CHN 6 - E learning

Environmental Health

"No amount of medical knowledge will lessen the accountability for nurses to do what nurses do;
that is, to manage the environment to promote positive life processes." Sister Calista Roy,

Commentary on Notes on Nursing, 1992

To enable the public health nurse to use the environment to assist the community in improving
its state of wellness, it is necessary to study the various relationships between the components
of the environment and human health. This chapter discusses the geophysical, social,
biological, and built environments of people that affect their health.
In 1998, the Department of Health (DOH), in its Implementing Rules and Regulations of Chapter
XX (Pollution of the Environment) of the Code of Sanitation of the Philippines, defined
environmental health as:

The characteristics of environmental conditions that affect the quality of health. It is the aspect of
public health that is concerned with those forms of life, substances, forces, and conditions in the
surroundings or person that may exert an influence on human health and well-being.
In 1993, the World Health Organization (WHO) described environmental health through a
consultation in Sofia, Bulgaria:

Environmental Health comprises of those aspects of human health, including quality of life, that
are determined by physical, chemical, biological, social, and psychosocial factors in the
environment. It also refers to the theory and practice of assessing, correcting, controlling, and
preventing those factors in the environment that can potentially affect adversely the health of
present and future generations.

Note that environmental health could refer either to the components of the environment that
affect human health or to the components of human health that are affected by the environment.
To provide emphasis that an individual is the client of the public health nurse (i.e., instead of the
environment), this chapter shall take this definition: Environmental health is the component of
the individual's well-being that is determined by interactions with the physical, chemical,
biological, social, and psychosocial factors external to him or her.

As the government takes the responsibility for providing an environment that supports the right
of people to lead healthy lives, it will seek the various expertise of its members including that of
the public health nurses. The Philippine government takes this course of action through
Executive Order No. 489: Institutionalizing the Inter- Agency Committee on Environmental
Health (IACEH). The member agencies are represented by the various secretaries and directors
of the executive branch of the government, headed by the Secretary of the DOH as chairperson,
and the Secretary of the Department of Environment and Natural Resources (DENR) as vice
chairperson.
The various roles of IACEH specified by law include the task of coordinating, monitoring, and
evaluating environmental health programs initiated by the government and private agencies to
achieve environmental protection for health promotion. To perform these roles, the National
Environmental Health Action Plan (NEHAP) had been developed.

NEHAP identified seven components of environmental health that will be assigned to the
leadership of the members of the IACEH, namely, solid waste, water, air, toxic and hazardous
waste, occupational health, food safety, and sanitation (SWATOFS). In July 2010, this has been
expanded to include climate change.
Environmental Health Records Management

In the Philippines, the maintenance of environmental health records is one of the responsibilities
given to city, municipal, and provincial health nurses. The current data management system
being used by the DOH is the Field Health Service Information System (FHSIS). Data collection
begins with the midwife and the barangay health workers. In the 2008 version of the FHSIS, the
midwife is tasked to maintain a monthly record of the environmental health program
accomplishments in the "Summary Table" form. The eight environmental health indicators that
need to be monitored are as follows:

1. Households with access to improved or safe water - stratified to Levels I, II, and III
2. Households with sanitary toilets
3. Households with satisfactory disposal of solid waste
4. Households with complete basic sanitation facilities
5. Food establishments
6. Food establishments with sanitary permits
7. Food handlers
8. Food handlers with health certificates

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

The public health nurse must therefore be abreast with the definition of these records that must
be maintained. The 2008 version of the FHSIS presents the following definitions:

● Households with access to improved or safe water supply-refers to those covered

by or have access to any of the three levels of safe water sources that conforms to the
national standards for drinking water.

● Level I (point source)- refers to a protected well (shallow or deep well), improved dug
well, developed spring, or rainwater cistern with an outlet but without a distribution
system. A Level I facility is generally adaptable for rural areas where the houses are
thinly scattered. It would normally serve 15-25 households and its outreach must not be
more than 250 meters from the farthest user. The yield or discharge is generally from 40
to 140 liters/minute.
The point of consumption of Level I systems is at the source itself, placing the water reservoir at
higher risk of contamination. In the FHSIS, if the Level I reservoir (e.g. a protected rainwater
cistern) is piped into the tap of households, they are then considered to have a Level III access
as the risk of reservoir contamination is minimized.

● Level II (communal faucet system or standpost) - refers to a system composed of a

source, a reservoir, a piped distribution network, and a communal faucet located not
more than 25 meters from the farthest house. It is generally suitable for rural and urban
areas where houses are clustered densely enough to justify a simple piped water
system. For reporting purposes in the FHSIS, Level II system may also include a
communal faucet where a group of households get their water supply even if the said
faucet is connected to a Level III source. The typical Level II system is designed to
deliver 40-80 liters per capita per day to an average of 100 households, with one faucet
per 4-6 households.

The piped distribution network takes the point of consumption away from the reservoir, thus
decreasing the risk of pollution coming from the consumers. Contamination of water from Level
II sources would more likely take place during its transport and storage in the individual
households.

● Level III (waterworks system) - refers to a system with a source, transmission pipes, a
reservoir, and a piped distribution network for household taps. It is generally suited for
densely populated areas. This level of facility requires minimum treatment of disinfection.
Examples of this include water districts with individual household connections. For
reporting purposes, a Level III system may also include a Level I system with piped
distribution for household taps, serving a group of housing dwellings such as apartments
or condominiums.

● Households with sanitary toilets - refer to households with their own flush toilets
connected to septic tanks and/or sewerage system or any other approved treatment
system, sanitary pit latrine, or ventilated improved pit latrine. The national target for this
component is 91% (96% for urban and 86% for rural areas).

● Households with complete basic sanitation facilities - refers to those that satisfy the
presence of the following basic sanitation elements, namely,
a. access to safe water,
b. availability of a sanitary toilet, and
c. satisfactory system of garbage disposal.

● Food establishments - refer to those where food or drinks are manufactured,

processed, stored, sold, or served, including those that are located in vessels.

● Sanitary permit- the written certification of the city or municipal health officer or sanitary
engineer that the establishment complies with the existing minimum sanitation
 requirements upon inspection conducted in accordance with Presidential Decrees Nos.
522 and 856 and local ordinances.

● Food handlers - refer to persons who handle, store, prepare, or serve any food item,
drink, or ice, or who come in contact with any eating or cooking utensil or food vending
machine.

As food handlers are taken as any human source of food contamination other than the
consumer, the interest of public health nurses as collators and consumers of FHSIS data is to
compare the number of food handlers with the number of those who have active health
certificates.

● Health certificate - a written certification, using the prescribed form, and issued by the
municipal or city health officer to a person after passing the required physical and
medical examinations and immunizations.
Solid Waste Management

The Philippine Development Plan (PDP) for the year 2011-2016 aspires to get a 50% increase
of the solid waste diversion (SWD) rate of 33% level in the year 2010. SWD refers to activities
that reduce, and possibly eliminate, the potentially recyclable materials in the waste stream
before they end up as added undesirable matter on the land known as land pollution.

This act to reduce the contamination of land supports the work of the public health nurse in
enabling the community to increase its level of wellness, as it necessarily protects some of the
health-supporting functions of land, such as:

1. Platform for human activities: Polluted soil may be contaminated with disease-causing
parasites and microbes.
2. Agricultural production: Alteration of soil composition can make the land unsuitable for
growing crops and threaten food security. Hazardous materials such as cadmium, lead,
and mercury from disposed batteries and mine tailings can accumulate in the land and
be present in the harvested products.
3. Habitat of members of the food chain: As hazardous materials accumulate in the soil;
they affect the lower life-forms in a process called "bioaccumulation." As these creatures
in the bottom of the food chain are consumed by the more superior creatures, hazardous
chemicals increase in concentrations in the food chain in a process called
"biomagnification." At the top of the food chain, the human is at risk of consuming the
hazardous materials.
4. Filter for surface water: Natural bodies of water and storm water percolate through the
layers of the soil until it finds its way to the groundwater. Soil saturated with pollution not
only acts as a poor filter but may also contaminate the seeping water. The nurse in
communities that rely on ground water must be interested in the routine testing of these
sources.

Through the definitions used by Republic Act 9003 otherwise known as the "Ecological Solid
Waste Management Act of 2000" and the DOH Manual on Healthcare Waste Management of
2011, a way by which solid wastes may be classified is as follows:

● Municipal waste refers to all discarded nonhazardous household commercial and

institutional waste, street sweepings, and construction debris.
● Health care waste (or biomedical wastes) refers to the refuse that is generated in the
diagnosis, treatment, or immunization of human beings or animals together with those
related to the production or research of the same. This can be classified as follows:

1. "Infectious wastes" refer to those suspected to contain bacterial, viral, parasitic,
or fungal pathogens in sufficient concentration so as to cause a disease in
susceptible hosts. These include, but are not limited to, laboratory cultures,
contaminated wastes from clients with infectious disease, and any other
 dressing, swabs, instruments, or materials that have been in contact with infected
persons or animals.
2. "Pathological wastes" refer to tissues, organs, body parts, human fetuses, animal
carcasses, and blood and body fluids. Within this category, recognizable human
and animal body parts are also called anatomical waste. This category should be
considered as a subcategory of infectious waste, even though it may also include
healthy body parts.
3. "Pharmaceutical wastes" include pharmaceutical products such as drugs,
vaccines, and sera that are no longer required and need to be disposed of
appropriately for any reason. This category also includes discarded items used in
handling of pharmaceuticals such as bottles or boxes with residues, gloves,
masks, connecting tubes, and drug vials.
4. "Chemical wastes" include the varied states of chemical matter from clinical or
laboratory activities, environmental work, housekeeping, and disinfecting
procedures. This subcategory has any of the five properties of hazardous wastes
and is therefore termed as "hazardous chemical wastes."
5. "Sharps" include biomedical wastes that could cause cuts or puncture wounds.
These include, but are not limited to, needles, broken glass, and scalpel blades.
6. "Radioactive wastes" include sealed radiation sources typically used in cancer
treatments, liquid, and gaseous materials contaminated with radioactivity, and
excreta of patients who underwent radionuclide diagnostic and therapeutic
applications, together with the related paraphernalia and tap water washings.

● Industrial waste refers to the refuse that arise from production and from agricultural,
and mining industries. Aside from rubbish, industrial wastes can be mixed with
contaminated soil, ashes, and hazardous wastes.
● Hazardous wastes are substances that pose either an immediate or long-term
substantial danger to human because of possessing any of the following properties:
1. Toxic
2. Corrosive such as acids of pH <2, and bases of pH >12
3. Flammable
4. Reactive such as those that can cause explosions
5. Genotoxic such as cytostatic drugs.

R.A. 9003 also defines solid waste management as the discipline associated with the control of
generation, storage, collection, transfer and transport, processing, and disposal of solid wastes
in a manner that is in accordance with the best principles of public health, economics,
engineering, conservation, aesthetics, and other environmental considerations, and that is also
responsive to public attitudes. It is the discipline that governs over the solid waste stream.

The pathway of municipal solid waste (solid waste stream) begins with waste generation. At this
stage, waste reduction can be done through the reuse of materials. Materials that cannot be
used should be segregated in trash bins with color-coded and labeled linings, so that each form
of waste item could be managed accordingly.
In the third edition of the Manual on Healthcare Waste Management, published by the DOH in
December 2011, the following color coding of hospital waste bins were prescribed:

● Black or colorless: Nonhazardous and nonbiodegradable wastes

● Green: Nonhazardous biodegradable wastes
● Yellow with biohazard symbol. Pathological/ anatomical wastes.
● Yellow with black band. Pharmaceutical, cytotoxic, or chemical wastes (labeled
separately)
● Yellow bag that can be autoclaved: Infectious wastes
● Orange with radioactive symbol: Radioactive wastes

The segregated wastes are collected and transported accordingly. Recyclable wastes such as
metals, plastics, paper, and glass can be sent to a materials recovery facility to generate
recycled raw materials for producers. Biodegradable and organic wastes can be sent to a
composting unit for processing and subsequent agricultural use. Only residual wastes (if any)
should be dumped into the sanitary landfill.

There are various waste processors that could be utilized by institutions, organizations, and
local government units (LGUs) including shredders, biological reactors, and thermal processors.
Individuals responsible for community surveys should note that the law excludes incineration
from the acceptable processes, as it is known to emit toxic and poisonous fumes. Public health
officers should also keep in mind that the Implementing Rules and Regulations of Republic Act
9003 has declared the following as some of the prohibited acts:

● Open burning of solid wastes

● Open dumping
● Burying in flood-prone areas
● Squatting in landfills
● Operation of landfills on any aquifer, groundwater reservoir, or watershed
● Construction of any establishment within 200 meters from a dump or landfill
Water Sanitation

Increase in access to safe water supply is one of the crucial steps to the achievement of the
health-related Millennium Development Goals (MDGs). According to the PDP of 2011-2016, the
percentage of households in the Philippines with access to safe water in the year 2007 was
82.9%. By 2016, the PDP aims to increase this ratio to 86.6%.

The DOH had identified three levels of access to safe water supply and had set the standards of
the quality of drinking water through the DOH Administrative Order No. 2007-0012, otherwise
known as the Philippine National Standards for Drinking Water of 2007.

The general requirements of safe drinking water cover the following:

1. Microbial quality tested through the parameters of total coliform, fecal coliform, and
heterotrophic plate count.
2. Chemical and physical quality tested through the parameters of pH, chemical-specific
levels, color, odor, turbidity, hardness, and total dissolved solids.
3. Radiological quality tested through the parameters of gross alpha activity, gross beta,
and radon.

DOH A.O. 2007-0012 directs all drinking water processors from large water systems to water
refilling stations to create a water safety plan. The three key components of water safety plans
include:

1. System assessment - to determine if the drinking water supply chain as a whole can
deliver water of quality that meets health-based targets.
2. Operational monitoring - to identify control measures in a drinking water system that will
collectively control identified risks and ensure that the health-based targets are met, and
to rapidly detect any deviation from the required performance.
3. Management plans - to describe actions to be taken during normal operations or incident
conditions.

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

Other than the concern on the standards of the quality of drinking water, DOH has also
produced the Implementing Rules and Regulations of the Code of Sanitation of the Philippines
Chapter II: Water Supply. Some of the provisions include:

1. Washing and bathing within a radius of 25 meters from any well or other source of
drinking water is prohibited.
 2. No artesians, deep, or shallow well shall be constructed within 25 meters from any
source of pollution (including septic tanks and sewerage systems). Drilling a well within a
50-meters distance from a cemetery is also prohibited.
3. No radioactive source or material shall be stored within a radius of 25 meters from any
well or source of drinking water unless the radioactive source is adequately and safely
enclosed by proper shielding.
4. No dwellings shall be constructed within the catchment area of a protected spring water
source, and it shall be off limits to people and animals.

Emergency water treatment

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

Pretreatment Processes:

● Aeration is done to remove volatile substances, reduce carbon dioxide content, and
oxidize dissolved minerals in preparation for sedimentation and filtration. A method for
aeration is to rapidly shake a container that is partially full of water for about 5 minutes.
● Settlement is done by allowing water to stand undisturbed in the dark for a day. This
process causes death to more than 50% of most harmful bacteria and settling of
suspended solids. Repetition of settlement in another container or pot increases the
effectiveness of the process, as water is made to settle for longer periods.
● Filtration is done by utilizing filters to block particles while allowing water to pass through.
Filters include clean cloth, sand, and ceramics.

Disinfection Processes:

● Boiling, despite being energy consuming, is considered as a very effective method for
water disinfection. The water should be brought to a "rolling boil" and kept in that state
for at least 1 minute at sea level. At higher altitudes, the water should be kept in a rolling
boil state for at least 3 minutes. This process causes the water to change taste. This can
be improved by performing aeration after the water has been cooled.
● Chemical disinfection can be done using various chemicals but the most widely used
remains to be chlorine as it can kill all viruses and bacteria. However, some species of
protozoa and helminths have been seen to be resistant to chlorination. Chlorine is
available in various size and strength; thus, it is important to follow the manufacturer's
instructions on their use.
● Solardisinfection (SODIS) follows the principle that ultraviolet rays from the sun destroy
harmful organisms in water. This can be done by filling transparent plastic containers 1
 to 2 liters in size with clear water, and exposing them to direct sunlight for about 5 hours.
If the skies are cloudy, the bottles are exposed for two consecutive days.

Water Storage and Consumption

● Wide-necked containers with tight-fitting lids are best for water storage as they are easy
to clean between use.
● Hands and utensils may come in contact with water, therefore educating people about
proper washing techniques is of high importance.
Air Purity

Public health nurses must be sensitive to the various sources of air pollution in their community.
The DENR, in its Administrative Order 2000-81, defines an air pollutant as any matter in the
atmosphere other than the natural concentrations of oxygen, nitrogen, water vapor, carbon
dioxide, and inert gases that may be detrimental to health or the environment.

The first 11 kilometers of the atmosphere from the earth is the troposphere where we live in. In
this layer, the temperature profile is warmest at sea level and coolest at higher altitudes. Public
health nurses serving mountainous communities should keep in mind that these communities
are generally exposed to cooler weather. Having in mind that as the air gets cooler, the less
water vapor it is able to carry, the public health nurse should be sensitive to the rise of
respiratory infections in these communities, as the moist "mucociliary blanket" protection of the
airways could be interrupted by the dry air.

The troposphere near sea level has a typical composition of gases that support healthy human
life. In general, it is thought to be 78% nitrogen, 21% oxygen, and 1% other gases (such as
carbon dioxide, argon, and water vapors). As the altitude increases, oxygen per-centages
decrease.

The typical composition of air can be disturbed by pollutants. Pollutants can be suspended in
particulate matter or the gases themselves. Particulate matter that is of public health concern is
approximately 10 pm in size (PM 10) as they can be suspended in air. Gases that exceed their
normal concentrations are considered as pollutants to healthy air.

The DENR A.O.2000-81: Implementing Rules and Regulations for R.A. 8746 identified some
of the pollutants that should concern communities such as ozone-depleting substances,
chlorofluorocarbons, particulate matter that refer to any material that exists in a finely divided
form as a liquid or solid other than water, greenhouse gases that can potentially induce global
warming such as carbon dioxide, methane, and oxides of nitrogen, chlorofluorocarbons, and
fuel components such as aromatics, benzene, and sulfur.

Then, there is the stratosphere where the ozone layer is found. The stratosphere has an
inverted vertical-temperature profile, that is, it gets warmer as you increase altitude. Public
health nurses of communities with airports know that this is the layer where most airplanes fly
and emit most of the products of jet fuel combustion. A.O.2000-81 defines an emission as any
measurable pollutant gas or unwanted sound from a known source, which is passed into the
atmosphere.

As public health nurses identify possible sources of air pollution, they should be aware of the
two major sources identified by the Clean Air Act, namely, mobile and stationary sources.

● Mobile source - refers to any vehicle/machine propelled by or through oxidation or

reduction reactions, including combustion of carbon-based or other fuel, constructed and
operated principally for the conveyance of persons or the transportation of property or
goods, that emit air pollutants as a reaction product.

● Stationary source - refers to any building or fixed structure, facility, or installation that
emits or may emit any air pollutant.

Other than air pollution, contamination with microorganisms is a public health concern in terms
of clean air. Infections with microbes generally follow the principles of particulate matter invasion
of the respiratory tract, in that the smaller the particle is, the more efficient it becomes in
reaching the lower airways.

The American Conference of Governmental Industrial Hygienists has defined a criteria

depending on the efficiency of various particle sizes in entering the respiratory tract as

1. Inhalable particulate matter starting at 100-μm diameter.

2. Thoracic particulate matter starting at 10-um diameter.
3. Respirable particulate matter starting at 4-um diameter.

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

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

Several programs have been initiated to address air pollution:

● Bantay Tsimineya Program that monitors point-source air pollution from industries.

● Bantay Tambutso Program and Standard Setting that adopted Euro-Il emission
standards for motorized vehicles. This program penalizes vehicle owners who fail to
meet the set-standards.
 ● Improved Fuel Quality Program that phased out leaded gasoline, and regulated the
sulfur, benzene, and aromatic content of fuels.

● National Research and Development Program for the Prevention and Control of Air
Pollution whose development was directed by DENR Administrative order 2000-81 to the
DENR-EMB, in coordination with the Department of Science and Technology (DOST).

Public health nurses serve as an expert resource not only for the mayors and governors of their
respective localities but also for the "Airshed" to whom the city or municipality belongs. An
airshed refers to an area with a common weather or meteorological condition and a common
source of air pollution.

The DENR Secretary, on the recommendation of the Environmental Management Bureau, has
the legal mandate to divide the geopolitical regions of the country into airsheds for a more
effective air quality management. The designation of airsheds shall be revised as additional
data, needs, or situations arise. Each airshed is tasked to develop and implement a common
action plan.

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

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

"...implement or enforce a ban on smoking inside a public building or an enclosed public place
including public vehicles and other means of transport or in any enclosed area outside of one's
private residence, private place of work or any duly designated smoking area which shall be
enclosed."

The public health nurse is tasked to be both a nurse who advocates for the client community,
and a government officer who must assure that the rights of the people are protected. People's
right to clean air has been clearly defined by the Republic Act 8749 also known as the
"Philippine Clean Air Act of 1999."
Pursuant to the principles of the said law, following rights of citizens are sought to be
recognized:

1. The right to breathe clean air.

2. The right to utilize and enjoy all-natural resources according to the principle of
sustainable development.
3. The right to participate in the formulation, planning, implementation, and monitoring of
environmental policies and programs and in the decision-making process.
4. The right to participate in the decision-making process concerning development policies,
plans, and programs projects or activities that may have adverse impact on the
environment and public health.
5. The right to be informed of the nature and extent of the potential hazard of any activity,
undertaking, or project and to be served timely notice of any significant rise in the level of
pollution and the accidental or deliberate release into the atmosphere of harmful or
hazardous substances.
6. The right of access to public records which a citizen may need to exercise his or her
rights effectively under this Act.
7. The right to bring action in court or quasi-judicial bodies to enjoin all activities in violation
of environmental laws and regulations, to compel the rehabilitation and cleanup of
affected area, and to seek the imposition of penal sanctions against violators of
environmental laws.
8. The right to bring action in court for compensation of personal damages resulting from
the adverse environmental and public health impact of a project or activity.
Toxic and Hazardous Waste Control

The government accounts the chemicals that it monitors in the Philippine Inventory of
Chemicals and Chemical Substances (PICCS). To date, there are 44,600 substances in the list,
five of which are controlled chemicals, namely, asbestos, cyanide, mercury, polychlorinated
biphenyls, and ozone-depleting substances.

The country has several poison control centers nationwide, headed by the National Poison
Management and Control Center (NPMCC) based in the Philippine General Hospital (PGH). In
2009, the centers reported a total of 1,286 poisoning cases. The top causes of poisons are the
following: jewelry cleaners (high in cyanide), pesticides, button batteries, Watusi firecracker,
Jatropha seeds, multivitamins, malathion and xylene, camphor with methyl ASA, and turpentine.

Air quality indices

24-hours average total suspended particulates (TSP) (ug/m3)

Good 0-80

Fair 81-230

Unhealthy for sensitive groups 231-349

Very Unhealthy 350-599

Acutely Unhealthy 600-899

Emergency 900 and above

24-hours PM10 - (ug/m3)

Good 0-54

Fair 55-154

Unhealthy for sensitive groups 155-254

Very Unhealthy 255-354

Acutely Unhealthy 355-424

Emergency 425-504
 TSP and PM10 specific statements for the general public

(1) Unhealthy for sensitive groups. People with respiratory disease, such as asthma, should limit
outdoor exertion.

(2) Very unhealthy pedestrians should avoid heavy traffic areas. People with heart or respiratory
disease, such as asthma, should stay indoors and rest as much as possible. Unnecessary trips
should be postponed. People should voluntarily restrict the use of vehicles.

(3) Acutely unhealthy People should limit outdoor exertion. People with heart or respiratory
disease, such as asthma, should stay indoors and rest as much as possible. Unnecessary trips
should be postponed, Motor vehicle use may be restricted. Industrial activities may be curtailed.

(4) Emergency Everyone should remain indoors, keeping windows and doors closed unless heat
stress is possible. Motor vehicle use should be prohibited except for emergency situations.
Industrial activities, except that which are vital for public safety and health, should be curtailed.

8-hours carbon monoxide

Good 0.0-4.4

Fair 4.5-9.4

Unhealthy for sensitive groups 9.5-12.4

Very Unhealthy 12.5-15.4

Acutely Unhealthy 15.5-30.4

Emergency 30.5-40.4

(1) Unhealthy for sensitive groups People with cardiovascular disease, such as angina,
should limit heavy exertion and avoid sources of CO, such as heavy traffic.

(2) Very unhealthy People should stay indoors and rest as much as possible.
Unnecessary trips should be postponed. People should voluntarily restrict the use of
vehicles and avoid sources of CO, such as heavy traffic. Smokers should refrain from
smoking

(3) Acutely unhealthy People with cardiovascular disease, such as angina, should avoid
exertion and sources of CO, such as heavy traffic, and should stay indoors and rest as
much as possible. Unnecessary trips should be postponed. Motor vehicle use may be
restricted. Industrial activities may be curtailed.

(4) Emergency Everyone should avoid exertion and sources of CO, such as heavy traffic,
and should stay indoors and rest as much as possible.
 24-hours sulfur dioxide (ppm)

Good 0.000-0.034

Fair 0.035-0.144

Unhealthy for sensitive groups 0.145-0.224

Very unhealthy 0.225-0.304

Acutely unhealthy 0.305-0.604

Emergency 0.605-0.804

8-hours ozone (ppm)

Good 0.000-0.064

Fair 0.0.65-0.084

Unhealthy for sensitive groups 0.0.85-0.104

Very unhealthy 0.105-0.124

Acutely unhealthy 0.125-0.374

1-hour nitrogen dioxide (ppm)

Acutely unhealthy 0.65-1.24

Emergency 1.25-1.64

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

Primary health care facilities should be capable of following the WHO recommendations on
essential symptomatic and supportive treatment of acute poisoning. Health care workers and
trained volunteers should wear personal protective equipment (PPE) to evacuate victims from
the contaminated environment.

In the event of skin contamination, the clothing is removed and the skin is washed with the
appropriate fluid.

Interventions that may be considered thereafter include gastric aspiration and lavage of adults,
induced emesis of children, administration of a high dose of activated charcoal into the stomach,
and administration of protective agents such as:

● Atropine for carbamate and organophosphate pesticides

● Methylene blue for chlorates and nitrites
● Acetylcysteine or methionine for paracetamol overdose
● Hydroxocobalamin or sodium thiosulfate for cyanide in silver cleaners

Referral to higher institutions allows the safe toxicological analysis and subsequent
administration of specific antidotes, anticonvulsants, antiarrhythmics, and analgesics.

The Toxic and Environmental Health Working Group is headed by the DENR (chairperson) and
the Department of Agriculture (vice chairperson).
Food Safety

The NEHAP defined food safety as the assurance that food will not cause any harm to the
consumer when it is prepared and eaten according to its intended use.

To gear toward the food safety, the DOH formed an interagency committee that is led by the
Food and Drug Administration (FDA).

In 2009, Republic Act 9711 was enacted and is now known as the Food and Drug
Administration Act, which strengthened the FDA in safeguarding the safety and quality of
processed foods, drugs, diagnostic reagents, medical devices, cosmetics, and household
substances.

The DOH has published the Implementing Rules and Regulations to define the sanitation
requirements for the operation of a food establishment.
The food establishment must have a sanitary permit from the city or municipality that has
jurisdiction over the business.

In the case of food-establishments on-board sea-crafts, the application must be filed in the
vessel's port of origin. The permit must be posted in a conspicuous place in the establishment,
available for inspection by health and other regulatory personnel.

The implementing rules state that no person shall be employed in any food establishment
without a health certificate properly issued by the city/municipal health officer. This must be
clipped on the upper left front portion of the garment of the employee while working.

No person shall be allowed to work on food handling if afflicted with a communicable disease,
including boils, infected wounds, respiratory infections, diarrhea, and gastro-intestinal upset.

Particular guidelines on sources, transportation, preparation, storage, and serving have been
set by the implementing rules and regulations. All of which are geared toward the preservation
of the quality and cleanliness of food, as well as the safety of the service and consumption of
the same.

The food preparation and storage rooms should never be used or be directly connected to a
sleeping apartment or a toilet. No animals can be kept in the food areas. The display of any live
animal in the food area is strictly prohibited. Floors, walls, and ceilings must be made of
materials that can be cleansed.

The rules have set standards for the adequacy of lighting, sufficiency of ventilation, and
minimum space requirements. It requires hand washing basins, appropriate toilet facilities, water
supply, and refuse management systems.

Utensils must be scraped of all food particles and be washed in warm water (49 °C) with soap. If
running water is not available, the wash water shall be changed frequently. The utensils are then
subjected to one of the following bactericidal treatments:

1. Immersion for at least 30 seconds in clean hot water (77 °C).

2. Immersion for at least 1 minute in lukewarm water containing 55-100 ppm of chlorine solution.
3. Exposure to steam for at least 15 minutes to 77 °C, or for 5 minutes to at least 200 °C.

It shall be the duty of the Sanitation Inspector of the city, municipality, or province to perform an
inspection and evaluation of the compliance of food establishments to the set standards at a
frequency specified by the implementing rules and regulations.

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

As monitored by the FHSIS, all food handlers must maintain an updated health certificate. The
public health nurses are at an advantageous position to participate in the monitoring and
implementation of the ordinance on food handlers as they are given the task to collate and
report data in the FHSIS system.
Sanitation

The Philippines Sanitation Sourcebook and Decision Aid developed by the DENR, the
DOH, and the Local Water Utilities Administration (LWUA) in 2005 limited the definition of
sanitation to "the hygienic and proper management, collection, disposal, or reuse of human
excreta (feces and urine) and community liquid wastes to safeguard the health of individuals
and communities".

This is proof of the development of the arts and sciences involved in the various fields of
sanitation, that is, a singular code on sanitation such as the Presidential Decree 856: the Code
on Sanitation of the Philippines of 1976 may need to be revisited and updated to provide a
more comprehensive coverage to this growing discipline.

The government keeps track on the proportion of the population that does not have the
approved types of sanitation facilities. One may observe fluctuations in the figures through the
years as the problem of service coverage is aggravated by the effect of disasters that damage
existing sanitary facilities.

The DOH is the chair of the sanitation sector, whereas the Department of Interior and Local
Government serves as the vice chair. It is to the nation's advantage that the public health nurses
working for or with the DOH become well-abreast with the various concepts on sanitation. For
example, microorganisms in human excreta and agricultural run-off may contaminate water
systems and cause an epidemic.

In 2005, the Sanitation and Hygiene Promotion Programming Guidelines developed the
F-Diagram that proposed the 6 Fs that form part of the means to transmit microorganisms in
fecal materials to a new host, namely, feces, fingers, fluids, flies, fields/floors, and food. It
featured the primary and secondary barriers that public health practice could implement to
prevent the transmission of the pathogens.

Primary barriers are the structures and facilities that prevent the fecal contamination of fingers,
fluids, flies, and fields/floors. Secondary barriers are practices that prevent contaminated
fingers, fluids, flies, fields/floors from coming in contact with food or the new host. Secondary
barriers include, but are not limited to, handwashing practices, insect and vermin control, water
treatment, and proper food handling. The following text focuses on the primary barriers.

Sanitation facilities generally have four components, namely, toilet, collection, treatment, and
disposal/reuse. The toilet could either be a receptacle (bowl) where the user sits down or a
squatting plate.

Collection systems, also known as sewerage systems, transport the wastewater for treatment or
disposal.
Treatment is the process of reducing liquid and solid waste to nonpolluting matter. Disposal or
reuse finally releases the treated waste to the environment.

The disposal can mean discharge to water bodies such as rivers, application to soils, or release
to the atmosphere in the form of gas.

Ecological sanitation moves for the reuse instead of the disposal of treated wastewater as they
can be safely used for irrigation of agricultural and landscaped plants and firefighting.

A general classification of sanitation systems could be done according to water reliance.

Water-reliant systems make use of water to flush and transport the waste material to the
collection system, thus requiring a continuous supply of water.

Communities or resettlement areas that do not have access to continuous water supply may
have problems in compliance to the use of these facilities.

On the other hand, nonwater-reliant systems make use of "dry" storage for urine and feces. It
is important to note, however, that a small amount of water may be used to cleanse the parts of
the dry system, such as that of vacuum-flush toilets of buses and airplanes.

These toilet systems treat or store the materials on-site as they are not connected to sewerage
systems. A toilet system that is not connected to a sewerage system is called a privy.

The Implementing Rules and Regulations of the Sanitation Code of the Philippines developed
by the DOH describes three components of a sanitary privy, namely, an earthen pit, a floor
covering the pit, and a water-sealed bowl.

Wooden floors and seat risers are not to be used anymore. The flooring should cover the pit
tightly and joined to the bowl with a water-tight and insert-proof joint. The pit should be at least 1
m2 wide.

The following are some of the sanitation facilities that a nurse or sanitation officer may
encounter in the community:

● Box-and-can privy (or bucket latrine): Fecal matter is collected in a can or bucket,
which is periodically removed for emptying and cleaning.

● Pit latrine (or pit privy): Fecal matter is eliminated into a hole in the ground that leads
to a dug pit. Generally, a latrine refers to toilet facilities without a bowl. It can be
equipped with either a squatting plate or a riser with a seat. The pit reduces the volume
of its contents as the liquid infiltrates the surrounding soil.

● Antipolo toilet: It is made up of an elevated pit privy that has a covered latrine. The
elevation ensures that the bottom of the pit is at least 1.5 meters above the water table.
● Septic privy: Fecal matter is collected in a built septic tank that is not connected to a
sewerage system. The septic tank contains water but there is no drop pipe from the
latrine that is dipped into the water.

● Aqua privy: Fecal matter is eliminated into a water-sealed drop pipe that leads from the
latrine to a small water-filled septic tank located directly below the squatting plate. The
drop pipe extends below the septic tank water level to form a simple water seal. An
effluent pipe is installed in the septic tank to prevent the overflow of water through the
squatting plate. Water loss is then replaced by adding water with each toilet use. A
ventilation pipe with a fly screen on top is part of the design of the housing of this facility.

●  verhung latrine: Fecal material is directly eliminated into a body of water such as a
O
flowing river that is underneath the facility. Public health organizations such as the WHO
recognize the acceptability of the use of such in disaster situations like heavy flooding
when the body of water is deemed polluted. The chosen body of water should be large
and freely flowing. The public health nurse should coordinate with downstream
communities on releasing advisory that the body of water is polluted.

● Ventilated-improved pit (VIP) latrine: It is a pit latrine with a screened air vent installed
directly over the pit. The ambient air that enters the pit hole pushes the foul air onto the
air vent. The screen on top of the vent prevents entry of insects attracted by the smell.
Filled pits are then covered with soil for composting, and the facility is redirected or
relocated to another pit.

● Concrete vault privy: Fecal matter is collected in a pit privy lined with concrete in such
a manner so as to make it water tight.

● Chemical privy: Fecal matter is collected into a tank that contains a caustic chemical
solution, which in turn controls and facilitates the waste decomposition.

● Compost privy: Fecal matter is collected into a pit with urine and anal cleansing
materials with the addition of organic garbage such as leaves and grass to allow
biological decomposition and production of agricultural or fishpond compost (or
nightsoil).

● Pour-flush latrine: It has a bowl with a water-seal trap similar to the conventional
tank-flush toilet except that it requires only a small volume of water for flushing. Feces at
the water-sealed trap are washed-off by small quantities of water hand-poured from a
container.

● Tank-flush toilet: Feces are excreted into a bowl with a water-sealed trap. The water
tank that receives a limited amount of water empties into the bowl for flushing of fecal
materials through the water-sealed trap and into the sewerage system. The trap retains
an amount of the flush to maintain the water seal.
 ● Urine diversion dehydration toilet (UDDT): It is a waterless toilet system that allows
the separate collection and on-site storage or treatment of urine and feces.The site could
be made up of a urine separation toilet with the urine side leading to a collecting
container for agricultural use and the fecal side leading to a ventilated vault. The fecal
vault is kept "dry" and the feces are left to dehydrate for agricultural use.

In 2010, the DOH published the Philippine Sustainable Sanitation Roadmap and defined the
three sanitation facilities that are considered sanitary under the DOH and the National Statistics
Office (NSO) definitions:

1. Water-sealed toilet connected to a sewer or septic tank, used exclusively by the

household.
2. Water-sealed toilet connected to other depository type, used exclusively by the
household.
3. Closed pit used exclusively by the household.

The same considers the following as unsanitary facilities:

1. Water-sealed toilet connected to a sewer or septic tank, shared with other households.
2. Water-sealed toilet connected to other depository type, shared with other households.
3. Closed pit, shared with other households.
4. Open pit.
5. Hanging toilet.
6. Other unsanitary types of practice.
7. Open defecation.
Vermin and Vector Control
The DOH had also prepared the Implementing Rules and Regulations of Chapter XVI Vermin
Control of the Code of Sanitation of the Philippines (P.D.856). This document defined the
following terms:

1. Vermin: A group of insects or small animals such as flies, mosquitoes, cockroaches,

fleas, lice, bedbugs, mice, and rats, which are vectors of diseases.
2. Insects. Flies, mosquitoes, cockroaches, bedbugs, fleas, lice, ticks, ants, and other
arthropods.
3. Pest. Any destructive or unwanted insect or other small animals (rats, mice, etc.) that
cause annoyance, discomfort, nuisance, or transmission of disease to humans and
damage to structures.
4. Rodent. Small mammals such as rats and mice, characterized by constantly growing
incisor teeth used for gnawing or nibbling.
5. Vector. Any organism that transmits infection by inoculation into the skin or mucous
membrane by biting; or by deposit of infective materials on skin, food, or other objects; or
by biological reproduction within the organism.

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

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

The DOH outlined the various vermin control and disinfestation methods, which include:

● Environmental sanitation control: The maintenance of cleanliness of the immediate

premises and proper building construction and maintenance so as to prevent access of
pests into human dwellings. Clean-up drives are aimed at altering or eliminating the
breeding sites of the vectors.
● Naturalistic control: A pest control method that utilizes nature and nature's systems
without disturbing the balance of nature.
● Biological and genetic control: A method that utilizes living predators, parasites, and
other natural enemies of the pest species to reduce or eliminate the pest populations. It
is aimed at killing the larvae without polluting the environment.
● Mechanical and physical control: A method that utilizes mechanical devices such as
rodent traps, fly traps, mosquito traps, air curtain, and ultraviolet light.
● Chemical control: A method that utilizes rodenticides, insecticides, larvicides, and
pesticides.
● Integrated control: A method that controls pests through the use of different methods
and procedures that are used to complement each other. These procedures may include
 the use of pesticides, environmental sanitation measures, and natural, as well as
mechanical and biological control methods.
Built Environments

The built environment refers to the man-made structures that provide a setting for human
activities. In the Philippines, Presidential Decree Number 1096 (P.D. 1096), also known as the
National Building Code of the Philippines, governs the design of built environments. In 2004, the
Department of Public Works and Highways developed the Revised Implementing Rules and
Regulations of the National Building Code of the Philippines. Some of the provisions enacted to
protect public health are as follows:

● Minimum air space shall be provided as follows:

➢ School rooms - 3.00 m3 with 1.00 m2 of floor area per person.
➢ Workshops, factories, and offices -12.00 m3 of air space per person.
➢ Habitable rooms - 14.00 m3 of air space per person.

● Minimum sizes of rooms and their least horizontal dimensions shall be as follows:
➢ Rooms for human habitations - 6.00 m2 with a least horizontal dimension of 2.00
m.
➢ Kitchen - 3.00 m2 with a least horizontal dimension of 1.50 m.
➢ Bath and toilet - 1.20 m2 with a least horizontal dimension of 900 mm.

● Ceiling height of habitable rooms:

➢ Rooms provided with artificial ventilation shall have ceiling heights not less than
2.40 m (8 ft) measured from the floor to the ceiling.
➢ Rooms with natural ventilation shall have ceiling heights of not less than 2.70 m
(9 ft).
➢ Mezzanine floors shall have a clear ceiling height not less than 1.80 m above and
below it.

● Minimum window sizes:

➢ Rooms intended for any use, not provided with artificial ventilation system, shall
be provided with a window or windows with a total free area of openings equal to
at least 10% of the floor area of the room, provided that such opening shall be
not less than 1.00 m2.
➢ Toilet and bathrooms, laundry rooms, and similar rooms shall be provided with
window or windows with an area not less than 1/20 of the floor area of such
rooms, provided that such opening shall not be less than 240 mm2.
➢ Such windows shall open directly to a court, yard, public street or alley, or open
watercourse.
Disaster Management
Communities throughout the world experience an emergency or disaster incident of one kind or
another on an almost daily basis. The media may only mention these events or may report on
them in great detail, depending on the number of deaths or injured, the degree of devastation or
damage to the area involved, and the extent of normal activity disruption in the community that
the event has brought about. The increasing severity of recent disasters is multifaceted and is
generally attributable to a number of societal and environmental changes.
The health of a community can be affected significantly by disasters. Tropical Storm (TS) Ondoy
(international code name Ketsana), which hit 26 provinces in the Philippines in September 2009,
is an example of how communities and health facilities are directly affected as a result of a
disaster. TS Ondoy brought heavy rains that caused widespread flooding in almost all parts of
Metro Manila and Central and Southern Luzon. The floods also affected some parts of Visayas
and Mindanao. Landslides occurred in the Cordillera Administrative Region. A total of 993,227
families/4,901,234 persons were affected. The storm left in its wake 1,030 casualties: 464 dead,
529 injured, and 37 missing persons. The estimated cost of damage was about Php 11 billion,
including damage to health facilities. The total number of houses damaged was 185,004.

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

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

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

An emergency is any event endangering the life or health of a significant number of people and
demanding immediate action. An emergency situation may result from a natural, man-made,
technological, or societal hazard.

A disaster is any event that causes a level of destruction, death, or injury that affects the
abilities of the community to respond to the incident using available resources. Emergencies
differ from disasters in that the agency, community, family, or individual can manage an
emergency using his or her own resources. But a disaster event, depending on the
characteristics of the disaster, may be beyond the ability of the community to respond and
recover from the incident using their own resources. Disasters frequently require assistance
from outside the immediate community, both to manage resulting issues and to recover
completely.

Some disasters (e.g. a house fire) may affect only a few persons, whereas others (e.g. a
hurricane) can impact thousands.

A mass casualty event is one in which 100 or more individuals are involved; a multiple
casualty event is one in which more than 2 but fewer than 100 individuals are involved.
Casualties can be classified as a direct victim, an indirect victim, a displaced person, or a
refugee.

A direct victim is an individual who is immediately affected by the event; the indirect victim may
be a family member or friend of the victim or a first responder. Displaced persons and refugees
are special categories of direct victims.

Displaced persons are those who have to evacuate their home, school, or business as a result
of a disaster, and refugees are a group of people who have fled their home or even their country
as a result of famine, drought, natural disaster, war, or civil unrest.
Types of Disaster

Disasters may result from natural, biological, technological, or societal hazards.

A natural hazard is a physical force, such as a typhoon, flood, landslide, earthquake, and
volcanic activity.

A biological hazard is a process or phenomenon of organic origin or conveyed by biological

vectors, including exposure to pathogenic microorganisms, toxins, and bioactive substances.
Examples are disease outbreaks and red tide poisoning.

A technological hazard arises from technological or industrial conditions, including accidents,

dangerous procedures, and infrastructure failures.

A societal hazard results from the interaction of varying political, social, or economic factors,
which may have a negative impact on the community. Examples are stampedes, armed
conflicts, terrorist activities, and riots.

A NA-TECH (natural-technological) disaster is a natural disaster that creates or results in a

widespread technological problem. An example of a NA-TECH disaster is an earthquake that
causes the structural collapse of roadways or bridges that, in turn, brought down electrical wires
and caused subsequent fires. Another example is a chemical spill resulting from a flood. Types
of natural disasters and man-made disasters, particularly those that are experienced in the
Philippines.
Injury or death from a disaster may be direct or indirect. For example, injuries from typhoons
occur because people fail to evacuate or take shelter, do not take precautions in securing their
property, and do not follow guidelines on food and water safety or injury prevention during
recovery.

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

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

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

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

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

Biological weapons of mass destruction

Biological organism Lethality Prevention Treatment Potential for use

Smallpox (incubation 1-5 High Vaccine Symptomatic; One person could

days) secondary possibly cause a national
infections epidemic

Anthrax (incubation 2-60 Very high Vaccine Antibiotics early; Likely agent; resistant to
days) if late, nothing weather; can be stored

Plague (Yersinia pestis) Very high No vaccine Antibiotics Not considered a likely
(incubation 1-3 days) 100% if agent; difficult to turn into
untreated a weapon.

Botulism High Vaccine Antitoxin; requires Not considered a likely

being tested intensive weapon
supportive care

Tularemia Moderate Vaccine Antibiotics Difficult to stabilize for use

being studied as a weapon

Ebola Very high No vaccine Minimal Not considered a likely

weapon; difficult to
acquire; poorly
understood

Brucellosis (incubation 5-21 Low No vaccine Antibiotics; begin Not considered a likely
days) upon suspicion of weapon; low lethality
disease

Q fever (Coxiella burnetii) Low Vaccine Antibiotics; begin Not considered a likely
(incubation 14-26 days) in incubation weapon; low lethality
period

Other potentials: Viral Venezuelan - - - -

equine encephalitis, cholera,
salmonella, influenza, and
staphylococcal enterotoxin B
 Chemical agents of mass destruction

Chemical agent Lethality Treatment Impact

Sarin (nerve agent) High Move to fresh air; Likely nerve agent;
wash skin; drugs chemicals needed to
limited effectiveness produce are banned
by International
Chemical Weapons
Convention

VX (nerve agent) Very high Move to fresh air; Not likely weapon;
wash skin; drugs difficult to
limited effectiveness manufacture

Tabun (nerve agent) High Move to fresh air; Easy to manufacture

wash skin; drugs nerve agent; likely
limited effectiveness agent to be used

Chlorine (pulmonary Low Move to fresh air; Readily available;

agent) was skin; no antidote likely agent because
of availability; breaks
down with water

Hydrogen cyanide Low to moderate Move to fresh air’ Industrial product;

(blood agent) wash skin; some some chemicals used
drugs mitigate effects to produce are
banned; likely agent
because of
availability
Characteristics of Disasters

Several characteristics have been used to describe disasters. These characteristics are
interdependent and therefore important to consider in plans for managing any disaster event.
Each is discussed briefly in the following text.

Frequency
Frequency refers to how often a disaster occurs. Some disasters occur relatively often in certain
parts of the world. Terrorist activities are occurring on an almost daily basis in Iraq, Pakistan,
and elsewhere in the world. Other examples are tropical cyclones, which occur with variable
frequency between the months of June and November. However, because of climate change,
the occurrence of typhoons has become more variable than in previous years.

Earthquakes occur periodically throughout the world. The Philippines runs along the so-called
Ring of Fire, which encircles the Pacific Ocean and is known for frequent earthquakes and
volcanic eruptions. The Philippine Institute of Volcanology and Seismology (PHILVOCS) records
daily earthquakes occurring in different parts of the country with variable intensity, with only a
very small proportion of the quakes felt by people. The most destructive earthquake in recorded
history occurred almost three decades ago on July 16, 1990 affecting Northern and Central
Luzon. The quake had an intensity of 7.8 on the Richter scale. More than 1,600 people lost their
lives in the earthquake.

Other disasters, such as volcanic eruptions, are far less frequent and are geographically limited
to certain regions of the country. PHIVOLCS has listed 23 active volcanoes in the country.
Mayon in the province of Albay, Taal in the province of Batangas, and Kanlaon in the province of
Negros Oriental are the top three most active volcanoes.
The eruption of Mount Pinatubo (located at the boundaries of Pampanga, Tarlac, and Zambales)
in June, 1991 is the second largest volcanic eruption of the 20th century. PHIVOLCS, together
with the US Geological Survey, was able to forecast the eruption, saving at least 5,000 lives.
Mount Pinatubo released a large amount of gas cloud into the atmosphere, causing global
temperature to drop by 0.5 °C from 1991 to 1993 (USGS, 2005).

Predictability

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

Preventability

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

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

when the event itself cannot be prevented. Primary prevention occurs in the nondisaster and the
predisaster stage refers to the period immediately before the disaster or when a disaster is
pending. Preventive actions during the nondisaster stage include assessing communities to
determine potential disaster hazards, developing disaster plans at local and national levels,
conducting drills to test the plan, training volunteers and health care providers, and providing
educational programs of all kinds.
The disaster plan is initiated predisaster or when a disaster is imminent. Primary prevention
actions during this stage include notifying the appropriate officials, warning the population, and
advising what response to take (e.g. shelter in place or evacuate).

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

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

Nurses are involved in all stages of prevention and related activities. In order to respond
effectively, personally, and professionally during different types of disasters, nurses need to
know the:

1. Kind of disasters that threaten the communities,

2. Injuries to expect from different disaster scenarios
3. Evacuation route,
4. Location of shelters or evacuation centers
5. Warning systems.

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

Imminence

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

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

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

Some disastrous incidents (e.g. terrorist attacks) have no warning time. Bioterrorist attacks are
generally silent, and the first awareness may be days or even weeks after exposure. For
example, individuals exposed to a pathologic agent (e.g. anthrax, smallpox) may arrive at health
care facilities at various times and to various providers, making diagnosis and early treatment
difficult. Nurses and medical personnel need to know the signs and symptoms of biological,
chemical, radiation, and nuclear exposure in order to identify the nature of the threat and then to
treat and control the spread of both biological and chemical agents.

Scope and number of casualties

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

The casualty count of TS Ondoy totaled to 1,030, with 464 deaths. The widespread flooding
caused by TS Ondoy in 2009 happened in Luzon during the daytime. In addition to the fact that
flood waters started to rise during the daytime, floods occur frequently in many areas in Luzon
like Metro Manila and Central Luzon. People were more conscious of tropical cyclones causing
floods.
In contrast, the casualties that resulted from TS Sendong were far greater, with a total number
of reported casualties of 7,520: 1,268 persons reported dead, 6,071 persons injured, and 181
missing. The last time Cagayan de Oro City and its surrounding areas had a flood was 75 years
before 2011. Most of the casualties resulted from flash floods brought about by heavy rainfall in
the evening of December 16 which continued until the early morning of December 17, when
people were mostly asleep.

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

Intensity

Intensity is the characteristic describing the level of destruction and devastation of the disaster
event. Tropical cyclones that affect the country are categorized according to intensity in terms of
wind speed near the center of the cyclone.

Factors contributing to the amount of damage from a disaster event such as a typhoon are the
distance from the zone of maximum winds, degree of exposure of the location to the disaster,
building standards, vegetation type, and resultant flooding. For instance, the casualties and
damage to property (estimated at more than Php 2 billion) are the result of a combination of
factors. The intense rainfall in the upstream portion of the Cagayan De Oro River resulted in the
swelling of the river and created a strong current that uprooted trees along the river banks. The
muddy water full of sediment and debris flowed downstream. Heavy rainfall was coupled with
the occurrence of a high tide that restricted the flow of flood waters.
Disaster Management

When one is aware of the types and characteristics of disasters, the question then becomes:
What can be done to prevent, prepare for, respond to, and recover from disasters? Disaster
management requires an interdisciplinary, collaborative team effort and involves a network of
agencies and individuals to develop a disaster plan that covers the multiple elements necessary
for an effective plan. Communities can respond more quickly, more effectively, and with less
confusion if the efforts needed in the event of a disaster have been anticipated and plans for
meeting them have been identified. The result of planning is that more lives are saved and less
property is damaged. Planning ensures that resources are available and that roles and
responsibilities of all personnel and agencies, both official and unofficial, are delineated.

Nurses need to know their personal, professional, and community responsibilities. They should
realize that conflicts may arise between their personal and professional responsibilities if these
have not been considered and planned for in advance. In addition, nurses may be direct or
indirect victims and may even be displaced persons themselves as a result of a disaster event.
Recognizing this possibility, nurses need to plan, prepare, practice, and teach their family and
significant others how to respond.

During a disaster, a nurse might face an ethical dilemma because of competing responsibilities
to family, employer, and patients, for example, a nurse who is a single parent with young
children and has a limited support system may be forced to decide between his or her
responsibility to care for his or her children or a mandate to report to work to care for patients.
Choosing may result in loss of employment or danger to the children. Potential conflicts such as
this should be considered, discussed, and decisions be made in conjunction with the employer
before a disaster event.

Disaster management stages

Prevention stage

The first stage in disaster management occurs before a disaster is imminent and is known as
the nondisaster stage. Potential disaster risks should be identified and risk maps created. For
example, geohazard maps are used in identifying areas prone to natural dangers like landslides,
flooding, and ground subsidence or sinking. The maps are used in preparing government
authorities and the people for possible disasters. The Department of Environment and Natural
Resources (DENR) spearheaded the creation of the geohazard maps through its Mines and
Geosciences Bureau.

The population demographics and vulnerabilities, as well as the community's capabilities,
should be analyzed. Primary prevention measures include educating the public regarding what
actions to take to prepare for disasters at the individual, family, and community levels. Further,
based on the assessment of potential risks, the community must develop a plan for meeting the
potential disasters identified.
With regard to bioterrorist attacks, prevention means that health care providers need to be
knowledgeable about the biological and chemical agents that might be used. In addition, health
care providers need to know the signs and symptoms of the various biological and chemical
agents that have been recognized as potential threats. As mentioned, unlike other disasters,
biochemical terrorist threats may be identified only when events raise the suspicions of health
care providers, rather than first responders at a particular site.


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

Preparedness and planning stage

Individual and family preparedness includes training in first aid, assembling a disaster
emergency kit, establishing a predetermined meeting place away from home, and making a
family communication plan.

Although there will be some variation according to the individual community's needs, all
community disaster plans should address the following elements: authority, communication,
control, logistical coordination of personnel, supplies and equipment, evacuation, rescue, and
care of the dead. The plan should indicate who has the power to declare that there is a disaster
and who has the power to initiate the disaster plan.

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

Communication is recognized as a very significant problem during disasters. Misinformation

and misinterpretation can occur when communication is ineffective. Reliance on telephone
systems or cell phones should not be the sole planned means of communicating because these
may not work or the systems might be overloaded.

The communication section of the disaster plan should address how the authority figure will be
notified of the disaster, how the emergency management team members will be notified, how
the community residents will be warned about the incident, and what actions will be required.
This section needs to address how communication between relief workers and authorities will
be maintained. Also, it should include information on the role of the media in keeping people
informed and in letting people know what assistance and supplies are needed. In case of
electric power interruptions, the use of battery-operated portable radios is advised so residents
may listen for instructions and updates about the disaster.

One of the most important elements to consider in communication is the early warning stage.
This generally impacts on how the community will respond to warnings of possible disaster,
which eventually will be very crucial in preventing the loss of lives.

The analysis of the population during the nondisaster stage should identify groups that need
special attention as to the process of notification. These people include those who speak
different languages, are homeless or poor, are without television or other means of
communication, and are in institutions such as prisons, custodial care facilities, day care
settings, or schools. Effective communication during a disaster must be credible, current, and
authoritative and must give some indication of future events.

The logistical section should specify where supplies and equipment are located or where
additional supplies and equipment can be obtained from, where these will be stored or found,
and how these will be transported to the disaster site.

Essential human resources (e.g. emergency and disaster specialists, officials of governmental
and voluntary agencies, engineers, weather specialists, and community leaders) should be
identified and tracked where they will be located. The plan should include information about
transportation for evacuation and rescue (particularly taking into account vulnerable groups),
documentation and record keeping, and plans for evaluation of the success or failure of the
plan.

A disaster plan is a dynamic entity. Planning is a continuous process, and plans change with
circumstances and when gaps are identified during drills or from previous disaster incidents.
The plan should set realistic expectations of effects and needs, should be brief and concise, and
should establish priorities and timelines for actions.
For a plan to be effective, it must be tested by having different disaster scenario drills. The more
times realistic scenarios are created to test the plan in actual practice sessions, the more
problems with the plan will be identified, and solutions for those problems can be found. Without
practice drills, plans may have many unrecognized faults and, as a result, many more
individuals may be harmed and communities damaged when an actual disaster occurs.

Response stage

This stage begins immediately after the disaster incident occurs. The community preparedness
plans that have been developed are initiated. If a disaster occurs, people should remain calm
and exert patience, follow the advice of local emergency officials, and listen to the radio or
television for news and instructions. If people nearby are injured, one should give first aid, seek
help, and check the area for dangerous hazards. Those at home should shut off any damaged
utilities, confine or secure pets, call family contact(s), and check on neighbors, especially the
elderly or disabled.
The plan may call for people to shelter in place or to evacuate, or for search and rescue to
begin. If the only response needed is shelter in place, then people need to know what to do if
they are at home, at work, at school, or in their vehicle.

Evacuation

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

Search and rescue

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

Staging area

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

Disaster triage

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

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

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

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

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

Although triage of individuals exposed to chemical warfare agents is basically the same as for
any multiple or mass casualty incident, it poses special challenges. For these events, the triage
area is set up in the "hot zone" to assist in determining priorities for resuscitation,
decontamination, pharmacological therapy, and site evacuation. Only specially trained
emergency personnel who are familiar with chemical agents and the use of personal protection
equipment should triage chemical agent victims. The same triage categories can be assigned to
these victims.
Psychological triage presents the challenge of determining who most needs help and deciding
what interventions will help. Mental health disorders related to disasters can include anxiety
disorders, exacerbation of existing substance abuse problems, somatic complaints, depression,
and, later, posttraumatic stress disorder (PTSD). Research has identified four keys to gauging
the mental health impact of such events, any two of which may result in severe, lasting, and
pervasive psychological effects. The key factors are as follows:

• Extreme and widespread property damage.

• Serious and ongoing financial problems.
• High prevalence of trauma in the form of injuries, threat to life, and loss of life.
• When human intent caused the disaster. In addition, panic during the disaster, horror,
separation from family, and relocation or displacement are factors that may play a part in
psychological impairment.

Nurses need to evaluate an individual's danger to self or others. Nurses need to know the
symptoms to look for and know what resources are available for people who need help.

Recovery stage

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

Governmental responsibilities

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

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

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

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

Public health system

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

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

The Philippine Red Cross

When it was officially founded in 1947, the PRC carried out two main functions: blood provision
and disaster-related services. Embodying the fundamental principles of the International Red
Cross and Red Crescent Movement (i.e., humanity, impartiality, neutrality, independence,
voluntary service, unity and universality), the present- day Red Cross offers she major services:

1. National Blood Services - provision of safe blood for medical purposes.

2. Safety Services - conduct of training in first aid, basic life support, water safety, accident
prevention, and other basic rescue courses.
 3. Social Services - among its wide range of services, social services relevant to disaster
and postdisaster situations include:
➔ Guidance and counseling.
➔ Psychosocial support program or critical incident stress management -helps in
stress during disasters.
➔ Tracing service - assists in locating displaced or missing person (s) during a
disaster that occurred either in the Philippines or in a foreign country where
normal channels of communication have become difficult for the families
concerned.
➔ Referral service.
➔ Early livelihood recovery program -supports restoration of livelihood after a
disaster.
➔ Hot meals-facilitates a feeding program to prevent malnutrition among calamity
victims, especially children.

4. Volunteer services - provides training courses for volunteers.

5. Community health and nursing services - offers training programs in Basic Health
Education Program and Primary Health Care (Community-Based Health Program) for
professional nurses and student nurses.

6. Disaster management services - involves disaster relief operations and services of

identifying hazard-prone areas and making vulnerability assessment of these areas. The
PRC offers several courses on Disaster Management, including Community-Based
Disaster Management Training. Specific disaster management services offered include:

➔ Relief operations
➔ Deployment of disaster response teams
➔ Organization of barangay disaster action team
➔ Pre-position of relief supplies


The PRC is one of the major nongovernmental agencies that work hand-in-hand with
government agencies in disaster risk reduction. This purpose of the PRC is specifically stated in
R.A. 10072 or the Philippine Red Cross Act.
The National DIsaster Risk Reduction and Management Plan

Signed into law in 2010, R.A. 10121, also known as the Philippine Disaster Risk Reduction and
Management Act, brought about a paradigm shift from disaster preparedness and response to
disaster risk reduction and management (DRRM). It also mentioned disasters brought about by
climate change. The law specified the policy of developing and implementing a National
Disaster Risk Reduction and Management Plan (NDRRMP)

The NDRRM framework envisions a country that has "safer, adaptive and disaster-resilient
Filipino communities toward sustainable development." The goal is to shift from being reactive
to proactive in DRRM. This means the focus is on:

1. Building individual, collective, and institutional capacities to adjust to situations

(increased resilience)
2. Decreasing vulnerabilities. Filipinos will continue to be subjected to risk factors
(hazards), but in due time, resources will be invested more on disaster prevention,
mitigation, preparedness, and climate change adaptation, rather than on response and
rehabilitation and recovery.


The NDRRMP aims to:
● Strengthen the capacity of the government-national and local- together with partner
stakeholders.
● Build the disaster resilience of communities.
● Institutionalize arrangements and measures for reducing disaster risks.
The plan has four priority areas:

● Disaster prevention and mitigation by reducing vulnerabilities and exposure and

enhancing capabilities of communities. Examples of activities that prevent and mitigate
disasters are hazard and risk mapping (geohazard mapping), construction of dams or
embankments that eliminate flood risks, regulations that do not permit any settlement in
high-risk zones, improved environmental policies, and increased public awareness.
● Disaster preparedness - the capacity to effectively anticipate, respond to, and recover
from the impacts of hazardous events or conditions. This includes such activities as
contingency planning, stockpiling of equipment and supplies, development of
arrangements for coordination, evacuation drills, and associated training.
● Disaster response - the provision of emergency services and public assistance during or
immediately after a disaster in order to save lives, reduce health impacts, ensure public
safety, and meet the basic subsistence needs of the people affected. It is sometimes
called "disaster relief.""
● Rehabilitation and recovery - measures that ensure the ability of affected communities to
restore their normal level of functioning by rebuilding livelihood and damaged
infrastructure and increasing the communities' organizational capacity.


R.A. 10121 has designated the Office of Civil Defense, an attached bureau of the Department of
National Defense, as the operating arm and the Secretariat of the NDRRMC. A focal agency
has been assigned to each of the four priority areas, and the heads of these agencies shall
serve as Vice Chairperson in the NDRRMC.
The other member of the Cabinet of the President, including the Secretary of Health, together
with the heads of various government offices and representatives of civil society organizations,
complete the composition of the NDRRMC.

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

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

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

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

Incident Command System

The Incident Command System (ICS) is a standardized, on-scene, all-hazard incident

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

Whenever possible, the local DRRMCs manage incidents with their own emergency teams and
material resources. The following criteria are used in defining which level of DRRMC should
take charge of a particular incident:

● The Barangay Development Committee (BDC), if a barangay is affected.

● The city/municipal DRRMC, if two or more barangays are affected.
● The provincial DRRMC, if two or more cities/municipalities are affected.
● The regional DRRMC, if two or more provinces within the region are affected.
● The NDRRMC, if two or more regions are affected.

The NDRRMC and intermediary local DRRMCS shall always act as support to local government
units (LGUs) that have the primary responsibility as first disaster responders to any incident
occurring within their jurisdictions.

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

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

The Command Staff, composed of people who report directly to the Incident Commander,
usually includes:

● The Public Information Officer who is responsible for providing the public, media, and/or
other agencies with required information related to the incident. Even a Unified
Command has a single Public Information Officer.

● The Safety Officer who monitors operations related to the incident and advises the
Incident Command on matters of operational safety, including the health and safety of
responding personnel. The Safety Officer is responsible for the safe conduct of the
incident management and has the authority to stop any unsafe act.
 ● The Liaison Officer who takes charge of coordinating with representatives from
cooperating and assisting agencies or organizations.

The General Staff is responsible for the functional aspects of the incident command structure. It
usually consists of the operations, planning, logistics, and finance/ administration.

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

Community responses to a disaster

The classic four phases of a community's reaction to a disaster are the heroic phase,
honeymoon phase, disillusionment phase, and reconstruction phase.

Heroic phase

During the heroic phase, nearly everyone feels the need to rush to help people survive the
disaster. Medical personnel may work hours without sleep, under very dangerous and
life-threatening conditions, in order to take care of their patients. Medical personnel may help
out in areas in which they are not familiar and have no experience. Disaster medical assistance
teams, consisting of professionals and paraprofessional medical personnel, provide emergency
relief during a disaster and may travel long distances to help out in a disaster. This was
illustrated by the people who volunteered to help in the immediate aftermaths of the Luzon
earthquake of 1990 and TS Ondoy.

Honeymoon phase

Individuals who have survived the disaster gather together with others who have simultaneously
experienced the same event; this is known as the honeymoon phase. People begin to tell their
stories and review over and over again what has occurred. Bonds are formed among victims
and health care workers. Gratitude is expressed for being alive.

Disillusionment phase

When time has elapsed and a delay in receiving help or failure to receive the promised aid has
not occurred, feelings of despair arise. Medical personnel and other first responders may begin
to experience depression due to exhaustion from many long days of long hours. Depression
may set in as a result of knowledge of what has happened to the community, friends, and family.
People realize the way things were before the disaster is not the way things are now and may
never be the same again. They recognize that many things are different and much needs to be
done to adjust to the current situation.

Reconstruction phase
Once the community has restored some of the buildings, businesses, homes, and services, and
some sense of normalcy is returning, feelings of despair will subside. Counseling support for
victims and helpers may need to be initiated to help people to recover more fully. During this
phase, people begin to look to the future.

Common individual reactions to a disaster

The reactions by individuals to a disaster vary. Some of the more commonly encountered
emotional, cognitive, physical, and interpersonal reactions to a disaster that may be
experienced. It should be noted that both victims and helpers are under stress as a result of a
disaster, thus disaster planning becomes futile if it fails to account for possible intra- and
intergroup conflicts.


Posttraumatic stress disorder

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

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

Pollutant Environmental Health Problems

1. Water Pollution Contaminated water, leading to stomach

problems such as Diarrhea.

2. Air Pollution Congested Air, no fresh air which can lead to

respiratory problems.

3. Soil Pollution Soil is robbed of its natural nutrients leading

to decreased fertility for the land.

4. Noise Pollution Too loud sound waves can cause distress.

5. Thermal Pollution Responsible for global warming.

STEP 1:
1. Receive emergency alerts and warnings by text messages from the NDRRMC and
tuning in to news.
2. Solidify house and stay-in.
3. Evacuation route would be through the house leading to the road.
4. Communication will be via phone or if no signal then invest in a walkie-talkie.
5. Emergency preparedness kit will be updated with more health emergency items
STEP 2: Specific Needs
● 1 senior citizen, 1 adult , 1 teen
● 1 adult responsible for mobility and teen responsible for medical.
● No dietary needs needed.
● Vitamin supplements
● 2 dogs
● 4 cats