purify questionable water, bring it to a roiling boil
        and keep it there for 10 minutes at least. If you don't have the fuel to boil it,
        you can kill the bacteria by mixing in a good quality household bleach at the
        rate of 10 drops per gallon, and letting it sit for at least 1/2 an hour. You can
        later get rid of the flat taste from boiling, or some of the chlorine taste when
        using bleach, by pouring it from one container to another several times.




    This guide then will be the best/only help that we can offer. If you are fortunate
enough to be exploring your family preparation needs and options before such a
future national crisis, there is much more that you can and should do now to insure
that they are even better prepared.
"A prudent man foresees the difficulties ahead and prepares for them;
the simpleton goes blindly on and suffers the consequences."

LIST OF SUPPLIES TO ACQUIRE LOCALLY
       If stores are still at all stocked, and safe to go to, try to buy as many of the
following items as possible... IMMEDIATELY! There are no quantities listed here on
the food items below as family size varies and because, as the emergency and panic
widens, many items will become quickly sold-out or quantities restricted and you'll
need to try to get more of what does remain on the shelves. At a minimum you
should be looking at two weeks of provisions, but much better to be aiming for two
Disaster-2008_Action Plan-08                75
months or more. The reality is, if/when we are attacked, it will be a very long time
before anything is ever 'normal' again, especially at any grocery stores. Nobody can
begin to imagine how bad the suffering will be, and for how long, if nuclear weapons
have gone off... and in multiple locations!
       The half-dozen top listed and UNDERLINED food items below are primarily
for use while in the shelter. They are mostly ready-to-eat that requires no cooking or
preparation, just a can opener at the most. (The iodine solution is included here
because of its importance for its thyroid-blocking topical use detailed above, but it's
NEVER to be ingested or swallowed.) The other foods listed below there are better
cost/nutrition staples for later use during the extended recovery period. Then follows
general non-food supplies, tools and equipment.
      It's much better to risk being a little early when securing your families
essential food and supplies, rather than a few hours too late...
Canned goods (pasta, soups, chili, vegetables, fruit, meats, beans, peanut butter,
etc.)
Ready-to-eat foods ( cheese, etc.)
Some perishable foods (breads and fruits like bananas, apples, oranges, grapes,
etc.)
Assorted drink mix flavorings (with no cold drinks, just plain water, kids will
appreciate it!)
Plenty of potent Multi-Vitamins, Vit C, etc.
Iodine solution, like Betadine (16 ounces)- NOT TO BE INGESTED OR
SWALLOWED!
Multiple big boxes of dried milk (Could include/use some inside shelter, too.)
Multiple big boxes of pancake and biscuit mix & syrup
Largest bags of rice
Largest bags of beans
Largest bags of flour
Largest bags of potatoes
Largest bags quick oats and other grains
Largest bags of macaroni
Large bag of sugar
Large jar of honey
Large 2 gallons or more of cooking oil
Baking powder & baking soda & spice assortment pack
Bottled water (especially if home supplies not secured yet)
Paper or plastic plates/bowls/cups/utensils
Quality manual can opener, 2 if you don't already have one at home
Kitchen matches and disposable lighters
New garbage cans and lots of liner bags (water storage & waste storage)
5 gallon bucket and smaller garbage bags sized for it (toilet)
Toilet seat for the bucket (or use one from inside the house)
Toilet paper and, if needed, sanitary napkins, diapers
Baby wipes (saves water for personal hygiene use)
Flashlights (ideally LED) and more than one portable radio
Plenty more batteries, at least three sets, for each of the above
Bleach (5.25%, without fragrance or soap additives)
Disaster-2008_Action Plan-08              76
Alcohol and Hydrogen Peroxide
Essential Medicines .
Prescription drugs filled, and as much extra as possible
First aid kits
Fire extinguishers
Plenty of inexpensive dust mask filter protectors
Cheap plastic hooded rain coats for everyone
Water filters and all other camping type supplies, such as
stove and fuel, etc., if any sporting goods stocks still available.
And, of course, rolls of plastic sheeting, duct tape, etc.

: Documentation and details
       Radioactive Iodine (Radioiodine) is a major radioisotope constituent of both
        nuclear power plant accidents and nuclear bomb explosions and can travel
        hundreds of miles on the winds. Even very small amounts of inhaled or
        ingested radioiodine can do grave damage as it will always concentrate, and
        be retained, in the small space of the thyroid gland. Eventually giving such a
        large radiation dose to thyroid cells there that abnormalities are likely to result,
        such as loss of thyroid function, nodules in the thyroid, or thyroid cancer.
       Chernobyl in Russia has shown, and continues to reveal, that the greatest
        danger from radioiodine is to the tiny thyroid glands of children. Researchers
        have found that in certain parts of Belarus, for example, 36.4 per cent of
        children, who were under the age of four at the time of the accident, can
        expect to develop thyroid cancer.
       Health experts now estimate that the greatest health concerns affecting the
        largest number of people from a nuclear accident, or nuclear bomb
        explosion(s) anywhere in the world, will likely be from the release of
        radioiodine that is then carried downwind for hundreds of miles. While there
        will also be many other dangerous radioisotopes released along with
        radioiodine, if they are inhaled or ingested they are normally dispersed
        throughout a body and pose less of a risk than if they were to be concentrated
        into one small specific area of the body, like radioiodine is in the thyroid gland.
        So, as a plume or cloud of radioactive isotopes disperses with the wind its
        danger also diminishes, but much less quickly so for radioiodine because
        whatever little there is that's inhaled will always then be concentrated into that
        small space of the thyroid gland.
       The good news is that taking either Potassium Iodide (KI) or Potassium Iodate
        (KIO3) before exposure will saturate (fill up) a persons thyroid gland with safe
        stable iodine to where there is no room for later uptake of radioactive iodine.
        Once the thyroid is saturated, then any additional iodine (radioactive or stable)
        that is later inhaled or ingested is quickly eliminated via the kidneys.
       KI is currently available on the market today.
       P.S.- KI or KIO3 would likely not be needed for the so-called ―Dirty Bomb‖ or
        RDD (Radiological Dispersal Device). Radioactive Iodine is only produced by
        a fission or fusion weapon detonation or in a Nuclear Power Plant as a

Disaster-2008_Action Plan-08                 77
        byproduct of that process. An RDD simply spreads around existing radioactive
        material and it's not very likely to have been composed of the relatively short
        half-life radioactive iodine.
Q: What is Potassium Iodide (KI)?
A: Potassium Iodide (chemical name 'KI') is much more familiar to most than they
might first expect. It is the ingredient added to your table salt to make it iodized salt.
Potassium Iodide (KI) is approximately 76.5% iodine.
        "In 1978, the U.S. Food and Drug Administration found KI "safe and effective"
        for use in radiological emergencies and approved its over-the-counter sale."
Most recently (November, 2001) the FDA states in Potassium Iodide as a Thyroid
Blocking Agent in Radiation Emergencies:
      "FDA maintains that KI is a safe and effective means by which to prevent
      radioiodine uptake by the thyroid gland, under certain specified conditions of
      use, and thereby obviate the risk of thyroid cancer in the event of a radiation
      emergency."
Q: How Does Potassium Iodide (KI) Pill Provide Anti-Radiation Protection?
      "The thyroid gland is especially vulnerable to atomic injury since radioactive
      isotopes of iodine are a major component of fallout."
      "There is no medicine that will effectively prevent nuclear radiations from
      damaging the human body cells that they strike.
        However, a salt of the elements potassium and iodine, taken orally even
        in very small quantities 1/2 hour to 1 day before radioactive iodines are
        swallowed or inhaled, prevents about 99% of the damage to the thyroid
        gland that otherwise would result. The thyroid gland readily absorbs
        both non-radioactive and radioactive iodine, and normally it retains
        much of this element in either or both forms.
        When ordinary, non-radioactive iodine is made available in the blood for
        absorption by the thyroid gland before any radioactive iodine is made
        available, the gland will absorb and retain so much that it becomes saturated
        with non-radioactive iodine. When saturated, the thyroid can absorb only
        about l% as much additional iodine, including radioactive forms that later may
        become available in the blood: then it is said to be blocked.

The Nuclear Regulatory Commission (NRC) stated July 1, 1998 in USE OF
POTASSIUM IODIDE IN EMERGENCY RESPONSE:
        "Potassium iodide, if taken in time, blocks the thyroid gland's uptake of
        radioactive iodine and thus could help prevent thyroid cancers and other
        diseases that might otherwise be caused by exposure to airborne radioactive
        iodine that could be dispersed in a nuclear accident."
     Potassium Iodide as a Thyroid Blocking Agent in a Radiation
Emergency:
        "Almost complete (greater than 90%) blocking of peak radioactive iodine
        uptake by the thyroid gland can be obtained by the oral administration of ...
        iodide ..."
        "A major protective action to be considered after a serious accident at a

Disaster-2008_Action Plan-08                78
        nuclear power facility involving the release of radioiodine is the use of stable
        iodide as a thyroid blocking agent to prevent thyroid uptake of radioiodines."
        "Stable iodine administered before, or promptly after, intake of radioactive
        iodine can block or reduce the accumulation of radioactive iodine in the
        thyroid."
        "The effectiveness of KI as a specific blocker of thyroid radioiodine uptake is
        well established (Il'in LA, et al., 1972) as are the doses necessary for blocking
        uptake. As such, it is reasonable to conclude that KI will likewise be effective
        in reducing the risk of thyroid cancer in individuals or populations at risk for
        inhalation or ingestion of radioiodine."
Q: Is this the Magic Anti-Radiation Protection Pill?
     "There is no medicine that will effectively prevent nuclear radiations from
        damaging the human body cells that they strike."
     "KI provides protection only for the thyroid from radioiodine. It has no impact
        on the uptake by the body of other radioactive materials and provides no
        protection against external irradiation of any kind. Potassium Iodide (and
        Potassium Iodate, KIO3) will provide a very high level of thyroid protection,
        taken in time, for the specific radio-isotopes of iodine, which is expected by
        many to cause the majority of health concerns downwind from a nuclear
        emergency. (And, is the reason most all developed countries have stockpiled
        it.)
However, there are numerous other, and very dangerous, radioactive noble gases
and/or radioactive fallouts that can be associated with nuclear emergencies. You are
still exposed to inhale, ingest, or be radiated externally from any number of
dangerous non-radioiodine sources.
If you are ever directed to evacuate in a nuclear emergency, do so immediately,
regardless of whether you have taken Potassium Iodide (KI) or KIO3, or not.


Note: KI or KIO3 would likely not be needed for the so-called "Dirty Bomb" or RDD
(Radiological Dispersal Device). Radioactive Iodine is only produced by a fission or
fusion weapon detonation or in a Nuclear Power Plant as a byproduct of that
process. An RDD simply spreads around existing radioactive material and it's not
very likely to have been composed of the relatively short half-life radioactive iodine.




Q: Radioactive Iodine: Bad News / Good News!?!
A: The "bad news" first:
1 - Radioactive iodine (predominantly iodine-131) is a major radioisotope constituent
in nuclear power plants.
2 - There are 103 currently active commercial nuclear reactors and 39 operating
non-power reactors in the United States. (434 worldwide as of 1998.) Additionally,
there are numerous other nuclear processing and storage facilities worldwide with
the potential for accidents, too.

Disaster-2008_Action Plan-08               79
The, September 29, 1999, Tokaimura, Japan nuclear accident took place, not in a
nuclear reactor power plant, but in an uranium processing plant.
                                           Radioactive iodine-131 gases were
                                           confirmed to have been released and
                                           was the primary reason for 320,000
                                           Japanese confined to their homes
                                           with their windows shut. It was also
                                           why you may have seen photos of
                                           Japanese      authorities  examining
                                           scores of children with geiger
                                           counters pressed against their necks.
3 - Radioactive iodine (predominantly iodine-131) is also a major constituent of
detonated nuclear weapons.
4 - Radioactive iodine can not only travel hundreds of miles on the winds, but also
still remain health threatening even as other radioisotopes are becoming dispersed
and diluted along with it and their likelihood of causing harm diminishes. It is often
overlooked that while there will also be many other dangerous radioisotopes
released along with radioiodine, if they are inhaled or ingested they are normally
dispersed throughout a body and pose less of a risk than if they were to be
concentrated into one small specific area of the body, like radioiodine is in the thyroid
gland. As a plume or cloud of radioactive isotopes disperses with the wind its danger
also diminishes, but always much less quickly so for radioiodine because whatever
little there is that's inhaled will always be concentrated into that small space of the
thyroid gland.
      "It .was detected in Belarus,
      Russia, and Ukraine. Notably,
      this increase, seen in areas
      more than 150 miles (300 km)
      from the site, continues to this
      day and primarily affects
      children who were 0-14 years
      old at the time of the
      accident...the vast majority of
      the thyroid cancers were
      diagnosed among those living
      more than 50 km (31 miles)
      from the site."
The recently updated (1999) World Health Organization (WHO) Guidelines for Iodine
Prophylaxis following Nuclear Accidents states in its abstract regarding thyroid
cancer caused by the Chernobyl disaster:
"This increase in incidence has been documented up to 500 km from the accident
site."

...and therefore...
"...that stockpiling (KI or KIO3) is warranted, when feasible, over much wider areas
Disaster-2008_Action Plan-08               80
than normally encompassed by emergency planning zones, and that the opportunity
for voluntary purchase be part of national plans."
The wind, of course, doesn't respect state boundaries
Even more importantly; "The report also estimates that children aged three to five
years probably received doses of radiation three to seven times higher than average
during the 90 nuclear tests that were carried out.
Remember, it's always the children who are at the highest risk of injury from
radioactive iodine and eventually developing thyroid cancer from that exposure.
Getting Back To The Future...
Commenting on the world health effects a nuclear exchange between India and
Pakistan would create, for example, Dr. Henry Kendall of the Union of Concerned
Scientists said in October of 1999: "It would be very similar to Cherynobl. But it could
be on a substantially larger scale."
Accordingly, you also have to assess the probable threat from nuclear war, either
directed at the U.S. or fallout contamination originating from elsewhere in the world.
Russia, China, North Korea, Pakistan, India, Iran, Israel, etc., where any of them are
exchanging nuclear blasts with any of their neighbors, could have the prevailing
west-to-east trade winds carrying the resultant radioactive fallout to our shores, too.
5 - Radioactive iodine (radioiodine) persists in the environment for a month or more.
6 - Most importantly, ingested or inhaled radioactive iodine (radioiodine) persists in
the body and concentrates in the thyroid. (Excess iodine in the blood, either
radioiodine or stable iodine, is quickly eliminated from the body, but only after the
thyroid has become saturated with one or the other type of iodine.) Even very small
amounts of radioactive iodine, because it is retained in the small space of the
thyroid, eventually will give such a large radiation dose to thyroid cells there that
abnormalities are likely to result. These would include loss of thyroid function,
nodules in the thyroid, or thyroid cancer. The most likely to see the worst effects, in
later life, are the youngest children.
Every year researchers are discovering more from Chernobyl as its legacy continues
to reveal itself. According to the World Health Organization, that disaster will cause
50,000 new cases of thyroid cancer among young people living in the areas most
affected by the nuclear disaster.
For all of the above reasons, health experts estimate that the greatest health
concerns affecting the largest number of people from a nuclear accident, or
nuclear bomb explosion(s) anywhere in the world, will likely be from the
release of radioactive iodine then carried downwind.
However, there really is some Good News amongst all this!
This deadly cancer agent, especially to our children, is easily, cheaply, and
effectively blocked!
"...a salt of the elements potassium and iodine, taken orally even in very small
quantities 1/2 hour to 1 day before radioactive iodine are swallowed or inhaled,
Disaster-2008_Action Plan-08               81
prevents about 99% of the damage to the thyroid gland that otherwise would
result."


        "Thus, the studies following the Chernobyl accident support the etiologic role
        of relatively small doses of radioiodine in the dramatic increase in thyroid
        cancer among exposed children. Furthermore, it appears that the increased
        risk occurs with a relatively short latency. Finally, the Polish experience
        supports the use of KI as a safe and effective means by which to protect
        against thyroid cancer caused by internal thyroid irradiation from inhalation of
        contaminated air or ingestion of contaminated food and drink when exposure
        cannot be prevented by evacuation, sheltering, or food and milk control."

What they learned was that children, with their thyroid glands being the most
sensitive to radioactive iodine uptake, have today grown up to be the most frequent
victims of thyroid cancers there. The children in Russia, the Ukraine and Belarus,
where potassium iodide (KI) was not widely distributed, are now experiencing high
levels of thyroid cancer. However, in Poland, where over 18 million doses of
Potassium Iodide (KI) were administered, and to 97 percent of the children, there
has been no similar increase in thyroid cancer. Also, key to Poland's radioiodine
protective strategy, was their aggressive interdiction of radioiodine contaminated
food stuffs and milk.


Bottom Line: For all its serious potential for widespread damage to populations (and
especially among our youngest), far downwind from the site of a nuclear event,
radioiodine health concerns can be largely neutralized by inexpensive thyroid
blocking via prompt prophylactic use of potassium iodide (KI). This, in addition to
successful evacuation, when indicated, and vigilance that food and milk are not also
radioiodine contaminated, has proven itself the best combination strategy.




Q: Dosage and Safety Regarding Potassium Iodide (KI) Usage?

A: In April of 1982 the Bureau of Radiological Health and Bureau of Drugs, Food and
Drug Administration, Department of Health and Human Services released "FINAL
RECOMMENDATIONS, Potassium Iodide As A Thyroid-Blocking Agent In A
Radiation Emergency: Recommendations On Use". These lengthy recommendations
are summarized in the FDA's "mandated patient product insert". (See a complete
copy below.) This insert is packed with every bottle of non-prescription Potassium
Iodide (KI) tablets sold. However, the lengthy FDA recommendations contain many
facts not mentioned in this required insert, including the following:




Disaster-2008_Action Plan-08               82
        "Based on the FDA adverse reaction reports and an estimated 48 x 106 [48
        million] 300-mg doses of potassium iodide administered each year [in the
        United States], the NCRP [National Council on Radiation Protection and
        Measurements] estimated an adverse reaction rate of from 1 in a million to 1
        in 10 million doses."




   TAKE POTASSIUM IODIDE ONLY WHEN PUBLIC HEALTH OFFICIALS
   TELL YOU. IN A RADIATION EMERGENCY, RADIOACTIVE IODINE COULD
   BE RELEASED INTO THE AIR. POTASSIUM IODIDE (A FORM OF IODINE)
   CAN HELP PROTECT YOU.
   IF YOU ARE TOLD TO TAKE THIS MEDICINE, TAKE IT ONE TIME EVERY
   24 HOURS. DO NOT TAKE IT MORE OFTEN. MORE WILL NOT HELP YOU
   AND MAY INCREASE THE RISK OF SIDE EFFECTS. DO NOT TAKE THIS
   DRUG IF YOU KNOW YOU ARE ALLERGIC TO IODINE (SEE SIDE
   EFFECTS BELOW).
   INDICATIONS
   THYROID BLOCKING IN A RADIATION EMERGENCY ONLY
   DIRECTIONS FOR USE
   Use only as directed by State or local public health authorities in the event of a
   radiation emergency.
   DOSE
   ADULTS AND CHILDREN ONE YEAR OF AGE OR
   OLDER: One (1) tablet once a day. Crush for small children.
   BABIES LESS THAN ONE YEAR OF AGE: One-half (1/2) tablet once a day.
   Crush first.
   DOSAGE: Take for 10 days unless directed otherwise by State or local public
   health authorities.
   Store at controlled room temperature between 15 and 30C (59 degrees to 86
   degrees F). Keep bottle tightly closed and protect from light.
   WARNING
   POTASSIUM IODIDE SHOULD NOT BE USED BY PEOPLE ALLERGIC TO
   IODIDE. Keep out of the reach of children. In case of overdose or allergic
   reaction, contact a physician or public health authority.
   DESCRIPTION


Disaster-2008_Action Plan-08               83
   Each (company trade name) Tablet contains 130 mg. of potassium iodide.
   HOW POTASSIUM IODIDE WORKS
   Certain forms of iodine help your thyroid gland work right. Most people get the
   iodine they need from foods like iodized salt or fish. The thyroid can "store" or
   hold only a certain amount of iodine.
   In a radiation emergency, radioactive iodine may be released in the air. This
   material may be breathed or swallowed. It may enter the thyroid gland and
   damage it. The damage would probably not show itself for years. Children are
   most likely to have thyroid damage.
   If you take potassium iodide, it will fill up your thyroid gland. This reduces the
   chance that harmful radioactive iodine will enter the thyroid gland.
   WHO SHOULD NOT TAKE POTASSIUM IODIDE
   The only people who should not take potassium iodide are people who know
   they are allergic to iodide. You may take potassium iodide even if you are
   taking medicines for a thyroid problem (for example, a thyroid hormone or anti-
   thyroid drug). Pregnant and nursing women and babies and children may also
   take this drug.
   HOW AND WHEN TO TAKE POTASSIUM IODIDE
   Potassium iodide should be taken as soon as possible after public health
   officials tell you. You should take one dose every 24 hours. More will not help
   you because the thyroid can "hold" only limited amounts of iodine. Larger
   doses will increase the risk of side effects. You will probably be told not to take
   the drug for more than 10 days.
   SIDE EFFECTS
   Usually, side effects of potassium iodide happen when people take higher
   doses for a long time. You should be careful not to take more than the
   recommended dose or take it for longer than you are told. Side effects are
   unlikely because of the low dose and the short time you will be taking the drug.
   Possible side effects include skin rashes, swelling of the salivary glands, and
   "iodism" (metallic taste, burning mouth and throat, sore teeth and gums,
   symptoms of a head cold, and sometimes stomach upset and diarrhea).
   A few people have an allergic reaction with more serious symptoms. These
   could be fever and joint pains, or swelling of parts of the face and body and at
   times severe shortness of breath requiring immediate medical attention.
   Taking iodide may rarely cause over activity of the thyroid gland, under activity
   of the thyroid gland, or enlargement of the thyroid gland (goiter).




Disaster-2008_Action Plan-08               84
   WHAT TO DO IF SIDE EFFECTS OCCUR
   If the side effects are severe or if you have an allergic reaction, stop taking
   potassium iodide. Then, if possible, call a doctor or public health authority for
   instructions.
   HOW SUPPLIED
   Tablets (Potassium Iodide Tablets, U.S.P.): bottles of [number of tablets in a
   bottle] tablets
   ( ). Each white, round, scored tablet contains 130 mg. potassium iodide.

The FDA new (November, 2001) guidance document, that brings it more in-line
with the recent World Health Organization recommendations below, is titled;
"Potassium Iodide as a Thyroid Blocking Agent in Radiation Emergencies".
It can be seen here fda.htm. That document represents the Food and Drug
Administration's current thinking on this topic.
In regards to the differences between the World Health Organization dosing
recommendations and these new FDA recommendations, this FDA document states:
        These FDA recommendations differ from those put forward in the World
        Health Organization (WHO) 1999 guidelines for iodine prophylaxis in two
        ways. WHO recommends a 130-mg dose of KI for adults and adolescents
        (over 12 years). For the sake of logistical simplicity in the dispensing and
        administration of KI to children, FDA recommends a 65-mg dose as standard
        for all school-age children while allowing for the adult dose (130 mg, 2 X 65
        mg tablets) in adolescents approaching adult size. The other difference lies in
        the threshold for predicted exposure of those up to 18 years of age and of
        pregnant or lactating women that should trigger KI prophylaxis. WHO
        recommends a threshold of 1 cGy for these two groups. As stated earlier,
        FDA has concluded from the Chernobyl data that the most reliable evidence
        supports a significant increase in the risk of childhood thyroid cancer at
        exposures of 5 cGy or greater.
Threshold     Thyroid           Radioactive       Exposures                       and
Recommended Doses of KI for Different Risk Groups

                               Predicted        KI     dose # of 130 mg # of 65 mg
                               Thyroid          (mg)        tablets     tablets
                               exposure(cGy)

Adults over 40 yrs             >500             130         1             2

Adults over 18 through >10
40 yrs

Pregnant       or     lactating > 5


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women

Adoles. over 12 through                         65           1/2          1
18 yrs*

Children over 3 through
12 yrs

Over 1 month through 3                          32           1/4          1/2
years

Birth through 1 month                           16           1/8          1/4

*Adolescents approaching adult size (> 70 kg) should receive the full adult dose (130
mg).
The World Health Organization recent recommendations has a step increase in
doses by age (chart below) and also states the potential benefit diminishes with older
adults. In fact, if only a limited number of Potassium Iodide (KI) or KIO3 tablets are
available, these should always be given to infants, children and young adults first as
they are the most vulnerable and also the risk of thyroid cancer fully developing
begins to drop off with adults much over 40 years of age.
The World Health Organization (WHO) Guidelines for Iodine Prophylaxis following
Nuclear Accidents states:
        "In general, the potential benefit of iodine prophylaxis will be greater in the
        young, firstly because the small size of the thyroid means that a higher
        radiation dose is accumulated per unit intake of radioactive iodine. Secondly,
        the thyroid of the fetus, neonate and young infant has a higher yearly thyroid
        cancer risk per unit dose than the thyroid of an adult and, thirdly, the young
        will have a longer time span for the expression of the increased cancer risk."
Also, the newly released (November, 2001) FDA document entitled Potassium Iodide
as a Thyroid Blocking Agent in Radiation Emergencies determined from the
Chernobyl data that:
        "They suggest that the risk of thyroid cancer is inversely related to age, and
        that, especially in young children, it may accrue at very low levels of
        radioiodine exposure." and also that "...adults over 40 need take KI only in the
        case of a projected large internal radiation dose to the thyroid (>500 cGy) to
        prevent hypothyroidism."
Dosing chart from the recently updated 1999 World Health Organization:




Disaster-2008_Action Plan-08               86
Guidelines for Iodine Prophylaxis following Nuclear Accidents
                               Mass     of              Mass       of Fraction of
                                             Mass of KI
   Age Group                   iodine                   KIO3          100     mg
                                             mg
                               mg                       mg            tablet
   Adults          and
   adolescents         100                   130        170            1
   (over 12 years)
   Children
                               50            65         85             1/2
   (3-12 years)
   Infants
   (1 month          to    3 25              32         42             1/4
   years)
   Neonates
                               12.5          16         21             1/8
   (birth to 1 month)
To help make sense of any possible dosing confusion and radiation level thresholds,
it should be remembered first that you should not commence dosing until so directed
by a doctor or public health officials. Also, the biggest difference in dosage and ages,
between the two recommendations, is that WHO suggests an adult dose (130mg KI)
for everyone over 12 where the FDA suggests an adult dose for everyone over 18,
unless the adolescent weighs 70kg (154 lbs) or more. And, again, the primary
reason for this divergence from the WHO recommendations is that, according to the
FDA: For the sake of logistical simplicity in the dispensing and administration of KI to
children, FDA recommends a 65-mg dose as standard for all school-age children
while allowing for the adult dose (130 mg, 2 X 65 mg tablets) in adolescents
approaching adult size.
At the WHO dosages recommended above, an adverse reaction rate of less than 1
in 10 million children and less than 1 in 1 million adults is expected. However,
Potassium Iodide should not be used by people allergic to iodine. According to the
WHO, contraindications for use of potassium iodide are: (1) past or present thyroid
disease (e.g., active hyperthyroidism), (2) known iodine hypersensitivity, (3)
dermatitis herpetiformis, and (4) hypocomplementaemic vasculitis.
You should also check with your doctor before taking this medication if you have
myotonia or hyperkalemia congenita or tuberculosis or kidney disease.
Pregnant women should consult a physician prior to continuing dosages for more
than two days. According to the WHO, "No negative consequences are to be
expected after one or two doses of stable iodine. However, especially in areas with
dietary iodine deficiency, prolonged dosage could lead to maternal and/ or fetal
thyroid blockage, with possible consequences for fetal development. ... Pregnant
women with active hyperthyroidism must not take stable iodine because of the risk of
fetal thyroid blockage."

For pregnant or nursing women, and for cautions to the proper dosing of neonates,
also read the appropriate sections here in the newly released (November, 2001)
FDA document entitled

Disaster-2008_Action Plan-08                  87
Potassium Iodide as a Thyroid Blocking Agent in Radiation Emergencies.
The WHO also states, and the FDA concurs, "Side effects in other parts of the body,
such as gastrointestinal effects or hypersensitivity reactions, may occur but are
generally mild and can be considered of minor importance."
One additional recommendation we urge at KI4U, now before any nuclear
emergencies, is simply to check with your doctor and inquire whether there is any
possibility of any adverse reactions if you, or your children, had to begin taking KI or
KIO3. If you are concerned enough to be reading this and considering acquiring KI or
KIO3 for your family, then checking with your doctor first should be a natural step in
your prudent preparations, too.
Besides contraindications with pre-existing medical conditions, this is also important
if you (or they) are taking any regular medications. Especially, though not limited to,
Spironolactone (like Aldactone), Triamterene (Dyrenium), Amiloride (Midamor), or
medicines for an overactive thyroid, or if you are on medications with any lithium-
based or potassium-sparing diuretics.
Better to have gotten that assurance from your physician now, before any
emergencies, rather than risk hesitating taking it later (or possibly suffering an
adverse reaction) because you didn't ask first. Again, that's just a part of your
prudent preparations, where anyone else being issued Potassium Iodide (KI) during
an emergency probably won't have that opportunity to find out first!
Any dietary iodine sources providing for a normal daily sufficient regimen of iodine
intake (about 150 micrograms/day in adults) is preferred in that it will then take less
stable iodine (and time) to saturate your thyroid in a nuclear emergency and there
will be less room there for radioactive iodine before you do. An iodine sufficient diet
will also greatly increase the effectiveness of KI or KIO3, but primarily only in the
following limited context and not as a substitute for KI or KIO3:
       An iodine sufficient diet is most beneficial, compared to an insufficient iodine
       diet, when the initial administration of KI had been unavoidably delayed and
       the KI could only be first taken after exposure to radioiodine.
       "The 131-I thyroid absorbed dose is two-fold greater with insufficient levels of
       dietary iodine, 2,900 cGy/37 MBq, than with sufficient levels of dietary iodine,
       1,500 cGy/37 MBq. When KI is administered 48 h or less before 131-I intake,
       the thyroid absorbed doses (in cGy/37 MBq) are comparably low with both
       sufficient and insufficient dietary iodine levels. When KI is administered after
       131-I intake, however, the protective effect of KI is less and decreases more
       rapidly with insufficient than with sufficient dietary iodine. For example, KI
       administration 2 and 8 h after 131-I intake yields protective effects of 80 and
       40%, respectively, with iodine-sufficient diets, but only 65 and 15% with
       iodine-deficient diets."
However, in regards to the effective thyroid-blocking protection directly afforded by
various sources of dietary iodine, and other iodine applications, taken alone without
also utilizing KI or KIO3, it was found...




Disaster-2008_Action Plan-08               88
From the Salt Institute:
       "U.S. salt producers use potassium iodide at a level of 0.006% to 0.01% KI."
According to Morton® Salt:
       "Each 1/4 teaspoon serving of Morton® Iodized Salt (1.5 gram weight)
       contains 130 MICROGRAMS of Potassium Iodide."
Thus, to achieve an intake of 130 MILLIGRAMS of Potassium Iodide (what one KI
adult dose tablet contains) would require ingesting 250 teaspoons or over 5 cups of
iodized salt per day! Don't even think about it! (Morton Lite Salt® Mixture comes in
lower yet, at only 90 MICROGRAMS of Potassium Iodide per 1/4 teaspoon!)
Sea Salt is an even worse 'option'. Iodine per Kilogram of sea salt is about 3 mg.
You'd be looking at over 33 kilograms of Sea Salt a day to achieve the amount of
iodine in a 130 mg dose of KI! Hardly an option!
A 6-ounce portion of ocean fish only contains about 500 MICROGRAMS of iodine.
Some specific seafood, portion size and their iodine content in MICROGRAMS:
Mackerel 150g 255 mcg, Mussels 150g 180 mcg, Cod 150g 165 mcg, Kipper 150g
107 mcg, Whiting 150g 100 mcg, Fish fingers 75g 75 mcg, Scampi 150g 62 mcg,
Herring 150g 48 mcg, Prawns 150g 42 mcg, Sardines, canned in oil 150g 35 mcg,
Trout 150g 24 mcg, Tuna 150g 21 mcg.
Well, you can do the math here! More fish per day would be required than most eat
in a year!
Medicines containing Potassium Iodide: Potassium iodide (KI) is an old drug used
as an expectorant in the treatment of asthma, bronchitis and emphysema. It is used
to treat coughs with phlegm, feeling of fullness in the chest or pressure in the
face/sinuses. Potassium iodide helps loosen phlegm (mucus) and thin bronchial
secretions to drain bronchial tubes and make coughs more productive. It increases
secretions in the respiratory tract in approximately 30 min. Today it is mainly used to
treat an overactive thyroid and, of course, to protect the thyroid gland from the
effects of radiation from inhaled or ingested (swallowed) radioactive iodine.
Potassium iodide also has anti-infective properties and is sometimes used to treat
certain skin conditions caused by fungus,
Regarding ingesting (drinking/swallowing) iodine, iodine tablets (widely sold for
water purification), tincture of iodine, or Povidone-iodine solutions (like the
Betadine® brand solution)
       Elemental (free) iodine is poisonous, except in the very small amounts in
       water disinfected with iodine tablets or a few drops of tincture of iodine.
       Furthermore, elemental iodine supplied by iodine tablets and released by
       tincture of iodine dropped into water is not effective as a blocking agent to
       prevent thyroid damage. If you do not have any potassium iodide, DO NOT
       TAKE IODINE TABLETS OR TINCTURE OF IODINE.
Iodine is normally used in doses of 8 PPM to treat clear water for a 10 minute
contact time. The effectiveness and safety of this dose has been shown in numerous
studies.
       "No adverse health effects were reported in men who drank water providing
       iodide at doses of 0.17-0.27 mg/kg of body weight per day for 26 weeks"


Disaster-2008_Action Plan-08              89
Everyone needs to understand that all 'tincture of iodine' bottles are clearly
marked "POISON" for a very good reason. Ingesting elemental free iodine,
such as 'tincture of iodine', in quantities sufficient to attempt thyroid-blocking
in a nuclear emergency is not a safe, nor an effective, alternative.
Finally, if someone does attempt thyroid-blocking for themselves or their children by
ingesting iodine, iodine water purification tablets, tincture of iodine, or
Povidone-iodine solutions (like the Betadine® brand solution), and we are strongly
advising against it, they can look forward to:
       shock (potentially fatal lowering of blood pressure)
       extreme thirst
       metallic taste
       sore teeth, gums and mouth
       severe headache
       fever
       no urine output (kidney failure)
       corrosive effects on the gastrointestinal tract
       esophageal stricture, asphyxiation (swelling of the throat, esophagus)
       vomiting
       diarrhea
       abdominal pain with internal damage
       delirium
       stupor

DO NOT INDUCE VOMITING. Give milk, cornstarch, or flour by mouth (15 gm in 500
ml, or just over a pint of water). Continue to give milk every 15 minutes.
BOTTOM LINE: DO NOT INGEST, SWALLOW OR DRINK 'TINCTURE OF
IODINE', IT IS POISON!


Topical Iodine Applications
There has been some interesting research, though, with both humans and dogs into
topically (on the skin) applied Povidone-Iodine (10%) solution (such as Betadine® or
Povidex® solutions), and also with tincture of iodine, to test the absorption rates of
iodine directly through the skin. But, it was found not to be as quick in providing
thyroid blocking as oral Potassium Iodide (KI) or KIO3, nor as consistent, and then,
often, at lower levels of protection. Questions remain of skin irritation, determining
the amount of Iodine solution to apply, where best to apply it, how long to apply it,

Disaster-2008_Action Plan-08                 90
and the effects of temperature and humidity on absorption through the skin. Also,
insufficient testing has been done on specific groups, such as infants, children, and
pregnant and nursing women to know how effective it would be and the full range of
complications that could be expected with repeated applications. For instance, the
skin absorption of iodine products in neonates with inhibition of thyroid function has
been documented in the past. The use of Povidone-Iodine is the most frequent
cause of this type of intoxication. Another study showed that Povidone-Iodine did not
significantly influence neonatal thyroid function if they were used to a full term
neonate only once and even to a wide skin surface.
Another source, non-medical, claims that by using the stronger 7% tincture iodine
and just dipping the index finger of the person being treated up to the first knuckle
(just above the fingernail) would provide the proper dosing. They claim this would
work for all people as our fingers are roughly proportionate to our size and weight.
That may be true, but that this technique would actually provide sufficient quantity
and effective absorption of iodine for thyroid-blocking has not been verified.
(Additional documentation and source references have been requested of that
author. And, will be promptly posted here if provided.)
Clearly more research is needed before embracing the topically applied techniques
as a one-size-fits-all solution, as its limitations must first be more fully understood.
        "Although there were large variations within each subject group in regard to
        serum-I levels and thyroid uptakes, the increase in serum-I concentration after
        topical-I application was effective in reducing the thyroid uptake of I131. The
        authors conclude that in the absence of KI, most humans would benefit from
        topical application of tincture of-I, and that in some the effectiveness would
        equal that of oral KI."




Potassium iodide (KI) is 76.5% iodine.
If the FDA recommended amount required for thyroid-blocking radiation protection is
130 milligrams of KI, then that translates into 99.45 milligrams of elemental iodine.
If you are looking at a product, like a kelp liquid for example, that says on the label...
       "2 drops contain -kelp standardized with potassium iodide to contain 0.15 mg
       (150mcg) of pure organic iodine (150%RDA)"
Then, to attain 99.45 milligrams of iodine (same as what's in one 130 mg tablet of KI)
would require ingesting 663 double drops or X 2 = 1326 single drops.
A couple drops is just fine for dietary supplementation of required iodine, but woefully
underpowered for saturating the thyroid for radioiodine radiation protection.
Is the Government Ready with Emergency Stocks of Potassium Iodide (KI)?
       "The American Thyroid Association through its Public Health Committee has
       strongly recommended the stockpiling of KI for prophylaxis in the event of a
       nuclear reactor accident. Unfortunately, the Nuclear Regulatory Commission

Disaster-2008_Action Plan-08                91
        has not accepted this recommendation."

        "As time is of the essence in optimal prophylaxis with KI, timely administration
        to the public is a critical consideration in planning the emergency response to
        a radiation accident and requires a ready supply of KI." and "FDA also
        emphasizes that emergency response plans and any systems for ensuring
        availability of KI to the public should recognize the critical importance of KI
        administration in advance of exposure to radioiodine."
But, at least your government is talking about it again...

  Potassium iodide is often billed on the Internet as a panacea for a nuclear
  emergency. It is nothing of the sort, offering no protection for most types of
  radiation exposure. But there is strong scientific evidence that it can protect the
  thyroid gland, the most radiation-sensitive part of the body, from absorbing trace
  amounts of radioactive iodine, particularly in young children.
  Potassium iodide is not expensive, nor is it difficult to manufacture or store for
  long periods. The drug is approved for thyroid protection by the Food and Drug
  Administration,
  The nuclear power industry, which stocks potassium iodide to protect workers in
  its plants, has long opposed a large public stockpile, carrying as it would the
  implication that nuclear power might be unsafe.
  These experts contend that evacuation and careful monitoring of the food supply
  would be better ways to protect public health.
  The World Health Organization recommends stockpiling for every country with
  nuclear reactors operating within or near its borders.
  Potassium iodide availability is one of those issues that rarely rises to public
  awareness, but it has a long underground history that has played out in
  Washington and in state capitals over decades. The arguments being heard
  today are familiar ones to participants in that debate, with fear of terrorism as the
  new twist.
  The value -- and the limitations -- of potassium iodide have been known to
  researchers for decades, and there is little dispute on the scientific points.
  Nuclear reactors produce many radioactive substances that can harm people.
  One, radioactive iodine, poses a particular worry because the human thyroid
  gland uses iodine as a fundamental building block of hormones that play critical
  roles in metabolism. The body cannot distinguish the safe form of iodine present
  in food and table salt from the radioactive form that comes from nuclear reactors.
  Thyroid cancer can usually be treated, but that may require surgery, regular
  monitoring and lifetime medication.
  The idea behind potassium iodide is that the thyroid gland can store only so
  much iodine. A potassium iodide pill given near the time of radiation exposure
  floods the gland with safe iodine and reduces or eliminates the absorption of

Disaster-2008_Action Plan-08               92
  radioactive iodine. Potassium iodide is the same chemical used to add iodine to
  table salt, but the pills contain higher doses. Anyone can buy the pills, though
  they are not widely available in stores and most people do not know about them.
  Potassium iodide can protect people only from radioactive iodine, not other kinds
  of radioactive fallout. Potassium iodide would be better than nothing.
  The NRC is still finalizing plans to implement that policy. Meanwhile, the Health
  and Human Services Department is considering buying some of the drug to add
  to its own anti-terrorism stockpiles. However, there is debate about whether the
  drug could be distributed from these regional stockpiles quickly enough to do any
  good.



Remember, too, that you must start taking Potassium Iodide (KI) before you are
exposed to attain the maximum flooding of your thyroid with stable iodine and thus
blocking subsequent uptake of radioiodine contamination.
Unless the government not only acquires sufficient Potassium Iodide (KI) stock for
the public, but also then provides it to each household to stock and hold themselves,
so as to have it ready on hand BEFORE a nuclear radiation emergency event, then
critical life-saving time would still be needlessly wasted trying to distribute it during a
nuclear radiation emergency.
Any government attempts to quickly dispense millions of doses to the affected and
frantic target populations downwind of an ongoing nuclear radiation emergency
would surely be a scene of great panic and disarray. The resultant delays created in
attempting to distribute KI, in mass, in that fearful and anxious atmosphere would
also have unnecessarily exposed that population to even higher radiation
contaminations.
Q: Will Potassium Iodide (KI) Flush Radioactive Iodine Out of the Thyroid Gland?
A: The question might better be; If you don't have any Potassium Iodide (KI) and rely
on the government to acquire and distribute KI, and after some delay, you do
eventually get Potassium Iodide (KI) for your family, but it's now hours or days into
the nuclear radiation emergency, will Potassium Iodide (KI) still help?
Yes, but only to the degree your thyroid is still less than 100% saturated with either
form of iodine (radioactive or stable). Then the Potassium Iodide (KI) will safely fill up
the balance so your thyroid will not have room for later additional uptake of
radioactive iodine.
But, No, Potassium Iodide (KI) can't flush out radioactive iodine that's already there
before taking KI.
        In fact, radioactive isotopes, once bound in the thyroid, cannot be flushed out
        by subsequent administration of non radioactive iodine. To be effective in
        preventing the uptake and binding of radioactive isotopes, stable iodine must
        be administered before exposure. A daily 130-mg dose of stable KI, starting
        one-half hour to one day before the arrival of fallout or other material
        contaminated with radioactive iodine, will effectively saturate the thyroid,
Disaster-2008_Action Plan-08                93
        giving 99% effective protection. A 130-mg tablet or four drops of a saturated
        solution of KI may be used.
        "...Only about 50 percent of the uptake is blocked if the iodide administration
        is delay six hours and little effect can be achieved if the delay is more than 12
        hours... If stable iodied is given after the first 24 hours, it may sometimes
        prolong the retention of iodine, since it suppresses the release of thyroid
        hormone..."
Clearly, any delay in flooding your thyroid with Potassium Iodide (KI) is a serious risk
to be aggressively avoided, especially for your children. To depend on government
KI emergency stocks that currently don't exist and some ad-hoc untested distribution
'plan' that'll likely be chaotic, at best, can only add up to unnecessary additional
delays and radiation exposure. Add to this having your family members possibly
scattered amongst work, home, school, etc. and all getting conflicting warnings and
at varied times, and it becomes clear that NOT already having your Potassium Iodide
(KI) in-hand could become your worst family nightmare.




Disaster-2008_Action Plan-08               94
CONTINGENCY PLAN FOR
WATER BORNE DISASES




                         GUJARAT STATE
                               2008




Disaster-2008_Action Plan-08    95
                      EPIDEMIC CONTROL CELL
          COMMISSIONERATE OF HEALTH, MEDICAL SERVICES
                AND MEDICAL EDUCATION (HEALTH)
                   5, DR. JIVRAJ MEHTA BHAVAN,
                           GANDHINAGAR.
GUIDELINES FOR SURVEILLANCE OF
EPIDEMIC OUTBREAK

INTRODUCTION

Surveillance of diseases is the continuing scrutiny of all aspects of the occurrence
and spread of a disease that are pertinent to effective control.
Sudden impact natural disasters like earthquakes are rarely followed by
communicable disease outbreaks. However, continued lack of water supply and
proper disposal of excreta, disrupted health services and environmental conditions,
there is always an increased risk of communicable disease outbreaks.
                      A core group of senior officers have to take up comprehensive
responsibility to plan, organize, supervise and monitor the state level management
cell which should include medical experts, epidemiologists and Entomologists.

OBJECTIVES
4.     Immediate provision of essential medical care
5.     Strengthening of epidemiological surveillance of selected epidemic prone
communicable diseases areas to generate early warning signals of potential
outbreaks.
6.      To undertake epidemiological investigation of potential outbreak, if any, and
to take rapid appropriate action for the containment of impending outbreak.

METHODOLOGY
B.    Essential medical care:
5.    Provision of medical expert teams
6.    Ambulance hospitals
7.    Local temporary hospitals
8.    Transport of ill persons to well equipped hospitals, provision of drugs/
equipment/ skilled medical and paramedical.

B. Diseases/syndromes/events to be covered:
     Acute diarrhoeal diseases
     Cholera
     Jaundice
     Typhoid
Disaster-2008_Action Plan-08             96
       Monitoring of drinking water quality & leakages
       Monitoring & Disposal of unhygienic food sold out in the market

Data collection, compilation and analysis
                     All the reporting units would collect and analyse data locally for
timely action and transmit it to Surveillance Unit where it would be further compiled,
analysed and information thus generated, will be transmitted accordingly.
Reporting Units:
                     All the reporting units in the district are to be identified which
may be field camps, mobile health units, dispensaries besides subcentres, PHCs,
new PHCs, CHCs, District Hospitals etc.



 Frequency of reporting:
                     Frequency should be daily from ―reporting units including field
camps― to Surveillance Unit and from there onwards. The data should reach
Surveillance Unit by 7.00-p.m. everyday.

Flow of information:
All reporting units'           Surveillance unit           State authorities
                                                                               NICD,
Delhi
                                                    of Health, Medical
                                                   Services and Medical
                                                   Education, Gandhinagar

Formats:
As per Annexure A and B

Action and Feedback:
                      Action and feedback would be the responsibility of District
Health authorities with all the help/supervision from Surveillance Unit. If needed, help
may be sought from state and other agencies/institutions. Apex institutes e.g. NICD,
WHO etc.

HOUSE FLY CONTROL MEASURES

ENVIRONMENTAL SANITATION AND HYGIENE

1 Source reduction
d.  Proper disposal of human and animal excreta
e.  Collection, transport, storage and disposal of garbage
f.  Avoiding soil mixed with organic matter nearer to the house Elimination of
    source that attracts flies from other areas.

2 Fly Control
f.   Environmental sanitation and hygiene – Long term measures
g.   Insecticidal control
h.   Biological control – Predators like spiders, parasitoids like wasps and
Disaster-2008_Action Plan-08                 97
        Microorganisms
i.      Other methods of control like Trapping methods
j.      Knowledge on susceptibility to insecticides is essential before the use of
        Insecticides.

3 Insecticidal control
-    Larvicides – Borax (Sodium Borate) Solution @ 1.4 Kg/m3
-    Adulticides
e.   Residual treatment with OP Compounds, Carbomates and Pyrethroids
     iii.   Malathion @ 1-2 gm/m2
     iv.    Fenthion 0.5-1% ready to use emulsion @ 20 liters/100m2
f.   Impregnated strips, chords etc.
g.   Toxic baits – Baygon bait @ 60gm/100m2
h.   Space sprays directly on adult flies with pyrethrum extract (0.1%)




Disaster-2008_Action Plan-08             98
                                   ANNEXURE - A
Daily Reporting Form
Surveillance of Epidemic-Water borne Communicable Diseases
Name of the Reporting Team Leader..............
Name of the Area Surveyed……………………
Population (Approx) ……..................................
Date     /    /

Sr.    Diseases                        Number Reported       Cumulative Since
No.                                    Cases     Deaths      Cases      Deaths
11     Acute Diarrhoea Vomiting.

3      Cholera
5      Jaundice
7      Typhoid


Name and Signature




Disaster-2008_Action Plan-08            99
The Operational Plan

Important Steps:

All these steps will be followed for health sector preparedness for WBD.

5. Preparing an accurate and authentic database for use in planning:

     a. Vulnerability mapping of Gujarat for the State and Districts/Corporation
        areas
               Vulnerability for specific WBD. – marking out WBD.zones of Gujarat
        state high risk zone, moderate risk zone, Low risk zone.

        b. Resource mapping for each district/corporation
           Resource mapping will include mapping of health facilities, specialties,
           manpower and equipment (Annexure-I to VI)

             iv.    Of government infrastructure- for identifying shortfalls in
                    equipments/training/manpower for up-gradation.
             v.     GOI units.
             vi.    Of other resources-private, trust hospitals, Grant-in-aid institutions.

6. Plan for effective management of resources

   Detailed planning for the optimum utilization of available resources will be done
   for the State/District/Corporation levels. The following specific plans will be
   prepared.
           iii. Manpower planning for - various components of public health
                (Disease surveillance, Maternal care, Child care)
           iv.  Logistics and infrastructure- ambulances, equipments and medical
                supplies
           iii Network of the supply systems, CMSO and the district infrastructure.
7. Setting up Mechanisms for quick response - Preplanning a proper
   sequence of response actions.

i.      Establishing a District and State response machinery
               For monitoring, supervision and co-ordination function during out
        break; the nodal officers at various levels will be identified. Additional Chief
        Secretary Health and Family Welfare is overall in charge for monitoring and
        co-coordinating health sector situation.
               Commissioner of Health organizes immediate field operations with the
        help of Additional Directors and State epidemic cell that is the nodal officer for
        WBD out break management. At District level Chief District Health officer and
        Superintendent of District hospital are Responsible for implementing various
        curative, preventive activities through the Superintendents of CHC/Sub-
        divisional Hospitals or Medical Officers, PHC of the affected areas. Deputy
        Director, Epidemic cell at State level and Chief District Health officer at District
        level are the Nodal Officers to implement public Health measures during WBD
        out break.

Disaster-2008_Action Plan-08                 100
ii.     Control Rooms.

Manpower at the control rooms with specified responsibilities

Role- Nil Out-break Period : Creating appropriate a data base –
      Information available at control room (Vulnerability mapping, resource
mapping, contact numbers, history of out breaks with analysis of the affected area.

Emergency time: Coordination (inter and intra), ensuring communication of the right
info at the right time within districts, state.

State Control Room
       Nodal Officer will be in central command and control at all times. A round the
clock control room will be started from precautionary stage at Commissionerate at
Gandhinagar, manned by a medical officer and supportive staff. Important phone
numbers are given as annex:
Important phone numbers:

Name of Officer                 Office           Fax                Residence
Deputy Director Epidemic        079 -23253336    079-23253343       079-23254831
Additional Director, Health     079-             079-23221854       9825749149
Services                        23253298-99      23253299
Commissioner,         Health,   079-23253279,    079-23223982       079-23221291
Medical, Medical Education      23253271
Secretary, Health & Family      079-23220069     079-23224409       -
Welfare

       Task forces will be formed in the Commissionerate of Health, Medical
Services & Medical Education (HS) Gandhinagar with a view to respond to state
control room (relief) state control (relief) will inform state control room (Epidemic
Division) which is turn activate various task forces as required.
                      Task forces shall be following nature and members:
(1)    Health& Medical Services.
          i.  Medical Officer
         ii.  Staff Nurse ANM/FHW
        iii.  Paramedical
        iv.   Field staff like BEE, Supervisors, MPW etc.
         v.   Driver, Cl-IV
        Such task forces will be formed in each district by CDHO will be activated by
 Additional Director (Health)

(2)    Specialist services task force :
                      This will be formed in each of Six Regional Deputy Director
zones with specialists from district hospitals and CHCs along with paramedicals,
one senior CHC superintendent will be designated as a team leader and he will
organize co-ordination and team working in pre-epidemic out break phase, will be
activated by Additional Director (Medical Services).
Disaster-2008_Action Plan-08             101
(3)    Multispeciality task forces :
        These will be formed in all of 6 Govt. Medial Colleges and Municipal /Trust
Medial Colleges. The team leader will be Associate Professor/Sr. Asstt. Professor
of Medicine with members from all essential medical specialists of ranks of Asstt.
Professor along with requisite staff of junior doctors–eg. Lecturers and resident
doctors and with requisite paramedical staff.
        These will be constituted by respective dean of the medical colleges and will
be activated by the Additional Director (Medical Education).
        These task forces will be equipped with essential medical supplies other
logistics vehicles and if possible with special communication systems.
        Two medical officers of Gandhinagar District Panchayat will be posted in
state control room as task force co-ordinator from health department.
        Similarly two medical officers will be posted in control room (Health
department) as task force co-ordinator.

Regional Deputy Director’s Control Room
      Similarly round the clock control rooms will be established at all six Regional
Deputy Director‘s offices. These will co-ordinate with various districts under them
and nodal officers control room.
           Sr.     Zone          STD            Phone No.    Phone    No.
           No.                   Code           office       Residence
           1       Ahmedabad     079            22680112     -
           2       Gandhinagar   079            23222788     9426018419
           3       Vadodara      0265           2432381      9426971777
           4       Surat         0261           23479175     9426027044
           5       Rajkot        0281           22440599     9825541665
           6       Bhavnagar     0278           22427330     22423123

District Level Command and Control
        The overall implementation of the action plan will be the responsibility of
designated district level officer. In districts with medical college, the Superintendent
of Govt. Medical College will undertake this responsibility. He will also supervise and
coordinate other medical institutions of Govt. local body/Private sector. The Chief
District Medical Officer / Civil Surgeon for implementation will assist him in district
level hospital, CHC‘s and grant-in-aid institutions. In districts without Govt. medical
colleges, the District Health Officer will be in overall charge. A detailed list of
designated officers for each district is given as annex.




Disaster-2008_Action Plan-08              102
Sr District             Hospital           Designation    STD     Phone     Phone
No                                                        code    Office    residenc
                                                                            e
1    Ahmedabad          Civil Hospital     Medi. Supdt.   079     2681379   2268503
                                                                  2123721   3
     Assisted by        Civil Hospt. Sola Civil           079     2747435   2745713
                                          Surgeon                 5         8
                                                                  2747435
                                                                  9
2    Vadodara           S.S.G. Hospital    Medi. Supdt.   0265    2242575   2748300
                                                                  1         3
     Assisted by        Jamnabai           Civil          0265    2246213   2242400
                        Hospt.             Surgeon                4         3
                                                                  2246140
                                                                  0
3    Surat              New Civil Hosp.    Medi. Supdt    0261    2224498   2224157
                                                                  5         4
     Assisted by        Old          Civil Civil          0261    2247931
                        Hospital           Surgeon                1
                                                                  2247961
                                                                  0
4    Jamnagar           Irwin    Group Medi. Supdt        0288    2255462   2251315
                        Hospital                                  9         7
                                                                  2255022
                                                                  6
     Assisted by        Govt. Hospital     Civil          02833   2235170   2234724
                        Jamkhambhaliy      Surgeon
                        a
5    Rajkot             General            Medi. Supdt    0281    2247931   2247668
                        Hospital                                  5         5
     Assisted by        P.K        Govt.   Civil          0281    2227136
                        Hospt., Rajkot     Surgeon
6    Bhavnagar          Sir T. Hospital    Med. Supdt.    0278
     Assisted by        Govt. Hospital     Civil          02848   2243075   222529
                        Palitana           Surgeon
7    Amreli             General            Civil          02792   2222587   2223416
                        Hospital           Surgeon                2222173
8    Ahwa               General            Civil          02631   2220205   2220397
                        Hospital           Surgeon                2220240
9    Kutch              G. K. General      Civil          02832   2250150   2250554
                        Hospital, Bhuj     Surgeon
                        Campus             Campus         02832   2220852   -
                        Director    New    Director
                        Dist.Hospital
10   Bharuch            General            Civil          02642   2243515   2264200
                        Hospital           Surgeon                2230307
11   Dahod              Govt. Hospital     Civil          02673   2246548   2221284
                                           Surgeon
12   Godhra             Gen.Hospital       Civil          02672   2242559   2242227

Disaster-2008_Action Plan-08                 103
                                        Surgeon
13   Gandhinagar        General         Civil      079     2322273   2747337
                        Hospital        Surgeon            3         4
                                                           2322193
                                                           2
14   Himatnagar         Sir       Pratap Civil     02772   2246618   2240033
                        Hospt.           Surgeon           2241892
15   Junagadh           Civil Hospital   Civil     0285    2620090   2650302
                                         Surgeon
16   Mehsana            General          Civil     02762   221217    253475
                        Hospital         Surgeon
17   Kheda              General          Civil     0268    2529074   2550073
                        Hospital Nadiad Surgeon
18   Navsari            Govt. Hospital   Civil     02742   2257001   258195
                                         Surgeon
19   Banaskantha        General          Civil     02742   2253083   2252475
                        Hospital         Surgeon           2253758
                        Palanpur
20   Patan              Govt. Hospital   Civil     02766   2233311   2230778
                                         Surgeon
21   Porbandar          Govt. Hospital   Civil     0286    2242910   2242882
                                         Surgeon           2240923
22   Narmada            Govt. Hospital Civil       02640   2220030   2220287
                        Rajpipla         Surgeon
23   Surendranag        General          Civil     02752   2222052   2233541
     ar                 Hospital         Surgeon
24   Valsad             General          Civil     02632   2251744   2253310
                        Hospital         Surgeon
25   Anand              Govt. Hospital Civil       02697   2224645   2224775
                        Petlad           Surgeon




Disaster-2008_Action Plan-08              104
       District level Health Advisory Committee: (Medical Relief)
              A District level Health Advisory Committee will be formed with following
       members to assist and coordinate. The committee chairman will be the
       administrative head of the district, while members will be all important officials from
       departments of health, police, fire, transport, army and other local bodies and
       voluntary organizations. All sub-sectors of health such as the major dist hospitals,
       teaching hospitals, other GOI hospitals and private hospitals if any should be
       represented in the committee.


       District level

             A District Level Coordination and Review Committee is constituted and
       headed by the Collector as Chairman in which all other related agencies and
       departments participate.

       18.      District Magistrate & Collector                       Chairman
       19.      District Development Officer                          Co-Chairman
       20.      Chief District Health Officer                         Member-secretary
       21.      Civil Surgeon/Supdt. Other Govt. Hospital             Member
       22.      Supdt. of Local body Hospt/specialty Hospt.           Member
       23.      District Superintendent of Police                     Member
       24.      Local I.M.A. President                                Member

       25.      Representative of Local bodies                        Member
       26.      Voluntary organization                                Member
       27.      R & B Dept. Ex. Engineer                              Member
       28.      Representative of Nodal officer EMO                   Member

ii.       Communications network
          The present communication facilities available with the State and districts will be
          assessed and a plan with the following objectives will be made:
                  Ensure that all district control rooms are connected with the State
                    control room with communication systems, which are not affected by
                    natural disasters.
                  The communication network of each district control room is easily
                    accessible to the local agencies and individuals.
       8. Allocation of responsibilities
              To the participant levels within the health department and other health
       sectors.

       Making teams for:

iii.         Mass cases & casualty management
             This plan deals with both pre-hospital and hospital emergency medical services.
             The main features will be TRIAGE at the site and the hospital, plan for referral
             services,



       Disaster-2008_Action Plan-08               105
Mass casualty management has Two Components

(i) Pre-hospital Management

      First aid Parties
      First Aid Posts(staticand mobile)
      Ambulance service
      Mobile Mdical Units.
(ii) Hospital
      Emergency Hospital Services (including I.C.U./C.C.U. facilities)
      Isolation wards
      Emergency Transfusion Services
      Emergency investigation facilities
           o X-Ray
           o Laboratory investigations.
           o E.C.G. facilities.


PREHOSPITAL MANAGEMENT

Objective
      To render first aid to victims at the spot, their transportation to nearby hospital
as a part of life saving measures.

Responsibility
       With guidance from District Command, Chief District Health Officer will be the
officer commanding Casualty services. RMO of the emergency hospital & CHC
Superintendent of the town will assist him. He (CDHO) will function in this capacity
also under guidance.

   First Aid Party

Objective:
       The Functions of the First Aid Party is to render First, Aid to Emergency cases
at the place of out break and transport the patients on stretchers to nearby first-aid
post.

Task of First Aid Party
9)     Will rush and render first aid and provide transport by stretchers.
10)    Party will consist of one Driver and four first aid trained workers / volunteers.
       The leader will be a health worker/fire brigade person.
11)    One car will be provided for 3 such parties.
12)    3 such parties will be constituted for 10,000 populations for towns' upto l lac,
       population. For additional, 3 parties per 20,000 population.
13)    Medical officer in charge will train personnel and young volunteers from
       different sectors.
14)    Officer will send the party to site in charge Party will have equipments
       specified in appendix 16
First Aid Posts
Disaster-2008_Action Plan-08               106
Objective
       Primarily the health workers in the team are meant for treating the less
serious cases those not requiring hospitalization 'thus relieving congestion at. the
hospitals.
       They are also responsible for screening cases sent by First Aid team, to sort
  out those who need immediate hospitalization. Cases demanding urgent medical
  attention may be sent direct to the hospital without delay.
       First aid team may be static or mobile. A mobile First Aid team is meant to
  rush medical aid to the site of outbreak for the treatment of cases on the spot.
  Structure and Operational Management

         6)     Control: A medical officer will be in charge of the team.
         7)     Location: it will be housed in existing govt. local body charitable or
                private dispensary.
         8)     Personnel : Medical officer
                              Nurse
                              Pharmacist
                              Health Worker
                              Driver
                              Sanitary worker
         4)     Stores: With required medicines

      All 63 dispensaries located in large cities at present will serve as First Aid
team. Notably the dispensaries as follows:

City/Town               Dispensary to Act as First Aid Team.

Ahmedabad               Dariyakhan Gummat, A colony; E-colony, Nr.Ambar cinema,
                        Srangpur; G-colony, Sukramnagar, Rakhial; F-colony, Shah
                        Alam Tolnaka; New Mental, Meghaninagar; Bechardas Disp.
                        Delhi Chakla; Sadvichar Eye Hospt. Naroda; Polytechnic-
                        Ambawadi;Govt. Quarter, Vastrapur; Shastrinagar, Naranpura;
                        Bombay Housing, Police line, Gomtipur; Gaukwad Haveli Police
                        line; Sardarnagar disp.; Kubernager disp.; SRP Group.2 disp.
                        Saijpur Bogha.
Vadodara                Fatehgunj Disp;Mohammadvadi Disp; SRP Group 1; SRP Group
2
Bharuch                 Kevadia Colony
Bhuj                    Branch Disp. Bhuj
Gandhinagar             Dispensaries of Sectors 16,20,22,28,& 30.
Rajkot                  Suchak disp, Dr.Radhakrishnan Road; SRP Disp Group 13
Bhavnagar               Jashwantsinhji disp; Benba disp; Umarjanbai disp,Haluria
                        chowk; Jawansinhji disp;Refugee camp disp.
Junagadh                New disp, Jaymala chowk; Police training college.
Porbandar               Plot disp; Gaikwad disp.
Disaster-2008_Action Plan-08                107
This is only guidance list. District Health Officer shall plan others as per need.

Responsibilities:

   All First Aid team will be manned round the clock. The Medical Officer will
maintain record of the bed state of the dependent hospital daily. Cases arriving at
the site of First Aid Team will be disposed off as under:

c) Seriously ill cases requiring hospitalization will be transferred by ambulances to
   the receiving hospital.
d) Cases not requiring immediate hospitalization will be treated at the site of First
   Aid team and then sent home with directions to report at the site as required.

   First Aid Team (Mobile)

Objective:
      A mobile First Aid Team consists of a complete. First Aid Medical Unit
mounted on wheels ready to proceed to the scene of a major outbreak and to set up
and provide treatment there.

Organization

d) It is a complete first aid unit on wheels, ready to proceed to scene, set up and
   provides treatment.
e) A big truck or a van will be the motor vehicle.
f) One unit shall be set up per 3 lac population. If less, then minimum 1 unit will be
   set up.

Each mobile team will carry the same equipment as the Static First Aid Team.

Responsibility:

All relevant action stated above for First Aid Team (static) will be applicable to the
Mobile First Aid Team.

Medicines and Equipment: As per Annexure II

   Ambulance Services

Objective:

       An efficient ambulance service is an essential part of the referral service for
the transportation of serious cases from the site of out break to First Aid Team and
Hospitals.
Vehicles:

      Ambulances and vehicles available with health dept. as shown below shall be
deployed immediately.
Disaster-2008_Action Plan-08               108
#     Type of institution                  Total                  Ambulances
                                           Vehicles(working)
1     Hospitals under medical section      226                    132
2     PHC‘S                                994                    -
3     Mobile clinics                       60                     -
4     ESIS Hospitals                       31                     31

Vehicles shall also be obtained from following institutions of Health Department.
      13.    285 CHC‘s
      14.    8 Medical colleges
      15.    140 Grant -in- aid institutions.
      16.    98 PP Units
      17.    11Jeevan Raksha Kendras
      18.    16 General Nursing Schools
      19.    1 SIH&FW and associated training centers
      20.    124 TB Centers
      21.    5 Mental hospitals
      22.    6 RDD Offices
      23.    Dental College
      24.    35 Leprosy units

Stores and equipment:
The scale of equipment is given in Annexure III

Actions during Precautionary Stage
7) CDHO will alert all first aid leaders (MO PHC) to stand by.
8) CDHO and Med. Supt./Supt. shall keep stores and reserves ready. He will
    identify vehicle and driver to be sent with each party.
9) Buildings for First aid Team (static) shall be ear-marked, personnel, stores,
    signposts kept ready and meetings arranged with members
10) Vehicles for first aid Team (mobile) earmarked, personnel, stores kept ready, and
    meetings arranged with members.
11) Vehicles requisitioned, stretcher fitments kept ready, drivers made familiar with all
    locations.
Actions during Epidemic Out break
7) First aid Team
              All members will report to CDHO Office
              Rosters of 8 hour duty prepared
              Vehicles allotted, their fuel, oil, maintenance ensured with the help of
               Collector
8) First aid Team (static)
              Ear-marked buildings taken over
              Personnel, stores and equipment kept ready
              Day and night visible signposts set up
              M.O. shall keep information of all vacant beds of attached hospital
              Severe cases transferred to the near by hospital
              Moderately ill patients attended & sent home with follow-up reporting
               advice.
                    Not seriously ill patients attended and sent home
Disaster-2008_Action Plan-08               109
                         Record of all patients maintained
      9) First aid Team (mobile): As Above.
      10) Ambulance services:
                    Available ambulances and other vehicles requisitioned
                    Equipped with stretcher, stores, staffed.
                    Fuel, oil, maintenance provisions made
      Details of number of first aid teams, first aid teams (static and mobile) , ambulances
      and total vehicles required for the areas should be listed .
             District Health Officer of non-affected districts will work out their requirements
      as per plan.
iv.       Public health issues –Disease surveillance Rapid Response Teams for outbreak
          management



      Monitoring and evaluation of actions taken during the epidemic out break.

      #     Phase        Task Force Team                      Action
      1     Pre Epidemic - Additional Director (Health)       Preparedness in respective
            out    break - Additional Director (Medical       branches mainly in Public,
            Phase          Services)                          health, Medical and Medical
                         - Additional Director Medical        Education.
                           Education)
                         - Additional Director (Vital
                           Statistical)
                         - Director (State Institute of
                           Health & Family Welfare,
                           Sola)
                         - Director, Central Medical
                           Store Organization.
      2     Impact and - Medical Teams – (M.O.)                -   First Aid
            Rescue          - Rapid Response Team              -   First Aid Teams
                            - Specialist Team                  -   Mobile Hospital
                          - Volunteers, NGOs, IMA,             -   Base Hospital
                            Red Cross.                         -   Referral Services
      3     Recovery      - Medical Teams – M.O.               -   Follow up of the patients
                                                               -   Survey of affected area

      5     Post      Out       -    Medical Team              -   Documentation        of
            break               -    Specialist Team               Causative factors & its
            Evaluation &                                           Remedial actions
            Re planning


            Use of chlorine tablets is another method for making water, safe for drinking.
      The dose is as follows:




      Disaster-2008_Action Plan-08                 110
                                  Strength of Chlorine       Quantity of water for
      Weight to tablets                                      disinfection.
      2.5 gram                    300 mg                     225 litres
      0.5 gram                    25 mg                      20 litres
      0.12 gram                   1.25 mg                    1 litre

         Tab. Chlorine to be distributed in plastic pouch as it is hygroscopic in nature.


         Tab. Chlorine to be crushed before placing in water pot, water should be used

after one-hour contact period of chlorine - it will kill all bacteria and inactivate all

viruses including Euterovirus like hepatitis virus and polio myelitis virus. These

viruses remain inactive for 12 – 20 hours.


         Bleaching power is used for disinfecting of water at community level.

CHLORINATION TECHNIQUE

(A)      Quantity of Bleaching powder required chlorinating water sources.

Quantity of water                           Requirement of Bleaching powder
1000 Gallon                                 1 Ounce
4500 liters                                 30 grams
100,000 liters                              660 grams
       1 Gallon = 4.5 liters
       1 Ounce = 30 Grams.

(B)      Method of calculating quantity of water in round well :

         (i)    In gallons –

                Diameter in feet x Diameter in feet x height of water (ft) = Water
                quantity ( in gallons).

         (ii)   In litres :

                3.14 x d x d x h x 1000 = water quantity in litres
                      4

                         d = diameter of well in meter
                         h = height of water column in meters
                         1 meters = feet

(C)      Method of calculating quantity of water in cubical storage tanks :


Disaster-2008_Action Plan-08                 111
        Length in meter X Breadth in meters X Height of water column in metre =
        quantity of water in liters.

(D)     Method of Chlorination :

        i.      Decide the required quantity of bleaching powder and take in container
                such as bucket.
        ii.     Add little water make paste of the powder.
        iii.    Add more water to make uniform suspension.
        iv.     Allow to settle lime at the bottom and take supernatant solution in
                another bucket.
        v.      The bucket full of bleaching powder solution should be immersed deep
                in water and the well water should thoroughly be rinsed from all sides
                so that disperses in entire water of the well.
        vi.     Test for residual Free Chlorine by using chloroscope after half an
                hour.



                          Laboratories of WASMO




Disaster-2008_Action Plan-08                 112
Laboratories of WASMO

Sr.No.        Name & Address                                        Tel.No.

1             Gujarat Jal Sewa Training Institute "G" Road,Sector-
              15,Gandhinagar-382016                                079-23223941-47


2             Public Health   Engineering    Laboratory,Geri
              Compound,Race-Course,Vadodara-390007           0265-2340545


3             District     Laboratory,First        Floor,Sterling
              Appt.Vaghavadi Road,Bhavnagar                         0278-2437381


4             Jal-Bhavan,Block-C,Ground          Floor,Nr.Milk-
              Dairy,Saru-Section Road,Jamnagar-361005           0288-2564023


5             District       Laboratory,Banni        Inspection
              Bunglow,St.Xevier's High School Road,Bhuj-Kutch   02832-220914




6             Public    Health  Engineering     Laboratory,First
              Floor,Chimanbhai   Patel   Vikas    Bhavan,Ruda 0281-2479621,
              Bulding,Jamnagar Road,Rajkot-360 002               0281-2441521.



7             District               Laboratory,Jal-Bhavan,First
              Floor,Opp.RTO,National   High     Road,Mehsana-
              384003                                             02762-250070



8             District Laboratory,Jal-Bhavan,Second Floor,Adajan
              water Tank Compound,Adajan Road,Surat-395009
                                                                    0261-2682145



9             Regional      Public       Health        Engineering
              Laboratory,(Sub-Divisional   lab.),Civil    Hospital
              Compaound,Nr.T.B.Hospital,Palanpur.                  02742-253750




Disaster-2008_Action Plan-08             113
   Action Plan for Leptospirosis Gujarat.
                 Epidemic Branch, Commissioner of Health, Gandhinagar
                 ---------------------------------------------------------------------------------

 INTRODUCTION

India with an 8,129 km long coastline and with endowment of plenty of natural
resources has one of the major important coastal, agro-ecosystem that supports
Livelihood of several million people and contributes substantially to the national
economy. However, this agro-ecosystem is highly fragile. Due to the rapid ecological
changes in the region during the past decade many new zoonotic diseases have
emerged and resulted in epidemics leading to significant morbidity and mortality
in humans. Leptospirosis is one among them. The change in the distribution and
incidence rate of Leptospirosis has occurred proportionately to the alterations in
the eco-system. Reclamation of wastelands, aforestations, and irrigation changes in
crops and agricultural technology have been important factors. The areas which
would have remained free of this infection have converted into potentially endemic
zones either by the changes brought out by man or the nature. The outbreaks of
Leptospirosis have been reported from coastal districts of Gujarat, Maharastra,
Kerala, Tamil Nadu, Andhra Pradesh, Karnataka and Andamans from time to time.
In addition, the cases have been reported from Goa and Orissa.Recently there was an
outbreak of Leptospirosis in Bombay city also in 2006.

 BACTERIOLOGY
Leptospirosis is primarily a contagious disease of animals, occasionally infect
Humans and is caused by pathogenic spirochete of the genus leptospira that
Traditionally consist of two species L.interrogans and L.bi. exa. The former includes
all pathogenic serovars and the later include the saprophytic strains. Leptospira
strains have been divided into 23 sub groups of which 2 belong to saprophytic
Leptospira. Each sub-group consists of several strains designated as serovars.
More than 260 host adopted leptospiral serovars are naturally carried by more
than a dozen species of rodents, wild and domestic animals in moderate to highly
Conducive abundantly available variety of hosts, resulting in very successful
Perpetuation of this organism. The leptospira serovars predominantly present in India
areL.andamana,L.Pomana,L.Grippotyphosa,L.Hebdomadis,L.Semoranga,L.Javanica,L.
Autumnalis,L.Canicola.




   Disaster-2008_Action Plan-08                        114
        Leptospirose magnified 200 times with dark-field microscope.




Disaster-2008_Action Plan-08             115
 Factors responsible for emergence of Leptospirosis
        The conditions that are favorable for maintenance and the transmission of the
  Leptospirosis are as follows –

  1 Reservoir and carrier hosts
      Leptospirosis has a very wide range of natural rodent and non-rodent reservoir
  hosts which include foxes, rabbits etc. The domestic animals carry the
  microorganisms and therefore act as carriers of the Leptospira. Together the rodents
  and the cattle excrete large number of organisms in their urine and thus are
  responsible for the contamination of soil as well large and small water bodies.
  2 Drainage congestion and water logging
  Heavy concentrated rainfall leaves a lot of surplus water. Developmental activities
  like canal network, roads and railway lines obstruct natural drainage of rain water
  causing its accumulation for longer periods. The water logged areas force the
  rodent population to abandon their burrows and contaminate the stagnant water
  by their urine. The farmers and agricultural laborers working in the water logged
  Contaminated. fields catch the infection.
   3 Soil salinization
  In fact, salinity and water logging are inter-linked problems. The salinity of
  the soil provides favorable environment for survival of leptospira for months
  together.
  4 Soil temperatures
  The soil of endemic areas in general has lower base saturation and the mean annual
  soil temperature at the depth of 50 cm is 220C or more and the difference between
  mean summer (June-August) and mean winter (December-February) temperature
  is less than 50C. This favors the survival of Leptospira for long durations.
    MODE OF TRANSMISSION
   Infection is acquired through contact with the environment contaminated with
   Urine of rodents, carrier or diseased animals. Direct transmission of leptospirosis
   is rare.
    AGE & SEX DISTRIBUTION
   Males suffer more frequently from leptospirosis than females because of greater
   Occupational exposure to infected animals and contaminated environment. Gender
   difference in susceptibility is not apparent under conditions where both men and
   women are at equal risk. Leptospiral infections occur more frequently in
   persons 20-30 years of age group. Leptospirosis rarely occurs in young
   children and infants, possibly, because of minimal exposure.
    SEASONAL VARIATION
   Leptospirosis is usually a seasonal disease that starts at the onset of the rainy
   Season and declines as the rains recede. Sporadic cases may occur throughout the
   Year.

   HIGH RISK GROUPS
   Agricultural workers such as rice field planters, sugar cane and pineapple field
   Harvesters, livestock handlers, laborers engaged in canal cleaning operations are
   Subjected to exposure with Leptospira which have reservoir in rodents, cattle,
   Swine, sheep, goats etc.

   Some occupational groups are –
   Fishermen, sewer workers and all those persons who are liable to work in rodent
   Disaster-2008_Action Plan-08            116
Infested environment.
Lorry drivers and masons - As lorry drivers may use contaminated water to wash
their vehicles and masons may come in contact with the organisms while preparing
the cement and sand mixture for construction work with contaminated water.

 SPECTRUM OF ILLNESS
 Clinical types:
The clinical spectrum of Leptospirosis is very wide, with mild Anicteric presentation
at one end to severe Leptospirosis with severe jaundice and multiple organ
Involvement on the other.
On the basis of these clinical features, two types of Leptospirosis are
Described.
Anicteric Leptospirosis
• It is the milder form of the disease.
• Patients have fever, Myalgia but do not have jaundice.
• Almost 90% of patients have this type of illness.
Icteric Leptospirosis
• It is the severe form of the disease.
• It is characterized by jaundice and is usually associated with involvement of
Other organs.
• About 5-10% of patients have these types of manifestations.




On the basis of these clinical features, two types of Leptospirosis are
described Anicteric Leptospirosis
• It is the milder form of the disease.
• Patients have fever, Myalgia but do not have jaundice.
• Almost 90% of patients have this type of illness.
Icteric Leptospirosis
• It is the severe form of the disease.
• It is characterized by jaundice and is usually associated with involvement of other
organs.
• About 5-10% of patients have these type of manifestations.
Anicteric Leptospirosis:
The patients present with:
• Fever - Patients have remittent fever with chills. It may be moderate to severe.
Disaster-2008_Action Plan-08              117
• Myalgia-It is a very characteristic finding in leptospirosis. Calf, abdominal &
lumbosacral muscles are very painful & severely tender. This symptom is very useful
in differentiating Leptospirosis from other diseases causing fever.
There is associated increase in Serum Creatinine Phosphokinase (C.P.K.)
which helps in differentiating Leptospirosis from other illnesses.
• Conjunctival Suffusion- There is reddish coloration of conjunctiva. Very
Useful sign in Leptospirosis. Usually bilateral, most marked on palpebral
conjunctiva, it may be associated with unilateral or bilateral Conjunctival
hemorrhage.
• Headache - Usually intense, sometimes throbbing, commonly in frontal region. It is
often not relieved by analgesics.
• Renal manifestations - Some form of renal involvement is invariable in
Leptospirosis. It usually occurs as asymptomatic urinary abnormality in the form of
mild Proteinuria with few casts & cells in the urine. Severe renal involvement in the
form of acute renal failure, (which occurs in Icteric Leptospirosis) is rare.
• Pulmonary manifestations - Manifested in most cases through cough & Chest
pain and in few cases by haemoptysis. Severe involvement leading to Respiratory
failure does not occur in Anicteric Leptospirosis.
• Hemorrhage- Hemorrhagic tendencies are also present in some cases.

Note: All the clinical features either decrease or disappear within two to three
Days and then they reappear.

• DIFFERENTIAL DIAGNOSIS -The patients of Anicteric Leptospirosis are likely to
be misdiagnosed as malaria, dengue hemorrhagic fever, viral hepatitis etc.

Note: In endemic area all cases of fever with Myalgia and Conjunctival suffusion
should be considered as suspected cases of Leptospirosis.

Icteric Leptospirosis: - (Weil’s syndrome)
This is the more severe form of Leptospirosis. As the name suggests all patients
Have jaundice. Patients present with: -
• Fever
• Same as in Anicteric Leptospirosis but may be more severe.
• Myalgia
• Headache
• Conjunctival suffusion
• Oliguria/Anuria and/or Proteinuria
• Nausea, vomiting
• Abdominal pain
In addition, they have features of organ involvement. An individual patient may have
features of one or more organ involvement.

The more severe form of disease with severe liver and kidney involvement is
known as Weil’s syndrome.
 Salient features of these organ involvements are described below.
 Hepatic:
Jaundice is the most important clinical feature. It may be mild to severe. It starts after
4 to 7 days of illness. Hepatic encephalopathy or death due to hepatic failure is rare.
Hepatomegaly & tenderness in right hypochondria are usually detected. Laboratory
Disaster-2008_Action Plan-08               118
investigations show raised level of serum bilirubin (direct) and alkaline phosphatase.
SGOT & SGPT are either normal or mildly elevated. This helps to Differentiate
Leptospirosis from viral hepatitis where SGPT is markedly elevated and also from
alcoholic hepatitis where SGOT is markedly elevated. High level of Creatinine
Phosphokinase (CPK) is suggestive of Leptospirosis. It is normal in viral
hepatitis and alcoholic hepatitis helps in differential diagnosis.
 Renal:
Renal involvement is almost invariably present in Leptospirosis. In severe cases
Patients have acute renal failure and present with:
• Decreased urine output (oliguria or even Anuria)
• Edema may be present on face and feet.
• Features of uremia like breathlessness, convulsion, delirium and altered level of
consciousness may be present in very severe cases.
Same as in Anicteric Leptospirosis but may be more severe.
The renal dysfunction worsens during the 1st week to the end of 2nd week, after
which it starts improving and complete recovery occurs by the end of the 4th week.
Usually there is no residual renal dysfunction.
 Pulmonary involvement:
High mortality due to pulmonary involvement is becoming a feature in Leptospirosis.
There are wide variations in pulmonary presentation. It is the commonest
cause of death due to Leptospirosis.
Symptoms: In mild cases patient will show only cough, chest pain and blood tinged
sputum. In severe cases patients have cough, haemoptysis, rapidly increasing
Breathlessness which may lead to respiratory failure and death.
On examination, these patients have increased respiratory rate with basal
crapitations, which rapidly spread upwards to middle and upper lobes.
X-ray shows basal and mid zone opacity in severe cases. It may be normal in
mild cases. The under lying pathology is intra-alveolar hemorrhage. More than
ninety percent (90%) of deaths due to Leptospirosis occur due to pulmonary
alveolar hemorrhage.
Cardiovascular system involvement:
Patients can have any one or more of the following features:
Hemorrhage
They occur because of
 1) Thrombocytopenia,
 2) Disseminated Intra-vascular Coagulation (DIC),
 3) Secondary to liver involvement leading to coagulation factor deficiency. Patients
may have spontaneous superficial bleeding i.e. petechial, purpura, epistaxis or GIT
bleeding. In severe cases ecchymosis or intra-cranial Hemorrhage can occur.



Hypotensive Shock: Patient will have hypotension, cold clammy extremities,
tachycardia, and thready pulse. JVP is either normal or decreased.
Echocardiography reveals normal systolic function of left ventricle hence
hypotension is due to either dehydration or peripheral vasodilatation.
Arrhythmias: Patient presents with palpitation and syncope & irregular pulse.
Common arrhythmias seen are supraventricular tachyarrhythmia and various
degrees of A.V. blocks. Ventricular tachyarrhythmia is infrequent. ST Segment

Disaster-2008_Action Plan-08             119
depression and T wave inversion may be present in some patients. All patients with
severe, multiple organ involvement should be referred to tertiary care centers

.
Summary of organs affected in Icteric Leptospirosis
Organ Clinical features Investigations reveal
Kidney: Decrease in urine output, Features of uremia, Increase in Serum Creatinine,
Increase in Blood Urea
Liver: Jaundice, Hepatomegaly Increase in Serum Bilirubin with normal or mildly
elevated SGPT and SGOT and increased CPK
Lungs: Cough, haemoptysis, dyspnoea with increase in respiration rate and basal
creps.
X ray chest shows lower and mid zone opacities.
Heart : Hypotension, irregular pulse ECG reveals the type of arrhythmia
Blood : Bleeding tendencies Decrease in platelet count
Brain : Altered consciousness with neck rigidity
CSF : shows increase in cells, increase in protein, normal sugar




 Differential diagnosis
Falciparum malaria, dengue hemorrhagic fever and viral hepatitis closely resemble
leptospirosis and are prevalent in areas reporting Leptospirosis. The correct
diagnosis need to be established before initiating appropriate treatment, viz.
antimalarial for falciparum malaria, antibiotics for leptospirosis and supportive
treatment for dengue hemorrhagic fever and viral hepatitis.
9 Guidelines for Prevention and Control of Leptospirosis
 Recommended case definition
 Clinical description
Acute febrile illness with headache, myalgia and prostration associated with any
of the following:
Disaster-2008_Action Plan-08            120
• Conjunctival suffusion
• Meningeal irritation
• Anuria or oliguria and/or proteinuria
• Jaundice
• Hemorrhages (from the intestines; lung bleeding is notorious in some areas)
• Cardiac arrhythmia or failure
• Skin rash and a history of exposure to infected animals or an environment
  contaminated with animal urine.
• Other common symptoms include nausea, vomiting, abdominal pain, diarrhoea,
  Arthralgiya.
 Case classification
Suspected: A case that is compatible with clinical description.
Confirmed: A suspect case with positive laboratory test.
 Laboratory criteria for diagnosis
Isolation (and typing) from blood or other clinical materials through culture of
pathogenic leptospires.
Positive serology, preferably Microscopic Agglutination Test (MAT), using a range
of Leptospira strains for antigens that should be representative of local strains.
 Collection and Transportation of serum sample
While collecting blood and separating serum proper procedures should be followed
to avoid lysis or contamination.
The important steps are
• use sterile syringe and needle
• collect 5 ml blood
• Transfer from syringe to sterile vial after removing needle
• syringe, needle and vial must be dry
• allow to stand at room temperature for 2-6 hours. Do not shake
• separate serum by dislodging retracted clot with a sterile Pasteur pipette. If facilities
for serum separation are not available then refrigerate at + 4-80 C.
Samples should not be frozen.
• Transfer the liquid portion to sterile centrifuge tube. Centrifuge at 3000 rpm for 5
mins.
• Transfer supernatant (serum) to sterile plastic disposable leak proof screw capped
vials. Add 5 µl of 1% solution of Sodium azide, if available, per 1 ml of serum
sample. Store and transport at + 4-80 C in vaccine carriers/ice box. If transportation
in the cold chain is not possible then use quickest mode of transportation.

 Labeling and transportation of the sample
Each sample should be properly labeled mentioning name, date of collection, first
serum sample or second serum sample and accompanied with a duly . labeled
proforma with relevant clinical details should be included. The specimen should be
kept cool preferably at 4- 80 C and sent to laboratory as early as possible. In case of
delay, the sample should be stored at 4- 80 C before transporting to the laboratory.

 Collection of clinical samples for isolation of leptospires
The isolation of leptospires from clinical specimens is the backbone of diagnostic
work and it con. rms the clinical diagnosis of the disease. Leptospires can be
isolated from a variety of clinical specimens such as
• blood
• urine
Disaster-2008_Action Plan-08                121
• CSF
• Other specimen includes autopsy tissues such as kidney or liver.
Collection of all the samples should be done taking recommended universal
precautions. Gloves should be used at all times for personal protection.

Blood culture
Ideal time:
• Within 10 days of the onset of the disease.
• Sample should be collected before antibiotics are started.
Media:
EMJH, Fletcher‘s and Stuart‘s (commercially available or obtain from the designated
regional/ district laboratory)
Procedure:
• Swab the area with the spirit
• Draw the blood using sterile syringe and needle by vein puncture
• Take 2 tubes containing 5 ml EMJH medium and inoculate two drops of blood in
the first tube and four drops in the second tube.
• Incubate at 300C for 4-6 weeks.
• Examine the culture using dark . field illumination initially on 1st, 3rd and 5th days
followed by at 7-10 days interval upto 6 weeks.
• Selective culture media containing 5FU 50-1000 µg/ml or a combination of nalidixic
acid 50 µg/ml; vancomycin 10 µg/ml and polymixin B sulphate 5 units/ ml or a
combination of actidione 100 µg/ml, bacitracin 40 µg/ml, 5-FU 250 mg/ml, neomycin
sulphate 2 µg/ml, polymixin B sulphate 0.2 µg/ml and refampicin 10 µg/ml can be
used to avoid the contamination.

2 Urine culture:
Time: 10-30 days after the onset of the disease
Media: Same as above
Procedure:
• Collect fresh midstream sample. The sample should be tested within 2 hours of
collection.
• Dilute the urine as follows: using sterile test tubes and sterile phosphate buffer (pH
7.2).
12 Guidelines for Prevention and Control of Leptospirosis
(a) Add 0.4 ml of urine to 3.6 ml of PBS (1in 10)
(b) Add 3 ml of (a) to 3 ml of PBS (1 in 20)
(c) Add 2 ml of (b) to 2 ml of PBS (1 in 40)
(d) Add 1 ml of (c) to 1 ml of PBS (1 in 80)
• Take 5 ml of medium in 4 separate tubes and add 0.5 ml each of a, b, c, d solutions
of PBS in 4 different medium tubes.
• Label tubes with dilution
• Incubate at 300C
• Examine the culture using dark field illumination at intervals of 7-10 days upto 6
weeks.
The above procedure should be repeated 2 or 3 times with urine samples collected
at/ on different times/days to increase the probability of isolation.
Urine can be filtered (through 0.22 µm. filter) and/or inoculated into selective culture
media to avoid contamination.

Disaster-2008_Action Plan-08              122
 CSF Culture
  Time: Within 5 - 10 days of the onset of the disease
  Medium: As above
  Procedure:
  Inoculate 0.5 ml of CSF into 5 ml of culture media
  Follow the same procedure as blood culture
 Labeling and transportation of the samples
  The specimen should be kept at room temperature and sent to laboratory as early
  as possible. In case of delay the sample should be stored at room temperature
  before transporting to laboratory.
 Diagnosis
  The de. nitive diagnosis of leptospirosis depends on sero-conversion or four fold
  rise in antibody titer or isolation of leptospirosis from clinical specimen.
 Serological Diagnosis of Leptospirosis
           Genus specific tests include ELISA & rapid immunodiagnostic tests (Lepto
  Dip-stick, Lepto Lateral Flow, Lepto Tek Dri-dot)
  a) Enzyme Linked Immuno Sorbent Assay (ELISA)
  Sensitivity and Specificity:
  ELISA is a sensitive and specific test for the immunological diagnosis of
  Leptospirosis. It is of particular value as a serological screening test because of its
  relative simplicity in comparison to the MAT (Microscopic Agglutination Test). ELISA
  test can also be used in epidemiological studies to determine the
  sero-incidence/ sero-prevalence of Leptospirosis
  b) Rapid immunodiagnostics:
  Lepto dip-stick, Lepto lateral flow and Lepto Tek Dri Dot assays are based on IgM
  detection.
  These are screening tests and the results require confirmation by MAT.
  Note:
  1. The sero-diagnostic tests being used for Leptospirosis has shown cross reactivity
  with hepatitis E and A. Thus, caution is necessary in the interpretation of serological
  data.
  2. The health facilities undertaking sero-diagnosis should send 5% of their sera
  samples to the designated laboratory for cross-verification to ensure correct
  diagnosis.
  The diagnostic tests to be carried out at different health facilities are as follows
 CHC / District Hospitals
  1. Detection of IgM antibodies against leptospires by rapid screening tests.
  2. Hematology and urine analysis gives an indication if following changes are
  observed
  • Total WBC count slightly elevated with neutrophilia
  • Increased erythrocyte sedimentation rate (about 60 mm)
  14 Guidelines for Prevention and Control of Leptospirosis
  • Thrombocytopenia
  • Increased BUN and serum creatinine
  • Sodium potassium - normal or slightly reduced
  • Urine analysis for proteinuria, heamaturia and casts
  • Increase in serum bilirubin (predominantly direct) levels.
  • Alkaline phosphatase, SGOT and SGPT moderately elevated.
  • Marked elevation in serum creatinine phosphokinase (CK) and MB
  variant.
 Disaster-2008_Action Plan-08               123
 Endemic states/tertiary level health care facility
  1. ELISA
  2. Microscopic Agglutination Test (MAT)
  3. Isolation
  4. PCR
 Laboratories where facilities for diagnosis are available:
  1. RMRC (ICMR), Port Blair – 744 101 (A&N) Tel: 03192-251158/251159
  2. NICD, 22-Sham Nath Marg, Delhi – 110054 Tel: 011-23971272/23971060/
  23912901
  3. Bacteriology & Mycology Division, IVRI, Izatnagar, UP, 243122 Tel: 0581-
  2301865
  4. DRDE, Gwalior (MP) Tel: 0751-2340730; 0751-2341550.
 Leptospirosis – Treatment
 Treatment at PHC (in Leptospirosis endemic areas)
  STEP – I: How to clinically suspect Leptospirosis?
  • All patients presenting with fever and any two of the following
  (1) Myalgia
  (2) Conjunctival suffusion
   (3) history of contact with animals or farmer by occupation – should be clinically
  suspected for Leptospirosis
  STEP- 2 : How to treat clinically suspected Leptospirosis?
  • All clinically suspected leptospirosis patients in Leptospira endemic area
  during rainy season should be given presumptive treatment of leptospirosis
  and Malaria i.e.
  (1) Tab. Doxycycline 100 mg twice daily for 7 days .
  (2) Tab. Chloroquine 600 mg stat in malaria endemic areas in adults and
  10 mg/kg stat for children.
  Note: In children less than 6 years 30 to 50 mg/kg/day of Cap. Amoxycillin/Cap.
  Ampicillin should be given in divided doses 6 hourly for 7 days.
  STEP- 3: Treatment at PHC for mild disease and rapid immunodiagnostic test
  positive cases
  • All such patients should be given Inj. Crystalline penicillin 20 lacs i.u. i.v.
  every 6 hrly after negative test dose (ANTD) in adults for 7 days.
  • For children the dose of crystalline penicillin should be 2 – 4 lacs units/kg/
  day for 7 days.
  STEP – 4: How to treat patients with negative ELISA and negative rapid
  immunodiagnostic test and clinically stable ?
  • Tab. Doxycycline 100 mg twice daily for 7 days.
  STEP – 5: When to shift patients to higher centre?
  All suspected leptospirosis cases whether positive or negative with rapid
  Immunodiagnostic test having feature of organ dysfunction as follows should be
  IMMEDIATELY shifted to higher centre.
  (1) Hypotension
  (2) Decreased urine output
  (3) Jaundice
  (4) Haemoptysis or breathlessness
  (5) Bleeding tendency
  (6) Irregular pulse
  (7) Altered level of consciousness

 Disaster-2008_Action Plan-08             124
  While shifting patients to higher centre, individual patient‘s record should be
  furnished in the following order
  Age, Sex,
  • Occupation- Rice Field planters, sugarcane and pineapple harvesters, workers
  engaged in canal cleaning operations, livestock handlers, sewer workers, fishermen
  and swimmers etc.
  • Clinical symptoms
  • Date of onset
  • Serological result
  • Hospitalization details-treatment given.

 Treatment at CHC/District Hospital
  STEP – I: How to clinically suspect Leptospirosis?
  All patients presenting with fever and any two of the following
  (1) Myalgia
  (2) Conjunctival suffusion
  (3) History of contact with animals or farmer by occupation – should be clinically
  Suspected of Leptospirosis
  STEP- 2: How to treat clinically suspected Leptospirosis?
  All clinically suspected leptospirosis patients should be given presumptive treatment
  of leptospirosis and Malaria i.e. (1) Tab. Chloroquine 600 mg stat. (2) Tab.
  Doxycycline 100 mg twice daily for 7 days.
  STEP – 3: Laboratory screening of all suspected leptospirosis cases by rapid
  Immuno-diagnosis test:
  Certain rapid tests are available for diagnosis of leptospirosis. They do not require
  expertise or any expensive instruments. However, they require confirmation by
  ELISA.
  STEP- 4 : Treatment at CHC for mild disease and rapid immunodiagnostic
  test positive
  All such patients should be given Inj. Crystalline penicillin 20 lacs iv every 6
  hourly after negative test dose. (ANTD)
  STEP – 5 : How to treat patients with negative ELISA and negative rapid
  immunodiagnostic test and clinically stable cases?
  • Complete 7 day course of doxycycline.
  • In children less than 6 years Cap. Amoxycillin/Cap. Ampicillin should be
  given in the dose of 30 – 50 mg/kg/day
  STEP – 6 When to shift patients to higher centre?
  All suspected leptospirosis cases whether positive or negative with rapid
  immunodiagnostic test having feature of organ dysfunction as follows should be
  IMMEDIATELY shifted to higher centre.
  Renal: Decreased urine output (< 400 ml per day)
  High blood urea (> 60 mg. % )
  High S. Creatinine (> 2.5 mg% )
  Clinical features of uremia, breathlessness, convulsion, delirium, and/
  or altered level of consciousness
  Hepatic: Deep jaundice
  High S.Bilirubin(>3.0m.g. %)
  Pulmonary: Breathlessness
  Haemoptysis
  Increased respiratory rate
  Disaster-2008_Action Plan-08             125
 X- Ray chest showing opacities
 Blood: Bleeding tendency
 Low platelet count
 Neurological: Altered level of consciousness
 While shifting patients relevant clinical profile along with the treatment given (as
 detailed under heading –Treatment at PHC) should be furnished
 Treatment at medical college/tertiary level treatment facility
  Treatment of leptospirosis is divided in two parts i.e. chemotherapy & organ
  Specific care.
 Chemotherapy
  It should be started as early as possible. Guidelines for chemotherapy are as
  under:
  Any case of fever (In leptospira endemic areas during rainy season):
  Adults: T .Chloroquine 600 m.g. stat; Children: Tab. Chloroquine 10 mg/kg
  stat
  Adults: T. Doxycycline 100 m.g. twice a day for seven days; Children : < 6 yrs.
  Cap. Amoxy/Ampicillin
 Organ Specific care at tertiary level treatment facility
  • Renal
  • Hepatic
  • Pulmonary
  • Cardiac
  • Hematological
  • Neurological
  In general, the treatment of these organ involvements does not differ much from
  the same manifestations due to non leptospiral causes.
 Renal
  • Mild Renal Involvement
  • When patients have only proteinuria and no signs of azotemia then we
  have to observe the patient and only chemotherapy against leptospirosis
  is to be given.
  • Severe renal involvement (acute renal failure)
  • Correction of hypovolemia by normal saline: if after correction of volume
  deficit urine output is not adequate then following treatment should be
  started.
  • Fluid Management: Input = urine output + insensible loss (roughly
  around 500-700ml (or 400ml/sq mt.+ urine output of previous day);
  depending on temperature of environment and patient‘s respiration).
  • Diet and Nutrition: Adequate calories (1000 Kcal + 100 Kcal/year of
  age); with sodium, potassium and phosphorus restriction.
  • Avoidance of Nephrotoxic Drugs: NSAIDS, Tetracycline, Vancomycin,
  Aminoglycosides should be avoided. Dosages of commonly used
  antibiotics e.g. PenicillinG, Doxycycline, Ampicillin have to be reduced
  in severe azotemia.

 • Additional renal insults like hypovolemia , hypotension, infection
 should be avoided.
 • Complications of renal failure should be promptly diagnosed and
 treated.
 Disaster-2008_Action Plan-08               126
• Dialysis: Peritoneal or Heamodialysis is indicated in following
conditions:
• Fluid overload, hyperkalemia, and acidosis refractory to conservative
treatment.
• Clinical features of uremia.
• Neurological conditions like : Encephalopathy, lethargy, seizures,
myoclonus, asterixis.
• Pericarditis

Hepatic
• Death due to hepatic failure is rare in leptospirosis.
• General measures to be taken:
• Diet and Nutrition : Provide adequate calories
• High carbohydrate diet with plenty of glucose
• Protein restriction in severe cases
• Following precipitating factors for hepatic encephalopathy should be avoided
and/or promptly corrected.
• Drugs and Toxins: Avoid sedatives, hypnotics, tranquilizers and
opiod drugs. Avoid hepatotoxic drugs like isoniazide, rifampicin,
pyrazinamide, and paracetamol. Alcohol should also be avoided.
• Hypovolemia to be avoided
• Hypokalemia and alkalosis ( Diuretics and Diarrhoea )
• Constipation
• Upper GIT Hemorrhage: Promptly remove the blood from gut by Ryle‘s
Tube aspiration and bowel wash. Transfuse fresh blood or fresh frozen
plasma.
• Surgery
• Hepatic encephalopathy
• Lactulose : 15-45 ml bid or qid initially and then to be adjusted to
produce three to . Five stools per day.
• Antibiotics: Adults: Ampicillin 2 gm 6 hourly; Children: Ampicillin 200
mg/kg/day 6 hourly
• Metronidazole 250 mg per orally three times per day or Neomycin 1 gm
orally every six hours.


Pulmonary
 • Continuous oxygen therapy.
 • Mechanical ventilation with positive end expiratory pressure (P.E.E.P.) if
         Respiratory failure develops.
 As this is the commonest cause of death and as the disease progresses very
  rapidly, these patients should be immediately shifted to a Tertiary care centre.
Cardiac
 • Shock: Most common cause is hypovolemia and responds to fluid replacement.
 • Vasopressors in the form of dopamine & dobutamine are indicated if blood
 pressure is not restored in spite of Fluid replacement.
 • Cardiac arrhythmias
 • Cardiac monitoring
 • Treatment of specific cardiac arrhythmia.

Disaster-2008_Action Plan-08              127
 Hematological
 • Thrombocytopenia:
 • Platelet rich plasma or platelet concentrate.
 • Coagulation defect Injection vit k 5-10 mg i.v. for 3 days corrects the increased
 prothrombin time.
Fresh blood or fresh frozen plasma.
 • Disseminated intravascular coagulation (DIC)
 • Fresh frozen plasma
 • Fresh blood


   Aseptic Meningitis
   • Symptomatic and supportive management
   Prevention and control
   Prevention of Leptospirosis is based on the control of reservoir hosts by means of
   environmental and personal hygiene. Control measures against leptospirosis should
   comprise of–
  Development of Training Modules & training programme to CDHO, CDMO, MO,
      Private practitioners Paramedical staff like field workers, Lab.Tech & Entomologist
      to improve the quality of surveillance & preventive actions.
  Surveillance activities should be done in pre-monsoon & post-monsoon period.
  Fund should be procured for the preparation & distribution of IEC material so -
      that IEC activities should be started
  Referral centers with the facilities of Heamodialysis & Ventilators should be
           developed.
 Diagnostic facilities in each district should be strengthened with the precaution of
      uniformity in testing kits and reporting format at each taluka level.
 Private & Corporate hospitals should be involved as a referral centers & reporting
       units.
  Meetings should be arranged for inter departmental collaboration & co-operation
           among Health, Agriculture, Animal-Husbandry, municipal corporation &
           others.

Protection of people against contagion by available means
 Hygienic methods such as avoidance of direct and indirect human contact with
 animal urine are recommended as preventive measures. Workers in flooded fields
 should be cautioned against direct contact with contaminated water or mud and
 should be advised to use rubber shoes and gloves. In case of any cuts or abrasion
 on the lower extremities of the body, the worker should apply an antiseptic ointment
 e.g. betadine, before entering the field and after exit.

 Health education
  The main preventive measure for leptospirosis is to create awareness about the
  disease and its prevention. This has to be carried out by an intensive educational
  campaign.

 Vaccination of animals
  Leptospiral vaccines confer a limited duration of immunity. Boosters are needed
  every one to two years. Vaccination should however be very selective and used
 Disaster-2008_Action Plan-08              128
 only in endemic situations having high incidence of Leptospirosis. The vaccine must
 contain the dominant local serovars. While this prevents illness, it does not
 necessarily protect from infection and renal shedding. Details of vaccines available
 are listed below:




Rodent control
 It is established beyond doubt that rodents are the major reservoirs of bacterium
 Leptospira interrogans with more than 200 serovars. Possibly in a human infested
 area, where significant number of Leptospira cases are reported, selective rodent
 control measures should be undertaken.

Mapping of water bodies for establishing a proper drainage system
 The mapping of water bodies and human activities in water logged areas should
 be carried out. This will help to identify the high risk population. Farmers may be
 educated to drain out the urine from the cattle shed into a pit, instead of letting it
 flow and mix with water bodies (rivers, ponds etc.)

Health impact assessment of developmental projects
 Health impact assessment should be made mandatory for all developmental projects
 along with environmental assessment.



 Leptospirosis should be made a reportable disease in all endemic states.

Chemoprophylaxis
 During the peak transmission season Doxycycline 200 mg, once a week, may be
 given to agricultural workers (e.g. Paddy field workers, canal cleaning workers in
 endemic areas) from where clustering of cases have been reported. The
 chemoprophylaxis should not be extended for more than six weeks.Inj.Crystalline
 Penicillin should also be procured at all referral centers.




 Disaster-2008_Action Plan-08             129
2. GENERAL
Necessity of State Action Plan for Leptospirosis in Gujarat.

        Prevalence of Leptospirosis in Gujarat Since 1994 shows ups & downs of
cases & death due to Leptospirosis year by year. In the year 2006 prevalence of
cases has increased in No. & it is found in other districts rather the districts of south
Gujarat only. This medical action plan for leptospirosis lays down details by whom
and how the instructions contained in this are to be implemented for medical
coverage in Gujarat.
Objectives of Action plan
     To ensure all agencies execute coordinated, precise measures.
     To ensure smooth working relationship between districts, state and the centre.
     To lays down details by whom and how the instructions contained in this are
        to be implemented.
Formulation and maintenance of medical action plan.
                        Since diagnostic and curative services are mainly provided
district hospitals, taluka hospitals, and community health centers, Deputy Director,
(epidemic) is appointed as state nodal officer by Commissioner, Health & Medical
Education and Research to formulate the action plan for Leptospirosis.
Responsibilities of state nodal officer

        2. To formulate and maintain the action plan.
        5 To keep liaison with Deputy Assistant Director General (EMR), DGHS,
           Nirman Bhavan, New Delhi, and state administration.
        6 Suggest amendments / additions to Union Ministry.
        7 To send reports as necessary.

State Action Committee

                    State nodal officer suggests that a Committee be set up
immediately for smooth implementation of action plan as under:

        Commissioner, Health, Medical, Medical Education and Research Chairman
        Additional Director, Medical services                              Member
        Additional Director, Medical Education and Research                Member
        Additional Director, Health                                        Member
        Additional Director, Family Welfare                                Member
        Additional Director, State Aids Control Society                    Member
        Director, CMSO                                                     Member
        Director, SIH&FW                                                   Member
        Director, ESIS                                                     Member
        Project Manager, Gujarat healthcare (ORET) project                 Member
        Representative of Director of Civil Defense / Home Secretary       Member
        R.D.D. ,Gandhinagar Zone                                           Member
        R.D.D. Ahmedabad                                                   Member
        Deans & Superintendents of Medical Colleges / Hospitals            Member
        Any other invitee as deemed necessary                              Member
        Deputy Director (Epidemic)                                   Nodal Officer


Disaster-2008_Action Plan-08               130
   Working Committee
   Following members will assist the State Nodal Officer for ease of implementation:
          1     Assistant Director (Epidemic Branch)
          2     R.D.D. ,All six Zones,
          3     M.O. Epidemic.
   Stages of Action
          1. Stage of peace: Plans prepared, officials made conversant with it.
          2. Precautionary stage: Implementation as planned.
          3. War stage: Full implementation.
   Areas of Action:
   Action plans are made for the following,
        Emergency Services
        Blood Transfusion Services
        Emergency Environment Health Measures
        Medical Stores And Equipment
        Manpower Requirement
        Agriculture Department
        Irrigation Department

   Central Command and control
          Nodal Officer will be in central command and control at all times. A round the
   clock control room will be started from precautionary stage at Commissionerate at
   Gandhinagar, manned by a medical officer and supportive staff.


  Important phone numbers:
Name of officers                                    Office     Fax          Residence

Dr.S.J.Gandhi         Deputy Director Epidemic      23253336   23253336     223254831

Dr.B.B Pandya         Additional Director, Medical 079-        079-         079-
                      services                     23253298    23253295     232
                      9825749149                   23253299    23253905

Dr.Amrajit singh      Commissioner,       Health, 079-         079-         cohealth@gujarat.
                      Medical, Medical Education  23253271,    23256430     gov.in
                      9825037421                  53279
                                                  (Direct)


Smt. Rita Teotia      Secretary, Health & Family    079-       079-
.                     Welfare                       3220069    3224409




   Disaster-2008_Action Plan-08               131
Regional Deputy Director’s Control Room

                    Similarly round the clock control rooms will be established
at all six Regional Deputy Director’s offices. These will co-ordinate with
various districts under them and nodal officers control room. The following
six R.D.Ds will arrange this.

Sr     Zone                    Name of R.D.D         STD    Phone No.      Phone No.
.                                                    code   office         Residence
N
o.
1      Ahmedabad               Dr.Avashya            079    22680112       M.9825286852
2      Gandhinagar             Dr.K.B..Patel         079    23259107-      M.9825582951
                                                            59113
3      Vadodara                Dr.B.B.Pandya         0265   2339632        2310623
                                                            2351579        2519297
                                                                           M.9377556006
4      Surat                   Dr.Khasgiwala         0261    2460673       M.9426027044
                               Saheb                        2479175
                                                            2460260
5      Rajkot                  Dr.S.C.Vashishtha     0281    2440599     M.9825541665
                                                             Fax)
                                                            2459488
                                                            2441255
                                                            (RFPTC)
6      Bhavnagar               Dr.N.S.Dafda          0278    2427330     27457138
                                                            2424535      M.9898015472
                                                            2427524(Hosp
                                                            t)

District Level Command and Control
The overall implementation of the action plan will be the responsibility of
designated district level command. In districts with medical college, the
District Health Officer will undertake this responsibility. He will also supervise
and coordinate other medical institutions of Govt. local body/Private sector.
The district Civil Surgeon for implementation will assist him in district level
hospital, CHC’s and grant-in-aid institutions.              In districts without Govt.
medical colleges, the Civil Surgeons will be in overall charge.




Disaster-2008_Action Plan-08                   132
    The following officers of Civil Hospitals in the District.

Sr District           Hospital    Desig    Name of officer   STD     Phone.     Phone
.N                                nation                     code    Office     No.
o                                                                               residence
1      Ahmedabad      Civil       Med.     Dr. Prabhakar     079     22681379   27912277
                      Hospital    Supdt.   M.9427305057              22683731
                                                                     22683721
       Assisted by    Civil       Civil    Dr.    Jagadish 079       7474355    079-
                      Hospt.      Surg.    Chavda                    7474359    3222132
                      Sola
2      Vadodara       S.S.G.Ho    Med.     Dr.       Kamal 0265      425751     342240
                      spt.        Supdt.   Phatak
       Assisted by    Jamnabai    Civil    Dr. B.B.Pandya  0265      462134     424003
                      Hospt.      Surg.                              461400
3      Surat          New Civil   Med.     Dr.S.K.Bajpai     0261    244985     242576
                      Hospt.      Supdt
       Assisted by    Old.Civil   Civil    Dr.               0261    479311
                      Hospt.      Surg.                              479610
4      Jamnagar       Irwin       Med.     Dr.Jaichandan     0288    554629
                      Group       Supdt                              550226
                      Hospt.
       Assisted by    Govt.Hos    Civil    Dr.        S.S. 02833     34704
                      pt.         Surg.    Hemamalini
                      Jamkham
                      bhaliya
5      Rajkot         Gen.        Med.     Dr.B.D.Parmar     0281    476402
                      Hospital    Supdt
       Assisted by    P.K Govt.   Civil    Dr.M.I.Oza        0281    227136     454545
                      Hospt,      Surg.
                      Rajkot
6      Bhavnagar      Sir         Med.     Dr.Singh M.P.     0278    421524     434181
                      T.Hospt.    Supdt
       Assisted by    Govt.       Civil    Dr. J.J.Gadhvi    02848   2175       2529
                      Hospt.Pal   Surg.
                      itana
7      Amreli         General     Civil    Dr.B.B.Patel      02792   22587      23416
                      Hospt.      Surg.                              22173
8      Ahwa           General     Civil    Dr.S.D.Parmar     02631   20205      20204
                      Hospt.      Surg.                              20240
9      Kutch          G.K.Gene    Civil    Dr.S.K.Bheda      02832   50852      50554
                      ral         Surg.
                      Hospt.Bh
                      uj
10     Bharuch        General     Civil    Dr.R.D.Patel      02642   43515
                      Hospt.      Surg.                              30307
11     Dahod          Govt.       Civil    Dr.K.M.Solanki    02673   20220      21284
                      Hospt.      Surg.

12     Godhra         Gen.Hos     Civil    Dr.L.M.Chandan    02672   42559      42205
                      pt.         Surg.    a



Disaster-2008_Action Plan-08                 133
13   Gandhinagar      Gen.        Civil   Dr.N.B. Dholakia   079     3222733   7473374
                      Hospt.      Surg.                              3221932

14   Himatnagar       Sir Pratap Civil    Dr.V.S.Ninama      02772   46618     40033
                      Hospt      Surg.                               41892


15   Junagadh         Civil       Civil   Dr.S.R. Avasia     0285    20050     65032
                      Hospt.      Surg.                              25736     50302
16   Mehsana          Gen.Hos     Civil                      02762   52219     53475
                      pt.         Surg.                              51784

17   Kheda            Gen.Hos     Civil   Dr.G.C.Patel       0268    61074     50073
                      pt.Nadiad   Surg.                              61386


18   Navsari          Govt.       Civil   Dr.B.M. Hathila    02742   53083     52475
                      Hospt       Surg.                              53758
19   Banaskantha      Gen.Hos     Civil   Dr.M.J.            02742   53083     52475
                      pt.         Surg.   Mayatra                    53758
                      Palanpur


20   Patan            Govt.       Civil   Dr.R.M. Mehta      02766   33311     30778
                      Hospt.      Surg.

21   Porbandar        Govt.       Civil   Dr.M.A.            0286    242910    242882
                      Hospt.      Surg.   Maheshwari                 240923
22   Narmada          Govt.       Civil   Dr.P.A.Joshi       02640   22163     20030
                      Hospt.      Surg.                              20030
                      Rajpipla

23   Surendra         Gen.        Civil   Dr.D.K. Vadher     02752   22052     33541
     nagar            Hospt.      Surg.
24   Valsad           Gen.        Civil   Dr.M.G.Damor       02632   54046     54049
                      Hospt.      Surg.                              54133

25   Anand            Govt.       Civil   Dr. N.S. Dafda     02697   24422     24775
                      Hospt.      Surg.                              123145
                      Petlad




Disaster-2008_Action Plan-08                134
DISTRICT LEVEL ADVISORY COMMITTEE: (Medical Relief )

                    A District level Advisory Committee will be formed with following
members to assist and coordinate.


1)      District Collector                                     Chairman
2)      Medical Supdt.(Teaching Hospt)/Civil Surgeon           Member
3)      Chief District Health Officer                          Member-secretary
4)      Supdt. Of Local body Hospt/specialty Hospt.            Member
5)      Civil Surgeon/Supdt. Other Govt. hosptital             Member
6)      Local I.M.A. President                                 Member
7)      Representative of Local bodies                         Member
8)     Voluntary organization                                   Member
9)     D.E.O.                                                  Member
10)    R & B Dept. Ex. Engineer                                 Member
11) Representative of Nodal office                              Member


Ambulance Services
      1) 1 Ambulance for every 50,000 population.
      2) Procurement: Hospital and CHC ambulances, fire dept ambulances, grant
          –in aid institutions and requisitioned trucks, lorries and buses
      3) Stationed at Civil Defense Depot.
      4) Staff: 1 driver & 1 attendant trained in first aid.
Ambulances and vehicles available with health dept. as shown below shall be
deployed immediately.

      Type of institution                  Total                 Ambulances
                                           Vehicles(working)



1     Hospitals under medical section      138                   88

2     PHC‘S                                758

3     Mobile clinics                       60

4     ESIS Hospitals                       31                    31


Disaster-2008_Action Plan-08              135
Vehicles shall also be obtained from following institutions of Health Dept
      1) 188 CHC‘S.
      2) 8 Medical colleges
      3) 140 Grant –in- aid institutions.
      4) 177 ICDS Blocks.
      5) 108 PP Units
      6) 11Jeevan Raksha Kendras.
      7) 17 General Nursing Schools.
      8) 1 SIH&FW and associated training centers
      9) 18 TB Centers.
      10) 4 Mental hospitals.
      11) 6 RDD Offices
      12) Dental College.
      13) Leprosy units.

Actions during Precautionary Stage

    1 CDHO will alert all first aid leaders to stand by.
    2 Officer in charge of civil defense in consultation with CDHO and Med.
      Supt./Supt. shall keep stores and reserves ready. He will identify vehicle and
      driver to be sent with each party.
    3 Buildings for First aid post (static) shall be ear-marked, personnel, stores,
      signposts kept ready and meetings arranged with members
    4 Vehicles for first aid post (mobile) earmarked, personnel, stores kept ready,
      and meetings arranged with members.
    5 Mobile surgical & medical units set up.
    6 Vehicles requisitioned, stretcher fitments kept ready, drivers made familiar
      with all locations.

Actions during Epidemic.

First aid party:
         All members will report to CDHO
         Rosters of 8 hour duty prepared
         Vehicles allotted, their fuel ,oil, maintenance ensured with the help of
           Collector
      First aid posts (static)
         Ear-marked buildings taken over
         Personnel, stores and equipment kept ready
         Day and night visible signposts set up
         M.O. shall keep information of all vacant beds of attached hospital
      First aid posts (mobile): As Above.
      Mobile surgical / Medical units:
         Ear marked vehicles requisitioned.
         Personnel to report to duty at short notice.
      Ambulance services:
         Available ambulances and other vehicles requisitioned
         Equipped with stretcher, stores, staffed.
         Fuel ,oil, maintenance provisions made

Disaster-2008_Action Plan-08             136
Details of number of first aid parties, first aid posts (static and mobile) , mobile
surgical units, ambulances and total vehicles required for 11 vulnerable towns of
Gujarat is listed in TABLE A.
       District Commands of non-vulnerable towns will work out their requirements
as per plan.

4. EMERGENCY SERVICES

Introduction:

        This chapter contains plans for Emergency Hospital Organization to render
effective and continues medical treatment to civilian casualties in emergency.

Organization:

-       Hospitals in vulnerable areas will be casualty-receiving hospitals.
-       Hospitals in safer areas will act as base hospitals
-       The Civil Surgeon or Superintendent of each vulnerable/base area will act as
        Superintendent of Emergency hospital organization.
-       In Emergency, all hospitals in an area will be included in Emergency Hospital
        organization.

Assessment of Requirements:

(1) Bed Strength: Table No.1.

    Details of plan for non-vulnerable area organization is given in Table No.2
    Details of Total Bed strength available in Gujarat State is given in Table No.3.

(2) Accommodation for extra beds will be done by utilizing all available space, such
    as veranda, lecture halls, transferring certain cases to base hospitals depicted
    and setting up extra bed capacities in designated other hospitals and institutions


(3) Personnel: Required medical specialists will be deputed from non-vulnerable
    area medical colleges, medical officers and other technical staff from CHC‘s,
    PHCs, teaching faculties of medical colleges, local volunteers from Indian
    Medical Association, Gujarat State Branch and Grant-in-aid institutions.




Disaster-2008_Action Plan-08               137
Table No.1
Emergency Hospital Organization

Sr Name           of Total No. of   Total no.           Additional beds
.N vulnerable                       of beds             arrangement
o Town               Beds           available           at places nearby
                                    at present          Emergency
                                                        hospital
1 Baroda             1066           SSG Hosp:1200       Mental Hosp:300
                                                        KG Children:100
2 Surat              2000           New Civil Hos:740   Med College:1000

3 Kakrapar           40             CHC Mandvi:50

4 Ahmedabad          4000           Civil Hosp:1470     Dental College:200
                                    VS Hosp: 750        Kidney Institute:350
                                    LG Hosp:500         Cardio Insti:70
                                    Shardaben Ho:350    Paraplegia Hosp:60
                                                        Victoria Jubilee:50
                                                        Mental Hosp:300
                                                        Rajasthan Hosp:100
                                                        Cancer Hosp:100
5 Bhuj               200            Gen Hosp:230        SwaminarayanSch:100
                                                        Indirabai GirlsSch:100
                                                        Alfred High School:100
6 Jamnagar           600            Irvin Hosp:1225     Ayurved hosp:100
                                                        ESIS Hosp:100
                                                        Anda Bawa:200
                                                        Oswal Jain Center:500
                                                        Patel Samaj:600
7 Kandla-            200            Govt Hosp:40        Port Trust:100
  Gandhidham
                                                        Primary School Gm:100
                                                        CHc Anjar:50
8 Naliya             40             CHC Naliya:50       Primary School :100
9 Ankleshwar         66             Muni Hosp:50        Primary School :101
1 Okha               66             CHC Dwarka:50       Dwarka:
0
                                                        LohanaMahajanVadi50
                                                        Sanatan Ashram:100
                                                        Swaminarayan
                                                        Dharmsala:50
                                                        Birla Dharamshala:25
1 Vadinar            40             Khambhaliya:100     Lohana Vadi:50
1
                                                        Kanji Dharamshala:20
                                                        Aradhana Dham:50
1 Gandhinagar        260            Gen. Hospital210    Community Hall-300
2
1 Mehsana            400            Gen Hosp-280        Lions Hospital 100
3




Disaster-2008_Action Plan-08              138
Table No.2
       A list of Hospitals in non-vulnerable areas that can also function as base
hospitals or receiving centers in case of evacuation of vulnerable area hospitals or
emergency hospital organization center in their area.
Sr.N Town/city                     Name of hospital           Bed strength
o
1      Bhavnagar                   Sir T. Hospital            360
2      Karamsad                    Pramukhswami Medical 600
                                   College
3      Amreli                      General Hospital           200
4      Dahod                       Govt. Hospital             60
5      Godhra                      Govt. Hospital             210
6      Gandhinagar                 Govt. Hospital             200
7      Himatnagar                  Sir Pratap Hospital        200
8      Junagadh                    Civil Hospital             434
9      Kheda                       Gen. Hospital              100
10     Limdi                       Gen. Hospital              212
11     Mehsana                     Gen. Hospital              243
12     Morbi                       Gen. Hospital              206
13     Nadiad                      Gen. Hospital              160
14     Palanpur                    Gen. Hospital              225
15     Porbandar                   Gen. Hospital              241
16     Rajpipla                    Gen. Hospital              81
17     Surendranagar               Gen. Hospital              126
18     Valsad                      Gen. Hospital              106
19     Bhiloda                     Govt. Hospital             70
20     Deesa                       Govt. Hospital             38
21     Dhoraji                     Govt. Hospital             56
22     Devgadhbaria                Govt. Hospital             81
23     Dharampur                   Govt. Hospital             36
24     Dhangadhra                  Govt. Hospital             79
25     Gondal                      Govt. Hospital             75
26     Jetpur                      Govt. Hospital             68
27     Lunavada                    Govt. Hospital             56
28     Lathi                       Govt. Hospital             50
29     Mandvi Kutch                Govt. Hospital             74
30     Palitana                    Govt. Hospital             56
31     Petlad                      Govt. Hospital             119
32     Santrampur                  Govt. Hospital             56
33     Rajkot                      P.K.Hospt.                 115
34     Santrampur                  Govt. Hospital             56
35     Savarkundla                 Govt. Hospital             81
36     Unjha                       Govt. Hospital             36
37     Upleta                      Govt. Hospital             56
38     Vansada                     Govt. Hospital             86
39     Visnagar                    Govt. Hospital             120



Disaster-2008_Action Plan-08            139
Table No.3
Total available Bed Strength in Gujarat for Emergency Hospital Organization.

Sr.No             Type of institution            Total No.of           Beds
                                                 institutions
1         C.H.C                                      188               6684
2         District hospitals                          25               4286
3         Taluka hospitals                            21               1444
4         Mental Hospital                              4               683
5         Other hospitals                              6                54
6         Medical college hospitals                    8               7460
7         Specialized hospitals                        4               420
8         Grant-in-aid institutions                  140               3610
9         Ayurved hospitals                           45               1745
10        ESIS Hospitals                              10               1395
          Total available beds                                        26,386

(5)     Stores and Equipments:
        Extra cots, mattresses, sheets will be furnished in peacetime.
        Medical stores for emergency will be identified and kept in reserve.

(6)    Oret Health Care Project
       This is a unique and first of its kind development project with co-operation of
Royal Government of Netherlands. All 23 district hospitals, 6 medical colleges and
36 taluka hospitals will be equipped with 28632 products of 570 varieties at a cost of
Rs.200 crores in a phased manner over next 2 years. Instruments for trauma centre
like 1000 MA X-ray machine, ultrasound units, image intensifier, T.V.; C.T. scan,
operation theatre equipments, ventilators, monitors, rehabilitation equipments, blood
bank facilities will be installed as per project.
       Hospitals at Gandhinagar, Ahmedabad, Civil Hospital Patan, Mansa, Jam
       Khambhaliya, Vyara, Dahod, Godhra, Bhiloda etc. have been already
       upgraded under this project. State trainers will train a total of 700 personnel.
       Applications training and modular training have been planned and initiated by
       Project Manager, Oret Gujarat Health Care Project.
               Maintenance and service centre for these instruments has been set up
       at Gandhinagar.
(7)    Other Actions Planned during Emergency.
       a)      Directional signs to be prepared in advance.
       b)      A record of death will be maintained.
       c)      Extra telephone/messenger services as alternate.
       d)      Additional sources of water planned e.g. Water tank/ tube well.
       e)      Standby generators
       f)      Transportation services for patients to be shifted
       g)      Transport of dead to mortuary.
       h)      Information centre will be set up.




Disaster-2008_Action Plan-08               140
5. BLOOD TRANSFUSION SERVICES.

General:
      Blood Transfusion services for each town and city are planned to arrange
proper collection of blood, its storage and distribution, Blood Transfusion services
and vulnerable hospitals.

Steps will be taken for:
      1)     Training adequate staff
      2)     Sufficient equipment
      3)     Dependable transport system.

Organization:
       Blood Transfusion services during emergency are based on facilities already
existing.  Main centers and sub centers are identified.              Co-ordination and
implementation of this plan will be the responsibility of Additional Director, State Aids
Control Society who will be the Chief Blood Transfusion Officer of the State.

Chief Blood Transfusion Officer of Gujarat State:

        Additional Director
        State Aids Control Society


Main Surveillance Centre for Gujarat.

        Department of Microbiology , B.J.Medical College, Ahmedabad.

-       It will be responsible for training and technical guidance and supply reagent
        kits.
-       Blood component separation, plasma & RBC from large blood collection
        exceeding requirement.

Zonal Main Centers.

        1)      Blood Bank, B.J.Medical College/Civil Hospt. Ahmedabad
        2)      ―       ―      Govt. Medical college,   Surat
        3)      ―       ―      ―     ―                  Baroda
        4)      ―       ―      ―     ―                  Jamnagar
        5)      ―       ―      Gen. Hospital,           Junagadh
        6)      ―       ―      ―     ―                  Amreli.
        These centers are presently Zonal Blood Testing Centers.
        These centers will enhance their storage capacity
        These centers will also impart training.



Disaster-2008_Action Plan-08                141
District wise Blood Bank Facility.

Sr.    District                                 No. of blood banks
No                             Govt.         Private       Vol.orgn.    Total
1      Ahmedabad                    7             18            6            31
2      Amreli                       2              -            1             3
3      Banaskantha                  1             3             1             5
4      Bharuch                      1             2             2             5
5      Bhavnagar                    3             3             2             8
6      Gandhinagar                  1             2             2             5
7      Jamnagar                     1             2             1             4
8      Junagadh                     1             4             2             7
9      Porbandar                    1              -            1             2
10     Kheda                        1             1             4             6
11     Anand                        1             3             3             7
12     Kutch                        3             3             2             8
13     Mehsana                      1             3             4             8
14     Patan                        2             1             2             5
15     Panchmahal                   1             1             1             3
16     Dahod                         -            2              -            2
17     Rajkot                       0             3             8            11
18     Sabarkantha                  1             5             2             5
19     Surat                        2             2             5             9
20     Surendranagar                3             3             1             7
21     Vadodara                     3             2             3             8
22     Dangs                        1              -             -            1
23     Valsad                       1              -            3             4
24     Navsari                       -             -            3             3
25     Narmada                       -             -             -            -
       Total                       38             63            59          159



A List of all Blood Banks of Gujarat is given in Annexure –1


No. Of Blood Banks modernized with help of
                   NCO and State Aids Control Society:                 55

Staff Available in Main District Level Govt. Blood Banks.

                  Pathologist and/or Biochemist          -      1
                  Medical officer                        -      1
                  Technician                             -      1
                  Lab. Assistant                         -      1
                  Blood Bank Attendant                   -      1




Disaster-2008_Action Plan-08                142
Training Programme.

       Additional Director, State Aids Cell will implement a training programme for
following categories of staff:

                Category of staff                 Duration of Training
                Medical officer                   3 weeks
                Technician                        4 weeks
                Staff Nurse                       1 week

        Training will be given to staff engaged for extra 100% reserve.

Other areas of Action in Government Blood banks

        1)      Enough plasma expanders/electrolytes stocked by hospitals, RDD and
                CMSO.
        2)      Adequate blood collection bags, administration set, sera stocked.
        3)      Excess blood transported to Ahmedabad Blood component separation
                unit.
        4)      Extra blood bank refrigerators will be ensured in Govt. blood banks.
        5)      Alternate water supply and generator unit planned.
        6)      Adequate Blood bag carriers to be made available.
        7)      Civil Surgeon/Supdt will provide transport facility.
        8)      Ensure 7 specified rooms in Blood Banks.
        9)      Maintain liaison with officer in-charge Blood Transfusion Services.


Actions during Precautionary stage.

      1)    Procure all required stores and sera.
      2)    Staff placed to man the centers.
      3)    Short revision courses included.
      4)    Transport and fuel facility set up.
      5)    Educate public to register as blood donors.
      6)    Master file of donors prepared.
Action during Emergency Stage.

        1)      Main centers and sub centers will start collection of blood, group and
                label them and keep them ready for dispatch as needed.
        2)      Replacement of utilized/dispatched stock.
        3)      Unused blood sent to component separation unit, Ahmedabad.
        4)      Chief Blood Transfusion Officer (Additional Director, Aids) will maintain
                liaison with army and vulnerable area towns and co-ordinate between
                producer and user.
        5)      A control room will be set up in Aids Control Society for Blood
                Transfusion service purpose.




Disaster-2008_Action Plan-08                143
6.      EMERGENCY ENVIRONMENT HEALTH MEASURES.

        Department of Public Health Engineering will be assisted and advised by all
        25 Chief District Health Officers (CDHO) for following responsibilities.
1)      Notification of Diseases to prevent epidemics.          CDHO through District
        Magistrate will bring out a notification enforcing this even in private
        practitioners.
2)      Regular and alternative sources of water supply subjected to chlorination and
        post chlorination tests carried out by chloroscopes by supervisors.
3)      Gamaxene powder applied over disposed wastes, refuse and animal
        carcasses by sanitary inspectors.
4)      Ensure food sanitation steps in general and in evacuee camps in specific.
5)      Control of vermin, especially mosquitoes, flies etc. by vector control measures
        by malaria officer.
6)      Initiate mass inoculation program for typhoid vaccine, cholera vaccine etc. by
        vaccinators.
7)      In peacetime, train volunteers and public for emergency treatment of water,
        refuse disposal, disposal of corpses, etc. by PHN, Block Extension educator.
8)      During precautionary stage, CDHO shall arrange for hygiene store, chemicals,
        and equipments and alert all concerned teams.
9)      During war stage all plans for emergency environmental health services will
        be put in action.
Medical Arrangements.

1)      Medical care will be given both during movement of evacuees and at
        destination.
        Camp hospital will be opened near evacuees‘ camps.
        Preventive vaccination carried out.
2)      Preparation for evacuation of hospitals from area of evacuation. Prepare list
        and staff to be evacuated. Select and equip base hospital where patients will
        be sent.
3)      Provide transport to patients' enroot and ensure they get priority in general
        evacuation plans.
4)      Provide medical facilities including maternity facility, Checking of provision of
        safe drinking water and sanitation facility at transit and refugee camps set up
        by civil authorities.
5)      Some mobile parties may accompany convoys on motorbikes / bicycles to
        avoid traffic congestion.
6)      Reception facilities set up at destination hospitals for quick attendance.
        Infectious cases will be isolated.
Disaster-2008_Action Plan-08                144
7)      In case of exodus by trains, medical care will be provided at key stations,
        sanitation and drinking water ensured.

 8. MEDICAL STORES AND EQUIPMENT.

 General:

 1)     The present Central Medical Stores Organization depots are located in
        Ahmedabad; Civil supplies Depot, near Airport, hence a highly vulnerable site.
        A new depot building is constructed and CMSO will shift to Gandhinagar by
        October 1999, at a less vulnerable site.
 2)     Director, CMSO will be the nominated official of State for procurement. He will
        procure stores and equipments planned by Additional director Medical
        Services, the State Nodal Officer.
 3)     A six-month reserve stock of medical stores, equipment, beds, linen, utensils
        etc. will be maintained at 11 category 1-town hospitals.
 4)     Timely plans will be made to procure sera and vaccines.
 5)     Requirements for essential items as in Appendix 24 of Union War Book are
        worked out for the whole State and procurement planned. Table No.4 shows
        lists of requirements for the state.
 6)     During war stage, indents will be placed both for Civil Defense casualty
        services and emergency hospital organizations.
 7)     There are a good number of drugs manufacturing companies in Gujarat.
        These shall be contacted in need and Commissioner, Health, will make direct
        purchases in dire emergency.

Table No.4
List of Essential Drugs, likely to become scarce in Emergency, State
Requirement.

 Sr.         Name of essential drug        Requirement for      Requirement for
 No.                                        1000 victims             State
1       Tab. Acetyl salicylic acid              1500                200000
2       Tab. Paracetamol                        1500                200000
3       Inj. Diclofenac                         5000                100000
4       Inj. Pethedine                          1000                200000
5       Inj. Phenobarbitone                      500                 10000
6       In. Morphine                             500                 20000
7       In. Diazepam                            5000                100000
8       Inj. Dopamine                            500                 10000
9       Inj. Mephentermine                       500                 10000
10      Inj Noradrenaline                        500                 10000
11      Inj.Dexamethasone                       1000                 20000
12      Inj Aminophylline                        100                  4000
13      Inj. Deriphylline                        500                 20000
14      Ini. Chlorpheniramine                    500                 20000
15      Inj.Atropine                             500                 20000
16      Inj. Pentothal Sodium                    500                 20000
17      Inj. Ketlar                              100                  4000

Disaster-2008_Action Plan-08              145
18      Cap Ampicillin                        5000              100000
19      Cap Amoxicillin                       5000              100000
20      Inj. Ampicillin 1 gm                   500               40000
21      Inj. Ringer Lactate                   1000               40000
22      Inj. Glucose saline                   5000              100000
23      Inj 5% Glucose                        1000               20000
24      Inj .Dextraven                         500               10000
25      Infusion Sets                         4000              100000
26      Inj. Tetanus toxoid                 3000doses         60000 doses
27      Inj AGS                                100                2000
28      Inj. Soda bi carb                      500               10000
29      Inj. Lasix                             500               10000
30      Inj. Pot. Chloride                     100               20000
31      Tr Iodine                              500               10000
32      Savlon Liquid                          500               10000
33      Tr Benzoin                             200                4000
34      Spirit (surgical)                    5 Litres          5000 Litres
35      Bandages
36      Dressings
37      POP Bandages                          1000               20000
38      Splints upper &lower limbs            1000               20000
39      Tourniquets                           1000               20000

 Instruments

Sr.      Name of Instruments          Requirement       for Requirement      for
No.                                   1000 victims          State
1       Laryngoscopes Child, adult             10                 200
2       Airway                                 10                 200
3       Mouth gag                              10                 200
4       Tongue holding Forceps                 10                 200
5       Dispo. endotracheal tubes              20                1000
6       Artery forceps                        200                4000
7       Needle holders                        100                2000
8       Dissecting forceps                    200                4000
9       Knife handles                         200                4000
10      Cut down sets                          5                  100
11      Abdominal sets                         2                  50
12      Craniotomy sets                        2                  50
13      Thoracic sets + Under water            2                  50
        seals
14      Dispo. needles and syringes           5000              100000
15      Towels

Disaster-2008_Action Plan-08          146
16      Gowns
17      Sheets
18      Steam sterilizers                           1                    25

                        9. MANPOWER REQUIREMENT

        Total available manpower in Health field in Gujarat State is as under :

                                                               Total

        Allopathic Doctors - Rural        4493                 15479
                             Urban        10986

        Ayurved doctors                                        20174
        Unani and Homeopathy                                   4186
        Dentists                                               1107
        Registered Nurses                                      13203
        Registered ANMs                                        5986
        Trained Dais                                           21297
        Untrained Dais                                         5789

Available Manpower with Department of Health and Family Welfare- Gujarat
State.

1)      Commissionerate of Health, Medical Services and Medical Education 29889

2)      Commissionerate of Food and Drugs Control Admin.                      1083

3)      Director, E.S.I.S                                                     5090

4)      Director, Indian system of Medicine & Homeopathy                      1915

5)      Director, Central Medical Store Organization                          104

        Total (including Sachivalaya)                                         38348




Disaster-2008_Action Plan-08               147
Staff Available for Emergency Hospital Organization.

Category              District hospital               No.    Teaching hospital

Class              I Full time                        413    949
specialists          Part time                        22

Cl.II                 Medical officers                490    626
                      Biochemist                      13
                      Administrative officers         43

Class III             Administrative staff            496    2790
                      Pharmacist                      378
                      Lab.,X-ray Technician           287
                      Drivers                         112
                      Nurses                          4503
                      Other Nursing staff             797

Class-IV                                              2566   2849



Actions during Epidemic or Endemic:

        1)   Staff will be positioned as required.
        2)   Nodal officer will contact Higher authority for any manpower
             requirement if needed from outside the state.
Hospital Organization.
        Will do greatest good to greatest number. Provide only essential treatment.

         MISCELLANEOUS.

 Public Co-operation.

 Medical persons will educate common people, the necessity of such a plan and their
 participation and training in, home nursing, & blood donation.
 List of volunteers for each category should be maintained with addresses.
 All voluntary organization‘s support and participation earmarked and listed.


 Printing and Stationery.
 Following will be necessary. State will print these and distribute.
       1)      Identity cards.
       2)      Register books.
       3)     Red Cross identity cards.
       4)     Any other card as deemed fit.
       Training for correct use of these should be given to concerned staff.
Surveillance Epidemiological team State Level

Disaster-2008_Action Plan-08                    148
Sr.                            Designation                   Responsibilities
No.
1      Deputy Director (Epidemic)
       Assistant Director (Epidemic)
       State Epidemiologist (Epidemic)                    Epidemic outbreak
                                                          Investigation
2      Medical Officer Epidemic Cl-II
3      Entomologist Cl-ll


Surveillance Epidemiological team Zonal Level
Sr.                            Designation                    Responsibilities
No.
1       Regional Deputy Directors,
        Assistant Deputy Directors
        Head of PSM Department,
        Head Of Medicine Department,                         Epidemic outbreak
                                                             Investigation
        Head of Microbiology Department,
        Head of Pediatric Department,
        CDHO &
        CDMO.
2       Epidemic Medical Officer Cl-II in the Office of
        RDD.


Surveillance Epidemiological team District Level
Sr.N                            Designation                    Responsibilities
 o.


1       CDHO, ADHO,RCHO, DTO, DLO, DMO.
                                                             Epidemic outbreak
                                                             Investigation
2       Epidemic Medical Officer Cl-II District Panchayat.
        MO DTT




Disaster-2008_Action Plan-08                  149
                         Activities             At what level        Responsibility
A     Planning, Organizing & Monitoring         State           Deputy            director
                                                                (Epidemic)

                                                District        CDHO

                                                Block           BHO

                                                Village         MO-PHC

B     Training                                  State           State Training Centre
                                                District        CDHO

                                                Taluka          BHO

C     Diagnostic Facility                       State           Medical College
                                                District        Civil Hospital

                                                Taluka          Referral Hospt.

D     Surveillance Activity                     District        CDHO,EMO
                                                Block           BHO

                                                Village         MO-PHC & Other staff

E     IEC- Activity                             District        CDHO,EMO
                                                Block           BHO

                                                Village         MO-PHC & Other staff

F     Anti-Rodent Activity                      District        CDHO,EMO
                                                Block           BHO

                                                Village         MO-PHC & Other staff

G     Chemoprophylaxis & Referral treatment     Block           Medical College
                                                Village         PHC or CHC

E     Funding                                   State           Health & Family-welfare
                                                                Department

                                                District        District Panchayat

F     Inter-Departmental Co-ordination          State           Health & Family-welfare
                                                                Department

                                                District        District Panchayat


Disaster-2008_Action Plan-08              150
Disaster-2008_Action Plan-08   151
               CONTINGENCY PLAN




                               (During War)




           GUJARAT STATE

Disaster-2008_Action Plan-08        152
1. PREFACE

         Gujarat is the western-most state of India. International border lies at its
north. It mainly has a vast desert and semi desert area, scarcely populated and
open to land invasion. On west, lies a large coastal area dotted with a number of
small and large ports, notably strategically vital Kandla Port. Arm, navy and airforce
establishments are also concentrated in Kutch and Saurashtra regions. Large
hydroelectric projects at Ukai, Kakrapar, and Narmada, thermal power stations at
Tarapur, Ahmedabad and Vanakbori and mega industries like IPCL at Vadodara,
GNFC at Bharuch Reliance and Essar at Jamnagar are also prime targets.
Somnath ,Dwarka and Palitana are sensitive religious places.
Considering all these vital sites and vulnerable cities, this Medical Contingency Plan
for state of Gujarat, based on the Ministerial War Book (1995) is prepared by the
appointed Nodal Officer for the state under the able guidance of Commissioner,
Health ,Medical , Medical Education and Research to extend all medical facilities to
civilian population during likely enemy action. It may be looked upon as the State
War Book for Gujarat.


2. GENERAL


      While it would be the responsibility of the armed forces to defend the country
against foreign aggression, it is necessary to protect the civilian population by a
number of other civil departments.

       This medical contingency plan lays down details by whom and how the
instructions contained in this are to be implemented for medical coverage in Gujarat.

Objectives of medical contingency plan

       To provide in a concise and convenient form a record of all executive actions
        involved in passing from a state of peace to a state of war.
       To ensure all agencies execute coordinated, precise measures.
       To ensure smooth working relationship between state and the centre.
       To lays down details by whom and how the instructions contained in this are
        to be implemented.


Formulation and maintenance of medical contingency plan


                         Since diagnostic and curative services are mainly provided
district hospitals, taluka hospitals, and community health centres, Deputy Director,
(epidemic) is appointed as state nodal officer by     Commissioner, Health ,Medical ,
Medical Education and Research to formulate the medical contingency plan.
Disaster-2008_Action Plan-08               153
Responsibilities of state nodal officer

         To formulate and maintain the medical contingency plan.
         To keep liaison with Deputy Assistant Director General (EMR) ,DGHS,
          Nirman Bhavan, New Delhi, and state administration.
         Suggest amendments / additions to Union Ministerial War Book.
         To send six monthly / weekly reports as necessary.

State War Book Committee

                    State nodal officer suggests that a Committee be set up
immediately for smooth implementation of action plan as under:

             Commissioner, Health, Medical, Medical Education and Research---
                Chairman
             Additional Director, Medical services--------------------------Member
             Additional Director, Medical Education and Research------- Member
             Additional Director, Health------------------------------------- Member
             Additional Director, Family Welfare-------------------------- Member
             Additional Director, State Aids Control Society--------------- Member
             Director, CMSO---------------------------------------------------- Member
             Director, SIH&FW------------------------------------------------- Member
             Director, ESIS------------------------------------------------------ Member
             Project Manager, Gujarat healthcare (ORET) project--------- Member
             Representative of Director of Civil Defense/ Home Secretary—Member
             R.D.D. ,Gandhinagar Zone------------------------------------ Member
             R.D.D. Ahmedabad----------------------------------------------Member
             Deans & Superintendents of Medical Colleges / Hospitals
             Any other invitee as deemed necessary------------------- Member
             Deputy Director (epidemic)----------------Member-secretary




Working Committee
                   Following members will assist the State Nodal Officer for ease
of implementation:
          Assistant Director
             R.D.D. ,Gandhinagar Zone,



Disaster-2008_Action Plan-08                   154
 Stages of Action
           Stage of peace: Plans prepared, officials made conversant with it.
              Precautionary stage : Implementation as planned.
              War stage: Full implementation.



 Areas of Action:

         Action plans are made for the following in vulnerable towns and cities:

              CASUALTY SERVICES
              EMERGENCY SERVICES
              BLOOD TRANSFUSION SERVICES
              EMERGENCY ENVIRONMENT HEALTH MEASURES
              EVACUATION
              MEDICAL STORES AND EQUIPMENT
              MANPOWER REQUIREMENT
              MASS CASUALTY CARE

 Central Command and control

         Nodal Officer will be in central command and control at all times. A round the
 clock control room will be started from precautionary stage at Commissionerate at
 Gandhinagar ,manned by a medical officer and supportive staff.
 Important phone numbers:


     Name                       Designation             Office        Fax          Residence
Dr.S.J.Gandhi        Deputy Director Epidemic         3253336      23253243        6871351
Dr.B. K.. Patel      Additional Director, Health      079-         079-            079-
                     Medical services, Gandhinagar    3220418      3220418         3220359

Dr.Amarjitsinh       Commissioner, Health, Medical, 079-           079-            079-
                     Medical Education,Gandhinagar 3222412,        3223982         3238910
                                                    53279
SMT;Rita             Secretary, Health & Family       079-         079-            079-
Teotia               Welfare,Gandhinagar              3220069      3224409         3224394




 Disaster-2008_Action Plan-08                 155
Regional Deputy Director’s Control Room

Similarly round the clock control rooms will be established at all six Regional
Deputy Director’s offices. These will co-ordinate with various districts under
them and nodal officers control room. The following six R.D.D’s will arrange
this.

Sr      Zone                   Name of R.D.D       STD code       Phone No.   Phone No.
.                                                                 office      Residence
N
o.
1       Ahmedabad              Dr.S. R. Awasya     079            2680112     6853837

2       Gandhinagar            Dr.K. B. Patel      079            3222788     079-
                                                                              7479910

3       Vadodara               Dr. Kanchhal        0265           432381      332133

4       Surat                  Dr.Khasgiwala       0261           479175

5       Rajkot                 Dr.Vashishth        0281           440599

6       Bhavnagar              Dr.N.F.Dafda        0278           427330      422520



District Level Command and Control
                       Command for Medical Relief.
       The overall implementation of the action plan will be the responsibility
of designated district level command. In districts with medical college, the
Superintendent of Govt. Medical College will undertake this responsibility. He
will also supervise and coordinate other medical institutions of Govt. local
body/Private sector. The district Civil Surgeon for implementation will assist
him in district level hospital, CHC’s and grant-in-aid institutions. In districts
without Govt. medical colleges, the Civil Surgeons will be in overall charge.
The following officers are designated as District
Sr. District             Hospital     Desig       Name of           STD     Phone.  Phone
No                                    natio       officer           code    Office  No.
                                      n                                             residence
1       Ahmedabad        Civil        Med.        Dr. Prabhakar     079     2681379 2681087
                         Hospital     Supdt                                 2123721
                                      .
        Assisted by      Civil Hospt. Civil       Dr.   Jagdish 079         7474355 98258454
                         Sola         Surg.       Chavda (I/C)              7474359 00
Disaster-2008_Action Plan-08                     156
2     Vadodara                 Med.
                         S.S.G.Hos      Dr.      Kamal 0265     425751   342240
                         pt.   Supdt    Phatak
                               .
      Assisted by Jamnabai     Civil    Dr. B.B.Pandya 0265     462134   424003
                  Hospt.       Surg.                            461400
3     Surat       New Civil Med.        Dr.S.K.Bajpai    0261   244985   242576
                  Hospt.       Supdt
      Assisted by Old.Civil    Civil    Dr.              0261   479311
                  Hospt.       Surg.                            479610
4     Jamnagar    Irwin        Med.     Dr.Jaichandan    0288   554629
                  Group        Supdt                            550226
                  Hospt.
      Assisted by Govt.Hospt Civil      Dr.      S.S. 02833 34704
                  .            Surg.    Hemamalini
                  Jamkhamb
                  haliya
5     Rajkot      Gen.         Med.     Dr.B.D.Parmar    0281   476402
                  Hospital     Supdt
      Assisted by P.K Govt. Civil       Dr.M.I.Oza       0281   227136   454545
                  Hospt,       Surg.
                  Rajkot
6     Bhavnagar   Sir          Med.     Dr.Singh M.P.    0278   421524   434181
                  T.Hospt.     Supdt
      Assisted by Govt.        Civil    Dr. J.J.Gadhvi   02848 2175      2529
                  Hospt.Palit Surg.
                  ana
7     Amreli      General      Civil    Dr.B.B.Patel     02792 22587     23416
                  Hospt.       Surg.                           22173
8     Ahwa        General      Civil    Dr.S.D.Parmar    02631 20205     20204
                  Hospt.       Surg.                           20240
9     Kutch       G.K.Gener Civil       Dr.S.K.Bheda     02832 50852     50554
                  al           Surg.
                  Hospt.Bhuj
10    Bharuch     General      Civil    Dr.R.D.Patel     02642 43515
                  Hospt.       Surg.                           30307
11    Dahod       Govt.        Civil    Dr.K.M.Solanki   02673 20220     21284
                  Hospt.       Surg.
12    Godhra      Gen.Hospt. Civil      Dr.L.M.Chanda    02672 42559     42205
                               Surg.    na
13    Gandhinagar Gen.         Civil    Dr.N.B.          079   3222733   7473374
                  Hospt.       Surg.    Dholakia               3221932
14    Himatnagar  Sir Pratap Civil      Dr.V.S.Ninama    02772 46618     40033
                  Hospt        Surg.                           41892
15    Junagadh    Civil Hospt. Civil    Dr.S.R. Avasia   0285  20050     65032
                               Surg.                           25736     50302
16    Mehsana     Gen.Hospt. Civil                       02762 52219     53475
                               Surg.                           51784
17    Kheda       Gen.Hospt. Civil      Dr.G.C.Patel     0268  61074     50073
                  Nadiad       Surg.                           61386

Disaster-2008_Action Plan-08           157
18    Navsari     Govt.           Civil    Dr.B.M. Hathila   02742 53083        52475
                  Hospt           Surg.                            53758
19    Banaskantha Gen.Hospt.      Civil    Dr.M.J.           02742 53083        52475
                  Palanpur        Surg.    Mayatra                 53758
20    Patan       Govt.           Civil    Dr.R.M. Mehta     02766 33311        30778
                  Hospt.          Surg.
21    Porbandar   Govt.           Civil    Dr.M.A.           0286  242910       242882
                  Hospt.          Surg.    Maheshwari              240923
22    Narmada     Govt.           Civil    Dr.P.A.Joshi      02640 22163        20030
                  Hospt.          Surg.                            20030
                  Rajpipla
23    Surendra    Gen.            Civil    Dr.D.K. Vadher    02752 22052        33541
      nagar       Hospt.          Surg.
24    Valsad      Gen.            Civil    Dr.M.G.Damor      02632 54046        54049
                  Hospt.          Surg.                            54133
25    Anand       Govt.           Civil    Dr. N.S. Dafda    02697 24422        24775
                  Hospt.          Surg.                            123145
                  Petlad


DISTRICT LEVEL ADVISORY COMMITTEE: (Medical Relief )

                    A District level Advisory Committee will be formed with following
members to assist and coordinate.

1)     District Magistrate & Collector                       Chairman
2)     Medical Supdt.(Teaching Hospt)/Civil Surgeon          Member-secretary
3)     Civil Surgeon/Supdt. Other Govt. hospital             Member
4)     Supdt. Of Local body Hospt/specialty Hospt.           Member
5)     Chief District Health Officer                         Member
6)     District Superintendent of Police                     Member
7)     R.D.C.                                                Member
8)     Local I.M.A. President                                Member
9)     Civil Defense Commandant                              Member
10)    Chief Fire Dept.                                      Member
11)    Representative of Local bodies                        Member
12)    Voluntary organization                                Member
13)    R.T.O.                                                Member
14)    D.E.O.                                                Member
15)    R & B Dept. Ex. Engineer                              Member
16)    Local Army Est. Representative                        Member
17)    Representative of Nodal office                        Member




Disaster-2008_Action Plan-08              158
3. CASUALTY SERVICES.

Introduction:
      Casualty Services organization is aimed to render prompt first aid at the spot
      of disaster, transportation and treatment of casualties. There are important life
      saving measures and also boost the morale of population during air raid.

Organization:
     Casualty services consists of
     1)     First aid parties
     2)     First and post (static and mobile )
     3)     Ambulance service
     4)     Mobile surgical units.

Command & Control:
        With guidance from District Command, Chief District Health Officer will be the
officer commanding Casualty services . RMO of the emergency hospital, & CHC
Superintendent of the town will assist him. He (CDHO) will function in this capacity
also under guidance of controller of Civil Defense who usually is the DM or Sub.Div.
Magistrate and coordinate also rescue and transport.

First Aid Party:
           Will rush and render first aid and provide transport by stretchers.
           Party will consist of one Driver and four first aid trained workers /
             volunteers. The leader will be a health worker/fire brigade person.
           One car will be provided for 3 such parties.
           3 such parties will be constituted for 10,000 populations for towns upto
             l lac, population. For additional, 3 parties per 20,000 population.
           These will be located at Civil Defense Depots.
           Medical officer in charge will train personnel and young volunteers from
             different sectors.
           Officer will send the party to scene in charge of Civil Defense, will
             report to incident officer/ warden and start work.
           Party will have equipments specified in appendix 16 of Union War
             Book.


First Aid Posts:
       These will treat lightly wounded casualties, screen patients sent by first aid
parties and decide who need hospitalization.
       First aid post may be static or mobile.

First Aid Post (Static)
           Control: A medical officer will be in charge.
           Location:- it will be housed in existing govt. local body charitable or
             private dispensary.
           Scale:- 1 such post for a population of 25,000.
           Lay-out:- it will have 3 rooms – reception, treatment and waiting
             room.
           Personnel :- Medical officer        1 + 2 relief
Disaster-2008_Action Plan-08              159
                               Nurse              1+ 2 ―
                               First aider        3+6 ―
                               Messenger          1+1 ―
                               Clerk              1
                               Sanitary worker    1
             Stores:          As per appendix –17 of Union War Book.

      All 63 dispensaries located in large cities at present will serve as First Aid
Posts. Notably the dispensaries as follows:

City/Town                      Dispensary to Act as First Aid Post.

Ahmedabad               Dariyakhan Gummat, A colony; E-colony, Nr.Ambar cinema,

                        Srangpur; G-colony, Sukramnagar, Rakhial; F-colony, Shah

                        Alam Tolnaka; New Mental, Meghaninagar; Bechardas Disp.

                        Delhi Chakla; Sadvichar Eye Hospt. Naroda; Polytechnic-

                        Ambawadi;Govt. Quarter, Vastrapur; Shastrinagar, Naranpura;

                        Bombay Housing, Police line, Gomtipur; Gaukwad Haveli Police

                        line; Sardarnagar disp.; Kubernager disp.; SRP Group.2 disp.

                        Saijpur Bogha.

Vadodara                 Fatehgunj Disp;Mohammadvadi Disp; SRP Group 1; SRP

                        Group 2

Bharuch dist            Kevadia Colony

Bhuj                    Branch Disp. Bhuj

Gandhinagar             Dispensaries of Sectors 16,20,22,28,& 30.

Rajkot                  Suchak disp, Dr.Radhakrishnan Road; SRP Disp Group 13

Bhavnagar               Jashwantsinhji disp; Benba disp; Umarjanbai disp,Haluria chowk;

                        Jawansinhji disp;Refugee camp disp.

Junagadh                New disp, Jaymala chowk; Police training college.
Porbandar               Plot disp; Gaikwad disp.
Disaster-2008_Action Plan-08                 160
This is only guidance list. Others shall be planned by District Command as per need.

First aid post- Mobile
       1) It is a complete first aid unit on wheels, ready to proceed to scene, set up
           and provides treatment.
       2) A big truck or a van will be the motor vehicle.
       3) One unit shall be set up per 3 lac population. If less ,then minimum 1 unit
           will be set up.

Mobile Surgical Unit
      1) It will have 3 doctors including an anesthetist, one trained nurse, two first
         aiders, one operation theatre nurse, and one driver.
      2) 1 unit will be set up for 3 to 5 lac population.

Ambulance Services
        Ambulance for every 50,000 population.
        Procurement: Hospital and CHC ambulances, fire dept ambulances,
          grant –in aid institutions and requisitioned trucks, lorries and buses
        Stationed at Civil Defense Depot.
        Staff: 1 driver & 1 attendant trained in first aid.

Ambulances and vehicles available with health dept. as shown below shall be
deployed immediately.

      Type of institution                  Total                  Ambulances
                                           Vehicles(working)



1     Hospitals under medical section      138                    88



2     PHC‘S                                758



3     Mobile clinics                       60



4     ESIS Hospitals                       31                     31




Vehicles shall also be obtained from following institutions of Health Dept

Disaster-2008_Action Plan-08             161
             188 CHC‘S.
             8 Medical colleges
             140 Grant –in- aid institutions.
             177 ICDS Blocks.
             108 PP Units
             11Jeevan Raksha Kendras.
             17 General Nursing Schools.
             1 SIH&FW and associated training centers
             18 TB Centers.
             4 Mental hospitals.
             RDD Offices
             Dental College.
             Leprosy units.




Actions during Precautionary Stage
             CDHO will alert all first aid leaders to stand by.
             Officer in charge of civil defense in consultation with CDHO and Med.
              Supt./Supt. shall keep stores and reserves ready. He will identify
              vehicle and driver to be sent with each party.
             Buildings for First aid post (static) shall be ear-marked, personnel,
              stores, signposts kept ready and meetings arranged with members
             Vehicles for first aid post (mobile ) earmarked, personnel, stores kept
              ready, and meetings arranged with members.
             Mobile surgical units set up.
             Vehicles requisitioned, stretcher fitments kept ready, drivers made
              familiar with all locations.



Actions during War Stage
    First aid party:
        All members will report to civil defense depot
           Rosters of 8 hour duty prepared
           Vehicles allotted, their fuel ,oil, maintenance ensured with the help of
            Collector


Disaster-2008_Action Plan-08               162
First aid posts (static)
           Ear-marked buildings taken over
           Personnel, stores and equipment kept ready
           Day and night visible signposts set up
           M.O. shall keep information of all vacant beds of attached hospital
           Severe casualty transferred to casualty hospital
           Moderate injuries attended & sent home with follow-up reporting advice
           Trivial injuries attended and sent home
           Record of all casualties maintained
           Casualty identity label if not given previously, is given
        First aid posts (mobile): As Above.


        Mobile surgical units:


           Ear marked vehicles requisitioned.

           Personnel to report to duty at short notice.

        Ambulance services:


           Available ambulances and other vehicles requisitioned


           Equipped with stretcher, stores, staffed.


           Fuel ,oil, maintenance provisions made




                Details of number of first aid parties, first aid posts (static and mobile) ,
        mobile surgical units, ambulances and total vehicles required for 11
        vulnerable towns of Gujarat is listed in TABLE A.




Disaster-2008_Action Plan-08                 163
       District Commands of non-vulnerable towns will work out their requirements
as per plan.

                                             Table A
                               Civil Defense (Medical Services)
                               Casualty Services –Requirements

                               No.of     No.of     No.of   No. of  Vehicles Required
                               first     first     first   Mobile
                                                            For Fo For Amb TOTAL
                               aid       aid       aid      first r        ula
                               parties   posts     posts          firs     nces
                                                                  t
                         require required required Surgical aid aid Mo for Vehicles
S Name of     Estimated d 3per                                    po bile trans
r. vulnerable Population                                          st       port
N Town                   10000 Static: Mobile: Units        par M Sur 1 per Require
o                        upto                               ties obi gica        d
                                                                  le: l
                         1 lac, 1per250 1per3      1per5    1p 1p Unit 5000
                         then    00       lac      lac      er er s        0
                                                            3
                         3/2000 Populati Populati Populati par M           Popu
                         0 popu on        on       on       ties obi       latio
                                                                  le:      n
1 Baroda      800000     135     32       3        2        45 3 2         16    66
2 Surat       1500000    240     60       5        3        80 5 3         30    118
3 Kakrapar    30000      9       1        1        0        3 1 0          1     5
4 Ahmedabad 3000000      465     120      10       6        15 10 6        60    231
                                                            5
5 Bhuj        150000     39      6        1        0        13 1 0         3     17
6 Jamnagar 450000        78      18       2        1        26 2 1         9     38
7 Kandla-     150000     36      6        1        0        12 1 0         3     16
   Gandhidha
   m
8 Naliya      30000      9       1        1        0        3 1 0          1     5
9 Ankleshwar 50000       15      2        1        0        5 1 0          1     7
1 Okha        50000      15      2        1        0        5 1 0          1     7
0
1 Vadinar     30000      9       1        1        0        3 1 0          1     5
1
1 Mehsana     300000     60      12       1        0        20 1 0         6     27
2
1 Gandhinaga 200000      45      8        1        0        15 1 0         4     20
3 r




Disaster-2008_Action Plan-08                 164
4.EMERGENCY SERVICES
Introduction:

        This chapter contains plans for Emergency Hospital Organization to render
effective and continues medical treatment to civilian casualties in emergency.


Organization:


-       Hospitals in vulnerable areas will be casualty-receiving hospitals.
-       Hospitals in safer areas will act as base hospitals
-       The Civil Surgeon or Superintendent of each vulnerable/base area will act as
        Superintendent of Emergency hospital organization.
-       In National Emergency, all hospitals in an area will be included in Emergency
        Hospital organization.


Assessment of Requirements:


(4) Bed Strength: Scale of Civil Defense Beds in category 1 towns is 1 bed per 750
    population and 1 bed for 3000 population for category II towns. Gujarat has 11
    Category I towns and nil in Category II (as per Union War Book Appendix 14).
    Details for Action Plan for these are as given in Table No.1.
    Details of plan for non-vulnerable area organization is given in Table No.2.
    Details of Total Bed strength available in Gujarat State is given in Table No.3.
(5) Accommodation for extra beds will be done by utilizing all available space, such
    as veranda, lecture halls, transferring certain cases to base hospitals depicted
    and setting up extra bed capacities in designated other hospitals and institutions
    as shown in Table. 1.
(6) Personnel: Required medical specialists will be deputed from non-vulnerable
    area medical colleges, medical officers and other technical staff from CHC‘s,
    PHCs, teaching faculties of medical colleges, local volunteers from Indian
    Medical Association, Gujarat State Branch and Grant-in-aid institutions.




Disaster-2008_Action Plan-08               165
Table No.1
Emergency Hospital Organization

S Name        of Estimat No. of Total no.              No.of   No.of beds          Additional beds
r. vulnerable    ed      Civil                         beds
N
o
   Town          Populat Defense of beds               that   available            arrangement
                 ion                                   can be
                         Beds    available             made in base hospital       at      places
                                                                                   nearby
                               Require at present      availab                     Emergency
                               d                       le
                               1 per                   for                         hospital
                               750                     Civil
                                                       De-
                               Populati                fense=
                               on                      1/3
                                                       of total
1 Baroda             800000 1066          SSG          400      Jamnabai          Mental
                                          Hosp:1200             Hosp:230          Hosp:300
                                                                                  KG
                                                                                  Children:100
2 Surat              150000 2000          New     Civil 240    Old Civil Hosp:100 Med
                     0                    Hos:740                                 College:1000
                                                               Gen.Hosp.Navsari
                                                               200
3 Kakrapar           30000 40             CHC          16      CHC Vyara:50
                                          Mandvi:50
                                                               New            Civil
                                                               Hos.Surat:740
4 Ahmedabad          300000 4000          Civil       1033     ESIS Hosp:500        Dental
                     0                    Hosp:1470                                 College:200
                                          VS    Hosp:          Sola Civil:100       Kidney
                                          750                                       Institute:350
                                          LG                   Gandhinagar          Cardio Insti:70
                                          Hosp:500             Civil:200
                                          Shardaben            Nadiad Civil:100 Paraplegia
                                          Ho:350                                    Hosp:60
                                                                                    Victoria
                                                                                    Jubilee:50
                                                                                    Mental
                                                                                    Hosp:300
                                                                                    Rajasthan
                                                                                    Hosp:100
                                                                                    Cancer
                                                                                    Hosp:100
5 Bhuj               150000 200           Gen          60      Rajkot         Med Swaminarayan
Disaster-2008_Action Plan-08                    166
                                  Hosp:230          CollegeHo:780      Sch:100
                                                                       Indirabai
                                                                       GirlsSch:100
                                                                       Alfred      High
                                                                       School:100
6 Jamnagar           450000 600   Irvin       300   Rajkot         Med Ayurved
                                  Hosp:1225         CollegeHo:781      hosp:100
                                                                       ESIS Hosp:100
                                                                       Anda Bawa:200
                                                                       Oswal       Jain
                                                                       Center:500
                                                                       Patel
                                                                       Samaj:600
7 Kandla-    150000 200           Govt        10    Gen           Hosp Port Trust:100
  Gandhidham                      Hosp:40           Bhuj:230
                                                                       Primary School
                                                                       Gm:100
                                                                       CHc Anjar:50
8 Naliya             30000 40     CHC         16    Gen           Hosp Primary School
                                  Naliya:50         Bhuj:231           :100
9 Ankleshwar         50000 66     Muni        16    Civil Bharuch:210 Primary School
                                  Hosp:50                              :101
1 Okha               50000 66     CHC         16    Irvin Hosp:1225    Dwarka:
0                                 Dwarka:50
                                                                        LohanaMahajan
                                                                        Vadi50
                                                                        Sanatan
                                                                        Ashram:100
                                                                        Swaminarayan
                                                                        Dharmsala:50
                                                                        Birla
                                                                        Dharamshala:2
                                                                        5
1 Vadinar            30000 40     Khambhaliy 33     Irvin Hosp:1226     Lohana
1                                 a:100                                 Vadi:50
                                                                        Kanji
                                                                        Dharamshala:2
                                                                        0
                                                                        Aradhana
                                                                        Dham:50
1 Gandhinagar 200000 260          Gen.        70    Civil      Hospital Community
2                                 Hospital210       A‘bad1470           Hall-300
1 Mehsana     300000 400          Gen Hosp- 90      Civil      Hospital Lions Hospital
3                                 280               A‘bad1470           100




Disaster-2008_Action Plan-08           167
                                    Table No.2
        A list of Hospitals in non-vulnerable areas that can also function as base
hospitals or receiving centers in case of evacuation of vulnerable area hospitals or
emergency hospital organization center in their area.
Sr.No     Town/city            Name of hospital           Bed strength
1         Bhavnagar            Sir T.Hospital             360
2         Karamsad             Pramukhswami Med.College   600
3         Amreli               General Hospital           200
4         Dahod                Govt. Hospital             60
5         Godhra               Govt. Hospital             210
6         Gandhinagar          Govt. Hospital             200
7         Himatnagar           Sir Pratap Hospital        200
8         Junagadh             Civil Hospital             434
9         Kheda                Gen. Hospital              100
10        Limdi                Gen. Hospital              212
11        Mehsana              Gen. Hospital              243
12        Morbi                Gen. Hospital              206
13        Nadiad               Gen. Hospital              160
14        Palanpur             Gen. Hospital              225
15        Porbandar            Gen. Hospital              241
16        Rajpipla             Gen. Hospital              81
17        Surendranagar        Gen. Hospital              126
18        Valsad               Gen. Hospital              106
19        Bhiloda              Govt. Hospital             70
20        Deesa                Govt. Hospital             38
21        Dhoraji              Govt. Hospital             56
22        Devgadhbaria         Govt. Hospital             81
23        Dharampur            Govt. Hospital             36
24        Dhangadhra           Govt. Hospital             79
25        Gondal               Govt. Hospital             75
26        Jetpur               Govt. Hospital             68
27        Lunavada             Govt. Hospital             56
28        Lathi                Govt. Hospital             50
29        Mandvi Kutch         Govt. Hospital             74
30        Palitana             Govt. Hospital             56
31        Petlad               Govt. Hospital             119
32        Santrampur           Govt. Hospital             56
33        Rajkot               P.K.Hospt.                 115
34        Santrampur           Govt. Hospital             56
35        Savarkundla          Govt. Hospital             81
36        Unjha                Govt. Hospital             36
37        Upleta               Govt. Hospital             56
38        Vansada              Govt. Hospital             86
39        Visnagar             Govt. Hospital             120

Disaster-2008_Action Plan-08               168
                                      Table No.3
Total available Bed Strength in Gujarat for Emergency Hospital Organization.

Sr.No     Type of institution             Total          No.of Beds
                                          institutions



1         C.H.C                           188                 6684


2         District hospitals              25                  4286


3         Taluka hospitals                21                  1444


4         Mental Hospital                 4                   683


5         Other hospitals                 6                   54


6         Medical college hospitals       8                   7460


7         Specialized hospitals           4                   420


8         Grant-in-aid institutions       140                 3610


9         Ayurved hospitals               45                  1745


10        ESIS Hospitals                  10                  1395


          Total available beds                                26,386




Disaster-2008_Action Plan-08              169
                Stores and Equipments:
                Extra cots, mattresses, sheets will be furnished in peacetime.
                Medical stores for emergency will be identified and kept in reserve.

            ORET Health Care Project
        This is a unique and first of its kind development project with co-operation of
Royal Government of Netherlands. All 23 district hospitals, 6 medical colleges and
36 taluka hospitals will be equipped with 28632 products of 570 varieties at a cost of
Rs.200 crores in a phased manner over next 2 years. Instruments for trauma centre
like 1000 MA X-ray machine, ultrasound units, image intensifier, T.V.; C.T. scan,
operation theatre equipments, ventilators, monitors, rehabilitation equipments, blood
bank facilities will be installed as per project.
Hospitals at Gandhinagar, Ahmedabad, Civil Hospital Patan, Mansa, Jam
Khambhaliya, Vyara, Dahod, Godhra, Bhiloda etc. have been already upgraded
under this project. State trainers will train a total of 700 personnel. Applications
training and modular training have been planned and initiated by Project Manager,
Oret Gujarat Health Care Project.
Maintenance and service centre for these instruments has been set up at
Gandhinagar.
(8)     Other Actions Planned during Emergency.
        i)       Directional signs to be prepared in advance.
        j)       A record of casualties will be maintained.
        k)       Extra telephone/messenger services as alternate.
        l)       Additional sources of water planned e.g. Water tank/ tube well.
        m)       Standby generators
        n)       Fire fighting equipments kept ready
        o)       Paper pasted on glasses to prevent shattered glass flying
        p)       Trenches dug near hospital for staff and patients
        q)       Transportation services for patients to be shifted
        r)       Transport of dead to mortuary.
        s)       Information centre will be set up.
        t)       Rehearsals
        u)       Keep 1/3 beds vacant in precautionary stage
        v)       Inform officer commanding casualty services No.of vacant bed

Disaster-2008_Action Plan-08                 170
5. BLOOD TRANSFUSION SERVICES.

General:

        Blood Transfusion services for each town and city are planned to arrange
proper collection of blood, its storage and distribution to Armed Forces, Blood
Transfusion services and vulnerable hospitals.

Steps will be taken for:

             Training adequate staff
             Sufficient equipment
             Dependable transport system.


Organization:

        Blood Transfusion services during emergency are based on facilities already
existing.       Main centers and sub centers are identified.         Co-ordination and
implementation of this plan will be the responsibility of Additional Director, State Aids
Control Society who will be the Chief Blood Transfusion Officer of the State.

Chief Blood Transfusion Officer of Gujarat State:

        Additional Director
        State Aids Control Society



Main Surveillance Centre for Gujarat.

        Department of Microbiology

B.J.Medical College, Ahmedabad.

-       It will be responsible for training and technical guidance and supply reagent
        kits.


-       Blood component separation, plasma & RBC from large blood collection
        exceeding requirement.




Disaster-2008_Action Plan-08               171
Zonal Main Centers.

             Blood Bank, B.J.Medical College/Civil Hospt. Ahmedabad
             ―         ―      Govt. Medical college,    Surat
             ―         ―      ―     ―                   Baroda
             ―         ―      ―     ―                   Jamnagar
             ―         ―      Gen. Hospital,            Junagadh
             ―         ―      ―     ―                   Amreli.
These centers are presently Zonal Blood Testing Centers.
These centers will enhance their storage capacity
These centers will also impart training.

District wise Blood Bank Facility.

Sr.    District                No. of blood banks
No                               Govt.         Private     Vol.orgn.   Total
1      Ahmedabad                    7            18            6         31
2      Amreli                       2             -            1         3
3      Banaskantha                  1             3            1         5
4      Bharuch                      1             2            2         5
5      Bhavnagar                    3             3            2         8
6      Gandhinagar                  1             2            2         5
7      Jamnagar                     1             2            1         4
8      Junagadh                     1             4            2         7
9      Porbandar                    1             -            1         2
10     Kheda                        1             1            4         6
11     Anand                        1             3            3         7
12     Kutch                        3             3            2         8
13     Mehsana                      1             3            4         8
14     Patan                        2             1            2         5
15     Panchmahal                   1             1            1         3
16     Dahod                        -             2            -         2
17     Rajkot                       0             3            8         11
18     Sabarkantha                  1             5            2         5
19     Surat                        2             2            5         9
20     Surendranagar                3             3            1         7
21     Vadodara                     3             2            3         8
22     Dangs                        1             -            -         1
23     Valsad                       1             -            3         4
24     Navsari                      -             -            3         3
25     Narmada                      -             -            -          -
       Total                       38            63           59        159

Disaster-2008_Action Plan-08                172
Staff Available in Main District Level Govt. Blood Banks.

                Pathologist and/or Biochemist            -      1
                Medical officer                          -      1
                Technician                               -      1
                Lab. Assistant                           -      1
                Blood Bank Attendant                     -      1


Training Programme.

        Additional Director, State Aids Cell will implement a training programme for
following categories of staff:

                Category of staff                 Duration of Training


                Medical officer                   3 weeks
                Technician                        4 weeks
                Staff Nurse                       1 week

        Training will be given to staff engaged for extra 100% reserve.


Other areas of Action in Government Blood banks

             Enough plasma expanders/electrolytes stocked by hospitals, RDD and
                CMSO.
             Adequate blood collection bags, administration set, sera stocked.
             Excess blood transported to Ahmedabad Blood component separation
                unit.
             Extra blood bank refrigerators will be ensured in Govt. blood banks.
             Alternate water supply and generator unit planned.
             Adequate Blood bag carriers to be made available.
             Civil Surgeon/Supdt will provide transport facility.
             Ensure 7 specified rooms in Blood Banks.
             Maintain liaison with officer in-charge Blood Transfusion Services.




Disaster-2008_Action Plan-08                173
Actions during Precautionary stage.

             Procure all required stores and sera.
             Staff placed to man the centers.
             Short revision courses included.
             Transport and fuel facility set up.
             Educate public to register as blood donors.
             Master file of donors prepared.

Action during War Stage.

             Main centers and sub centers will start collection of blood, group and
                label them and keep them ready for dispatch as needed.
             Replacement of utilized/dispatched stock.
             Unused blood sent to component separation unit, Ahmedabad.
             Chief Blood Transfusion Officer (Additional Director, Aids) will maintain
                liaison with army and vulnerable area towns and co-ordinate between
                producer and user.
             A control room will be set up in Aids Control Society for Blood
                Transfusion service purpose.




Disaster-2008_Action Plan-08               174
6.      EMERGENCY ENVIRONMENT HEALTH MEASURES.


Department of Public Health Engineering will be assisted and advised by all Chief
District Health Officers (CDHO) for following responsibilities.



      Notification of Diseases to prevent epidemics.             CDHO through District
        Magistrate will bring out a notification enforcing this even in private
        practitioners.
      Regular and alternative sources of water supply subjected to chlorination and
        post chlorination tests carried out by chloroscopes by supervisors.
      Gamaxene powder applied over disposed wastes, refuse and animal
        carcasses by sanitary inspectors.
      Ensure food sanitation steps in general and in evacuee camps in specific.
      Control of vermin, especially mosquitoes, flies etc. by vector control measures
        by malaria officer.
      Initiate mass inoculation program for typhoid vaccine, cholera vaccine etc. by
        vaccinators.
      In peacetime, train volunteers and public for emergency treatment of water,
        refuse disposal, disposal of corpses, etc. by PHN, Block Extension educator.
      During precautionary stage, CDHO shall arrange for hygiene store, chemicals,
        and equipments and alert all concerned teams.
      During war stage all plans for emergency environmental health services will
        be put in action.




Disaster-2008_Action Plan-08                175
7.      EVACUATION.

                         Civil Surgeons and Chief District Health Officers shall in co-
ordination give medical cover during evacuation. Evacuation can occur in following
circumstances.

             Massive enemy air attack.
             Threat of enemy occupation during war.
             To facilitate military‘s own operations.

Medical Arrangements.

      Medical care will be given both during movement of evacuees and at
        destination.
        Camp hospital will be opened near evacuees‘ camps.
        Preventive vaccination carried out.
      Preparation for evacuation of hospitals from area of evacuation. Prepare list
        and staff to be evacuated. Select and equip base hospital where patients will
        be sent.
      Provide transport to patients enroot and ensure they get priority in general
        evacuation plans.
      Provide medical facilities including maternity facility, checking of provision of
        safe drinking water and sanitation facility at transit and refugee camps set up
        by civil authorities.
      Some mobile parties may accompany convoys on motorbikes / bicycles to
        avoid traffic congestion.
      Reception facilities set up at destination hospitals for quick attendance.
        Infectious cases will be isolated.
      In case of exodus by trains, medical care will be provided at key stations,
        sanitation and drinking water ensured.




Disaster-2008_Action Plan-08                 176
 9. MEDICAL STORES AND EQUIPMENT.


 General:

      The present Central Medical Stores Organization depots are located in
         Ahmedabad; Civil supplies Depot, near Airport, hence a highly vulnerable
         site.    A new depot building is constructed and CMSO will shift to
         Gandhinagar by October 1999, at a less vulnerable site.


      Director, CMSO will be the nominated official of State for procurement. He
         will procure stores and equipments planned by Additional director Medical
         Services, the State Nodal Officer.




      A six-month reserve stock of medical stores, equipment, beds, linen, utensils
         etc. will be maintained at 11 category 1-town hospitals.


      Timely plans will be made to procure sera and vaccines.




      Requirements for essential items as in Appendix 24 of Union War Book are
         worked out for the whole State and procurement planned. Table No.4 shows
         lists of requirements for the state.


      During war stage, indents will be placed both for Civil Defense casualty
         services and emergency hospital organizations.




      There are a good number of drugs manufacturing companies in Gujarat.
         These shall be contacted in need and Commissioner, Health, will make direct
         purchases in dire emergency.




Disaster-2008_Action Plan-08                    177
                                     Table No.4
List of Essential Drugs, likely to become scarce in Emergency, State
Requirement.

Sr.     Name of essential drug           Requirement    for Requirement   for
No.                                      1000 victims       State
1       Tab. Acetyl salicylic acid       1500               200000
2       Tab. Paracetamol                 1500               200000
3       Inj. Diclofenac                  5000               100000
4       Inj. Pethedine                   1000               200000
5       Inj. Phenobarbitone              500                10000
6       In. Morphine                     500                20000
7       In. Diazepam                     5000               100000
8       Inj. Dopamine                    500                10000
9       Inj. Mephentermine               500                10000
10      Inj Noradrenaline                500                10000
11      Inj.Dexamethasone                1000               20000
12      Inj Aminophylline                100                4000
13      Inj. Deriphylline                500                20000
14      Ini. Chlorpheniramine            500                20000
15      Inj.Atropine                     500                20000
16      Inj. Pentothal Sodium            500                20000
17      Inj. Ketlar                      100                4000
18      Cap Ampicillin                   5000               100000
19      Cap Amoxicillin                  5000               100000
20      Inj. Ampicillin 1 gm             500                40000
21      Inj. Ringer Lactate              1000               40000
22      Inj. Glucose saline              5000               100000
23      Inj 5% Glucose                   1000               20000
24      Inj .Dextran                     500                10000
25      Infusion Sets                    4000               100000
26      Inj. Tetanus toxoid              3000doses          60000 doses
27      Inj AGS                          100                2000
28      Inj. Soda bi carb                500                10000
29      Inj. Lasix                       500                10000
30      Inj. Pot. Chloride               100                20000
31      Tr Iodine                        500                10000
32      Savlon Liquid                    500                10000
33      Tr Benzoin                       200                4000
34      Spirit (surgical)                5 Litres           5000 Litres
35      Bandages
36      Dressings
37      POP Bandages                     1000              20000
38      Splints upper &lower limbs       1000              20000
39      Tourniquets                      1000              20000




Disaster-2008_Action Plan-08             178
 Instruments
 Sr.             Name of Instruments              Requirement for    Requirement for
 No.                                               1000 victims           State


1       Laryngoscopes Child, adult            10                    200

2       Airway                                10                    200

3       Mouth gag                             10                    200

4       Tongue holding Forceps                10                    200

5       Dispo. endotracheal tubes             20                    1000

6       Artery forceps                        200                   4000

7       Needle holders                        100                   2000

8       Dissecting forceps                    200                   4000

9       Knife handles                         200                   4000

10      Cut down sets                         5                     100

11      Abdominal sets                        2                     50

12      Craniotomy sets                       2                     50

13      Thoracic sets + Under water seals     2                     50




14      Dispo. needles and syringes           5000                  100000

15      Towels

16      Gowns

17      Sheets

18      Steam sterilizers                     1                     25




Disaster-2008_Action Plan-08            179
                        9. MANPOWER REQUIREMENT

        Total available manpower in Health field in Gujarat State is as under:

                                                               Total


        Allopathic Doctors - Rural        4493                 15479
                               Urban      10986


        Ayurved doctors                                        20174
        Unani and Homeopathy                                   4186
        Dentists                                               1107
        Registered Nurses                                      13203
        Registered ANMs                                        5986
        Trained Dais                                           21297
        Untrained Dais                                         5789




Available Manpower with Department of Health and Family Welfare- Gujarat State.



1)      Commissionerate of Health, Medical Services and Medical Education --29889
2)      Commissionerate of Food and Drugs Control Admin.                     1083
3)      Director, E.S.I.S                                                    5090
4)      Director, Indian system of Medicine & Homeopathy                     1915
5)      Director, Central Medical Store Organization                         104
        Total (including Sachivalaya)                                        38348




Disaster-2008_Action Plan-08               180
Staff Available for Emergency Hospital Organization.

    Category                   District hospital              No.         Teaching hospital
Class-I               Full time                          413        949
specialists           Part time                          22
Cl-.II                Medical officers                   490        626
                      Biochemist                         13
                      Administrative officers            43
Class III             Administrative staff               496        2790
                      Pharmacist                         378
                      Lab. ,X-ray Technician             287
                      Drivers                            112
                      Nurses                             4503
                      Other Nursing staff                797


Class-IV                                                 2566       2849

Actions during Peace Stage:

         1)     Nodal officer will prepare manpower requirement for emergency.
         2)     All Civil Surgeons will keep a list of all private doctors, nurses and other
                paramedics and keep a list of those willing to offer service in
                emergency.
         3)     Training of all involved personnel.
         4)     Arrange for any training not available in State of Gujarat e.g. Disaster
                Management Training, Mass Nuclear Hazard Training etc.
         5)     A list of retired health personnel willing to render service be prepared.
         6)     Will work out requirements of personnel for Civil Defense Casualty
                services and emergency hospital organization.




Actions during Precautionary stage:

         1)     Warn all earmarked persons.
         2)     Call all volunteers.
Disaster-2008_Action Plan-08                       181
Actions During war:

        3)      Staff will be positioned as required.
        4)      Nodal officer will contact DGHS for any manpower requirement if
                needed from outside the state.




Disaster-2008_Action Plan-08                 182
                                    10. MASS CASUALTY CARE.

 Introduction:

        This is for guidance of preparation and action plan for thermonuclear war so
 that District Commands of vulnerable areas are prepared for any eventuality and
 render medical aid as per already laid down priorities.

 Nature of Injuries by Atomic Explosions:

        Thousands of casualties may occur, demanding immediate attention. Injuries
are of following types:
        1)      Blast injuries, wounds from shock wave and collapsing building.
        2)      Temporary blindness by light flash
        3)      Burns from heat flash / fires.
        4)      Radiation injuries and burns causing local tissue damage.
        5)      1/5 of survivors suffers from radiation sickness later.

Estimation of Casualties.

        Maps of vulnerable cities will be prepared showing maximum and minimum
population density at mid-day and mid-night. A transparent overlay is prepared at 1
km. distance scale around the hypothetical ground ‗O‘ and percentage casualties
thereby read as from below:

No    Radius                   % of deaths          % of injuries      Injury type
                               Withou With          Withou With
                               t        warning     t         warnin
                               warnin               warnin g
                               g                    g
1     In 1 Km                  90       75          10        15       Severe injuries
                                                                       Radiation burns
2     1 – 2 Km                 50      30           35       20        -do-
3     2 – 3 Km                 15      5            40       25        Burns more than
                                                                       radiation injuries
4     3 – 4 Km                 2       1            18       10        Mainly        mech.
                                                                       Injuries, few burns,
                                                                       no radiation effect
5     4 – 5 Km             0           0            10       5         -do-
6     5 – 6 Km             0           0            5        1         All mech. Injuries
7     More than          6 0           0            <1       0         -
      Kms

Disaster-2008_Action Plan-08                      183
Organization will consist of:
   First aiders -      Will sort out injuries and give first aid. Will have to be trained to
    sort out.
   Ambulance service-Will carry casualty from First aiders to Forward Medical Aid
    Unit. – Requisite adequate number of vehicles.
   Forward Medical Aid Unit- Mobile Medical Unit, Casualties attended by Doctors
    and nurses. Usually 30 to 45 kms. from center. Brings medical knowledge as
    near as possible.




Sorting Casualties.
        Aim: - To devote attention to those who will benefit. Low priority to lightly
                 Injured and critically injured with no survival chances.


        Nature of casualties:
                1/3 of total: Major lacerations
                1/3 of total: Uncomplicated Burns
                1/6 of total: Injuries to limbs
                1/6 of total: other injuries.


           Some may be complicated. by thermo burns and radiation injuries.
           Conventional warfare categorization not applicable.

Minor injuries – contusions, minor lacerations, simple fractures of upper limbs,
minor Burns treated on spot by improvisations and not transferred.

Major injuries: Burns more than 40%, penetrating wounds of chest and abdomen
are left as such. If they improve, do not deteriorate after some hours, internal vital
organ injury is unlikely and they have a better survival chance. They are evacuated
after seriously ill patients taken care off.

Treatment is concentrated on those who have a chance of survival even after 7
days with limited surgical procedure.           One has to be ruthless if to be effective.
Doctors have taken such decisions in past in the interest of nation.
Disaster-2008_Action Plan-08                      184
Training to be imparted for sorting:
        To volunteers of First Aid Parties
        To mobile Medical units
        To Emergency hospital sorters.

Forward Medical Aid Unit.
        Will consist of 4 doctors, 4 nurses, 38 nursing assistants, administrative
personnel, local volunteers will be stretcher-bearers.

Duties of this Unit.
        1)      Sort casualties and determine priorities.
        2)      Evacuate suitable cases without delay to hospital.
        3)      Provide emergency and supportive treatment to serious before transfer
                to hospital.
        4)      Hold casualties with very little hope of survival and give them palliative
                treatment.



To perform their duties, unit will have following areas:

        1)      Reception and sorting area
        2)      Rest and holding area
        3)      Treatment area
        4)      Transfer/evacuation area.

Following casualties will be immediately treated here.

        1)      Severe hemorrhage from open wound – control hemorrhage.
        2)      In complete amputation – complete it
        3)      Severe limb flesh wound – dress / release tissue tension
        4)      Fracture long bones – splint these.
        5)      Sucking chest wound.
        6)      15-20% burns
        7)      Unconscious patients
        8)      Airway obstruction – Do tracheostomy.



Disaster-2008_Action Plan-08                 185
Palliative Treatment only will be given to following:


        1)      Deep trunk wounds, 25-45 % burns, compound skull fracture, severe
                multiple injuries. Give pain relievers, splint, and review for transfer.
        2)      Gross facial injuries, severe burns, extensive multiple injuries.
        3)      Cared locally till general condition improves.


        4)      Severe injuries with survival unlikely. Relieve pain, give nursing care.
                Few will still survive. Review later and then transfer.



Hospital Organization.
Will do greatest good to greatest number. Provide only essential treatment.
Hospital Evacuation:

All hospitals upto 45 Kms from ground ‗O‘ will be evacuated, within 5 days.
Home Cover Hospital:

With 15% of bed strength of evacuated hospital, it will function for local sick and
injured. Usually 30 bedded.
Casualty Receiving Hospital:

Usually located 45-60 Kms. Away.
Auxiliary Hospital:

Will be located near casualty receiving hospitals. Will provide shelter, and
minimum medical care to patients already treated in main hospital.


Special Hospital : for mental patients, chronic sick and maternity cares.


Provision of Extra Accommodation: for casualty-receiving hospital will be made by
Requisitioning nearby buildings, even putting tents shelters and hutments.

Administration and Control of entire organization: Usually the Medical
Superintendent of Teaching Hospital or Civil Surgeon will be in-charge of the
organization. Any hospital will have to act as forward or support hospital depending
on site of blast.


Disaster-2008_Action Plan-08                  186
    11 MISCELLANEOUS.

 Public Co-operation.

        During peace time medical persons will educate common people, the
 necessity of such a plan and their participation and training in First aid, home
 nursing, & blood donation.
 List of volunteers for each category should be maintained with addresses.
 All voluntary organization‘s support and participation earmarked and listed.
 Printing and Stationery.
        Following will be necessary. State will print these and distribute.
        5)      Casualty indenty cards.
        6)      Casualty Register books.
        7)      Red cross identity cards.
        8)      Any other card as deemed fit.
        Training for correct use of these should be given to concerned staff.
Exercises:

        Collective training & repeated exercises and drills would be done to ensure
efficiency and confidence in individual and group worker.
________________________________________________




Disaster-2008_Action Plan-08                187
RED CROSS IDENTITY CARD (Front)

                           Identify Card for Civil Medical Personnel.

Name: - - - - - - - - - -- -- - -- - -- -- - - - -- - - - - - Age- - -- - - - Sex - - - - - - - -

Address: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

       The bearer of this card is protected by the Geneva Convention of 12th August,
1949 relative to the protection of civilian persons in time of war, in his capacity as _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

Date of Issue

                                                       Seal and signature
                                                       Of issuing authority

------------------------------------------------------------------------------------------------------------
(Reverse of Card)

Photo of Bearer                            Signature or finger
                                           Print of bearer
Height ______                        Colour of eyes ______ Colour of Hair ____

Distinguishing marks __________________________________




Disaster-2008_Action Plan-08                            188
CASUALTY IDENTITY LABEL

First aid party No. ________________                     Casualty label No. ________

Name __________________                     AGE________ Sex ______Next of kin
________

Sr. No. _________
Address: __________________________

Nature of Injury__________________                       Time ______
                                                         Date :_________

Stretcher                      Disposal to          Treatment and
Sitting                              First Aid post             Instructions
                               Hospital


                                      Signature
                                      Leader –First Aid Party.
___________________________________________________________
___________________________________________________________




Disaster-2008_Action Plan-08                189
First Aid Post

Date :__________                                    No. _______

Time in :_______                       Treatment and
                                       Instructions.
Date
Time out ____________


Disposal to Hospital _______________

Out patient                                  Signature
                                             M.O. I/c First Aid Post.




Disaster-2008_Action Plan-08           190
                  CONTINGENCY PLAN




       CYCLONE / FLOODS / HEAVY RAINS

                               GUJARAT STATE




                           EPIDEMIC CONTROL CELL
               COMMISSIONERATE OF HEALTH, MEDICAL SERVICES
                     AND MEDICAL EDUCATION (HEALTH)
                        5, DR. JIVRAJ MEHTA BHAVAN,
                                GANDHINAGAR.


Disaster-2008_Action Plan-08        191
FLOODS:-


        Natural calamities due to heavy rains and floods are common periodical
phenomenon in our state. Some parts of our state are more prone than others. By
now information about villages and blocks which are affected regularly by heavy
rains and floods are available to the district health authorities. Necessary remedial
measures are also well known to the district authorities.


        With the scientific development of forecasting system advance forecasting of
flood and heavy rains for precise area has become possible. Public Health measures
are planned well in advance, in the systematic and scientific manner based on
forecast. Some of the highlights of health problems relating to Cyclones, heavy rains
and floods have been summarized below:


        Health problems related can be either due to direct impact on human
population such as due to devastation of properties, dwellings, disruption of road
transport drowning and in direct impact on existing health infrastructure resulting into
defective functioning of available facilities i.e.


 Water supply.
 Power supply and
 Sanitation facilities.
 Destruction – demodulation of health felicities.

01.     Forcing the community to consume unsafe water and stay in unsanitary
        conditions, leading to water borne diseases.
02.     Heavy rains and floods bring heavy damages to the housing facilities and the
        affected population is exposed to adverse climatic condition leading to
        diseases particularly respiratory infection and fever.
03.     Flood and heavy rains also damage ration shops and other shops which may
        lead to shortage of food supply in an affected community, leading semi
        starvation condition and accidental incidence of food poisoning due to



Disaster-2008_Action Plan-08                 192
              consumption of soiled food – grains (due to fungus infection of the food –
              grain leading afflotoxin poisoning).


            Above factors combined together may temporarily change living conditions of
      the community, till they are finally rehabilitated. Sudden change in the environment
      leads to the following sequel.

04.         People are shifted from the flooded area/marooned are to temporary shelters
            (rehabilitation / relief camps.) This results into overcrowding at one place with
            poor sanitary and hygienic facility favoring transmission of water born and air
            born diseases. Along with the problems of safe drinking water, the problems at
            toilet facilities, bathing facilities and cooking facilities which leads to unsanitary
            conditions which again leads to different types of diseases, specially water-
            borne diarrhoeal diseases which may turn into epidemic if prophylactic
            measures are not adequately planned.

      05.     Loss of property and loss of life to relatives bring tremendous tension
              and pressure on the minds resulting into anxiety neurosis or depression. The
              following are the common aliments / diseases following the flood situation.




      Disaster-2008_Action Plan-08                   193
Type of aliments                          Due to
1. Injuries                               Due to collapse of houses or any
                                          standing structures.
2. Waterborne diseases cholera, Non – availability / inadequate safe
Gastroenteritis, Dysentry, enteric drinking water due to,
fever, viral hepatitis and poliomyelitis. a) Flooding of wells with polluted
                                              drinking water.
                                          b) Disruption of piped water supply.
                                          c) Inaccebility of available water
                                              sources.
                                          d) Unsanitary condition in the
                                              villages / evacuee camps due to :
                                          1) Accumulation of water.
                                          2) Lack of proper excreta disposal
                                              facility.
                                          3) Lack of / disruption of drainage
                                              facility.
                                          4) Sludge which increases the
                                              breeding place for files.
                                          5) Overcrowding.
                                          6) Indiscriminate Dumping of dried
                                              refuges.
                                          7) Indiscriminate dumping of animal
                                              excreta.
                                          8) Indiscriminate       dumping     of
                                              crercass.
3. Respiratory diseases.                  Adverse leaving conditions including
                                          overcrowding.
4. Skin/Eye Diseases.                     Personal hygiene and over crowding
5. Snake/insect bite                      Water entering into snake burrows/
                                          shelters.
6. Malaria and other vector borne Increases in mosquito breeding
diseases.                                 places
7. Zoonotic diseases Leptospirosis.       Due to ecological changes following
                                          flood and earthquake resulting into
                                          death of wild rats and wild rodent
                                          population migrating to domestic area
                                          and bringing enzootic illness like
                                          plague,       Leptospirosis   Epidemic
                                          sylvetic diseases of plague entering
                                          domestic rat flee cycle and bringing
                                          human bubonic plague epidemic.




Disaster-2008_Action Plan-08              194
        Use of chlorine tablets is another method for making water, safe for drinking.
The dose is as follows:

Weight to tablets              Strength of Chlorine      Quantity of water for
                                                         disinfection.
2.5 gram                       300 mg                    225 ltrs.
0.5 gram                       25 mg                     20 ltrs.
0.12 gram                      1.25 mg                   1 ltrs.

        Tab. Chlorine to be distributed in plastic pouch as it is hygroscopic in nature.

        Tab. Chlorine to be crushed before placing in water pot, water should be used

after one-hour contact period of chlorine - it will kill all bacteria and inactivate all

viruses including Euterovirus like hepatitis virus and polio myelitis virus. These

viruses remain inactive for 12 – 20 hours.


        Bleaching power is used for disinfecting of water at community level.

CHLORINATIIION TECHNIQUE



(A)     Quantity of Bleaching powder required chlorinating water sources.

Quantity of water                          Requirement of Bleaching powder
1000 gallon                                1 ounce
4500 liters                                30 grams
100,000 liters                             660 grams



1 Gallon = 4.5 liters

1 Ounce = 30 Grams.
(E)   Method of calculating quantity of water in round well :

        (iii)   In gallons –


Disaster-2008_Action Plan-08                195
                Diameter in feet       x Diameter in feet x height of water (ft) = Water
                quantity ( in gallons).


        (iv)    In liters :


                3.14 x d x d x h       x 1000 = water quantity in litres
                        4
                        d = diameter of well in meter
                        h = height of water column in meters
                        1 meters = feet



(F)     Method of calculating quantity of water in cubical storage tanks :


        Length in meters X Breadth in meters X Height of water column in meters =
        quantity of water in liters.

(G)     Method of Chlorination :


        vii.    Decide the required quantity of bleaching powder and take in container
                such as bucket.
        viii.   Add little water make paste of the powder.
        ix.     Add more water to make uniform suspension.
        x.      Allow to settle lime at the bottom and take supernatant solution in
                another bucket.
        xi.     The bucket full of bleaching powder solution should be immersed deep
                in water and the well water should thoroughly be rinsed from all sides
                so that disperses in entire water of the well.
        xii.    Test for residual Free Chlorine by using Chloroscope after half an hour.




CYCLONE / FLOODS / HEAVY RAINS CONTINGENCY PLAN

Disaster-2008_Action Plan-08                    196
INTRODUCTION: -

        Cyclonic storms have been causing considerable damage to life and property
in the coastal areas of India. They generally originate in the bay of Bangle or the
Arabian sea during the pre-monsoon (April and May ) and post monsoon (October to
December ) seasons. They are extremely rare in the winter months.



        The Cyclone is vast violent whirl in the atmosphere, which moves from the
high seas towards coastal areas, its occurrence is confined to a defined regions of
the earth, usually in the tropical portion of the location. The havoc caused by cyclone
is mostly due to strong winds, accompanied by torrential rains, tidal waves and
resultant inundation.



        Pre-monsoon and post – monsoon cyclone are by and large of very great
intensity with inner cores of very strong wind velocity, reaching 100 KMPH or even
above. The cyclonic storms are common on eastern side of India i.e. originating in
the by of Bengal and to the western side i.e. originating from Arabian Sea.



        In India, cyclone and tidal waves are common n the eastern coast, on an
average, every year one or two cyclonic storms lash the coastal districts, Cyclonic
storms are sometimes accompanied by the tidal waves with height of 5 meters and
sometimes reach 20 KM in coastland with the wind speed of 150 Km/h. Cyclones are
classified in to following categories:



Terminologies for Tropical cyclone:



The classification adopted by India Meteorological Department to classify such
Disturbances is based on maximum strength of sustained wind in the circulation.




Disaster-2008_Action Plan-08              197
Type of Disturbance                         Associated wind speed

___________________                   :     ___________________


Low Pressure area                     :     Less than 17 kts
Depression                            :     17 – 27 kts
Deep Depression                       :     28 – 33 Kts.
Cyclonic Storm                        :     34 – 47 kts
Severe Cyclonic storm                 :     48 – 63 Kts.
Very Severe Cyclonic storm            :     64 – 119 Kts.
Super cyclonic Storm                  :     120 Kts and above.
                           ( 1 knot = 1.85 kmph)
Expected wind speed                   :     Expected damage


60 – 90 kmph                          :     Tree branches broken off: some
                                            damage to kutcha houses


90 – 120 kmph                         :     Trees uprooted, Pucca houses
                                            damaged, communications disrupted.


120 kmph and above                    :     Big trees uprooted; widespread damage
                                            to houses and installations. Total
                                            disruption of communication.


DESTRUCTION           POTENTIAL OF CYCLONES:
HIGH WINDS HEAVY RAINFALL STORM SURGES FROM THE SEA.


High Winds :->


Very strong winds may damage installations, dwellings, communication systems
trees etc. resulting in loss of life and property.



Disaster-2008_Action Plan-08                 198
Heavy Rainfall :- >


Heavy rains caused by cyclone are another source of destruction and dislocation in
communications, train services and railway embankments which are washed away.
Even the railway tracks are washes away by torrents, rivers over flow their banks
flooding fields and destroying standing crops.


Storm surges from the Sea: -


The third and the severest destructive feature of a Tropical Cyclone is the storm
surges or storm wave popularly called, as TIDAL WAVE cyclones are associated
with high-pressure gradients and consequent strong winds. These in turn generate
storm surge. A storm surge is an abnormal rise of sea level near the coast caused by
severe tropical cyclone as a result sea water inundates low lying areas of coastal
regions drowning human beings and live stock, eroding beaches and embankment
destroying vegetation and reducing soil fertility. A surge can occur both during high
tide and low tide but it is accentuated if it occurs at the time of high tide. Wind
blowing over the sea from sea to land causes the water to pile up.




Action taken by the State Government to deal with the post flood health
hazards in the flood affected areas Gujarat State – 2006


What we did?
According to heavy rain and flood situation first we analyzed the affected area in the
distribution of district, taluka, villages and population. Then we estimated the human
resources and material required for that situation. Immediately teams from other non
affected districts were sent with drugs, equipments and vehicles. District's health
authorities are high alerted for staff position and material management and starting
round the clock control rooms in all affected districts and keep in close contact with
state Epidemic office, Gandhinagar.




Affected District -                                          09
Disaster-2008_Action Plan-08             199
Affected Taluka -                                                51
Affected PHCs -                                                  192
Affected Villages -                                              678
Benefited Populations -                                           1702110
Medical Teams            procured                                1133
Medical officers deputed                                         727
Paramedicals deputed                                             1917
How we did?
Strengthening of surveillance and rapid                response for epidemic prone
diseases.


       Control rooms were started round the clock during & after flood at state and
district level for close monitoring of the health situation and mobile teams were
stationed till first week of October 2006 (7/10/2006) when normalcy was restored.
       Surveillance      (epidemiological,   water   quality   monitoring   and   vector
surveillance) was continued for three months after flood, in anticipation of any
waterborne disease outbreaks.
       A multi- disciplinary rapid response team (RRT) consisting of a public health
expert, clinician, laboratory personnel and an entomologist are constituted in every
district with the responsibility to investigate any trigger event and to institute
containment measures immediately. These teams have been constituted in
consultation with respective medical colleges.
       1133 Medical teams Comprising of 727 Medical Officers and 1917
paramedicals were deputed in flood affected areas for preventive, promotive and
curative steps in the affected areas. These teams were actively involved in:
       Surveillance of Diseases
       Treatment of cases
       Chlorination of Drinking Water
       IEC activities
       Reporting




Ensuring safe water supply:-

Disaster-2008_Action Plan-08                  200
       Chlorination of drinking water sources was regularly done by Water Supply
        department as well as respective Gram Panchayat, Nagarpalica and
        Municipal Corporation authorities and wherever it is not possible distribution of
        chlorine tablets to the families for pot chlorination at house hold level was
        done by health department functionaries, particularly in slums peri urban and
        rural areas.
       Health department was regularly monitoring the chlorination of drinking water
        by checking the residual chlorine at consumer's points.
       Supply of safe drinking water by Tankers in affected community.



Plague surveillance:-


  Surat Municipal Corporation and Mobile Epidemiological Team Surat was
     closely monitoring status of density of rat fleas and takes anti- flea measures
                       In addition to rodent serology dog sera are also screened by
     Plague surveillance unit.


Extensive IEC activities:-


             During and after flood situation extensive IEC activities was undertaken
                for use of tablet chlorine, ORS packet, signs and symptoms of
                epidemic prone diseases, importance of reporting of diseases and
                general sanitation and personal hygiene.
             An intensive radio and TV campaign was launched to educate people
                about the preventive steps required against the water borne diseases.
                Posters were distributed through schools, NGOs as well as the self
                help groups. Panel discussions were organized to create awareness
                about the health issues in the post flood period.
             1000000 pamphlets were printed and distributed in affected districts.
             For Heavy Rain / Flood Grant of Rs. 20 crores. Under Calamity Relief
                Fund -2006 has been allotted as per annexure -1 to Health
                Department.
Disaster-2008_Action Plan-08                201
             This grant has been allotted to different state level programme officers
                as well as heavy rain affected district Panchayat for effective utilization
                as per their requirements and prescribed norms.
Medicine/ Equipments Supplied:


                During the acute phase of flood 60 medicine kits supplied through air in
                Surat. Through CMSO Gandhinagar medicines of Rs. 9765107
                supplied to flood affected areas. Through UNICEF Gandhinagar 130
                lacs chlorine tablets, 5 lacs ORS packets, 5000 baby blankets, 50
                generator sets, 45000 AD syringes (0.5 ml), 1000 AD syringes (0.1 ml),
                and 100 Fogging machines supplied.(Annexure-2).




FLOOD AFFECTED AREA:

SR       AFFECTED DISTRICTS               AFFECTED TALUKA
NO.
1        SURAT                            SURAT MUNICIPAL CORPORATION
                                          OLPAD
                                          BARDOLI
                                          VYARA
                                          KAMREJ
                                          MANGROL
                                          PALSANA
                                          MANDAVI
                                          MAHUVA
                                          VALOD
                                          SONGADH
                                          UCHHAL
                                          NIZAR
                                          CHORYASI
2        AHMEDABAD                        AMC AREA
                                          DHOLKA
3        KHEDA                            NADIAD
                                          MAHUDHA
                                          KATHLAL
                                          KAPADVANJ
                                          KHEDA
                                          MATAR
                                          MEHMDAVAD
                                          THASARA
                                          BALASINOR
                                          VIRPUR
Disaster-2008_Action Plan-08                 202
                               NADIAD, DAKOR & KHEDA CITY
4        PANCHMAHAL            SAHERA
                               GODHARA
                               LUNAVADA
                               KANPUR
                               KALOL
5        DAHOD                 ZALOD
                               FATEHPURA
                               LIMKHEDA
6        ANAND                 ANAND
                               BORSAD
                               PETLAD
                               KHAMBHAT
                               TARAPUR
                               ANKLAV
                               SOJITRA
7        VADODARA              KARJAN
                               PADRA
                               VADODARA & VMC
                               DABHOI
                               SAVLI
                               NASVADI
                               SANKHEDA
                               VAGODIA
                               KAWANTH
                               PAVI-JETPUR
8        GANDHINAGAR           GANDHINAGAR
                               DEHGAM
                               MANSA
                               KALOL
9        BHARUCH               BHARUCH
                               HANSOT
                               VAGARA
                               AMOD
                               ANKLESHWAR
                               ZAGADIA
                               JAMBUSAR




Disaster-2008_Action Plan-08     203
               CONTIGENCY PLAN

                                     FOR

                               DROUGHT



 HEALTH & FAMILY WELFARE DEPARTMENT

                               GUJARAT STATE



                               EPIDEMIC CONTROL CELL


        Due to Shortfall of Rain in Gujarat State there is likelihood of scarcity in the
state. There will be severe shortage of water and food grains in most of the affected
villages.



Disaster-2008_Action Plan-08               204
        Failure of monsoon creates shortage of green leafy vegetables for humans
and green fodders for cattle. This will also result in less yield of milk which in turn
leads to malnutrition and causation of water borne diseases.

        Drought is a slow onset disaster, where situation deteriorates gradually
resulting in serious consequences unless necessary relief measures are initiated on
time. Moreover women and children are worst affected.

        Following things would fulfill medical relief measures in the drought affected
areas. 18 districts are considered for the projection with estimated 35 Lacs labourers
in peak period.
        FINANCIAL REQUIREMENTS
No.      Item                                                         Funds required
                                                                      (Rs. In lakh)

A        Drugs, ORS packets
       Bleaching powder                                               870
       Chlorine tablets
Total – A
B        First Aid Box (Rs. 500 each) x 2000                          30
C        Health Education material                                    50
D        POL for medical and paramedical teams and supervisory
         officers                                              100

E        Contingencies                                                100
F        Nutritional Supplementation                                  560
G        1-Worker/Village for Malaria Surveillance-Link Workers       789
Total : A + B + C + D + E + F + G                                     2499




      Thus the estimated expenditure would be about Rs. 24.99 Crores.
Expenditure for nutritional supplementation by ICDS is included in this estimate.




Disaster-2008_Action Plan-08              205
An action plan to tackle the problem will consist of the following:-

    1.       Regular health and medical check up by medical officers and
             preparedness to extend emergency care.

    2.       Nutritional & RCH services will be provided to target group through ICDS &
             MCH services.

    3.       Immunization to pregnant women & targeted children.

    4.       Distribution of O.R.S. Packets to scarcity affected population.

    5.       Stocking of essential medicines at sub centers, PHCs and CHCs.

    6.       Prompt medical services to tackle any water borne epidemics and referral
             services.

    7.       For safe water supply monitoring of chlorination of drinking water sources .

    8.       Provision of first aid boxes at work sites.

    9.       Distribution of Iron Folic Acid tablets and Vitamin ‗A‘ syrup in scarcity
             affected areas.

    10.      Referral services in case of emergency.

    11.      Health education to people about need to maintain Hygiene and
             importance of safe drinking water.

    12.      Malaria Link Worker in each village will do Malaria work in affected
             villages.

          Provision of prompt and effective health, medical and nutritional services will
need coordinated inter sectoral approach with active participation of various NGOs.




Disaster-2008_Action Plan-08                  206
     GUIDING PRINCIPLES FOR HEALTH SECTOR DROUGHT MANAGEMENT

        Drought whatever the cause has continued unabated to ravage many nations
in the world.       It is true that many of the countries have suffered from drought,
followed by famine, as far back as history can tell. The drought in the year 1987 was
one of the worst disasters that had be fallen India so far.

        Drought is a protracted emergency, which invariably leads to shortage of food.
The problem gets multiplied if poverty, illiteracy and backwardness are also
associated.     The impact is thus most in the sphere of nutrition in general and
especially among children, lactating and pregnant mothers.
        The estimated population of children in the age group below 5 years will be
11.5% and that of lactating and pregnant mothers will be 4% or in other words,
15-16% of the population will need special care immediately. It has also been noted
that in the drought areas infant mortality is very high and incidence of waterborne
disease like Diarrhea and dysentery are also very high.
Common types of disease are:
1.      NUTRITIONAL DEFECIENCY DISEASES:
        Due to Vitamins and Mineral deficiencies.


        1.      Vitamin ' A ' deficiency
                -       Night blindness
                -       Xeropthalmia
                -       Xerosis
                -       Intercurrent infections of respi. & urinary tract.


        2.      Vitamin ' B ' Complex Deficiencies.
                -       Angular stomatitis
                -       Glossitis and Cheillosis
                -       Hypervascularisation of sclera and around cornea.
                -       Anaemia
                -       De-pigmentation of hair and skin
                -       Mental apathy and peripheral neuritis
                -       Partial deafness due to neuritis


Disaster-2008_Action Plan-08                  207
        3.      Others.

                -       Acute Otitis Media
                -       Acute Conjunctivitis
                -       Miscarriages and abortions


2.      WATER BORNE DISEASE:
        -       Diarrheas
        -       Cholera
        -       Enteric fever
        -       Viral hepatitis
        -       Dysenteries
3.      RESPIRATORY INFECTION :


        -       Pneumonia
        -       Acute bronchitis


4.      INFECTIOUS DISEASES:


        -       Measles
        -       Chicken pox
        -       Diphtheria
        -       Pertussis


5.      SKIN DISEASE :


        -       Secondary infected dermatitis
        -       Scabies
6.      PARASITIC DISEASE:
        -       Malaria
        -       Ascariasis & other worm infestations.




Disaster-2008_Action Plan-08                   208
7.      EFFECTS OF FAMINE ON ADULTS :


        The undernourished starved are characterized by wasting of muscles.


        1.       Loss of all fat (adipose tissue)
        2.       Atrophy of skeletal muscles, overlying skin become wrinkled, loose
                and flabby.
        3.       Shrinkage of all viscera except brain until a waking skeleton is left for
                 the last, agonizing journey to death.
        4.      Those, who survive the ordeal, the psychology and mental trauma of
                starvation lingers for a very long time after recovery.
        5.      Long before death people become apathetic and uninterested in what
                is going on around them.


8.      EFFECT OF FAMINE ON CHILDREN :


        The most dramatic effect of famine is seen on small children. The smaller the
child, the worse the effect. The breast-fed infant with the milk of its mother as the
only source of sustenance starts to slow down in growth with no weaning food
available.
        Following effects are seen :
        1.      The child becomes inactive and cries persistently.
        2.      The child growth is stunted and it becomes severely underweight until it
                literally becomes skin and bone, when it develop ‗ Marasmus‘ or severe
                PEM.
        3.      The child apathetic, miserable, inert, withdrawn and anorexic.
        4.      The face becomes puffy and swollen.
        5.      Edema of the legs also develops.
        6.      Distended and protruding abdomen.
        7.      The skin becomes hypo-pigmented and flabby while the hair loses its
                luster and turn brownish red in colour.       The child is said to have
                developed ‗Kwashiorkor‘ a disorder due to lack of proteins.
        8.      Vitamin A deficiency occurs and in its mildest from causes night
                blindness or at its worst blindness and death.
Disaster-2008_Action Plan-08                  209
9.      LONG - TERM EFFECT :
        Although children may recover from the acute state of malnutrition if they
receive additional and appropriate food in time, the long-term effects of these
disorders result in deficient mental and physical development and are a matter of
great concern. Several studies of children who have recovered from severe Protein-
Energy-Malnutrition have shown a lower IQ (Intelligence Quotient) compared to well-
fed children from the same socio-economic background and the working capacity in
adults is markedly diminished.

10.     EFFECT OF MOVEMENT AND MIGRATION OF POPULATION :

        The extreme and the classical movement of a whole population results in
hazardous journeys.            For the already weekend and the malnourished, these are
often too much to bear and they die on the way from exhaustion, starvation and
dehydration.

        Many more come into contact for the first time with diseases such as malaria
which easily prove fatal as resistance is low.        During the prolonged and severe
famine situation, the following communicable diseases are rampant and rapidly
reach epidemic proportion;

        (a)     Measles,
        (b)     Meningitis,
        (c)     Acute Diarrhea and dysentery;
        (d)     Typhus,
        (e)     Relapsing Fever,
        (f)     Viral Hepatitis,
        (g)     Typhoid,


        The spread of these diseases is often made worse by overcrowding and
unsanitary conditions. These develop, particularly when people from the droughty
stricken area migrate to towns and cities indiscriminately over burdening existing
water supply and sanitation system.




Disaster-2008_Action Plan-08                   210
         CONTINGENCY PLAN FOR MEDICAL CARE DURING DROUGHT.

1.      State Level Direction:

             A cell should be established under the charge of Deputy Director
     (Epidemic) in the Commissionerate of Health Services to exclusively monitor and
     review the public health measures for the drought affected areas in State.



2.      Control Rooms:

             Control rooms are established at state and district to facilitate transmission
     of information for immediate measures and passage of regular database is also
     made.



3.      Resources:

             The epidemiological cell of the Commissionerate of Health Services
     should be alert and keeps itself ready to meet any eventuality if any epidemic
     diseases breaks out. The unit is prepared to take anticipatory preventive
     measures in the form of obtaining information in respect of epidemic prone
     disease, immunization of preventable disease etc. emergency drugs, vaccine etc.
     are procured and kept ready.



4.      District Nodal Officer :
             Chief District Health Officer is identified at the district level Nodal Officer to
        coordinate and monitor all public health measures for the drought affected
        areas in the district.

5.      Communication:

             The Commissionerate of Health Services has stated to send regular
     information to the Department of Health and Family Welfare, Sachivalaya and
     Relief Commissioner, Sachivalaya, Govt. of Gujarat for necessary feed back.




Disaster-2008_Action Plan-08                  211
6.      Care for Mothers and Children:

            Children below 6 years, expectant and nursing mothers are the special
     victims of drought. Every effort should be made to reach these population groups
     on a priority basis. In the entire drought affected areas, they will be around 15-
     16% of the total population. In addition, the aged, the infirm, the disable and the
     destitute will pose special problems during drought. The health officials should
     be instructed to look after these categories of people.

7.      Control of water borne / water related diseases:

            During drought, diseases like gastro-enteritis, dehydration, pneumonia,
     cholera, typhoid, dysentery, measles, parasitic diseases and others including
     nutritional disorders will pose special problems. While working out the
     requirement for the drugs and vaccines, diseases listed above need to be kept in
     view. Adequate provision for antibiotics, ORS, Vitamins-Micronutrients and other
     essential drugs are made. District Collector / DDO will arrange for supervision.

8.      Chlorination of water sources/water supply:

            All drinking water sources are identified and every efforts are made to
     chlorinate the same with chlorinating agent. It is advised to carry out daily
     chlorination during the drought period to prevent onset of epidemic. However,
     depending upon the resources and the nature of water sources, this could be
     done two or three times a week under certain circumstances.

9.      Treatment Services:

            Fix visits are organized from District level officers to District Supervisors,
     Medical Officers, Sup. Male / female and para-medical. All relief workers visited
     once a week by M.O. and PHC staff and every fortnight by District Supervisor.

            Immediate steps need to be taken to protect children and the pregnant
     women with the protective vaccine used for the programme through a special
     drive. All primary health centers should be provided with adequate stock of
     vaccines and instructed to carry out special immunization programme in respect
     of identified population on a priority basis.

            Adequate provision should be made to provide disposable syringes,
     needles, soaps, bags, towels and other equipment.
Disaster-2008_Action Plan-08                 212
10.        Referral Treatment Centers:

               In addition to the existing established units of dispensaries, primary health
      centers, sub divisional hospitals, medical and health camps are established to
      provide emergency medial care and other Medicare services to the affected
      persons. Arrangements for transport are made available for every medical health
      camps to transport critically ill persons to higher level referral centers. Referral
      treatment centers are identified and names are displayed at relief works.



11.        Health Education:

               Adequate awareness should be given to inform the people about the
      location of the various medical and health camps and other medical units and
      people should be educated to protect themselves against preventable diseases
      by    accepting    the   immunization    programme.     Necessary    messages     are
      disseminated by pamphlets, hoardings and health talks.

      CHECK LIST OF POINTS FOR MONITORING ARRANGEMENTS FOR
      PUBLIC HEALTH AND MEDICAL PROBLEMS IN DROUGHT AFFECTED
      AREAS.

1.         GENERAL

           o      Have all those villages which are affected for acute drinking water
                   scarcity during the drought period been identified ?
           o      Has the minimum requirement of water during the drought period of the
                   population of these villages been worked out ?
           o      Has the quantum of available water during drought period in these
                   villages been estimated with the help of Public Health Engineering
                   Department (PHED) ?
           o      To make up for the shortage, have alternative sources of water for
                   supply so these villages been identified with the help of Public
                   Engineering Department (PHED)?




Disaster-2008_Action Plan-08                   213
2.      PLANNING

        o       The requirement of medical and para medical staff for attending to the
                 health needs of drought-prone villages during the drought period to be
                 assessed.
        o       Have the medical and para medical personal who may be required to
                 be deployed been identified?
        o       Have such personal been given special training to attend to medical
                 and health problems which may arise in drought affected areas ?
        o       Have surveillance teams consisting of bacteriologists to conduct on the
                 spot random stool examination been constituted?
        o       Has the requirement of drugs, disinfectants like bleaching powder,
                 chlorine tablets and vaccine etc. worked out?
        o       Has the availability of existing stocks been estimated?
        o       Have arrangements been made for the procurement of additional stock
                 required?
3.      ACTION

        o        Has adequate publicity been given in the drought prone areas about
                 how to use the disinfectants and take other precautionary measures?
        o       Have the Anti-fly and anti mosquito measures been taken?
        o       Have the treatment centers been identified?
        o       Do the villagers of each village know which treatment center to go to in
                 case of need?
        o       Has the adequacy of the existing treatment centers been assessed?
        o       If additional treatment center are required to be temporarily set up have
                 their location been identified?
        o       In case additional treatment centers are required have the sources
                 from which additional staff would be obtained been identified.
        o       Has the availability of various drugs, vaccine etc. at such treatment
                 centers been assessed?
        o       Have arrangements been made to supply additional drugs and
                 vaccines etc in treatment centers where existing stocks are not
                 adequate?


Disaster-2008_Action Plan-08                 214
4.      MONITORING

        o        Has a senior officer in the Commissionerate of Health Services been
                 identified to look after exclusively the problems of drought probe areas
                 during the drought period?
        o        Have such officers been earmarked at the district & in the block levels.
        o       Have arrangements been made for feed-back information from primary
                 health center to block, district and state headquarters for periodical
                 assessment of the situation and availability of staff and stock position?
        o       An arrangement should be done to get report from the treatment
                 centers to higher levels about any rise in the incidence of gastro-
                 enteritis, dysentery, cholera, jaundice and polio etc.?




Disaster-2008_Action Plan-08                  215
                                  Annexure - I

MASTER PLAN FOR SCARCITY - HEALTH AND MEDICAL SERVICES.


SN                                           Who will do?          When?
       Type of Work
1      Data Collection
       Information about,
        1. Scarcity affected areas.          C.D.H.O.              As      soon   as
        2. Name of the village where         E.M.O.                scarcity     work
            scarcity work carried out.       E.C.S.S.              starts.
       3. No. of labourers on each work.     D.S.I.
2      First Aid Box                         C.D.H.O.              Before scarcity
       1. First - aid box available.         E.M.O.                declared.
       2. First - aid box distributed.
       3. First - aid box required.
3      Information of sources of water      M.O. - P.H.C.          Before scarcity
       villages.                            M.P.W. (M/F)           declared.
                                            M.P.H.S. (M/F)
4      Occurrence of water borne diseases E.C.S.S.                 In the month of
       in last five years e.g. Diarrhea, D.S.I.                    January
       Gastro-enteritis, Cholera, Jaundice,
       Typhoid, Dysentery etc,
5      Stock of Drugs/Disinfectants                                Before scarcity
        1. District Level                                          declared.
        2. P.H.C. Level
        3. Sub Center Level
        4. At Worksite
6      Control Room

        1. P.H.C. Level                      MPW/FHW           Immediate after
                                             MO, Local Staff   scarcity  work
                                                               starts.
        2. District Level                    C.D.H.O., E.M.O., -- " --
                                             E.C.S.S.

        3. State Level                       Deputy     Director   Round the clock
                                             (Epidemic)            As and when
                                             State                 required.
                                             Epidemiologist        Phone No.
                                                                   23253333-34-35
                                                                   Fax - 23253343




Disaster-2008_Action Plan-08           216
SN                                             Who will do?          When?
       Type of Work
7      Visit of Scarcity worksites             1. M.P.W. (M/F)       Once in a week
       Regularly on fix days and time.         2. M.P.H.S. (M/F)     Once in a week
                                               3. M.O., B.E.E.       Once in a week
                                                                     and or as and
                                                                     when required.
                                               4. Ophth. Asstt.      Once in fortnight
                                               5. Dist. Supervisor   Once in fortnight
                                               6. Dist. Officers     Fortnightly & as
                                                                     & when required.
8      Chlorination Surveillance
       (i) At village source                   1. Gram               Daily
                                                  Panchayat
                                               2. M.P.W. (M)         During      visits,
       (ii) At Scarcity site                   1. Work    charge     Daily
                                                  clerk.
                                               2. M.P.W. (M)         During visits.
       (iii) Chlorination Status               1. Work charge        Daily
                                                  Clerk.
9      A. Maternal and Child Health
       (i) Registration of pregnant and F.H.W.                       During visits
             lactating mothers.
       (ii) Registration of 0 to 5 years M.P.W. (M/F)                During visits
             children.
       (iii) Registration of grade III and IV A.W.W.                 During      visits,
             children under ICDS.                                    weekly.

       B. Antenatal Care
       Tab. Iron and Folic Acid, Tab. Poly- F.H.W., F.H.S.           During visits
           vitamin, Inj.T.T.

       C. Child Care
       Immunization, Tab. Iron Folic Acid, M.P.W. (M/F)              During visits
       Vitamin 'A', O.R.S.                 M.P.H.S. (M/F)
                                           A.W.W.
10     Family Welfare Services
       1. Health Education and I.E.C.      M.P.W. (M/F)              During visits
                                           M.P.H.S. (M/F)
       2. Temporary methods (Condom, M.P.W. (M/F)                    During visits
          Oral pills, Copper-T)            M.P.H.S. (M/F)
       3. Sterilization                    M.O./Surgeon              During visits
11     Medical Treatment
       Case Treatment                      M.O., M.P.W. (M/F)        Weekly/as and
                                           M.P.H.S.     (M/F)        when required.
                                           Work charge Clerk




Disaster-2008_Action Plan-08             217
Sr.                                           Who will do ?          When ?
No.    Type of Work
12     First Aid
        (i) Treatment of minor ailments and M.P.W. (M/F)             During visits
             minor injuries.                  M.P.H.S.       (M/F)   During visits
                                              Work charge Clerk      Daily
        (ii) Refilling of First aid box.      M.P.H.S. (M/F)         Weekly / as and
                                              M.O. P.H.C.            when required
13     Miscellaneous
       (i)     Monitoring of F.T.D. Center at Malaria Supervisor     During visits
             every worksite.                  M.P.W. (M/F)           During visits
                                              M.P.H.S. (M/F)         During visits
       (ii) Distribution of ORS packets ; to As above.               During visits.
             work charge clerk.
       (iii) Water samples.                   District Supervisor    During visits or
                                                                     as and when
                                                                     required.
14     Referral Services at
       (i) P.H.C.                            M.O., P.H.C.            As and      when
       (ii) C.H.C.                           C.H.C. Suptd. and       required.
                                             Medical Staff.          -- do --
       (iii) District Hospital.              C.D.M.O. and other      As and      when
                                             Medical Experts.        required
       (iv) Rapid Response Action during District R.R.T.             As and      when
             outbreak.                       State R.R.T.            required
15     Laboratory Surveillance
       (i) At P.H.C. Level                   M.O., P.H.C.            As and      when
                                             Lab. Technician         required
       (ii) District Level                   Microbiologist          As and      when
                                             Pathologist             required
                                             Lab. Technician
16     Reporting
       (i) Regular at P.H.C. Level           M.O., P.H.C.            Fortnightly /
                                             M.P.H.S. (M/F)          Monthly
       (ii) Regular at District Level        C.D.H.O., E.M.O.,       Fortnightly /
                                             E.C.S.S., Dist. Sup.    Monthly
       (iii) Diseases for Surveillance
             12 Diseases - P.H.C.            M.O., P.H.C.
                            - District Level C.D.H.O.                Every Saturday
                            - State Level    Deputy Director         Every Monday
       (iv) Outbreak Reporting :                                     Every Tuesday
             - At worksite                   Work charge Clerk       Immediately
             - At P.H.C. Level               M.O., P.H.C.            Immediately
             - At District Level             C.D.H.O., E.M.O.,       Immediately
                                             District Supervisor.

            - At State Level                   Deputy Director       Immediately


Disaster-2008_Action Plan-08             218
                                       Annexure - II

Check-list for Medical Officer / Health Supervisor during Scarcity worksite visit.


Name of the village :                                   Population :
P.H.C. :                    Taluka :                    District :
Name of worksite:
No. of Labourers:
Name of Muster Clerk:               1.



                                    2.


1.     Points to be examined:
       (a) Availability of sufficient stock:
       1. First aid box.                                        Yes / No
       2. Savlon                                                Yes / No
       3. Dettol                                                Yes / No
       4. Tr. Benzoin                                           Yes / No
       5. Tr. Iodine                                            Yes / No
       6. Eye Ointment                                          Yes / No
       7. Skin Ointment                                         Yes / No


       (b) Chlorinating agents:
                                                                              Quantity
       1. TCL                                                   Yes / No      …………
       2. Tab. Chlorine                                         Yes / No      …………


2.     Sources of Drinking Water:
       1. Well / Hand Pump / Pond /Tanker/Tank/Tanki.
           Adequate ?                                           Yes / No
       2. Regular Chlorination                                  Yes / No


3.     Free Residual Chlorine:                          ………….P.P.M.


4.     Date of Refilling of First Aid Box:              Date: …………….
5.      Availability of Shed:                        Yes / No


6.      Distance of Fair Price Shop:
        a. From worksite                                   ……………Km.
        b. From residence                            ……………Km.

7.      Information regarding cases and treatment.


                                       # of Cases # of Cases Total # of
SN     Diseases
                                       Treated    Referred   Cases

1      Diarrhea

2      Vomiting
3      Typhoid
4      Jaundice

5      Dysentery

6      Fever
7      Scabies
8      Other Skin Infection

9      Eye Diseases

10     Night Blindness
11     Worm Infection
12     Ear Discharge

13     Anaemia

14     Protein Caloric Malnutrition
15     Vitamin Deficiency (Specify)
16     Mental stress (depression)

17     Other (Specify)




                                       Signature of Medical Officer/Health Sup.
                                       Name      :
                                       Designation :


Disaster-2008_Action Plan-08            220
STATEMENT SHOWING DISTRICTS, TALUKAS & VILLAGES AFFECTED BY
DROUGHT DURING THE YEAR 1999-2000, 2000-2001 & 2002-2003.


                                  1999-2000              2000-2001           2002-2003
Sr.
      District                                                            Taluk
No                             Taluka   Villages      Taluka   Villages           Villages
                                                                          a
1     Ahmedabad                   5        29           11       539        5        120
2     Amreli                     11       627           11       627        -         -
3     Banaskantha                14       661           10       607        8       742
4     Vadodara                    -        -            11      1249        -         -
5     Bhavnagar                  11       823           11       824        -         -
6     Bharuch                     1        68            6       193        -         -
7     Gandhinagar                 -        -             4       167        -         -
8     Jamnagar                   10       675            8       573        10      674
9     Junagadh                   12       529           14       595        11      368
10    Kheda                       2        2            10       616        6       144
11    Kutch                      10      1000           10       897        10      899
12    Mehsana                     4       111            9       352        -         -
13    Panchmahal                  9       857           11      1192        2        37
14    Rajkot                     14       865           14       865        14      822
15    Sabarkantha                 5       314           13      1162        5       212
16    Surat                       -        -             6       200        -         -
17    Surendranagar               8       439           10       529        8       630
18    Anand                       -        -             8       216        3        17
19    Dahod                       9       985            7       696        -         -
20    Narmada                     -        -             4       459        -         -
21    Patan                       8       527            8       439        6       366
22    Porbandar                   3       154            3       149        3       113
23    Navsari                     -        -             1        2         -         -
24    Valsad                      -        -             -        -         -         -
25    Dang                        -        -             -        -         -         -
TOTAL…                           136     8666           200     13148       91      5144




Disaster-2008_Action Plan-08                    221
                    HEALTH AND FAMILY WELFARE DEPARTMENT
                           GOVERNMENT OF GUJARAT

A short note on Health and Medical Relief measures carried out in the
expected drought affected areas of Gujarat – 2004.


1.    In the entire 18 drought affected districts of the State, health and medical relief
      has been provided to expected 13000 affected villages in the entire state.


2.    A cell is established under Deputy Director, Epidemic Control, Health services,
      to extensively monitor and review the health and medical relief activities carried
      out in the drought affected areas. Control rooms had been set up both at the
      state level as well as at the district head quarters.


3.    Chief District Officers assigned the responsibility of District Nodal Officers
      to plan, implement, monitor and review relief measures in the affected areas.
      They have to carry their work under the administrative guidance from district
      relief committees, collectors and District Development Officers.


4.    Primary Health Canters (PHC) Medical Officer had to pay one visit to every
      relief work every week with paramedical and sufficient drugs. Nevertheless,
      Multipurpose Health Workers (Male / Female) had also conducted regular visits
      to scarcity works once in a week.


5.    ……………Pregnant and ……………lactating mothers were being provided
      …………………… Iron folic acid tablets by paramedical and Anganwadi
      workers in the drought affected districts at relief sites.


6.    Essential health and medical services made available at the relief work site
      itself and on the spot. Essential drugs like anti-diarrhoeal and O.R.S. packets,
      drugs for skin infections, painkillers like Paracetamol and Poly-vitamin for
      vitamin supplementation were also provided in first aid box at each site. In
      order to provide safe water, chlorine tablets were made available with due
      guidance for pot chlorination to prevent water-borne diseases.



Disaster-2008_Action Plan-08                 222
7.    The Health and Family Welfare Department is reviewing and monitoring the
      scarcity, health and medical relief works services every week at state level and
      providing necessary guidelines to improve and strengthen the relief measures.




                                   SCARCITY PROPOSAL
                                 HEALTH AND NUTRITION


        During scarcity period, health care measures require intensification. Regular
Health checkup at the relief sites provision of vitamins, medicines, ORS packets and
additional nutrition has to be made. In a drought situation due to shortage of water
and food especially milk and green leafy vegetables and due to shortage of water for
drinking and unhygienic conditions diseases related with the immunity status of the
people usually increase.         The women and children are affected the most.    The
problem gets compounded and multiplied if poverty, illiteracy and backwardness
exists also. The estimated population of children below 5 years is 11.5 % and
pregnant and lactating women is 3.5%. Care shall have to be taken for people in
drought affected areas as well as for those working at work sites.


EFFECTS OF DROUGHT ON HEALTH STATUS OF AFFECTED PEOPLE


               Infant mortality rises
               Malnutrition
                -       Protein energy malnutrition
                -       Vitamin-A deficiencies such as Xeropthalmia, night blindness,
                        keratitis, photophobia, bitot‘s spots and blindness in extreme
                        cases.
                -       Anaemia
                -       Multiple vitamin deficiencies.
               Waterborne diseases like diarrhea and dysentery
               Skin infection such as scabies
               Worm infestation
               Conjunctivitis
               Injuries while working at work sites.

Disaster-2008_Action Plan-08                 223
CONTINGENCY PLAN FOR MEDICAL CARE DURING DROUGHT.


        Health and Family Welfare Department will monitor and review public health
measures at state level.
        1.      Commissioner, Health, Medical Services and Medical Education will
                implement the public health measures for the drought affected areas in
                the State.
        2.      Deputy Director, Epidemic Control will work as nodal officer under the
                guidance of Additional Director (Health Services) to review and monitor
                scarcity relief services in the drought affected areas.
        3.      Provision of prompt and effective health and medical and nutritional
                services will be coordinated under guidance of District Development
                Officer, District Collector and other senior officers in the district.. Chief
                District Health Officers will also monitor and review the public health
                measures for drought-affected areas in the Districts.
        4.      Provision of adequate bleaching powder and chlorine tablets to
                disinfect the identified drinking water sources.
        5.      Stocking of essential drugs including ORS packets at Community
                Health Centers, Primary Health Centers and Sub centers.
        6.      The people in drought-affected areas are prone to suffer from various
                grades and types of malnutrition. The deficient intake of food in the
                form of calories and protein leads to protein energy malnutrition. The
                deficiency of micronutrients due to shortage of green leafy vegetables,
                milk etc. causes various vitamin deficiencies such as Vitamin-A
                deficiency, multiple Vitamin deficiency and Anaemia. Mega dose of
                vitamin-syrup will be provided to children below 5 years. Similarly iron
                folic Acid tablets will be given to pregnant and lactating women,
                children and persons suffering from Anaemia.
        7.      Measles, Diphtheria, Whooping cough, Neonatal tetanus, poliomyelitis
                and childhood tuberculosis are the vaccine preventable diseases
                usually affecting children. The severity of morbidity and the mortality
                increases if the nutritional status of children is compromised.
                Therefore, regular immunization activity will be required to be
                undertaken in drought-affected areas.
Disaster-2008_Action Plan-08                 224
        8.      Scarcity affected areas witness increased morbidity of various
                communicable diseases associated with malnutrition. It is necessary to
                make the treatment facilities available and easily accessible to the
                people in drought-affected areas. There is a fairly well developed
                health care infrastructure in the State, Consisting of Primary Health
                Centers and Community Health Centers. Sufficient stock of medicines
                will be kept in various health centers for the ailments usually occurring
                in drought-affected areas. To prevent vaccine preventable diseases,
                enough vaccine will be also made available.           The immunization
                sessions will be held regularly to immunize children and pregnant
                women.
        9.      Medical teams comprising of medical and paramedical staff will visit the
                villages and also the work sites to provide immunization against six
                vaccine preventable diseases, distribution of Iron Folic Acid tablets and
                Vitamin-A. They will also provide treatment for minor ailments.
        10.     Reporting and feedback mechanisms will be established between
                PHCs, CHCs, District and State.
        11.     First aid boxes will be made available at the work sites.
        12.     Health education to the people regarding the need of maintaining
                hygiene and consumption of safe drinking water. Lack of personal
                hygiene leads to certain skin infections, eye infections, worm
                infestation etc. and consumption of unsafe water leads to waterborne
                diseases like diarrhea, and dysentery. People should be made aware
                to maintain personal hygiene and consume safe water. They should
                be informed about need of chlorination of water. This will be done
                through various methods of health education.          The medical and
                paramedical staff visiting the villages and work sites will disseminate
                message of safe health behavior through interpersonal communication.
        13.     NGOs would be also actively involved, as there are various NGOs in
                the State who have taken keen interest in providing relief services
                during calamities in the past.




Disaster-2008_Action Plan-08                225
                               HEALTH FOR HUMANITY


   Health and medical relief measures in the areas affected by communal
violence in Gujarat




Immediate measures on 27th February 2002


The report of the burning of a bogie of Sarbamati express at Godhra was received at
8:30 A.M. The Minister of Health rushed to Godhra with a renowned plastic surgeon
from B.J.Medical College, Ahmedabad. Teams of specialist doctors, nurses and
Paramedical also rushed from Medical College, Baroda and from nearby hospitals,
and CHCs and PHCs with ambulances. Health Minister and MOS (Health) camped
in Godhra all day to make arrangements for the injured patients and to oversee relief
activities.


Medical relief to the injured




Ambulance services were operationalised immediately at site at 8.30 AM to provide
first aid to the injured and shift the seriously injured to the hospital. 17 of the affected
people were provided treatment in the OPD.           21 severely injured patients were
admitted to Godhra Civil Hospital, 16 patients were transferred to Civil Hospital,
Ahmedabad and 3 patients were transferred for inpatient treatment at Medical
college hospital, Vadodara. All these patients were accompanied by specialists for
enroute care.
Postmortem was conducted on 58 dead bodies recovered from the affected bogie
(S-6) by 4.30 pm, at the site of the accident.


Shifting the dead to Ahmedabad


Of the 58 dead, 4 bodies were identified and handed over to relatives in Godhra
itself. Thereafter, the remaining 54 dead bodies were brought to Sola Civil Hospital,
Ahmedabad at 3.30 am on 28th Morning. In the normal course the dead bodies would
Disaster-2008_Action Plan-08                226
have been brought to the civil hospital at Ahmedabad. However, as the civil hospital
happens to be in the heart of the city it was decided to bring the dead bodies to a
hospital slightly outside the Ahmedabad city limits.


The bodies were placed in ice in a condition where they could be identified by the
relations and friends. Police arrangements for preparation of legal documents were
made on site. A press note was issued on Doordarshan as well as other channels
and AIR asking the relatives and friends to identify and collect the dead bodies at
Civil Hospital, Sola.


35 bodies were identified and handed over to the relatives. Arrangements were
made by the health department to transport the dead bodies to their respective
homes through government ambulances and funeral vans. Remaining 19
unidentified bodies, which were in an advanced stage of decay were subjected to
tissue reporting for DNA fingerprinting in Hyderabad. Thereafter, they were cremated
by the Health Department in accordance with the religious rites.

Immediate medical relief


Control room was activated at Commissionerate of Health and in all the districts on
27/2/02 to make arrangements for immediate treatment of injured people and post
mortem of dead bodies received at the hospitals. In all 105 medical institutions
provided relief and treatment to the injured.


Meeting convened by Health Minister with the elected representatives of the AMC for
coordinated care to the injured in Ahmedabad. The Chief Secretary, Revenue
Secretary, Relief Commissioner and Commissioner Health visited relief camps to
assess the medical and other relief requirements.




927 persons were examined and treated in three major camps in Shah-Alamroja,
Dariakhan gummad and Taslim society Vatva on 4/3/2002 by B.J. Medical
college/Civil Hospital, Ahmedabad. 11 seriously ill people were shifted to Civil
Hospital.


Disaster-2008_Action Plan-08               227
Rescue operations in a spirit of communal amity




During the period of rioting expert medical services were provided by the Civil
Hospital Ahmedabad to 466 seriously affected patients without any discrimination on
grounds of religion. Scenes of communal harmony at the hospital amidst general
misery were appreciated by the Joint Parliamentary Committee and all other
dignitaries.


The total number of injured treated in the different hospitals in the state during the
period of riots can be seen in table – 1 below.


        Table –1.       OPD, indoor patients and deaths due to violence in Gujarat


                   Date                OPD          Indoor    Total
                                                              Death
                   27/28-2-2002        190          134       95
                   Total               190          134       95
                   1-3-2002            662          623       328
                   2-3-2002            277          188       125
                   3-3-2002            60           36        21
                   4-3-2002            267          61        33
                   5-3-2002            58           57        53
                   6-3-2002            44           14        17
                   7-3-2002            77           28        11
                   8-3-2002            3            0         2
                   9-3-2002            9            10        3
                   10-3-2002           6            12        4
                   11-3-2002           11           4         6
                   12-3-2002           7            2         0
                   13-3-2002           22           6         0
                   14-3-2002           3            5         0
                   15-3-2002           25           14        2
                   16-3-2002           24           8         0

Disaster-2008_Action Plan-08                228
                   17-3-2002   36         34   4




Disaster-2008_Action Plan-08        229
                    18-22/03/02   39         52     13
                    23/03/02      6          3      1
                    24/03/02      5          7      2
                    25/03/02      44         6      0
                    26/3/02       7          6      1
                    27/3/02       4          4      1
                    28/3/02       0          1      0
                    29/3/02       6          3      0
                    30/3/02       11         4      3
                    31/3/02       84         40     13
                    Total         1797       1228   643
                    ¼/02          4          2      1
                    2/4/02        34         20     6
                    ¾/02          30         15     0
                    4/4/02        13         11     0
                    5/4/02        13         7      6
                    6/4/02        4          1      1
                    7/4/02        19         1      0
                    8/4/02        28         2      0
                    9/4/02        8          3      1
                    10/4/02       4          1      0
                    11/4/02       1          0      0
                    12/4/02       12         12     0
                    13/4/02       3          3      0
                    14/4/02       13         12     5
                    15/4/02       23         28     4
                    16/4/02       26         17     2
                    18/4/02       2          0      5
                    19/4/02       14         0      0
                    20-21/4/02    55         81     19
                    22/4/02       49         30     3
                    23/4/02       26         23     1
                    24-25/4/02    26         19     2


Disaster-2008_Action Plan-08           230
                    26-30/4/02           31         33       6
                    1/5/02               11         13       1
                    2/5/02               8          4        0
                    3/5/02               4          2        2
                    4/5/02               8          14       3
                    5-6/5/02             49         24       4
                    7/5/02               48         44       15
                    9/5/02               20         25       3
                    10/11/12/5/02        35         39       5
                    13-14/5/02           2          0        0
                    15-16/5/02           12         4        0
                    17-31/5/02           0          0        0
                    1-30/6/02            0          0        0
                    1-7-02 to 31/12/02   0          0        0
                    TOTAL                2744       1920     878




RELIEF ACTIVITIES IN CAMPS


       205 Medical officers and 273 Paramedical staff providing health care services
        in 113 relief camps


       450596 cases treated, in other words each camp patient has been examined
        on an average 3-4 times by our doctors.


       As a result the prevalence of various illnesses, which could have been very
        high has been kept in check as can be seen from the table below.




Disaster-2008_Action Plan-08                  231
   Disease profile in the camps in comparison with the prevalence in the state
  Type          of Prevalence in Gujarat during 2002                In         relief
  cases                                                             camps
                     January   February   March     April    May    6/3           to
                                                                    31/12/02
  Diarrhoea          3.85%     3.46%      3.62%     3.77% 3.75% 4.05%
  Gastroenteriti     0.18%     0.17%      0.36%     0.42% 1.58% 0.15%
  s
  ARI                11.27%    13.27%     9.54%     11.33    8.66% 4.88%
                                                    %


Care for community


The emphasis was on provision of medical care to the injured and shifting of serious
cases to the hospitals


Arrangements were made to set up medical teams in all the relief camps. Teams of
doctors, paramedical staff mobilized from CHCs and PHCs surrounding Ahmedabad.
Initially 64 medical teams were established, with75 MOs and 56 paramedical staff.
12 vans equipped with doctors, paramedical staff and medicines provided to MLAs in
Ahmedabad to provide relief in their respective constituencies.


Employees State Insurance Scheme (ESIS) dispensaries were providing medical
relief even to the non-member, riot affected population through their dispensaries at
Ahmedabad.


Currently, there is 1 relief camps in Ahmedabad city. Medical Teams consisting of 1
Medical Officers, provide relief in bigger camps. In addition 14 ESIS mobile teams
were providing to the 14 MLAs in Ahmedabad. This was supplemented by19 ESIS
dispensaries as well as14 mobile teams of ESIS hospital up to 3rd May 2002. Mobility
was provided to these medical personnel by 50 ambulances. So far 405440 patients
have been treated by these teams in Ahmedabad in co-ordination with the local
social workers.



Disaster-2008_Action Plan-08              232
In addition, there were no camps in 7 other districts of the state. 45156 cases had
been treated in these camps.
Table – 2 Health services to Persons in relief camps as on 31-12-2002.



                                 Medical Team                           No. of
                                                              No of     Treated   Progres-
      Name       of No. of                          No. of
No.                                    Para                   Treated   Patients sive
      District     Camps                            Persons
                                 MOs   Medical                Patients Previousl Total
                                       s                                y

                   --        1   1     1            495       63        308860    308923

                   Mobil
                                                                        65873     65873
      Ahmedab e
1
      ad
              ESIS                                                      27259     27259

                   AMC                                                  3385      3385

TOTAL - A          --        1   1     1            495       63        405377    405440

2     Godhra       --        -   -     -            -         -         10783     10783

3     Mehsana --             -   -     -            -         -         3776      3776

      Sabarkant
4                  --        -   -     -            -         -         13282     13282
      ha

5     Anand        --        -   -     -            -         -         7760      7760

6     Vadodara --            -   -     -            -         -         4142      4142

7     Dahod        --        -   -     -            -         -         4300      4300

8     Kheda        --        -   -     -            -         -         1113      1113

TOTAL - B          --        -   -     -            -         -         45156     45156

TOTAL A + B --               1   1     1            495       63        450533    450596




Disaster-2008_Action Plan-08                  233
Disease profile of the cases treated in camps


As can be seen from the chart below, most cases needing medical treatment are for
fever, acute respiratory infections, gastro-enteritis, diarrhoea, and injuries.



                         Diseases Profile in Relief Camps


                                                                               I nj ur y
                                                                               1. 4 1%

                                                                                     D i ar r ho ea
          O t her                                                                        5. 2 7%
         74 . 58 %                                                                           GE
                                                                                           0 .2 4 %




                                                                                ARI
                                                                               9 .4 3 %


                                                                    F ever
                                                                    9 . 0 7%




Adequate medicines have been procured and have been made available to the
hospitals and mobile teams.


In addition eye check up is being carried out for detection of refractive errors and
cataract under the National Programme for Control of Blindness.


Testing for malaria is being carried out regularly to prevent the spread of malaria.




Preventive action




Immunization of children




Disaster-2008_Action Plan-08                234
Chlorination of drinking water is strictly ensured. A log book is maintained by medical
team in each of the camps. More then 2.25 million chlorine tablets have been
supplied so far, for this purpose


Coordination of hygiene and sanitation with Ahmedabad Municipal Corporation,
mobile toilets has been operationalised.


Checking of food articles by the Prevention of Food Adulteration staff, to ensure
fresh and hygienically prepared food is provided in the camps.


DDT and Malathion sprayed for sanitation and control of mosquitoes in the area.




Disaster-2008_Action Plan-08               235
                               Mother and child care a priority


To boost up MCH and Immunisation services at relief camps, the State RCH Officer
has been assigned the job to plan and monitor the MCH care activities such as
Tetanus Toxoid to pregnant women, distribution of Iron Folic Acid to pregnant
women and lactating mothers and children. ORS packets are being distributed to
reduce morbidity due to diarrhoea. At the same time care is being taken to prevent
pneumonia. The measles immunization campaign has been planned, and
implemented to cover the children of the age group from 9 months to 59 months. To
effectively carry out this program training program was conducted on 15th March,
2002 for medical officers and paramedical staff regarding the use of auto destruct
syringes and aseptic precautions for measles immunization. Measles immunization
campaign has been implemented on 16th March, 2002 in all the relief camps. Utmost
care was taken to maintain vaccine potency and efficacy through cold chain
maintenance.


In all 4333 pregnant women have been examined and 503951 Iron Folic Acid tablets
have been distributed. 2001 pregnant women have been given Tetanus Toxoid
injections. 12407 children of 9 months to 59 months age group have been covered
under measles campaign. In addition 66640 ORS packets have been made available
in all camps.


16847 doses of Polio vaccine have been given to children.


2593 children were covered for deworming.


30 post graduate lady doctors and 33 ANMs providing health services in the relief
camps.


Total deliveries in camp—36 & outside camp—90 Total deliveries—126




Disaster-2008_Action Plan-08                 236
TERTIARY CARE ACTIVITIES


       Teams of 30 gynecologists, pediatricians, mental health experts, sent by
        rotation to different camps have provided expert gynecology services to 1330
        women, pediatric services to 4488 children, medical services to 628 patients,
        ophthalmology services to 292 patients and dermatological care to 343
        patients.


       804 patients referred to tertiary care facilities for in-patient care.
MEDICAL RELIEF ACTIVITIES BY CENTRAL HEALTH TEAM (DGHS),GOI
.
           7247 Patients were examined and provided treatment as below,


                o Obs. & Gynac------324
                o Pediatrics-----------1926
                o Medicine------------3408
                o Psychiatry----------1
                o Ophthalmology----671
                o Dermatology-------798
                o Dental---------------1
MENTAL HEALTH


               Therapeutic intervention in camp were given to 1267 persons
               Group Counselling given to 1018 persons with specific Mental health
                problems who required specific drug treatment or individual psycho
                therapeutic intervention
               Two teams are attending the camps on Monday and Friday of the week
                in specific relief camps allotted to them.
               Training was given to 170 participants for Psycho-social work.




Disaster-2008_Action Plan-08                  237
Activities for control of Blindness




Ophthalmic care is being provided to the needy in the relief camps with the help of
ophthalmologists as well as paramedical ophthalmic assistants. So far 11624
patients have been examined. 5050 pairs of spectacles have been provided to those
with refractive errors. 229 cataract cases were detected with cataract. Out of this 213
cataract operations have already been performed. The remaining cataract surgeries
are also proposed to be carried out in the days to come.




Information Education and Communication (IEC) activities




IEC officers of the State Health Education Bureau are providing health education and
counseling to the internally displaced persons. The IEC material regarding sanitation,
as well as water chlorination is being provided by WHO as well as State Health
Education Bureau. The case definition manual has also been provided to each team
to facilitate the diagnosis and reporting.




Management structure for the relief works


The medical relief in the camps is being carried in a very systematic manner. The
whole operation is headed by the Additional Director of health Services. He is
assisted by the two Regional Deputy Directors who look after the management of
medical teams as well as the supply of drugs and medicines to the camps.
Supervisory teams are headed by a senior class one Zonal Health Officer and
Assisted by Medical Officer. The whole structure can be seen in the chart below.


The Supervisory teams visit almost all camps in allotted regions and inspect the work
of the medical teams. At the end of day Zonal officers collect the daily report
regarding medical relief, sanitation, chlorination and other health related activities

Disaster-2008_Action Plan-08                 238
from the medical teams. Corrective measures are taken by the teams on the spot.
Where required the attention of Ahmedabad Municipal Corporation is drawn to
improve sanitation in the camps.


   Management Structure for
         Relief Work



                                                      Dr. A. P. Kaswekar
                                                  Additional Director ( Health)



                                                    ( RDD - Gandhinagar)                  ( RDD - Ahmedabad)
                                                 Management of MedicalTeams               Management of Drugs



   Nodal Supervision Officers    CDHO - Ahmedabad                        Addl. DHO - Ahmedabad              Addl. Dir. STDC- Ahmedabad
                                East Zone - supervision                  South Zone - Supervision         North & Central Zone - Supervision



                                         Control Room Duty                 DTO- Gandhinagar               M.O. - Gandhinagar
                                                                       Medical Team, Medicine and                 MIS
                                                                          Vehicle Management




Monitoring and evaluation




Independent monitoring is being carried out by WHO to ensure all the above actions
are carried out rigorously. Proforma developed by WHO during earthquake in Bhuj
being used for proper follow-up action.


Similarly the Preventive and Social Medicine Department of the local BJ Medical
College is also doing a daily review of the activities and providing a report to the
Commissionerate of Health.

The Indian Red Cross has also started reviewing the relief work in the camps and
reporting to the government on the necessary corrective measures required to be
taken.
Monitoring and evaluation is being carried out by State health authorities. Senior
officers of the department visit different camps on a daily basis to ensure that above
work is being carried out. All affected districts are reporting at state level in
prescribed format. The reports are compiled and feed back is provided for corrective
action. The consolidated report is being sent daily to Relief Commissioner at State
control room, of the Revenue Department.

Disaster-2008_Action Plan-08                                     239
                                     Health for humanity
                         Department of Health, Government of Gujarat
                                in the service of the riot affected
IMMEDIATE MEDICAL RELIEF


         4664 patients treated in 113 health care facilities.


         1920 of these patients admitted as indoor patients
RELIEF ACTIVITIES IN CAMPS


         205 Medical officers and 273 Paramedical staff providing health care services
          in 113 relief camps


         450596 cases treated, in other words each camp patient has been examined
          on an average 3-4 times by our doctors.


         As a result the prevalence of various illnesses, which could have been very
          high has been kept in check as can be seen from the table below.




   Disease profile in the camps in comparison with the prevalence in the state
  Type           of Prevalence in Gujarat during 2002                       In         relief
  cases                                                                     camps
                     Januar      February March           April       May   6/3           to
                     y                                                      31/12/02
  Diarrhoea          3.85%       3.46%        3.62%       3.77%       3.75% 4.05%
  Gastroenteriti     0.18%       0.17%        0.36%       0.42%       1.58% 0.15%
  s
  ARI                11.27%      13.27%       9.54%       11.33%      8.66% 4.88%




Disaster-2008_Action Plan-08                    240
PREVENTIVE ACTION


       2.25 million Chlorine tablets used for chlorination of drinking water
       Checking of food articles by PFA staff
       Malathion spray for control of mosquitoes
       Antifly spray for control of flies




SPECIAL ATTENTION TO MOTHERS AND CHILDREN


       State MCH officer assigned overall responsibility


    Mothers - ante natal care
       4333 expectant mothers registered under the ante natal care program, 127 of
        these who were identified as high risk, have already been examined by expert
        gynecologists
       2001 expectant mothers provided TT protection
       647 dai delivery kits have been distributed
       126 safe deliveries out of which 36 were handled in camps
       580445 iron folic acid tablets distributed to anemic mothers
    Children
       2.76 lack iron folic acid tablets distributed to children
       16847 children given polio vaccine
       12407 children protected with measles vaccine
       3851 children given DPT protection
       2593 children covered for deworming
       66640 ORS packets distributed
       30 post graduate lady doctors and 33 ANMs providing health services in the
        relief camps




Disaster-2008_Action Plan-08                 241
TERTIARY CARE ACTIVITIES


       Teams of 30 gynecologists, pediatricians, mental health experts, sent by
        rotation to different camps have provided expert gynecology services to 1330
        women, pediatric services to 4488 children, medical services to 3408 patients,
        ophthalmology services to 671 patients and dermatological care to 798
        patients.
       804 patients referred to tertiary care facilities for in-patient care.
       Activities for control of blindness


               11624 patients examined


               5050 pairs of spectacles distributed


               213 IOL operations performed


MEDICAL RELIEF ACTIVITIES BY CENTRAL HEALTH TEAM (DGHS),GOI


           7157 Patients. were examined and provided treatment as below,


                o Obs. & Gynec------324
                o Pediatrics-----------1926
                o Medicine------------3408
                o Psychiatry----------1
                o Ophthalmology----671
                o Dermatology-------798
                o Dental---------------1


MENTAL HEALTH


               Therapeutic intervention in camp were given to 1267 persons
               Group Counselling given to 1018 persons with specific Mental health
                problems who reqired specific drug treatment or individual psycho
                therpetic intervention

Disaster-2008_Action Plan-08                  242
               Two teams are attending the camps on Monday and Friday of the week
                in specific relief camps allotted to them.
               Training was given to 170 participants for Psycho-social work.


PROMOTIVE ACTIVITIES


       IEC materials distributed


       Volunteers used for chlorination, and maintenance of hygiene in camps and
        health promotion




MONITORING AND EVALUATION


       Routine monitoring and evaluation being carried out by the Senior officials of
        the Health Department. In addition there is independent monitoring by:


            o PSM department of BJ medical College
            o WHO surveillance teams and
            o UNICEF


       This is what they had to say:
        Clean Drinking water available in all camps.


        Medical teams deputed by the department were found to be regularly visiting
        the camps. There was adequate supply of medicines.


        Cold chain was very good, disposable syringes were being used and there
        was good coverage of children in the camps under immunization programme


       The High Court of Gujarat has observed that ‗so far as medical facilities are
        concerned, proper care has been taken by the State‘




Disaster-2008_Action Plan-08                 243
IMMEDIATE MEDICAL RELIEF.


No. of Health Care facilities            No. of Treated Patients No. of Indoor Patients
113                                      4664                     1920



RELIEF ACTIVITY IN CAMP.


# Of Relief Camp          # Of Medical Officer     # Of Paramedical   #   Of    Patients
                                                                      Treated
113                       205                      273                450496


TERTIARY CARE ACTIVITY.


(1)     Treatment given by specialist.


                Total No. of Patient examined - 7081
Gynecology           Paediatric        Medical            Ophthalmology Dermatology
                                       Services
1330                 4488              628                292             343


(2)     Medical Relief activity by Central Health Team from (DGHS),
        Govt. of India.
                Total No. of Patient examined - 7247
        Obs. & Gynac                               324
        Paediatric                                 1926
        Medicine                                   3408
        Psychiatry                                 1
        Ophthalmology                              671
        Dermatology                                798
        Dental                                     1
(3)     Mental Health.
       Therapeutic Intervention                   1297 persons
       Group Counseling given                     1018

Disaster-2008_Action Plan-08                 244
       Training given for Psycho-social 170 participants
       work
(4)     Blindness Control.
       Patients Examined                           11624
       Spectacles given                            5050
       Cataract cases detected                     229
       Cataract Operation performed                213
(5)     Mother & Child Care.
        Mother Care:
       Total expectant Mother                      4333
       High risk mother                            127
       Inj. T.T. given                             2001
       Dai Delivery kits distributed               647
       Tab. Iron folic acid distributed            580445
       Total Deliveries :                          126
                                      in camp      36
                               Outside in Camp     90


        Child Care:
       Tab. Iron Folic Distribution                2.76 Lacs
       Polio Vaccine given                         16847
       Measles Vaccine                             12407
       D.P.T. given                                3851
       Deworming                                   2593
       O.R.S. Packets Distributed                  66640


(6)     Preventive Action.


       No. of Chlorine Tab. Distribution           2.25 Million
       Checking of Food articles                   By PFA staff
       Control of Mosquitoes & Flies               By Malathion & Antifly spray




Disaster-2008_Action Plan-08                     245
               Occupational Health & Disaster
        Gujarat is the most industrialized state in India. It contributes more than 13
per cent of national industrial production. As far as the state economy is concerned,
manufacturing sector alone contribute 32.6 per cent of the state income & 16 per
cent of total workforce.


        Due to favorable policies, the industrial base got increasingly diversified with
petrochemical and fertilizers, pharmaceutical and drugs, dyestuff as well as
engineering and electronic industries.


        According to the 2001 Census there are 212.47 lakhs workers in the state and
43 lakhs were marginal workers.


        In 2001 the women's work participation rate in rural & urban areas is about 39
per cent & 13.5 per cent respectively.


        In terms of occupational diversification, urban women workers are engaged in
more diversified activities than the rural women workers.


        Occupational Health is basically a preventive medicine. Occupational Health
should aim at the promotion & maintenance of the highest degree of physical, mental
and social wel-being of the workers in all occupation even at the time of
Occupational disaster.




Disaster-2008_Action Plan-08               246
        The level of application of prevention is the same
                                Health Promotion


                               Specific Protection




                                 Early Diagnosis




                                 Early Treatment




                               Disability Limitation




                                  Rehabilitation




Disaster-2008_Action Plan-08          247
        For          the         prevention   of   Occupational
Hazards, the tools in Occupational Disaster are




                               Epidemiologic Approach




                                     Statistics




                                  Health Screening




                                  Health Education




Disaster-2008_Action Plan-08           248
            Industrial workers constitute the segment of the general population, so the
factors that influence the health of the population also apply equally to industrial
worker i.e. housing, water sewage and waste disposal, nutrition & education----
---------
            In addition to these the workers working in the factories are also at risk of

Occupational health problems, as well as the                consequences of
occupational disasters.
            Today the Industrial Workers are placed in a highly complicated environment.
Basically there are three types of interactions in an occupational environment.
Physical, Chemical & Biological Agents.
Physical Agents:
Heat,
Cold Humidity,
Air Movement,
Heat Radiation,
Light,
Noise,
Vibrations and Ionizing Radiation.
            The amount of working and breathing space, toilet, washing and bathing
facilities are also important factors in an occupational hazard.
Chemical Agents:
            Includes large no. of chemicals, toxic dusts and gases which are potential
hazards. Some chemical agents cause disabling respiratory illnesses, some agents
cause injury to skin and some have a drastic effect on the blood and other organ of
the body.
Biological Agents:
            The workers may be exposed to viral, bacterial, rickettsial, and parasitic
agents due to close contact with animals or their products, contaminated
water, soil or food.
Man & Machine:
            Unguarded machines and its moving pats, poor installation and lack of safety
measures lead to the accidents which is a major factor in occupational hazards.



Disaster-2008_Action Plan-08                 249
        Due to long working hours in unphysiological postures is the cause of fatigue,
backache, joint diseases, and muscular diseases leads to impairment of worker's
health and efficacy.




Man &Man:
        Numerous psychological factors related to human relationships
amongst workers and the authority.
        The psychological factors include
         Type and rhythm of work,
        Work stability,
         Service conditions,
         Job satisfaction,
        Leadership style,
        Security,
        Workers participation,
        Communication,
        System of payment,
         Welfare conditions,
        Degree of responsibility,
        Trade union activities,
        Incentives and a host of similar other factors come in the field of human
relationship.


        Now a day the emphasis is upon the people, the condition in which they work,
their hopes, fears and their attitude towards their work, their fellow workers and the
employers.


The domestic environment also affects the efficiency at the place of work
which may turn in to an accident.




Disaster-2008_Action Plan-08              250
Hazards in Occupational Disasters
        There are five types of Occupational hazards. They are as follows-----




                     Physical Hazards
                     Chemical hazards
                     Biological hazards
                     Mechanical hazards
                     Psychological Hazards
Physical hazards
Heat and Cold
It is a common hazard in industries which leads to Burns, Heat-Exhaustions, Heat-
stroke & Heat cramps.
The indirect effects are Decreased efficiency, increased fatigue leads to enhanced
accident rate.
Heat radiation is common in the industries having oven & furnaces in foundry, gas &
steel industry.
Heat stagnation in cotton & jute industry.
High temperatures are also found in mines.
Physical work under these conditions is very stressful & impair the health &
efficiency of the worker.
Important hazards with cold work are chilblains, erythrocynosis, immersion
foot and frostbite due to cuteness vasoconstriction.

Light
The workers are exposed to poor illumination or excessive brightness.
Poor illumination leads to eye strains, headache, eye pain, and lacrymation,
congestion around the cornea & eye fatigue.
The chronic effect leads to "miner nystagmus"
Excessive light leads to discomfort & visual fatigue, blurring of vision leads to an
accident

Noise
The effects of noise are auditory & non auditory depends upon intensity
frequency duration of exposure & individual susceptibility.
Leads to temporary or permanent hearing loss, nervousness, fatigue, interference
with communication by speech, decreased efficiency & annoyance.

Vibration
Vibration may be encountered in drill & hammers
Exposer leads to constriction of vessels in the fingers leads to "White fingers" & also
leads to injury to the joints of the hands elbow & shoulder.

Disaster-2008_Action Plan-08                       251
Ultra violet radiation
It occurs in arc welding.
It affects the eyes causing intense conjunctivitis & Keratitis ("Welder's flash") i.e.
redness of eyes & pain.

Ionizing Radiation
It is common in medical industries.
E.g. X rays and radio active isotopes. Cobalt 60 and Phosphorus 32.
This may lead to genetic changes, malformation,cancer,leukaemia,depilation,
ulceration, sterility,& in extreme cases leads to death.
The maximum level of exposure is 5 rem per year to the whole body.

Chemical hazards


         Chemical hazards are on increase due to introduction of newer complex
          chemicals.
         They act in three ways, local action, inhalation & ingestion.
         Local action causes dermatitis, eczema, ulcers and even cancer by primary
          irritant action.
         Some chemicals such as TNT and aniline are absorbed through skin
          causing systemic effects.
         Occupational dermatitis is a great problem in industry due to machine oil,
          rubber, rays, caustic alkalies and lime.
         Inhalation of dusts, they are small solid particles with size of 0.1 to 150
          microns are released during crushing, grinding, abrading, loading and
          unloading operations.
         The dust are of two types Soluble & non soluble.
         The soluble are excreted but the non soluble dusts remains in the lungs
          causing Pneumoconiosis, silicosis & anthracosis.
         Exposure to gases specifically Carbon monoxide is frequently reported in a
          coal-gas manufacturing plants.
         Some of the metals & their compounds are inhaled causing the toxic effect
          of lead, antimony, arsenic, beryllium, cadmium, cobalt, manganese mercury,
          phosporus, chromium, zink and others.
         The effect depends upon duration of exposure, concentration dose.
         Occupational diseases can occur from ingestion of chemical substances like
          lead, mercury, arsenic etc….Much of the ingested material is excreted
          through faeces but small proportion may go in to circulation.
Disaster-2008_Action Plan-08                252
Biological hazards
  The worker may expose to infective & parasitic agents t the place of work.
  These may lead to brucellosis, Leptospirosis, anthrax, hydatidosis, psittacosis,
    tetanus, encephalitis, fungal infection, schishtosomiosis etc….
  Persons working in animal products e.g. hair, wool, hides & agriculture are more
   prone to biological hazards.


Mechanical hazards
   About 10% of accidents are due to protruding or moving parts of the machines.


Psychological hazards


   The psychological hazards arise from failure to adopt the alien psychological
      environment due to frustration, lack of job satisfaction; insecurity; poor human
      relationships & emotional tension are the factors which undermine the physical
      & mental health of the worker.
   These may lead to Psychological & Behavioral changes including hostility,
      aggressiveness, anxiety, depression tardiness, alcoholism, drug abuse,
      sickness & absenteeism.
   these may also lead to Psychosomatic ill health including fatigue, headache,
      shoulder pain, neck pain,bachepain,hypertension,heart diseases & rapid aging


Health Protections of Workers

The aim of the occupational is "the promotion and social well-being of workers
in all occupations"
The measures of the general health protection of workers are as follow--------
    1-      Nutrition in developing countries malnutrition is the key factor to poor
            health of workers & low work output. Malnutrition may also affect the
            metabolism of toxic substance & also the tolerance mechanism.
    2-      Communicable Diseases Control
             The industry should provide an excellent opportunity for early
                diagnosis, treatment, prevention and rehabilitation.



Disaster-2008_Action Plan-08                253
             The specific communicable diseases in India are tuberculosis, typhoid,
                viral hepatitis, Amoebiasis, intestinal parasites, malaria & venereal
                diseases.
             There should be an adequate immunization programme against
                preventable communicable diseases.
             Anthrax, undulant fever and Q fever are the examples of
                communicable diseases of occupational origin.
             There should specific sanitary measures in handling of working
                materials & substance.

3--         Environmental sanitation.
To prevent the spread of communicable diseases by water, food or other means the
following measures should be taken with in the industrial establishment.
            A sufficient supply of drinking water.
            Education of food handlers & others measures to prevent G.I.tract
               diseases.
            There should be sufficient number of latrines & urinals of the sanitary
               type. Garbage & waste disposal to avoid the breeding of flies and
               vermin.
            General plant cleanliness is one of the fundamentals of accident
               prevention & also contributes to the efficiency of the workers.
            Sufficient floor space to prevent respiratory infection & to provide
               comfort.
            There should be sufficient & suitable lighting artificial ,natural or both in
               every part of the factory.
            Effective & suitable measures should be taken for maintaining adequate
               ventilation & temperature.
            Protection against hazards to protect the worker from dust, fumes &
               other toxic substance.
4--        Mental Health
                     To promote the health & happiness.
                     To detect the signs of emotional stress & strain & to ensure
                         relief from stress & strain where possible.
                     Treatment & rehabilitation of those who are mentally ill.


Disaster-2008_Action Plan-08                  254
5-- Measures for women & children
             Expectant mothers should be given maternity leave.
             Provision of free antenatal & postnatal services.
             Women & children should not be employed in certain dangerous
                occupation.


6-- Health Education


                     Health is the basic need in workers about personal hygiene &
                        protection of workers in planning & operation.


7- Family planning
                     Family planning is the decisive factor in for the quality of life.




Disaster-2008_Action Plan-08                 255
                                Prevention
        (1) Medical Measures
                Pre-placement examination
                Periodical Examination.
                Medical & Healthcare Services
                Notification
                Supervision of working environment
                Maintenance & analysis of records.
                Health Education & counseling.
        (2) Engineering Measures


             Design of Building
             Good Housekeeping
             General Ventilation
             Mechanization
             Substitution
             Enclosure
             Isolation
             Local exhaust ventilation
             Protective devices
             Environmental monitoring
             Statistical Monitoring
             Research
        (3)Legislation


             Factory laws has been framed to govern the conditions in the industries
                & to safeguard the health & welfare of the worker.
             The most important factory laws in India are The Factory Act-1948 &
                The Employees State Insurance Act--1948


        Today there is no such organization for occupational hazards in India
but the organizations are cumulatively doing this job.
Disaster-2008_Action Plan-08               256
                                 No. EPC/Disaster Management Plan/Gujarat/462007/B.
                                 Commissionerate of Health, Medical
                                 Services & Medical Education (HS)
                                 Block No.5 Dr. Jivraj Mehta Bhavan,
                                 Gandhinagar.
                                 Dt.15/02/2007




To,
Dr.P.Ravindran,
Director,
Emergency Medical Relief,
Directorate General of Health Services,
Nirman Bhavan,
New Delhi.
Disaster-2008_Action Plan-08              257
Sub:- About the State Disaster Management Plan-2007.

Respected Sir,


        In reference to the subject cited above, here with I am sending a copy of State
Level Disaster Management Plan-2007 Gujarat State.




Thanking you,




                                                            Yours Faithfully,



                                                       Deputy Director (Epidemic)
                                                     Office of the Comm. of Health,
                                                  Block No.-5,Dr.Jivaraj Mehta Bhavan,
                                                              Gandhinagar,
                                                                 Gujarat.




                                   No.EPC/Disaster Management Plan/Gujarat/462007/B.
                                   Commissionerate of Health, Medical
                                   Services & Medical Education (HS)
                                   Block No.5 Dr. Jivraj Mehta Bhavan,
                                   Gandhinagar.
                                   Dt.15/02/2007




To,
Dr.Shiv Lal,
National Institute of Communicable Diseases (NICD)
22,Shamnath Marg,
New Delhi,-110054


Disaster-2008_Action Plan-08              258
Sub:- About the State Disaster Management Plan-2007.


Respected Sir,


        In reference to the subject cited above, here with I am sending a copy of State
Level Disaster Management Plan-2007 Gujarat State.




Thanking you,




                                                            Yours Faithfully,



                                                       Deputy Director (Epidemic)
                                                     Office of the Comm. of Health,
                                                  Block No.-5,Dr.Jivaraj Mehta Bhavan,
                                                              Gandhinagar,
                                                                 Gujarat.




Submission :-
        We have prepared a Comprehensive State Level Disaster
Management Plan for the year-2007 which includes the following
Action Plans for necessary actions
             Earth-Quake
             Bioterrorism
             Avian Influenza
             Water Borne Diseases
Disaster-2008_Action Plan-08              259
             Leptospirosis
             Contingency Plan During War
             Contingency Plan for Cyclone/Flood/Heavy Rains.
             Contingency Plan for Drought
             Action Plan For Communal Violence.
             Occupational Health & Disaster


This action plan is prepared for the current year and
submitted here with for your kind perusal. We may put this
plan on Gujarat State Web-site through Vital Statistics
Branch with your kind permission.

MO



Asst.Director (Epidemic)



Deputy Director ( Epidemic)



Addl.Director ( Health)


Submission :-                                            Date: 21/02/2007

        Here with we are submitting instruction letter to Commissioner of
Municipal Corporation Surat, after observing high AFI & SFI reports in three
zones of Surat Municipal areas under plague surveillance activity and to
undertake appropriate actions to prevent further rise of indices in the areas of
SMC.
        Another letter submitted is to Deputy Director MET Surat regarding
finding of Zero report for the samples of Tetera Indica Subtype of rat in the

Disaster-2008_Action Plan-08          260
traps laid, in most of the places of plague Surveillance activity done in Surat
rural areas.




MO.




Asstt.Director (Epidemic)



Deputy Director ( Epidemic)




Additional Director ( Health)




Commissioner (Health)




Disaster-2008_Action Plan-08          261

				
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