-Dr Muzaffar Ahmad

19th June 2018

Emergency Medical response amp preparedness in Chemical Industry

DISASTERbull Defined in the Disaster Management Act 2005

asbull ldquoA catastrophe mishap calamity or grave

occurrence in any area arising from natural or man-made causes leading to accidents and resulting in substantial loss of life or human suffering or damage to and destruction of property or damage to or degradation of environment and is of such a nature and or magnitude as to be beyond the coping capacity of the community of affected areardquo

MAJOR MAN-MADE DISASTERS

ChemicalBiologicalRadiologicalNuclearTransport (AirRailwaysRoad trafficMarine)Urban Flooding ndash One of the major causesRiotsCivic DisturbancesTerrorism

Industrial Accidents

ldquoIndustrial Accidents are caused bychemical mechanical civilelectrical or other process failuresdue to accident negligence orincompetence in an industrial plantwhich may spill over to the areasoutside the plant causing damage tolife and propertyrdquo

Industrial AccidentsThese may originate in

bull Manufacturing and formulation installations including during commissioning and process operations maintenance and disposal

bull Material handling and storage in manufacturing facilities and isolated storages warehouses and god owns including tank farms in ports and docks and fuel depots

bull Transportation (road rail air water and pipelines)

bull Fire

bull Explosion

bull Toxic release

bull Poisoning

bull Combinations of the above

Major Threats

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

DISASTERbull Defined in the Disaster Management Act 2005

asbull ldquoA catastrophe mishap calamity or grave

occurrence in any area arising from natural or man-made causes leading to accidents and resulting in substantial loss of life or human suffering or damage to and destruction of property or damage to or degradation of environment and is of such a nature and or magnitude as to be beyond the coping capacity of the community of affected areardquo

MAJOR MAN-MADE DISASTERS

ChemicalBiologicalRadiologicalNuclearTransport (AirRailwaysRoad trafficMarine)Urban Flooding ndash One of the major causesRiotsCivic DisturbancesTerrorism

Industrial Accidents

ldquoIndustrial Accidents are caused bychemical mechanical civilelectrical or other process failuresdue to accident negligence orincompetence in an industrial plantwhich may spill over to the areasoutside the plant causing damage tolife and propertyrdquo

Industrial AccidentsThese may originate in

bull Manufacturing and formulation installations including during commissioning and process operations maintenance and disposal

bull Material handling and storage in manufacturing facilities and isolated storages warehouses and god owns including tank farms in ports and docks and fuel depots

bull Transportation (road rail air water and pipelines)

bull Fire

bull Explosion

bull Toxic release

bull Poisoning

bull Combinations of the above

Major Threats

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

MAJOR MAN-MADE DISASTERS

ChemicalBiologicalRadiologicalNuclearTransport (AirRailwaysRoad trafficMarine)Urban Flooding ndash One of the major causesRiotsCivic DisturbancesTerrorism

Industrial Accidents

ldquoIndustrial Accidents are caused bychemical mechanical civilelectrical or other process failuresdue to accident negligence orincompetence in an industrial plantwhich may spill over to the areasoutside the plant causing damage tolife and propertyrdquo

Industrial AccidentsThese may originate in

bull Manufacturing and formulation installations including during commissioning and process operations maintenance and disposal

bull Material handling and storage in manufacturing facilities and isolated storages warehouses and god owns including tank farms in ports and docks and fuel depots

bull Transportation (road rail air water and pipelines)

bull Fire

bull Explosion

bull Toxic release

bull Poisoning

bull Combinations of the above

Major Threats

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Industrial Accidents

ldquoIndustrial Accidents are caused bychemical mechanical civilelectrical or other process failuresdue to accident negligence orincompetence in an industrial plantwhich may spill over to the areasoutside the plant causing damage tolife and propertyrdquo

Industrial AccidentsThese may originate in

bull Manufacturing and formulation installations including during commissioning and process operations maintenance and disposal

bull Material handling and storage in manufacturing facilities and isolated storages warehouses and god owns including tank farms in ports and docks and fuel depots

bull Transportation (road rail air water and pipelines)

bull Fire

bull Explosion

bull Toxic release

bull Poisoning

bull Combinations of the above

Major Threats

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Industrial AccidentsThese may originate in

bull Manufacturing and formulation installations including during commissioning and process operations maintenance and disposal

bull Material handling and storage in manufacturing facilities and isolated storages warehouses and god owns including tank farms in ports and docks and fuel depots

bull Transportation (road rail air water and pipelines)

bull Fire

bull Explosion

bull Toxic release

bull Poisoning

bull Combinations of the above

Major Threats

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

bull Fire

bull Explosion

bull Toxic release

bull Poisoning

bull Combinations of the above

Major Threats

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

bull Meteorology of the area wind speed and direction rate of precipitation toxicityquantity of chemical released population in the reach of release probability of formation of lethal mixtures and other industrial activities in vicinity

COMPOUNDING OF EFFECTS OF ACCIDENTS

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Impact of Industrial Accidents

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Living Organisms

Industrial Accidents

Environment Property

Humans Livestock Plants

Immediate Short-termand Long-term Effects

Soil and Water BodiesAtmosphere

PollutionDeath Injury Disease and Disability

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Major Consequences

Loss of life injuries Impact on livestock Damage to Florafauna Environmental Impact (air soilwater) Financial losses to industry

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

MAJOR ACCIDENTAn occurrence such as bull Loss of life inside or outside the installationbull Ten or more injuries insidebull One or more injuries outside bull Release of toxic chemicals or explosion or

fire or spillage of hazardous chemicalsbull Onsite or offsite emergenciesbull Damage to equipment leading to

stoppage of processbull Adverse effects to environment

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Types of Emergencies

bull Onsite Emergencybull Offsite Emergency

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

ONSITE EMERGENCY

bull If the consequences of emergency are limited to the four walls of the industrial activity

bull Management of the plant shall be responsible for the response and containment as per their plan

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

OFFSITE EMERGENCY

bull If the consequences of emergency exceeds the four walls of the industrial activity

bull Involvement of District Administration in saving the life and property

bull various department and organizations of the district to provide response as per Emergency Plan

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Emergencies

bull Firebull Explosionbull Toxic Releasebull Combination of the above

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Some high impact world-wide chemical disasters

bull Flixborough Nypro UK (1st June 1974)Chemical released was cyclohexane due to which 28 persons died 36 were injured The plant was completely demolished and over 1821 houses and 167 factories suffered tremendous losses

bull Seveso Italy (10th July 1976)Chemical released was 2378-TCDD (Dioxin) which has resulted in the death about 10 lakhs animals evacuation of 760 persons and contamination of an area of about 4450 acres

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

FILXBOROUGH 01061974 UK

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

MEXICO CITY 19111984

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

GASOLENE TANK FIRE- South East Asia 2000

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

20

FIRE RISK

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

25

EXPLOSION

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

26

Boiler Explosion

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

30

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

31

CATASTROPHE RISKS- CYCLONE

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

33

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Flooding - industrial parksThailand Floods 2011

Flooded cement factory

Flooded factories in a industrial estate in Ayutthaya province nearly 200 factories had to temporarily close

Photos BBC

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia

bull Destruction to oil storage tanks oil filled barrels and pesticide depots in Banda Aceh Meulaboh and Krueng Raya areas were detected Throughout the whole facility area oil was mixed in with mud and water

bull Limited data regarding damage and loss on industrial locations from Indian Ocean Tsunami is available

A displaced fuel storage tank in Kreung Raya

Photo Joint UNEPOCHA unit report

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Dam Failure ndash environmental consequence

July 28th 2010 Jilin China - Heavy rain caused an upstream dam to rupture and flash floods rushed into warehouses of two chemical factories The floods washed away about 7000 chemical barrels into Songhua River The river was Jilin cityrsquos main water supply to its inhabitants Consequence ndash Public hysteria authorities were finding it difficult to retrieve barrels and were blamed for irrational layout of chemical industries downstream of Songhua river

Photo BBC

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Lightning strikes on petrochemical operationsLightening strikes are indicated as one of the main causes for storage tank accidents(Chang and Lin 2006)

East Malaysia 2012 - Petronassubsidiary MISC Berhard lost at least US$40 million when one of its oil tankers was struck by lightning and caught fire

ThailandMap Ta Phut Industrial Park 2012 ndash Bangkok Synthetics Co (BSC) Lightning Strike at a toluene vessel ndash

12 dead 129 injured environmental damages fines and plant closure of several manufacturersReported Losses exceed US$1 Billion

Oil tanker ablaze in East Malaysia Photo gCAPTAIN

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Oil Rig Explosion

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

BHOPAL GAS TRAGEDY 1984

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

JAIPUR OIL DEPOT FIRE 2009

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

slide 49 Uran Plant

IOC JAIPUR - 2009

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

slide 50 Uran Plant

IOC Fire JAIPUR - 2009

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Sivakasi Factory Fire 2012

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

East Godavari Distt Andhra Pradesh GAIL Pipeline Accident June 2014

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Overall Indian Scenario

bull In India there are more

than 40000 hazardous

industries with around

31 million workers

bull 1861 Major Accident

Hazard (MAH) units

spread across total 301

districts and 28 States

and UTs in India Source ndash NIDM MoEF

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Legislations related to Chemical Emergency Management

bull Environment Protection Act 1986bull Factories Act 1948 as amended in 1987bull Manufacture Storage and Import of Hazardous

Chemicals rules 1989 as amended in 1994 and 2000

bull Public Liability Insurance Act 1991 and Rulesbull Chemical Accidents (Emergency Planning

Preparedness and Response Rules) 1996 bull Central Motor Vehicles Rules 1989 as amended

in1993

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Legislations related to Chemical Emergency Management

bull Hazardous Wastes (Management and Handling) Rules 1989 as amended in 2000 and 2003

bull The Explosives Act 1884 bull The Explosive Rules 2008bull The Static and Mobile Pressure Vessels

(Unfired) Rules1981 as amended in 1993 2000 amp 2002

bull The Gas Cylinders Rules 2004bull The Petroleum Act 1934 amp The Petroleum Rules

2002

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL

RULES 1989 INSPECTION OF THE FACILITY AT LEAST ONCE IN A CALENDAR

YEAR NOTIFICATION OF MAJOR ACCIDENT WITHIN 48 HOURS UNDERTAKING OF ANY INDUSTRIAL ACTIVITY BY THE

OCCUPIER ONLY AFTER EXPLICIT APPROVALS SAFETY REPORTS AND SAFETY AUDIT REPORTS REGULAR MONITORING AND SUPERVISION PREPARATION OF ONSITE EMERGENCY PLAN BY THE

OCCUPIER PREPARATION OF OFF-SITE EMERGENCY PLAN BY THE

AUTHORITY SPECIFICS WITH RESPECT TO IMPORT OF HAZARDOUS

CHEMICALS59

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Responsibilities of MAH Installations

bull Preparation of onsite emergency plan including first aid and transfer arrangements

bull Notification of major accidentbull Preparation of safety reports and safety audit

reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of District

Crisis Group

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Information to be furnished in OSEP

bull Key personnel for medical amp first aid and their responsibilities

bull Assistance from outside agenciesbull Liaison arrangement between organizationsbull PHA

bull Types of accidentsbull Events that lead to accidentbull Hazardsbull Safety related components

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Local Crisis Groups--- Functionsbull Pocket Preparation of local emergency plan

for the industrial Accidentsbull Ensure devitalizing local plan with district

planbull Train personnel for first aid amp measures to

be taken chemical accident managementbull Educating public community awarenessbull full scale mock drill every six months

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Responsibilities of MAH Installations

bull Preparation of onsite emergency planbull Notification of major accidentbull Preparation of safety reports and safety

audit reportsbull Conducting mock drills to test the onsite

emergency planbull Aid assist and facilitate functioning of

District Crisis Group

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Essentials for Offsite Planning amp Response

bull Awareness to all Govt Officials nearby villagers amp volunteers

bull Prompt Communication to inform outside plant (DM CO Fire

Station CMO DRM RTO DIO and nearby VillageTown Heads)

bull Wind direction based evacuation of all concerned

bull Law amp Order enforcement through Police Deptt

bull Clearance diversion of traffic by Transport Deptt

bull Food water telephone connectivity for people shifted

Contd

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Medical Responses to disaster aim to

1) Reverse adverse health effects caused by the event 2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event) 3) Decrease the vulnerability (increase the resiliency) of the society to future events and 4) Improve disaster preparedness to respond to chemical industrial accidentevents

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

bull Examples of events that may generate mass casualties include In CIDM transportation accidents tornadoes terrorist bombers avalanches in inhabited areas etc

bull The impact of such events depends upon the ability of the affected society to cope with the circumstances whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Consequences of disasters on health services

Disasters can cause serious damage to health facilities water supplies and sewage systems Structural damage to facilities poses a risk for both health care workers and patients

Limited road access makes it at least difficult for disaster victims to reach health care centers

Disrupted communication systems lead to a poor understanding of the various receiving facilitiesrsquo military resourcesrsquo and relief organizations actual capacity Consequently the already limited resources are not effectively utilized to meet the demands

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Consequences of disasters on health services

bull Increased demands for medical attentionClimatic exposure because of rain or cold weather puts a

particular strain on the health systemInadequacy of food and nutrition exposes the population to

malnutrition particularly in the vulnerable groups such as children and the elderly and

If there is a mass casualty incident health systems can be quickly overwhelmed and left unable to cope with the excessive demands

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Consequences of disasters on health services

bull Population displacementA mass exodus from the emergency site places additional stress and

demands on the host country its population facilities and health services particularly

Depending on the size of the population migration the host facilities may not be able to cope with the new burden and

Mass migration can introduce new diseases into the host community

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Consequences of disasters on health servicesbull Major outbreaks of communicable diseasesWhile natural disasters do not always lead to massive infectious

disease outbreaks they do increase the risk of disease transmission The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement all culminate in an increased risk for disease outbreaks

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Role of emergency health services in Industrial disasters

To minimize mortality and morbidity it is also necessary to organize the relief response according to three levels of preventive health measures

bull Primary prevention is the ultimate goal of preventive health care It aims to prevent the effect of hazardous material to generally healthy populations

bull Secondary prevention identifies and treats as early as possible affected people to prevent from progressing to a more serious complication or death

bull Tertiary reduces permanent damage from accident such as a patient being offered rehabilitative services to lower the effects of paralysis due to trauma injuries

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Public Health for Emergency Preparedness and

Response for Chemical Industrial Diasters MAH units

Effective public health emergency preparedness and response depends upon the coordinated efforts of multiple people from many different agencies working in concert

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

ldquoSystemrdquobull More than just the public health Department

agencybull ldquoPublic health systemrdquo

ndashAll public private and voluntary entities that contribute to public health in a given area

ndashA network of entities with differing roles relationships and interactions

ndashAll entities contribute to the health and well-being of the community

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

The Public Health System

MCOsHome Health

SDMADDMA

industry

WCD ICDS

AshaAWW

Mass Transit

WASH Nutition Food

s

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory

Facilities

Hospitals

EMS Community Centers

Doctors

Health Departme

nt

Religious Groups

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

To be Prepared What Does Public Health Need

bull Incident command and support structure

bull Preparedness and response plansbull Communicationsbull Epidemiology and surveillancebull Laboratorybull Environmentaloccupational health

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Emergency Support Function Public Health and Medical

bull lead agencybull Assessment of healthmedical needsbull Surveillancebull Medical care personnelbull Health and medical suppliesbull Patient evacuationbull Hospital carebull Fooddrugmedical device safetybull Worker health and safety

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Disaster preparednessbull The health objectives of disaster preparedness are to Prevent morbidity and mortalityProvide care for casualtiesManage adverse climatic and environmental conditionsEnsure restoration of normal healthRe-establish health servicesProtect staff andProtect public health and medical assets

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Public Health PreparednessDisasters and Emergencies

7 Core Capacitiesbull Workforcebull Information Systemsbull Communicationbull Epidemiologysurveillancebull Laboratorybull Policy and Evaluationbull Preparedness and Response

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Mass Casualty Incident (MCI)

bull is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

bull Requires1 the pre-establishment of basic guidelines and principles of

an Incident Command System (ICS) 2 triage and 3 patient flows according to the hospitalrsquos plan

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

National guidelines

81

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

NATIONAL DISASTER MANAGEMENT AUTHORITY

NATIONAL GUIDELINES

Section 6 (2) (d amp e) of the DM Act mandates NDMA to prepareGuidelines on the basis of which Plans will be made by theMinistries Departments of the Government of India and the States

Approach

bull All inclusive participatory and consultative process withrepresentatives from the Ministries Departments ofGovernment of India and other stakeholders

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

National guidelines on chemical disasters

83

REGULATORY FRAMEWORK

FACTORIES ACT 1948EXPLOSIVES ACT 1884THE INSECTICIDE ACT 1968THE PETROLEUM ACT 1934THE ENVIRONMENT PROTECTION ACT 1986REGULATIONS IN TRANSPORTATION INSURANCE LIABILITY

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

SALIENT FEATURES OF THE GUIDELINES

84

INSITUTIONAL FRAMEWORK AND COMPLIANCE (MHA MOEF MOLE MOA MOPamp NG MO CampF MOSRT ampH MO Camp I) DEA MOFMAJOR ACCIDENT HAZARD CONTROL SYSTEMHAZARD ANALYSIS STUDIES OF INDUSTRIAL POCKETSGIS BASED EMERGENCY MANAGEMENT SYSTEMENVIRONMENT RISK REPORTING AND INFORMATIONS SYSTEMS (ERRIS)EMERGENCY RESPONSE CENTRES (ERCS) AND POISON CONTROL CENTRESCAPACITY DEVELOPMENTCONTROL ROOM CONCEPTNATIONAL NETWORKING OF EMERGENCY OPERATION CENTRES (EOCS)RESPONSIBLE CARE

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

OTHER COMMON FEATURES

85

CODES OF PRACTICES PROCEDURES AND STANDARDSSTATUTORY INSPECTION SAFETY AUDITING AND TESTING OF EMERGENCY PLANS

INSPECTION SYSTEM BY REGULATORY BODIES

SAFETY PLAN FOR COMMISSIONING AND DECOMMISSIONINGSAFETY AUDITING

REGULAR TESTING OF EMERGENCY PLANSEDUCATION AND TRAININGCREATION OF APPROPRIATE INFRASTURCTUREAWARENESS GENERATION

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Concerned Ministries and Enforcing Deptts

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

IMMEDIATE CONCERNS

Search amp Rescue

First Aid

TransferEvacuate to Medical institutions

Restoration of Essential services eg Medical services Water Electricity Communication networks etcProvision of Minimum Standards of Disaster in Relief Camps eg Food Drinking water Shelter Sanitation Medical cover

Disposal of Dead bodies

Prevention of Epidemics

Debris Removal

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Seven ChapterChapter 1 Vulnerability and Effects Need for creation of aninstitutional mechanism Enhancing Capacity and Capabilities ofHospitals and Healthcare WorkersChapter 2 Review of Existing Heath Framework MedicalPreparedness of MoD MoR IRCS NGOs and LaboratoriesStrengthening of approaches for Mass Casualty ManagementChapter 3 Salient Gaps in Preparedness and Mitigation HospitalPreparedness IDSP Blood Transfusion Services CBRNManagement Stakeholder Particiaption Psycho-Social andMental HealthChapter 4 Roles and Responsibilities of Various StakeholdersEstablishment of Early Warning Medical First RespondersEmergency Medical Evacuation EMS Alternate Mobile HospitalsHDM Plans ICS Capacity Development Development of TraumaServices Burn Wards Blood Banks Networking of Labs RampDand Psycho-Social SupportChapter 5 Response Rehabilitation and Recovery

Chapter 6 Medical Preparedness for CBRN

Chapter 7 Approach for Implementation

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Emergency Medical Response Pre Hospital Care

Certified Medical First Responders (MFRs) will be -

Fully trained in resuscitation triage and Basic Life Support

Well-equipped and supported by all emergency services and material logistics

Informed continuously about the dynamics of the disaster based on indicators

Communication backups at the Incident Response site to handle all kinds of Mass Casualty events within the golden hour

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Casualty EvacuationIntegrated Ambulance Network (IAN) including road rail aerial and water ambulance networks integrated at various levels Equipped with Personnel trained in Basic Life

Support Basic Life saving equipment and

drugsIt will work in conjunction with

Emergency Response Centres (ERCs)

Medical services and Evacuation Plan of district based

on the Public-Private Partnership model

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centres of 30 beds in Medical Colleges Tertiary Care Hospitals and Distrcts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Specialized Medical Facilitiesbull Strengthening of Integrated Disease Surveillance

Programmebull Trauma Care (Infrastructure and Capacity Development)

ndash State Apex Trauma Centre (JPN Apex Trauma Centre)ndash Regional Trauma Centre (50 beds)ndash District Trauma Centre (10 beds)

bull Licensed Blood Banks critical for management of shock networked to cater to surge requirement during disasters

bull Burn Centers of 30 beds in Medical Colleges Tertiary Care Hospitals and Distracts having more than 10 Major Accident Hazards (MAH)

bull Network of Bio-Safety Laboratoriesbull Tele-medicinebull National Highways Ambulatory Services and

Infrastructure

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Salient Gaps in Emergency Medical Response amp Preparedness

Non Implementation of Guidelines on Mass Casualty Management by States Lack of Designated Rapid Response

Teams and certified first Medical Responders BLS PHTLS trained

( Armed forces NDRF CPF State police) Lack of competency and Skills for

Emergency care of Chemical Accidents in health workers

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

bull Lack of proper communication facilities bull Lack of coordination between health fire

services police Govt and DM departmentbull Lack of Policy for competency development

for BLS PHTLS ATLS for specialist Doctors and other staff in urban and rural areas

bull Lack of proper regulatory mechanismbull Lack of adequate resourcesbull Non Availabilty of Training centers for

Chemicals amp CBRNE Response in the Health Sector

bull

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotesbull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions in Govt amp Pvt Sector

bull Lack of occupational health workers in India

bull Lack of training institutions in Occupational Health

96

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

bull Hospital DM Plan will be a part of ldquoall Hazardrdquo

bull District DM Plan catering to

bull Coordinated Structured Framework with detailed actions

and roles of each health care provider

bull Crisis Expansion of Beds Hospital Support Services

bull Emergency Medicines Disposables Blood Transfusion

Services Diagnostic amp Operative Service

bull Hospital Incident Command Structure(ICS)

bull Laboratory backup and Bio safety

bull Hospital Evacuation Plans

bull Decon amp Sepsis Wards

bull Patient referral Movement Plans

bull Treatment Protocols for Chemical Accidents

Hospital DM Planning

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

HOSPITAL DM PLANNINGChemical Casualty Management

Resources Inventory as per Risk Analysis ndash Antidotes amp Decorporation agents Agent Bio-waste Disposal Facilities

Treatment Protocols Immediate Long Term Delayed Effects

Rehabilitation Psychosocial Support amp Mental Health ServicesRehearsed twice a year

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Emergency Procedures

Training of employees Rehearsal of the plan 10 of workers shall be trained in first aid

and fire fighting Information on chemicals to physician

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

BHOPAL GAS TRAGEDYThis was the lsquoBeautiful UnionCarbide Plantrsquo from which on thenight of 2-3 December 1984 forty-two tons of methyl Iso Cynate(MIC) leaked The wind wasblowing in the direction of theneighboring slums The toxicclouds caused between sixteenand thirty thousand deaths Forreasons of economy a number ofsafety systems had beendeactivated

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Bhopal Gas Tragedybull Worst industrial disaster in historybull 2000 people died on immediate aftermathbull Another 13000 died in next fifteen yearsbull 10-15 persons dying every month bull 520000 diagnosed chemicals in blood causing different health

complicationsbull 120000 people still suffering from

ndash Cancerndash Tuberculosisndash Partial or complete blindness ndash Post traumatic stress disordersndash Menstrual irregularities

bull Rise in spontaneous abortion and stillbirth

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Consequence and Medical Responsebull The gas being heavier than air started entering into homes of

unwary population Many who panicked and ran out also gotcrushed in stampedes

bull Doctors and Hospitals were unaware of nature of the gas - lack of knowledge for management and treatment of MIC

bull Doctors practitioners were unable to diagnose and treat

Lack of hospital casualty management plans and mechanism for referral

Lack of knowledge and non-availability of antidotes

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Observations amp Lessons

bull Offsite emergency plan was not preparedbull Lack of knowledge about alarm systembull Lack of knowledge and non-availability of

antidotes bull Doctors practitioners were unable to

diagnose bull Large settlements permitted close to the

hazardous plantbull Detailed Hazop study risk analysis not

carried out prior to plant modificationbull PPEs not available

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Observations amp Lessons

bull Information about leakage not given to policebull Excessive storage of MIC 10 times more than

permissiblebull Critical refrigeration section not operationalbull Iron pipelines used in MIC instead of SSbull No improvements in safety even after pointing

out by the safety audit teambull Negligence on the part of factory officials for

various safety aspectsbull Lack of proper handingtaking over system

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Jaipur Oil Depot Fire 2009

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Observations amp Lessons

Onsite medical response was not availableWorkers were referred outside

Basic operating procedures were notfollowed Accident could have been bettermanaged if safety measures had beenfollowed

Lack of coordination between the plantdistrict administration and district healthofficials

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Observations amp Lessons

Land use planning was not adhered institutesresidential complexes unauthorized constructionand illegal settlements in the vicinity delayed theresponse

Proper protective equipments was not availablefor rescue work

Non availability of secondary exit causedproblems in response

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

MEDICAL PREPAREDNESS FOR CIDM

108

CREATING AWARENESS AMONGST MEDICAL ANDPARAMEDICAL STAFF AS WELL AS EMPLOYEES OFINDUSTRY AND COMMUNITYCREATION OF TRAINED SPECIALISED MEDICAL FIRSTRESPONDERS (MFRs)CREATION OF DECONTAMINATION FACILITIES IN THEONSITE AND OFF SITE EMERGENCY PLAN OF MAHUNITSUNIFORM CASUALTY PROFILE AND CLASSIFICATIONOF CASUALTIES AND THEIR ANTIDOTESRISK INVENTORY AND RESOURCES INVENTORYPLANS FOR EVACUATIONPROPER CHEMICAL CASUALTY TREATMENT KITSCRISIS MANAGEMENT PLAN AT THE HOSPITALSMOBILE HOSPITALMEDICAL TEAM

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

EMERGENCY MEDICAL RESPONSE

109

EMR INCLUDING RESCUE RELIEF AND REMEDIAL MEASURES( QRMTs WITH PPE TO REACH SITE ALONGWITH RESUSCITATION PROTECTION DETECTION AND DECONTAMINATION EQUIPMENTS)TRIAGE AND EVACUATION AS PER SOPs TO BE DONE SYMPTOMATIC TREATMENT AND ANTIDOTE ADMINISTRATIONBLOOD ANALYSIS FOR IDENTIFICATION OF CHEMICALSHOSPITAL EMERGENCY ROOM TO BE EQUIPPED WITH ALL THE NECESSARY EQUIPMENT ANTIDOTES ETC

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

EMERGENCY MEDICAL RESPONSE

110

HOSPITAL DM AND SAFETY PLANS TO BE IN PLACE AND REHEARSED PERIODICALLYCAPACITY DEVELOPMENT OF HEALTH AND HOSPITAL STAFF TO DEAL WITH CHEMICAL EMERGENCIESPLANS FOR SURGE IN HOSPITALS NETWORKING AND COORDINATION WITHIN HOSPITAL AND VITAL HEALTH SET UPSCOORDINATION WITH OTHER RESPONSE AGENCIESSOPS FOR MANAGEMENT OF DEADREGULAR FOLLOW UPSMEDICARE RECONSTRUCTIVE SURGERY AND REHABILITATION amp CLOSE MONITORING FOR LONG TERM EFFECTS

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Burn Centres

bull Non-availability of adequate facilities for management of burns at CHCDistrict Hospital level

bull Some Medical Colleges have a Burn Wardsbull All Tertiary Care hospitals have a Burn Centrebull Districts having more than 10 Major Accident

Hazard (MAH) Unit should have a designated Burn Centre

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT

RESPONSEPREPARATION OF TOXICOLOGY DATABASEAVAILABILITY OF INFO ON DIAGNOSTIC FACILITIES

AND SPECIALISED EXPERTISEINFORMATION ON SPECIFIC ANTIDOTESCREATION AND MAINTENANCE OF PUBLIC HEALTH

RESPONSE TEAMSSAFETY AND HYGIENCE STANDARDSSTRENGTHENING OF POISON CONTROL CENTRESPsychosocial support

112

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Poison Information Centers in India

bull Poison Information Centers (PIC) play a vital role in providing information and management

bull All India Institute of Medical Sciences (Department of Pharmacology)

bull National Institute of Occupational Health Ahmedabad

bull Government General Hospital Chennaibull Amrita Institute of Medical Sciences and

Research Cochin

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Functions of Poison Information Centers

bull Information Service Provide information and guidance to the public and healthcare professionals

bull Technical Advise to healthcare professionals and the public to avoid unnecessary exposure to toxins and contain the impact of the disaster

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Areas of concern in India

bull Inadequate human resources trained manpower

bull Non-availability of PPE amongst the responders

bull Lack of availability of antidotes

bull Lack of inter agency coordination

bull Poor communication and networking amongst the health institutions

bull Lack of community awareness education115

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Areas of concern in India

bull Improper drainage uncontrolled dumping

bull Lack of occupational health workers in India

bull Lack of training institutions

bull Lack of formal training curriculacourses

bull Lack of Poison Centers in StatesMajor Urban Areas with Laboratory and Hospital Back-up

116

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Not my job

Not my job

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

THERE IS A NEED TO THINK PROACTIVELY ndashINVEST IN BUILDING CAPACITIES ndash

THROUGH AWARENESS TRAINING AND EDUCATION

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

Key referencesbull Slides 3-4 A Joint Study of the Asian Development Bank and the Asian Development Bank

Institute Disaster Risk Management in Asia and the Pacific Issues Paper April 2013bull Slide 4 httpwwwasiapathways-adbiorg201302natural-disasters-and-production-

networks-in-the-asia-and-pacific-regionbull Slide 5 ndash CEFIC data ndash httpwwwceficorgFacts-and-Figuresbull Slide 6 - Thai floods httpwwwbbccouknewsbusiness-15398566bull Slide 7 - Indian Ocean Tsunami Disaster of December 2004 UNDAC Rapid Environmental

Assessment of Aceh Indonesia - Joint UNEPOCHA unit Feb 2005bull Slide 9 - httpreliefwebintreportchinairrational-layouts-chemical-factories-blamed-life-

threatening-accidents-chinabull Slide 10 - Changa I J Lin C 2006 A study of storage tank accidents Journal of Loss

Prevention in the Process Industries 19 pp 51ndash59bull Slide 10 - The 100 Largest Losses (1972-2001) Large Property Damage Losses in the

Hydrocarbon-Chemical Industries Marsh 2003bull Slides 11 ndash 14 Cochran T B Mackinzie M G Global Implications of the Fukushima Disaster

for Nuclear Power World Federation of Scientistsrsquo International Seminar on Planetary Emergencies Erice Sicily August 19-25 2011

ldquo If I have the belief that I can do it I shall surely acquire the capacity to do it even if I may not

have it at the beginningrdquo- Mahatma Gandhi

Thank you

hmuzaffarahmadyahoocom

• Slide Number 1
• DISASTER
• MAJOR MAN-MADE DISASTERS
• Industrial Accidents
• Industrial Accidents
• Slide Number 6
• Slide Number 7
• Impact of Industrial Accidents
• Slide Number 9
• Major Consequences
• Slide Number 11
• Types of Emergencies
• ONSITE EMERGENCY
• OFFSITE EMERGENCY
• Emergencies
• Some high impact world-wide chemical disasters
• Slide Number 17
• Slide Number 18
• GASOLENE TANK FIRE- South East Asia 2000
• FIRE RISK
• Slide Number 21
• Slide Number 22
• Slide Number 23
• Slide Number 24
• Slide Number 25
• Slide Number 26
• Slide Number 27
• Slide Number 28
• Slide Number 29
• Slide Number 30
• Slide Number 31
• Slide Number 32
• Slide Number 33
• Flooding - industrial parksThailand Floods 2011
• Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia
• Dam Failure ndash environmental consequence
• Lightning strikes on petrochemical operations
• Oil Rig Explosion
• Slide Number 39
• Slide Number 40
• Slide Number 41
• Slide Number 42
• Slide Number 43
• Slide Number 44
• Slide Number 45
• Slide Number 46
• BHOPAL GAS TRAGEDY 1984
• JAIPUR OIL DEPOT FIRE 2009
• Slide Number 49
• Slide Number 50
• Sivakasi Factory Fire 2012
• Slide Number 52
• Slide Number 53
• Slide Number 54
• Slide Number 55
• Overall Indian Scenario
• Legislations related to Chemical Emergency Management
• Legislations related to Chemical Emergency Management
• MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL RULES 1989
• Responsibilities of MAH Installations
• Slide Number 61
• Slide Number 62
• Responsibilities of MAH Installations
• Essentials for Offsite Planning amp Response
• Medical Responses to disaster aim to
• Slide Number 66
• Consequences of disasters on health services
• Consequences of disasters on health services
• Consequences of disasters on health services
• Consequences of disasters on health services
• Role of emergency health services in Industrial disasters
• Slide Number 72
• ldquoSystemrdquo
• Slide Number 74
• Slide Number 75
• To be Prepared What Does Public Health Need
• Emergency Support Function Public Health and Medical
• Disaster preparedness
• Public Health Preparedness Disasters and Emergencies7 Core Capacities
• Mass Casualty Incident (MCI)
• National guidelines
• Slide Number 82
• National guidelines on chemical disasters
• SALIENT FEATURES OF THE GUIDELINES
• OTHER COMMON FEATURES
• Concerned Ministries and Enforcing Deptts
• IMMEDIATE CONCERNS
• Slide Number 88
• Slide Number 89
• Emergency Medical Response Pre Hospital Care
• Casualty Evacuation
• Specialized Medical Facilities
• Specialized Medical Facilities
• Salient Gaps in Emergency Medical Response amp Preparedness
• Slide Number 95
• Slide Number 96
• Hospital DM Planning
• HOSPITAL DM PLANNING
• Slide Number 99
• BHOPAL GAS TRAGEDY
• Bhopal Gas Tragedy
• Consequence and Medical Response
• Observations amp Lessons
• Observations amp Lessons
• Jaipur Oil Depot Fire 2009
• Observations amp Lessons
• Observations amp Lessons
• MEDICAL PREPAREDNESS FOR CIDM
• EMERGENCY MEDICAL RESPONSE
• EMERGENCY MEDICAL RESPONSE
• Burn Centres
• PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT RESPONSE
• Poison Information Centers in India
• Functions of Poison Information Centers
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• THERE IS A NEED TO THINK PROACTIVELY ndash INVEST IN BUILDING CAPACITIES ndash THROUGH AWARENESS TRAINING AND EDUCATION
• Slide Number 121
• Key references
• Slide Number 123
• Thank you

Thank you

hmuzaffarahmadyahoocom

• Slide Number 1
• DISASTER
• MAJOR MAN-MADE DISASTERS
• Industrial Accidents
• Industrial Accidents
• Slide Number 6
• Slide Number 7
• Impact of Industrial Accidents
• Slide Number 9
• Major Consequences
• Slide Number 11
• Types of Emergencies
• ONSITE EMERGENCY
• OFFSITE EMERGENCY
• Emergencies
• Some high impact world-wide chemical disasters
• Slide Number 17
• Slide Number 18
• GASOLENE TANK FIRE- South East Asia 2000
• FIRE RISK
• Slide Number 21
• Slide Number 22
• Slide Number 23
• Slide Number 24
• Slide Number 25
• Slide Number 26
• Slide Number 27
• Slide Number 28
• Slide Number 29
• Slide Number 30
• Slide Number 31
• Slide Number 32
• Slide Number 33
• Flooding - industrial parksThailand Floods 2011
• Indian Ocean Tsunami 2004Damage to oil storage tanks ndash Indonesia
• Dam Failure ndash environmental consequence
• Lightning strikes on petrochemical operations
• Oil Rig Explosion
• Slide Number 39
• Slide Number 40
• Slide Number 41
• Slide Number 42
• Slide Number 43
• Slide Number 44
• Slide Number 45
• Slide Number 46
• BHOPAL GAS TRAGEDY 1984
• JAIPUR OIL DEPOT FIRE 2009
• Slide Number 49
• Slide Number 50
• Sivakasi Factory Fire 2012
• Slide Number 52
• Slide Number 53
• Slide Number 54
• Slide Number 55
• Overall Indian Scenario
• Legislations related to Chemical Emergency Management
• Legislations related to Chemical Emergency Management
• MANUFACTURE STORAGE AND IMPORT OF HAZARDOUS CHMEMICAL RULES 1989
• Responsibilities of MAH Installations
• Slide Number 61
• Slide Number 62
• Responsibilities of MAH Installations
• Essentials for Offsite Planning amp Response
• Medical Responses to disaster aim to
• Slide Number 66
• Consequences of disasters on health services
• Consequences of disasters on health services
• Consequences of disasters on health services
• Consequences of disasters on health services
• Role of emergency health services in Industrial disasters
• Slide Number 72
• ldquoSystemrdquo
• Slide Number 74
• Slide Number 75
• To be Prepared What Does Public Health Need
• Emergency Support Function Public Health and Medical
• Disaster preparedness
• Public Health Preparedness Disasters and Emergencies7 Core Capacities
• Mass Casualty Incident (MCI)
• National guidelines
• Slide Number 82
• National guidelines on chemical disasters
• SALIENT FEATURES OF THE GUIDELINES
• OTHER COMMON FEATURES
• Concerned Ministries and Enforcing Deptts
• IMMEDIATE CONCERNS
• Slide Number 88
• Slide Number 89
• Emergency Medical Response Pre Hospital Care
• Casualty Evacuation
• Specialized Medical Facilities
• Specialized Medical Facilities
• Salient Gaps in Emergency Medical Response amp Preparedness
• Slide Number 95
• Slide Number 96
• Hospital DM Planning
• HOSPITAL DM PLANNING
• Slide Number 99
• BHOPAL GAS TRAGEDY
• Bhopal Gas Tragedy
• Consequence and Medical Response
• Observations amp Lessons
• Observations amp Lessons
• Jaipur Oil Depot Fire 2009
• Observations amp Lessons
• Observations amp Lessons
• MEDICAL PREPAREDNESS FOR CIDM
• EMERGENCY MEDICAL RESPONSE
• EMERGENCY MEDICAL RESPONSE
• Burn Centres
• PREPAREDNESS FOR PUBLIC HEALTH AND ENVIRONMENTAL EFFECT RESPONSE
• Poison Information Centers in India
• Functions of Poison Information Centers
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• THERE IS A NEED TO THINK PROACTIVELY ndash INVEST IN BUILDING CAPACITIES ndash THROUGH AWARENESS TRAINING AND EDUCATION
• Slide Number 121
• Key references
• Slide Number 123
• Thank you