[FINAL v6] PDF 2014- 2015 Malaysia Floods

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2014 - 2015 Malaysia Floods:
Challenges For The Health and Medical
Services In Pahang
Editors:
Nur Aiza Z
Zainal AO
Rahimah I
Aina M
PAHANG DARUL MAKMUR STATE HEALTH DEPARTMENT
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CONTENTS
LIST OF CONTRIBUTORS........................................................................................... VI
COMMITTEE ............................................................................................................ VII
ACKNOWLEDGEMENT .................................................................................................. 1
INTRODUCTION .......................................................................................................... 2
ARTICLE 1 ................................................................................................................... 4
PAHANG STATE DISASTER PREPAREDNESS PLAN: HOW WE PLAN? ........................... 4
N.AIZA.Z, M.HAMINUDDIN.H, A.BAKAR.A.N, N.FARKEEZAH.A.G, AZLIR.H ..................................... 4
ARTICLE 2 .................................................................................................................13
PAHANG STATE POST FLOOD HEALTH RECOVERY PLAN : A MESSY AFFAIR .............13
RAHIMAH I, CHE ASIAH T, NORAZIAH M.N, WAN ABD HARIS W.S SULAIMAN MM, USAMAH I..............13
ARTICLE 3 .................................................................................................................32
APPLYING MENTAL HEALTH COMPONENT IN PSYCHOLOGICAL FIRST AID FOR THE
FLOOD VICTIMS: PAHANG EXPERIENCE 2014-2015 .................................................32
FATIMAH AM 1 , A ZAFRI AB 2 , NOORAZIDA ZM 2 , BALRAJ S 3 , NURAZIAN I 4 .......................................32
ARTICLE 4 .................................................................................................................42
HOSPITAL AS A DISASTER RELIEF CENTRE FOR STAFF AND COMMUNITY IN A
FLOOD DISASTER ......................................................................................................42
NGAH, B.A; NYAKABDULLAH, N; LIM, F; AHMAD, A. .................................................................42
ARTICLE 5 .................................................................................................................57
MAJOR FLOOD AFFECTING HAEMODIALYSIS SERVICE JERANTUT HOSPITAL,
PAHANG, MALAYSIA : CLINICAL EFFECTS ON PATIENTS CARE. ...............................57
MOHD NOR A, 1 ADAM S, 1 HUSAIN R, 1 MAT DELI H, 1 THEEBAN S, 1 ABDULLAH R 2 ..............................57
ARTICLE 6 .................................................................................................................65
MANAGING VOLUNTEERS IN PAHANG FLOOD 2014-2015: A LESSON LEARNT........65
ROSLI I. , AR KANAGARAJAH , NORIMAH AG., NOOR FAEZAH A. N. FAZILAH, AZMI ST., NORA, LEOW
CHEE CHENG ...................................................................................................................65
ARTICLE 7 .................................................................................................................80
COMMUNICABLE DISEASE DURING PAHANG FLOOD 2014: WE MANAGED TO
CONTROL ..................................................................................................................80
SAPIAN M, SHARIFAH MAHANI SMA, AKMALINA H, SHAHIDAN H, AZNITA IRYANY MN, HAFEEZ I .........80
ARTICLE 8 ...............................................................................................................101
MEDICAL RELIEF DURING MAJOR FLOOD IN PAHANG 2014: SHARING EXPERIENCES
FROM FOUR DISTRICTS: BERA, JERANTUT, KUALA LIPIS AND MARAN ................101
SUZANA M.H., RAHIMI H., ROSEALAIZA W.A.G., RAHIM W.A ................................................... 101
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ARTICLE 9 ...............................................................................................................111
CHALLENGES AND OBSTACLES INOVIDING MEDICAL SERVICES DURING DISASTER
RESPONSE: ARE WE DOING ENOUGH? ...................................................................111
SUZANA M.H., RAHIMI H., ROSEALAIZA W.A.G., RAHIM W.A ................................................... 111
ARTICLE 10 .............................................................................................................120
WORST HIT DISTRICT IN PAHANG : HOW WE SURVIVED ? ...................................120
RAFIDAH AL 1 , ZAINAL AO 2 , ROHAYA AR 2 , M.ZAINIE 1 ............................................................. 120
ARTICLE 11 .............................................................................................................136
FLOOD MANAGEMENT (DIS 2014~JAN 2015) IN PAHANG: FROM FOOD SAFETY
ASPECTS ..................................................................................................................136
NOR KHAMISAH ABDUL RAHMAN@TAHIR 1 , MOHAMMAD JEFRICROSSLEY 2 , NORBAHIYAH BAKAR 3 , CHENG
LAI PING 4 , FATIMAH MD SALLEH 5 , NORISULIANAISHAK 2 , ISNIZAM SAPUAN 2 .................................. 136
ARTICLE 12 .............................................................................................................150
REVISED AND UPDATED DISASTER PREPAREDNESS PLAN FOR PREVENTION OF
FOOD AND WATER BORNE DISEASE IN FLOOD RELIEF CENTRES ‘KUANTAN MASSIVE
FLOOD 2014’: LESSONS LEARNED ..........................................................................150
SHAHDATTUL DEWI NUR KHAIRITZA, T., POORNIMA, K., MARIAH, A., NOOR AZURAH, W.C., AHMAD
ZULFADLI, M.N., AMIRULLAH, A. ........................................................................................ 150
ARTICLE 13 ............................................................................................................162
READY FOR FLOODS IN PEKAN 2014-2015: SHARING OF EXPERIENCES ...............162
SITI ZUBAIDAH AR 1 , MOHD RAHIM S 2 , DAUD O 3 , FADILLANORLI M 4 , FARIDAH J 5 . .......................... 162
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LIST OF CONTRIBUTORS
Chairman
Dato’ Dr Zainal Ariffin Bin Omar
Director of Pahang State Health Department
Editors
Dr Nur Aiza Binti Haji Zakaria
Senior Principal Assistant Director,
Occupational and Environmental Health Unit,
Pahang State Health Department.
Dato’ Dr Zainal Ariffin Bin Omar
Director of Pahang State Health Department
Dr Rahimah Binti Iberahim
Acting Deputy Director of Pahang State Health Department
(Public Health) Pahang State Health Department.
Dr Aina Mardhiah Binti Mohd
Assisstant Director,
Occupational and Environmental Health Unit,
Pahang State Health Department.
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Committee
A.Bakar.A.N
Noorazida ZM
Adam S
Noraziah M.N
Abdullah R
Norimah AG
Ahmad A
Noor Faezah A. N. Fazilah
Akmalina H
Nora
AR Kanagarajah
Nor Bahiyah Bakar
Ahmad Zulfadli
Nor Khamisah Abdul Rahman @Tahir
Azmi ST
Norisuliana Ishak
Azlir.H
Noor Azurah, W.C.
Aznita Iryany MN
Nyak Abdullah N
A Zafri AB
Nur Azian I
Balraj S
Nur Hazirah MK
Che Asiah T
Poornima K
Cheng Lai Ping
Rahimah I
Daud O
Rafidah AL
FadillaNorli M Rahimi H.
Fatimah AM
Rahim W.A
Fatimah Md Salleh
Rohaya AR
Faridah J
Rosealaiza W.A.G.
Hafeez I
Rosli I
Husain R
Sapian M
Isnizam Sapuan Shahdattul Dewi Nur Khairitza T.
Leow Chee Cheng
Shahidan H
Lim F
Sharifah Mahani SMA
Mariah, A.
SitiZubaidah AR
Mat Deli H
Sulaiman MM
M.Haminuddin.H
Suzana M.H.
M.N. Amirullah, A.
Theeban S
Mohammad Jefri Crossley
Usamah I
Mohd Nor A
Wan Abd Haris W.S
Mohd Rahim S
M.Zainie
Ngah B.A
N.Farkeezah.A. G
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ACKNOWLEDGEMENT
The editors wish to acknowledge the help from all the contributors, reviewers,
external readers, and others in the production of this book.
Highly appreciation given to staffs of Occupational and Environmental Health Unit
(KPAS), State Health Department of Pahang, all District Health Officers in Pahang, Pahang
District Hospital Directors and to individuals who were involved in the success of compiling
these articles.
Our appreciation also goes to all government agencies, the NGOs, private companies
and other parties and individuals who directly or indirectly contributed to the success of
managing the worst flood in Pahang 2014- 2015.
We would also like to thank the Deputy Directors of Pahang Health Department for
their support in ensuring prevention and control activities during and post flood phase. We
wish to thank the staff of district health offices and other state health departments for
giving all their efforts and overwhelming supports to Pahang state.
Thank you.
Editors
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INTRODUCTION
ZAINAL AO
Director Of Pahang State Health Department
The 2014-2015 floods had affected Malaysia from 15 th December 2014 to 3 rd January 2015.
More than 200,000 people were affected while 21 were killed. These floods have been
described as the worst floods in decades. By 23 December, most rivers in Kelantan,
Pahang, Perak and Terengganu had reached dangerous levels. Due to the flood, about
60,000 people were evacuated on the following day. The state of Kelantan had the most
evacuees, followed by Terengganu, Pahang (10,825), Sabah and Perlis.¹
The Malaysian National Security Council or MKN (in Malay: Majlis Keselamatan Negara
Malaysia) has defined disaster as ‘an incident that occurs unexpectedly, complex in nature,
resulting in the loss of lives and damages to properties and the environment as well as
interfering in the daily activities of the local community’. As of 12 pm, 29 December 2014,
MKN reported 101, 702 people from Kelantan, Terengganu, Pahang, Johor and Perak have
been placed at flood relief centres.
MKN and many other states, local and NGO’S relief agencies had done their best during and
after the flood to aid hundreds of thousands of people in the affected states who were
forced to evacuate their homes. One of the hardest- hit district in Pahang was Temerloh,
which was almost completely flooded.
Pahang is the third largest state in Malaysia, after Sarawak and Sabah, and the largest in
Peninsular Malaysia. The state occupies the huge Pahang River basin. It is bordered to the
north by Kelantan, to the west by Perak, Selangor, Negeri Sembilan, to the south by Johor
and to the east by Terengganu and the South China Sea. Its capital is Kuantan, and the
royal seat at Pekan. Other important towns include Jerantut, Kuala Lipis, Temerloh, and the
hill resorts of Genting Highlands, Cameron Highlands, Bukit Tinggi and Fraser Hill.
Health and Medical Care Services in Pahang are provided through eleven hospitals, 348
primary care clinics and 42 dental clinics. In addition, to static facilities, Pahang Health
Department also has mobile clinics to serve people in less accessible areas and for the
indigenous people settlements.²
As with any disaster, the challenge for all government agencies including health and
medical services are enormous. Relief agencies and workers have to provide survivors with
food, water, shelter, health and medical services. In addition, agencies must also help
survivors and their own services return to some sense of normalcy as soon as possible.
Displacement is an important issue that give impacts to the physical and mental health of
refugees.
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During the flood, disruption in electricity, communication, inaccessibility of landtransportation
and water supply posed great challenge to most agencies including health
and medical services especially in managing emergency cases and to give primary care
services to the community of the affected areas.
To make matters worse, flood waters can overload the sewage system and contaminated
the flooded areas. Lack of drinking water, poor sanitation and the close quarters offered in
many emergencies shelters create ripe conditions for spreading many communicable
diseases, such as E.Coli, food poisoning, upper respiratory infections, rotaviruses and
others.
During the flood, the Pahang State Health Department faced some challenges regarding
service delivery of the routine services, medical emergency services, deployment of human
resources and supply to the affected areas. Fortunately, other agencies and NGOs were
very helpful by providing supplemental medical sources and arranging for evacuation of
injured or sick patients to hospitals.
CONCLUSIONS
Based on those experiences in managing the big flood in Pahang in 2014-2015, the Pahang
State Health Department is adequate for responding to flood-related health problems in
terms of preventive, treatment and post-flood healthcare. It is very important, that by
developing clear facility preparedness plans in which it gives on detail standard operating
procedures during floods and identify specific job descriptions so that it would strengthen
responses to future floods. Health facilities should have contingency funds available for
emergency response in the event of floods and other disaster. Health facilities should
ensure that standard protocols exist in order to improve responses in the event of floods.
Introduction of robust tools and equipment for communication system would accelerate
information sharing and data processing. In addition, national and local policies need to be
strengthened and developed in a way that transfers into action in local situations.
REFERENCES
1. ‘Record numbers evacuated in Malaysia’s worst floods in decades’. Reuters.
Investing.com. 26 December 2014. Retrieved 28 December 2014.
2. Laporan Tahunan 2015. Jabatan Kesihatan Negeri Pahang, 2015.
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ARTICLE 1
PAHANG STATE DISASTER PREPAREDNESS PLAN:
HOW WE PLAN?
N.Aiza.Z, M.Haminuddin.H, A.Bakar.A.N,
N.Farkeezah.A.G, Azlir.H
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PAHANG STATE DISASTER PREPAREDNESS PLAN; HOW WE PLAN?
N.Aiza.Z, M.Haminuddin.H, A.Bakar.A.N,
N.Farkeezah.A.G, Azlir.H
ABSTRACT
Disaster can be defined as a sudden accident or a natural catastrophe that causes great
damage or loss of lives. Pahang is the largest state in peninsular of Malaysia which is being
exposed to flood disaster every year. The changes of the monsoon especially the North-
East monsoon brings heavy rain to the east coast region. Unfortunately in December 2014,
Pahang was badly hit by the flood, the worst hit since 43 years ago. Besides that, other
states were also affected such as Kelantan, Terengganu, Perak, Sabah and Sarawak. Due
to this widespread disaster, National Security Council declared it as level two disaster
(which defined as more serious incidence; covers a wide area or had exceeding two
districts and has a potential to spread). There were 98,345 number of evacuees with 338
disaster relief centre (DRC) opened during that time. Whilst this phase, the Critical
Preparedness Responds Centre (CPRC) was activated at the ministry level and also the
state health level. The aim of this centre is to organize all the issues related to health and
to plan the action accordingly. At the state level, Disaster Operation Control Centre (DOCC)
was led by the State Police Officer and other government agencies in the management of
flood victims, evacuees and rescuers. In general, the flood disaster that occurred from 18 th
December 2014 to 16 th January 2015 caused 7 deaths due to drowning. The estimated
property loss was amounted up to millions of Malaysian Ringgit.
BACKGROUND
Pahang is located at the east coast peninsular of Malaysia bordered by Kelantan state in
the North whereby states such as Perak, Selangor and Negeri Sembilan are at the west.
Johor state is in the south whilst the South China Sea is in the east. Pahang consists of 11
districts, and its size is about 35,965 km 2 . Currrently, a total of 1,597,700 people are living
here with the source of income are focused on industrial activities, mining, tourism,
fishering, foresting and others.
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There are 11 hospitals, 11 district health offices, 84 health clinics and 240 community
clinics in Pahang. Geographically, Pahang is unlikely to be hit by catastrophic disasters such
as earthquakes, typhoons and volcanic eruptions but unfortunately, flood is an annual
jeopardy event.
Pahang was affected by two waves of flood during this monsoon. The first wave started on
18 th December 2014 to 22 nd December 2014 which only affected Kuantan district.
Subsequently the second wave began on 23 rd December until 16 th January 2015. During
these 26 days, all districts in Pahang except Cameron Highlands were affected. 23,205
families were transferred out to designated DRC in order to prevent casualties.
There are integration within multi agencies such as Fire Department, Police Force, Army,
Civil Defence Department and Welfare Department headed by district officer (DO). Few
references are being used for this disaster management such as National Security Council
(Directive-20), Garis Panduan Pengurusan Banjir (Ministry of Health 2008) and Garis
panduan Pengurusan Bencana (Pahang State Health Department 2014). Occupational and
Environmental Health Unit in Pahang State Health Department was responsible to lead the
Pahang CPRC. The standard operating procedure is being used to reduce the morbidity and
mortality amongst flood victims through the integration and standardization in the disaster
management. This includes the pre-diaster, during disaster and post disaster
management.According to the National Security Council Directive No.20, a few terms were
used in determining the level of disaster.
Level I Disaster
Incident which localised could be controlled and has no potential of spreading. It is not
complex and could cause only a small damage to life and property. The form of disaster
would not be jeopardy to local daily activity in a large scale. The district level authority is
capable of controlling such incident through district level agencies without or with a limited
assistance from outside.
Level II Disaster
More serious incident covers a wide area or has been exceeding two districts and has a
potential to spread.
Level III Disaster
Any incident caused by level III disaster is more complex in nature or affecting a wide area
or more than 2 states.
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DATA COLLECTION
Following are the data collected during the recent flood disaster in Pahang.
Districts
No of
DRC
Static
clinic
Total
families
Total of evacuees
Kuantan 53 14 5900 21,871
Rompin 6 0 122 471
Maran 44 3 1629 1629
Jerantut 59 3 1161 4418
Temerloh 77 16 5978 22,865
Pekan 85 4 3912 15,298
Bera 19 1 869 3327
Raub 16 0 200 668
Lipis 34 1 1173 4442
Bentong 2 0 20 101
Total 395 42 20,964 75,090
Figure 1: Data of Flood Victims in Pahang
Districts
Prepared Team
Medical team
Health team
Kuantan 24 13
Rompin 9 8
Maran 12 9
Jerantut 11 9
Temerloh 8 11
Pekan 11 12
Bera 13 6
Raub 6 12
Lipis 12 10
Bentong 6 4
Total 112 94
Figure 2: Pahang State Health Department - Medical Team, Health Team and Resources in facing the disaster
(Preparedness Plan)
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PREDISASTER
Pahang State Health director is the Chairman of the Medical Sub-Committee under the
State Disaster Management and Assistance Team. Medical Sub-Committee meeting
involving inter - agencies such as Department of Social Welfare, Department of
Broadcasting Affairs, State Information Department, Royal Malaysian Police, Department of
Chemistry, Civil Defence Department, 4th Brigade Mechanical, Malaysian Red Crescent
Society, St. John Ambulance Malaysia and the Royal Malaysian Air Force will be held around
September or October before the monsoon season begins. Pahang State Health
Department regularly holds a technical meeting involving all the Hospital Directors, District
Health Officers, head of units in the Public Health Department, the Pharmacy Department,
the Food Safety and Quality and the Management Officers by September or October yearly.
The Occupational & Environmental Health Unit will be the coordinator for the state CPRC.
Issues related to health services will be updated as their preparedness plan for the district
level. Among the information to be updated such as the list of names of officers in-charge,
the secretariat team, lists of medical equipment, medical supplies, communication lines, the
number of DRC registered with the Social Welfare Department and other related medical
items.
A liaison officer (LO) will be sent to the Flood Operation Service Centre in order to give
latest information pertaining to the flood situation and numbers evacuees. Medical team
and health team will be set up separately at the district health office where the health team
will do the pre-assessment of all the DRC registered. This health team will also make sure
safe water supply with good sanitation and proper handling of food at the DRC during the
disaster and they will also monitor the environmental health issues during the post-disaster
at the localities which were affected by flood. For the medical team, they will be sent to the
DRC when it is occupied by the evacuees and will be led by a doctor to treat patients. This
is to make sure patients with chronic illnesses such as diabetes mellitus, hypertension,
heart diseases and asthmatic patients are not interrupted with their medication. All
pregnant mothers who are expected to give birth during this expected flood season, high
risk pregnant mothers, pregnant mothers who are more than seven months, postnatal
mothers, children under one year of age, mental patients, cancer patients who are still on
follow-up, haemodialysis patients and post operative patients who are living in this floodprone
areas will be advised to lodge at nearest hospital or to their relative houses which
are not affected by flood. The pharmacy department will make sure all medical supplies are
sufficient for use during flood (three months stock) including other non-drug substances
such as chloride of lime, Lysol and chlorine tablet are adequate and kept in good condition.
Health education materials related to diseases, food hygiene during and after the flood will
be distributed to all DRC.
All districts health department will ensure that there will be enough vehicles which are well
maintained and can be used in any situation.
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DURING DISASTER
During the flood, the standardization management at the state level is very important. Due
to the large-scale of disaster in the recent flood, it is necessary for the secretariat at the
state level to adjust all requests from the district to ensure the continuity of health and
medical services delivered to all the victims, especially for those who are placed in disaster
evacuation centres. Health and medical teams were the main element in the management
of flood evacuees. These two teams will be deployed to all DRC evacuation sites to enable
the service delivered. As for the medical team, they provide services in terms of medical
check-ups including treatments to the injured victims. Evacuees who have chronic health
problems and no complications will be given adequate medicines. On the contrary, those
with complications will be referred to the nearest hospital. The medical team should visit
the DRC at least twice a day. Problem arises when the DRC is not accessible by road which
in this situation it limits the medical team to continue the service. In order to overcome this
problem alternative routes will be used either by boat or by helicopter. The medical team in
the previous disaster managed to reach 100% coverage of the DRC and had given
appropriate medical treatment.
As for the health team, activities that were being carried out during flood disaster were
vector control, clean-water and food quality control, sanitation inspection and health
promotion. On the other hand, the health team also have to cover surrounding areas
against potential pandemic disease. The health promotion team will educate the evacuees
in the DRC on personal hygiene, the do’s and don’ts during the flood especially in the
prevention of disease outbreak. Apart from that, demonstrations, group discussions and
poster were also provided in all DRC as a mean of delivering information related to
hygiene, infectious disease symptoms and any information related to health. During the last
flood, Psychological First Aid (PFA) team played a very important role in the DRC. PFA is a
group consist of a psychiatrist, medical officer and nurses who were trained to provide
group counselling, talks and monitoring the evacuees with the Depression, Anxiety & Stress
Scale (DASS) Tests. Psychological impact of flood-related disaster on victims will be
referred to the hospital for further treatment. The same DASS Test will be conducted by
PFA team to staff who works on field. The PFA is now becoming a new element in disaster
management to control stress among victims and officers during a disaster. Last flood
disaster has showed a solid commitment and involvement PFA team to flood-affected areas
in Pahang. The presence of these teams did help in controlling and diagnosing the stress
among victims, volunteers and staffs.
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POSTDISASTER
Post-disaster is the most critical time in prevention of outbreaks of infectious disease within
the disaster stricken community. It may lead to a very serious consequence if it is not being
handled properly and immediately in this post disaster phase. Health teams in all the
District Health Department play a major role to ensure post-floods activities were done
properly and timely. The activities include inspecting the sanitation, environmental hygiene
and control of Aedes mosquitoes breeding sites at the localities that were hit by the flood.
All of these information of activities are be submitted to secretariat (State CPRC) within a
month from the closure of the DRC. For example, the last DRC closed was Sekolah
Kebangsaan Batu Kapor, Temerloh. The report will be submitted daily for the first week,
once for the second, third and fourth week after the flood. The reporting period must be
done within a month to allow all processes and procedures for infectious disease control
and public health surveillance are done appropriately. The final report should include data
related to health education activities, drinking water quality control, food safety and
environmental control. The Secretariat will collect all the reports from the districts for the
purpose of reference and improvement for the post-mortem disaster meeting. The State
Health Director will chair the meeting for improvement and also identify the urgent needs
for full recovery of the health facilities. The post mortem meeting for inter-agency level will
also be held by the Pahang State Secretary.
From the last flood there are several problems that were identified; communication
equipment such as Government Integrated Radio Network (GIRN) should be available at all
the Operation rooms at the state health department, district health department and also at
the hospitals. The rapid increase in water level had caused several power stations to be
shut down by TNB in order to avoid electrical shock. With this, the only main
telecommunication network using a mobile phone in rural area could not be used. Our
health department was able to use only the GIRN services after two weeks from the hit.
Besides that the essential services to the community were also cut off. Absence of
alternative power sources such as generator in the preparation of the pre-disaster phase
had caused a huge toll to our health services.
As we know, flood that occurred at the end of December 2014 until middle of January 2015
ago were among the worst in the history of the state of Pahang. The flood did not only
brought destruction to the environment and private properties but also damages to many
health facilities comprising rural clinics and health clinics. A total of three health facilities
were declared as total loss (Klinik Desa Paya Pasir, Maran, Klinik Desa Tekal, Temerloh and
Klinik Desa Cegah Perah, Kuala Lipis) with total damage evaluated 4,257,000.00Malaysia
ringgit.
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CONCLUSION
The past flood disaster really taught the importance of preparation at all level of
management. Pre-disaster management and preparedness are important in identifying
possible disaster. By having the standard operating procedure, all team members should be
equipped with sufficient knowledge when disaster comes to reality. In Pahang, flood
disaster becomes an annual impact of heavy rain due to the changes of the North-east
Monsoon. Therefore, by August to October every year the Pahang State secretariat will
make sure that every health districts offices prepare themselves with the guidelines
provided. In the recent disaster, unpredictable big cities in Pahang were involved in the
flood. The affected residents were unable to perform their daily activities due to abrupt rise
in water level. Most of the main roads involved in the flood had caused difficulty in
providing our health and medical services.
At this time, bigger boats with experienced boatmen were needed to face the strong waves
of Pahang River. CPRC Pahang which was led by State Occupational and Environmental
Health unit, is located at the main office of Pahang State Health Department plays a role as
a coordinator in providing health and medical services towards evacuees. In this case,
services are provided at all designated DRC in order to monitor all health issues amongst
the evacuees. There are mobile clinics which will cover at least 3 DRC in a day and the
team have to visit the DRC twice a day. This clinic comprises of a team of medical officer,
staff nurse or assistant medical officer, assistant health care and a driver. The medical
team should be equipped with all basic medical instruments and medications in order to
perform their services as needed. Cases which cannot be handled in this mobile clinic will
be referred to tertiary hospital for further management.
For Pahang static clinics will be established once DRC is occupied with more than 500
evacuees. They are divided into 2 shifts which runs for 24hours a day. For Pahang,
pregnant women (more than 28 weeks), postnatal (less than 8 weeks), person with special
needs (e.g. bedridden) and infants are to be lodged at the nearest hospital by static or
mobile medical team. As for the health team, they are to be established in the pre- disaster
stage. They have to do risk assessment to all the DRC’s identified by the Welfare
Department. The activities include disinfectant, Aedes control, water quality assessment
and environmental hygiene. Those DRC which do not comply with the health standard will
not allowed to be used. In public health, units such as promotion, communicable disease
control (CDC), Vector, BKKM and psychiatric department are important to tackle any
important issue which might raise in DRC. These units are under public health section
which will take part in managing the flood disaster not only by performing activities on
health but also in accessing potential risk of stress among evacuees. Continuous education
was being provided by putting up the posters, demonstration on hygiene and small group
discussion in the DRC.
In Pahang CPRC, the data from all the districts will be collected by personnel’s in the state
which then will be forwarded to the Ministry of Health CPRC. These data are very important
in identified the weakness of the management and to discuss if there is any issue raise in
11

each district. By that, prompt action can be taken with the advice from the commander
who is the Pahang State Health Director
REFERENCES
1) National Security Council (Directive-20), Garis Panduan Pengurusan Banjir (Ministry of
Health 2008)
2)Garis panduan Pengurusan Bencana (Pahang State Health Department 2014).
12

ARTICLE 2
PAHANG STATE POST FLOOD HEALTH RECOVERY PLAN :
A MESSY AFFAIR
Rahimah I, Che Asiah T, Noraziah M.N, Wan Abd Haris W.S
Sulaiman MM, Usamah I
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PAHANG STATE POST FLOOD HEALTH RECOVERY PLAN :
A MESSY AFFAIR
Rahimah I, Che Asiah T, Noraziah M.N, Wan Abd Haris W.S
Sulaiman MM, Usamah I
ACKNOWLEDGEMENT
The authors acknowledge the contribution of Dr Wan Maizatul Akmar bt Wan Mahmood in
compiling data during the flood and all health care workers in affected districts for their
perseverance and motivation. Appreciation also goes to the State Health Directors and
Deputy State Health Director (Public Health) for the support and guidance during the
recovery process.
ABSTRACT
This paper examines the recovery planning process and framework after the severe flood
occurred in the State of Pahang at the end of 2014. An assessment team was formed
consisted of technical personnel from the State Health Department. The team was
responsible to carry out evaluation on the impact of the flood to the health infrastructure
and assets, health services deliveries, health governance process and the vulnerability and
health risks of the affected population. Subsequently, the planning for recovery were
carried out based upon the analysed data on impact of the flood on the healthcare system
in Pahang. The main objectives of the recovery plan was to restore the health system to
its pre disaster conditions, to address underlying vulnerabilities that may have contributed
to the extent of the disaster’s effects and to strengthen the resilience of the health system
and communities to manage better future disasters and their risks to health. In addition,
the planning to rebuild the damaged health facilities was carried out based on the Built
Back Better (BBB) concept.
KEYWORDS:
Pahang, Post-Flood Recovery Planning, Flood Effect Assessment, Disaster Preparedness,
Built Back Better (BBB)
14

1. INTRODUCTION
The flood occurred at the end of 2014 was considered to be one of the worst
disasters experienced by Malaysia in many decades. It has inundated many districts in the
East Coast States of Malaysia. The State of Pahang was not spared whereby the flood
affected 10 districts with 81,927 people being displaced. As for the healthcare services, 78
facilities were affected either physically submerged by flood water or being isolated due to
surrounding flood. Like any other disasters, it has huge impact on the physical
infrastructures, services and the lives of the community.
As the flood receded and the situation was under control, the State Health
Department started the planning for the Post Flood Recovery Activities.
The Pahang State Health Department plays an important role in protecting the
safety and health of the community members as the recovery efforts are under way.
Health personnel are directly involved in recovery activities such as environmental cleanup,
disease monitoring and surveillance, public education campaigns, providing mental
health support and bringing hospitals and other health care facilities back on-line.
The main goal of recovery after disasters is to ensure the economic sustainability of
the community and the long term physical and mental well-being of its citizens, to rebuild
and repair the physical infrastructure, and to implement mitigation activities to reduce the
impact of future disasters. The Pahang State Health Department aimed to built the health
sector back better which means the system will have safer infrastructure, be prepared for
future disasters and provide equitable and affordable services to all.
2. METHODS
An Assessment Team was formed consisted of Public Health Medical Specialist,
District Health Officers, Engineers (civil, mechanical, electrical), Development Officer and
Finance Officer. The approach used by the post recovery planning teams was based on the
World Health Organisation Post Disaster Needs Assessment Guidelines. 1
Decisions were made based upon data and information collected from Crisis
Preparedness Response Center (CPRC).
The analysis was divided into four components :-
i. Health infrastructureand assets.
ii. Deliveryof health services, accessto and changes in demand for services
iii. Health governanceprocesses
iv. Vulnerability and health risksof the affected population
15

The classification of flood severity at the facilities was based upon the Ministry of
Health Malaysia classification method in order to standardize the data collection for the
ease of the monitoring agencies. The classification set by the Ministry are as follows:
Level 1 - Shallow flood
Level 2 - Water reach landscape level
Level 3 - Water level reach 2 feet
Level 4 - Water level reach 4 feet
Level 5 - Water level reach roof top
The recovery plan activities were divided into three phases. The immediate
measures carried out within 5 months, short term within 5-12 months and long term 12-36
months
The objectives of the Recovery Plan are:-
i. To restore the health system to its pre disaster conditions,
ii. To address underlying vulnerabilities that may have contributed to the extent
of the disaster’s effects,
iii. To strengthen the resilience of the health system and communities to
manage better future disasters and their risks to health.
3. FLOOD EFFECT ASSESSMENT
3.1 POPULATION AFFECTED
The flood occurred almost throughout the State of Pahang affected ten districts with
the exception of Cameron Highlands. The worst flood were in Lipis, Jerantut, Bera,
Temerloh, Maran and Pekan districts. The districts of Rompin, Raub, Kuantan and
Bentong experienced flood but were minimally affected. The longest duration of the flood
was in Pekan from 23 rd December to 13 th January 2015 (22 days). The extend of the
flooded areas varies between the districts with Temerloh and Pekan being the worst.
Pekan District was able to minimize the impact of the flood due to the delayed
arrival of flood water hence giving ample time for co-ordinated disaster preparedness and
response. In addition, they have more experience due to annual flooding occurring in the
district.
There were 81,927 flood victims registered into 403 flood relief centres opened
throughout the districts. However, the true figure of people affected by the flood may be
higher. Some people may not check into the relief centers as they have moved to their
family or friends houses in unaffected areas.
16

3.2 HEALTH FACILITIES AFFECTED
The total number of public health facility affected by the floodwater were thirty-eight
( 38 ) consisted of 27 community clinics, 8 health clinics and 1 Klinik 1Malaysia. In
addition, another forty health facility (32 community clinics, 8 health clinics) were isolated
due to roads closure by floodwater.
The worst affected government health facilities were in Temerloh District (54.3%),
followed by Jerantut District (51.4%) and Pekan District (36.4%) as mentioned in table 1.
Table 1: Flooded and Disconnected Health Facilities
District Community Clinic Health clinics/ MCHC/ K1M Total Total
Population in
the operation
areas
Flooded Disconnected Flooded &
disconnected
Flooded Disconnected Flooded &
disconnected
Kuantan 0 3 0 0 1 0 4 12,609
Jerantut 0 9 3 0 5 2 19 45,111
Maran 0 2 6 0 0 1 9 8,712
Pekan 0 4 7 0 0 1 12 15,070
Temerloh 0 9 5 0 1 4 19 116,014
Lipis 0 0 5 0 0 0 5 6,882
Bera 0 3 1 0 1 1 6 29,220
Bentong 0 0 0 1 0 0 1 63,000
Rompin 1 2 0 0 0 0 3 2,422
Total 1 21 27 1 3 9 78 299,040
The total population within the operational areas of the affected health facilities were
299,040 people and the highest affected population amounted to 38.8% are from the
Temerloh District.
3.3 EFFECT AND IMPACT ON INFRASTRUCTURE AND PHYSICAL ASSETS
The initial data was collected by the State Health Department during the first few
days of disaster via phone calls. During the initial stage most affected areas were still
under water and access to the villages were still closed. Soon after the flood receded,
the assessment teams from Engineering Unit, State Health Department were deployed
to all the districts to assess the damages and losses. The summary of flood severity
level for the facilities involved are shown in Table 2.
17

Table 2: Flood severity level for the facilities involved according to districts in Pahang
No. District No. Of facilities
Flood Severity
Level 1 Level 2 Level 3 Level 4 Level 5
1 Jerantut - - 3 1
2 Maran - - 2 3 1
3 Pekan - 8 3
4 Temerloh 1 - 4 2 2
5 Lipis - - 2 2 1
6 Bera - - - 2 1
7 Rompin - 1 - - -
8 Bentong - 1 - - -
9 Kuantan - - - - -
10 Raub - - - - -
TOTAL 1 10 14 10 5
Note : Health Facilities in Kuantan and Raub were not affected by floodwater.
3.3.1 PHYSICAL DAMAGE TO INFRASTRUCTURE
The damage to the physical structure of affected health facilities varies from no
physical damage , minor damage, major damage and total loss of building that need
to be abandoned. The type of damages are classified into physical, electrical,
mechanical and telecommunications.
The severity of damage of the health facilities are summarized in the following Table
3.
18

Table 3: Number of facilities damage according to category of severity.
No. Category Total number
of facilities
1 Total loss- unsafe to be occupied ,
need to be rebuilt
3
2 Major repair ( health clinic) 4
3 Major repair ( community clinic) 18
4 Major repair of staff quarters 15
5 Minor repair ( health and community
clinic)
6 Minor repair ( staff quarters) 4
13
7 No repair required 2
Note : major repair if cost estimated to be > than RM 100,000.00
The cost for repairs that need to be carried out on the affected facilities are
estimated to reach RM 13 million. The following Table 4 shows the estimation
according to the type of facilities.
Table 4 : Estimated Cost of Repair of Affected Facilities.
No. Category of Facility
Esimated repair cost
(RM)
1 Health Clinic 2,600,000. 00
2 Staff quarters in Health Clinic 2,350,000.00
3 Community Clinic 6,040,000.00
4 Staff quarters in community clinic 1,920,000.00
5 Klinik 1Malaysia 100,000.00
6 Other facilities 50,000.00
Total Cost 13,060,000.00
19

3.3.2 PHYSICAL DAMAGE TO EQUIPMENTS AND MEDICAL SUPPLIES
The damaged of equipment and medical supplies in the affected health facilities
were considered as moderate. The damage of equipment was divided into two
groups .i.e. medical equipment and non-medical equipment. The estimated worth
of damaged to the medical equipments were RM 1,278,369.00 consisted of 90%
(RM 1,152,315.00) in affected health clinics and community clinics and 10% (RM
126,054.00) in dental clinics.
Whereas, damaged of non-medical equipment only amounted to about RM
952,927.00 (99.1% in health clinics and community clinics, 0.9% in dental clinics).
The highest damaged occurred in health clinic that being inundated for longer
duration such as Kuala Krau Health Clinic. The water level rose up to the roof of the
building for several days causing extensive damage to the building, equipments,
consumables and drugs.
Table 5: Estimated Value of Damage and Loss of Equipment in Health Facilities in Pahang
Flood 2014
Distrits Damage of Medical Equipments (RM) Damage of Non-Medical Equipments (RM)
Health
Facilities
Dental
Facilities
Total
Health
Facilities
Dental
Facilities
Jerantut 200,660 NA 200,660 83,600 NA 83,600
Maran 75,960 NA 75,960 98,000 NA 98,000
Pekan 81,740 NA 81,740 79,250 NA 79,250
Total loss (RM)
Temerloh 564,755 126,054 690,809 571,540 8287 579,827
Lipis 189,300 NA 189,300 74,250 NA 74,250
Bera 27,900 NA 27,900 10,400 NA 10,400
Bentong 12,000 NA 12,000 27,400 NA 27,400
Total 1,152,315 126,054 1,278,369 944,640 8287 952,727
NA=not affected
The damaged of medical supplies was valued at RM 112,316.00 consisted of 11.6%
consumables, 78.2% drugs and vaccines and 10.1% reagents.
The health staffs had managed to transfer equipments and medical supplies at their
clinics to safer areas such as community halls and other health facilities before the
flood worsened resulted to the minimal loss of medical supplies.
20

Table 6: Physical Damage to Medical Supplies in Health Facilities in Pahang Flood
Districts
Damage of Medical Supplies (RM)
Consumables
Drug/
Vaccines
Reagents
Total
Jerantut 4319 3,529 2314 10163
Maran 4201 250 0 4451
Pekan 4095 0 0 4095
Temerloh 0 83,004 9067 92071
Lipis 0 1086 0 1086
Bera 0 0 0 0
Bentong 0 0 0 0
Total 13,064 87,870 11,381 112,316
3.4 EFFECTS ON SERVICE DELIVERY, ACCESS AND DEMAND
The majority of health facilities involved were flooded or disconnected temporarily
for less than 2 weeks. However, there were four (4) health facilities in Pekan District
being flooded between 3-4 weeks and another eight (8) health facilities being
disconnected for more than 2 weeks.
The service delivery of the affected health facilities were interrupted during and post
flood. However, health services were continued to be delivered to the population
through temporary clinics at the disaster relief centre or at other designated places
such as schools and community hall. During this period, the health services were
more focus on antenatal care, outpatient care especially management of infectious
diseases such as acute respiratory diseases and diarrhea. High risk patient was
referred immediately to nearby hospital either via boat or helicopter (MERCY Flight).
This has resulted to overcrowding of hospital wards and out-patient department. The
availability of drugs and laboratory reagents were not hindered because of earlier
planning for disaster and adequate stock was ensured.
As the flood receded, the service delivery of the affected health facilities restarted
within 2-3 days after the completion of cleaning and washing done by the health
staffs. The service delivery of the badly damaged health facilities were carried out in
temporary health facilities such as tents, cabins and community hall while awaiting
repair or rebuilding of new premises.
21

Table 7: Duration of affected and Disconnected of Government Health Facilities
Districts Flood Distrupted Health Facilities FasilitiKesihatanPutusHubungan
1-2
weeks
3-4 weeks >4 weeks 1-2
weeks
3-4 weeks >4 weeks
Kuantan 0 0 0 4 0 0
Pekan 4 4 0 4 7 1
Temerloh 9 0 0 19 0 0
Lipis 5 0 0 5 0 0
Maran 7 0 0 9 0 0
Jerantut 5 0 0 19 0 0
Rompin 1 0 0 2 0 0
Bera 2 0 0 4 0 0
Bentong 1 0 0 0 0 0
Total 34 4 0 66 7 1
The flood in Pahang occurred in November, December of 2014 and January 2015.
The total antenatal attendances in government health facilities in10 affected districts
were reduced (14%-21%) as compare to pre flood period.
Similar observation was seen in the total attendances of children below 5 years old
in affected government health facilities. The attendances in December 2014 was
20,618 children with a reduction of 6.8 % as compared to the pre- flood period in
October 2014 at 22,130 children.
22

number of delivery
total number of attendance
Figure 1: Antenatal Attendances in 10 districts
12000
10000
8000
6000
4000
2000
0
Bentong Bera Jerantut Kuantan Lipis Maran Pekan Raub Rompin Temerlo
h
October 1615 1521 1921 9872 1589 2754 2400 1157 2734 4908
Nov 1836 1455 1957 10922 1476 2645 2522 1331 2767 4076
Dec 1701 1111 1838 10858 1177 2051 2139 1265 1722 3993
Jan 1773 1257 1760 11101 1443 2364 2292 1210 2629 3481
Feb 1572 1363 1823 8804 1449 2469 2453 1198 2335 4085
The data on deliveries during the period of flooding showed no increase in unsafe
deliveries as compared to the period prior to the disaster. The reason mainly due to
the instruction given for all antenatal mothers near expected date of deliveries from
flood prone areas to be evacuated to hospitals or transit centre or to stay with their
friends or relatives.
Figure 2: Number of Unsafe Deliveries during flood in state of Pahang
20
17
15
10
5
5
2
5
6
0
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15
23

3.5 EFFECTS ON GOVERNANCE AND SOCIAL PROCESSES
The collaboration between government and non-governmental agencies during the
flood and post flood period were good. Many NGOs group came forward to assist
in health services delivery at affected villages and flood relief centers throughout the
state. All of the activities and deployment of teams were under the direction and
supervision of the District Health Offices.
The communication between National Crisis Preparedness and Response
Centre(CPRC) at the ministerial level with state and district CPRC were uninterrupted
and daily correspondences being made via telephone, email and live video
conferencing. This ensures accurate data being disseminated vertically and
appropriate and timely measures being taken to any cropping issues.
It was observed that during the flood and immediate post flood period the health
care workers were seen to be overworked and stressed out, especially among the
hospital staff and staff who work shift duty in the temporary clinic at the flood relief
centre. A large number of health staffs ( i.e more than 850 stafffs ) were also
directly affected when their house being flooded. Some have not report for duty at
their workplace. However, Health Department has responded immediately by
acquiring help from other states as well as regrouping existing staffs from within the
departments.
3.6 EFFECT ON RISKS AND VULNERABILITIES OF POPULATION
3.6.1 WATER-BORNE DISEASES
Flooding is associated with an increased risk of infection. The major risk factor for
disease outbreaks associated with flooding is the contamination of drinking water
facilities. The outbreak can be minimised if the risk is well recognized and disasterresponse
addresses the provision of clean water as a priority.
There is an increase risk of water-borne diseases contracted through direct contact
with polluted waters, such as wound infections, dermatitis, conjunctivitis, and ear,
nose and throat infections. However, these diseases are not epidemic-prone.
The only epidemic-prone infection which can be transmitted directly from
contaminated water is Leptospirosis. The transmission occurs through contact of the
skin and mucous membranes with water, damp soil or vegetation or mud
contaminated with rodent urine.
The incidence of Leptospirosis was found to be significantly increased by 50% after
the flood (6 cases per week) as compared to the number of cases prior to the flood
(4 cases per week).
24

Number of Cases
3.6.2 VECTOR-BORNE DISEASES
Floods may indirectly lead to an increase in vector-borne diseases through the
expansion in the number and range of vector habitats. Standing water caused by
heavy rainfall or overflow of rivers can act as breeding sites for mosquitoes. The risk
of outbreaks is greatly increased by complicating factors such as changes in human
25iarrhea25 (increased exposure to mosquitoes while sleeping outside, a temporary
pause in disease control activities, overcrowding), or changes in the habitat which
promote mosquito breeding (landslide, deforestation, river damming and rerouting).
The incidence of dengue fever in Pahang were already showing increasing trend
toward the end of year 2014 until the early of 2015. This finding was repeatedly
observed during the same period every year resulted from the similar annual
weather pattern. Flooding may initially flush out mosquito breeding, but it comes
back when the waters recede.
Figure 3: Number of Dengue Cases by Epidemiology Weeks 2014 till week 6 of 2015
140
120
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344454647484950515253 1 2 3 4 5 6
Epid week
There was no significant difference in the number of other infectious diseases such
as acute gastroenteritis, malaria, typhoid fever, cholera cases before and after the
flood. This is because of the concerted effort in prevention activities done by health
staffs. They educate the community on good personal hygiene practice, ensure safe
food preparation techniques, ensure boiling or chlorination of drinking water and
importance of seeking early treatment if they fall sick. The surveillance of infectious
diseases is continuing after flood to detect any risk of an outbreak.
The people affected by the flood are at risk of acute malnutrition if there is lack of
access to appropriate and adequate food during flood or after flood. Infants from 6
months onwards and older children need hygienically-prepared and easy-to-eat,
digestible foods that nutritionally complement breast feeding. The affected people
especially children are at risk of getting food waterborne diseases such as diarrhea,
dysentery, cholera, hepatitis A and typhoid fever. Severely infected children may be
25

DASS Screening
Referred Counsellor
Refferred Psychitrist
DASS Screening
Referred Counsellor
Refferred Psychitrist
at risk of acute malnutritition and death if delayed and inappropriate treatment was
given. There was no evidence of increased number of malnutrition among children
during flood and post flood in Pahang. This is because the duration of flood was too
short and there were adequate food supply given to flood victims especially in flood
relief centres.
The morbidity and mortality among high risk patients in flood affected areas in
Pahang were low because they have been identified and were admitted to hospital
or transit centre prior to the flood episode.
3.6.3 PSYCHOLOGICAL ASSESSMENT
A calamity can cause both emotional and physical stress to affected person through
loss of loved one, destroyed home and properties. Unattended psychological needs
can lead to long term psychological impact on the flood victims. Study done by
Nasir et al among flood victims in Johor 2006/2007 showed that the victims suffered
cognitive, emotional and behavioural shortfall such as fear, anxiety, hopelessness
and depression.
The Psychiatrist team from the tertiary hospital in Pahang had implemented
Psychological First Aids to the evacuees in relief centers. They also carried out
psychological assessment (DASS screening) on affected government health staffs
during and after flood. A total of 724 staffs were screened during flood and 1132
were screened during post flood. The result showed 17 cases detected as having
abnormal mental health and they were referred to hospital for further assessment as
mentioned in Table 8.
Table 8: DASS Screening During and After Flood Among Health Staffs
Districts During Flood Post Flood
Kuantan 196 0 6 792 0 0
Temerloh 464 47 5 289 1 17
Lipis 54 0 0 0 0 0
Bentong 10 0 0 51 0 0
Total 724 47 11 1132 1 17
26

4. RECOVERY PLAN
4.1 IMMEDIATE RECOVERY (< 5MONTHS)
Healthcare facilities involved in flood basically are dangerous to be occupied without
proper inspection on electrical safety and structural integrity. Failure to conform may
lead to injury or fatal loss to the staffs or patients.
Following this, as soon as the flood receded a reminder was addressed to all affected
clinics to conduct electrical safety procedures during disaster as circulated by
Electrical Department, Public Works Department (JKR). On top of that, for facilities
which were submerged until roof top (level 5), electrical engineers from Health State
Department with the assistance of electrical charge man from hospital maintenance
concessionaire, Radicare (M) Sdn. Bhd. Were assigned to re-evaluate the electrical
safety and conduct necessary inspection and testing. At the same time, staffs from
individual facilities with the help from NGO’s and volunteers were carrying out
cleaning process.
For structural integrity inspection, technical teams from Health State Department
were observing the physical aspects of the building such as columns, wood floorings
and roof trusses. Overall, most of the facilities affected were structurally sound and
need minor repairs only. To resolve this issue, District Health Officers have taken
immediate action by assigning local contractors to repair all the minor damages.
These were made urgently so that the operation of the facilities could be resume
soonest possible.
In some areas, electrical supply from Tenaga Nasional Berhad (TNB) were cut off for
safety purposes and only re-connected after the flood receded. Fortunately, during
the calamity a private organization had voluntarily contributed 20 units of stand-by
generator sets to the health department for temporary electrical supply in those
areas. All units were distributed to the rural clinics, mostly in Jerantut, Temerloh,
Maran, Bera and Pekan district.
To ensure continuous healthcare services in those affected areas Ministry Of Health
had procured tents and they were installed in facilities which were not safe and
severely damage. Seven units of tents were provided in different community clinics
and health clinics in Temerloh, Maran and Pekan district. The tents served as a
temporary station for primary healthcare services until the existing facilities are
repaired or sturdier cabins are built. For the comfort of the staffs and patients, the
tents were equipped with window-type air conditioners and also electrical sockets for
computers and medical equipments power supply. Prior to installation of the tents,
all utility services such as electricity and water supply were ensured to be available
in every location.
27

4.2 SHORT TERM RECOVERY (5-12 MONTHS)
After the flood receded, the facilities have been reassessed and it was found that the
damages cost were less than the figure estimated earlier. It was because more detail
inspection could only be done after the cleaned up and on –site measurements could
be made.
Some of the facilities that have been badly affected and declared beyond economic
repair and unsafe to be used, Ministry Of Health have provided alternative
infrastructure as a replacement of the temporary tents. The solution is to build a
cabin structure for clinics and hostel quarters and is expected to last up to three
years. The option is targeted for clinics and facilities that need to be replaced due to
the fact that they are unsafe and in the need of major repair.
In Pahang, there are four rural clinics that were declared unsafe and are to be
replaced with new buildings, i.e. Klinik Desa Chegar Perah (Lipis), Klinik Desa Kuala
Tekal (Temerloh), Klinik Desa Paya Pasir(Maran) and Klinik Desa Mambang (Pekan).
Hence, cabin facilities for clinics and quarters will be built in those locations except in
Kampung Chegar Perah due to logistic constraints. The installation works of the
cabins is expected to be completed in September 2015.
Beside the four clinics, other partially damage facilities will also be repaired and
upgraded to restore their functions and safety. Ministry of Health has been given
adequate funds to implement this task. The funds are distributed to all state involved
and all refurbishment projects will be done through minor works procurements at
each district. In Pahang, total cost incurred for all refurbishment projects is RM
4.257 million (excluding the replacement clinics cost). Engineering Unit of Pahang
State Health Department is responsible to identify the projects’ scopes and
specifications as well as to monitor the implementation. All projects shall complete in
the year 2015.
Table 9: Cost of repair by districts, State of Pahang
District
Total repair cost (RM)
1 Lipis 400,000.00
2 Bera 90,000.00
3 Maran 1,110,000.00
4 Temerloh 1,370,000.00
5 Jerantut 750,000.00
6 Pekan 537,000.00
TOTAL 4,257,000.00
28

4.3 LONG TERM RECOVERY (12 TO 36 MONTHS)
The Government is committed to provide the best healthcare services and facilities
to the public. Thus, it is compulsory that all the badly damage clinics be replaced
with new ones.
In Pahang, all four destroyed community clinics will be replaced and the project
proposals have been listed in the 11 th Malaysia Plan (2016-2020). In addition, few
other facilities which experienced flood annually have also been included in the
development programme either being up-graded on site or shifted to another safe
location. The Development Unit of Pahang State Health Department has identified
new locations for the replacement clinics in each district and they are in flood-free
areas in order to prevent similar mishap from recurring.
Table 10: Summary Of Recovery Plan According to District in Pahang
Health Clinic /
Community Clinic
Recovery Needs
According to District
in Pahang
Interventions
Immediate Recovery
(< 5 months)
Maran 1. Purchasing the
Temerloh
basic medical
equipment /nonmedical
equipment
Lipis
2. To provide
alternative place/
shelter for health
Jerantut
services
Pekan
Bera
Bentong
3. To do a safety risk
assessment and
adequate repaired
in the facilities
4. To facilitate flood
aids from other
agencies/ NGO’s
Medium Term Recovery
(5-12 months)
1. Procure the replacement
of all the complete
medical / non nonmedical
equipment in the
facilities
2. To replace the temporary
shelter to the sturdy
facility eg. Cabin
clinic/quarters
3. To do a major repairing of
the facilities to become
more resilience and safe
for the staff and the
patient
Long
Term
Recovery ( 12- 36
month)
1. To replace and
build new
facilities which
are more
resilience and
free flood risk
area
2. To make a good
medical record
system which can
be restore after
the damage or
loss
5. SUMMARY
The flood occurred in the State of Pahang at the end of 2014 and early 2015 was one of
the worst floods ever happened in many decades. It has affected ten districts in the
state with the only exception for Cameron Highlands. There were 81,927 flood victims
registered into 403 flood relief centres opened throughout the districts.
29

The total number of public health facility affected by the floodwater were thirty-eight
( 38 ) consisted of 27 community clinics, 8 health clinics and 1 Klinik 1Malaysia. In
addition, another forty health facility (32 community clinics, 8 health clinics) were
isolated due to roads closure by floodwater.
The worst affected government health facilities were in Temerloh District (54.3%),
followed by Jerantut District (51.4%) and Pekan District (36.4%)
Fifty seven of the affected facilities suffered various degree of damages from minor
damage with low cost repair to major damage that cost more than RM 100,000.00 to
repair. In addition, 4 community clinics were totally destroyed and needed temporary
facilities such as tents and cabin as temporary outlet for health care deliveries while
awaiting new facility to be built within the next 2 to 3 years.
The health services during the flood and post flood period was minimally and
temporarily impaired as temporary static clinic were formed at the flood relief centres or
community hall. However, during and after the period of flood, decreased attendances
to the antenatal and child health clinic were observed. There was no reduction in the
number of safe deliveries as preventives measures were instituted prior to the flood that
ensures safety of pregnant mothers that are due to gives birth within that period.
No significant rise seen in the incidence of infectious disease such as water – borne,
vector-borne and food-borne diseases. However, significant increase in the incidence of
Leptospirosis were noted after the flood.
The recovery process after the disaster was divided into three categories, i.e.
intermediate, ( less than 5 months) , short term ( 5 to 12 months) and long term ( 12-
36 months)
6. CONCLUSION
During the planning and recovery process of flood disaster in Pahang, there were some
highlight of challenges and limitation that hinder smooth implementation of the recovery
process.
Firstly, the gathering of reliable and sufficient data may be difficult at the beginning of the
process as influx of data coming in from the fields were either repeated or not verified.
However as the process developed and specific formats were distributed, this issue was
resolved.
The Primary Health Care services should be easily accessible to remaining populations in
the affected areas. In addition to the temporary static clinic at the flood relief center, the
needs of people not affected in the community should also be addressed by ensuring easy
access to unaffected facilities through proper referral system. Moreover, health facilities in
areas that has significant increase numbers of evacuee center need to be strengthened to
cope with the increased number of patients. The availability of essential packages of health
services needs to be reviewed, and how these may need to be adapted to changes in
disease profiles that often seen after disasters
Secondly, the delay of budget allocation to replace and repair damage buildings and
equipments by the ministry makes the recovery process slower than expected. However a
strategy of sequencing prioritization to procure urgently needed basic equipment and
30

furniture using existing budget has been used awaiting the disaster funds promised by the
government.
In terms of long term recovery, large amounts of budget are needed to rebuild new
infrastructures that are more resilience at a new location that is not prone to flood.
Innovative and creative building design based upon the Built Back Better (BBB)
approaches should be considered and implemented in all flood prone areas. The new
buildings must be built with the capacity to withstand future hazards and remain functional
when the next disaster happens.
Proper handling and storage of medical records is deemed important at the times of
disaster as experienced by some health clinics during the last flood. Patient’s records and
reports in badly affected facilities were mostly destroyed. Implementation of new option of
records keeping such as home based record and electronically saved records need to be
looked into seriously by the authority.
Finally, the authority needs to integrate the emergency and disaster management into
legislative frameworks, policies and plans in order to minimize the impact of similar disaster
in the future. The Ministry should consider forming a multidisciplinary unit in the MOH with
authority, capacity and resources to provide coordination of health emergency
management activities at all levels within the health sector and with other sectors.
REFERENCES
1. World Health Organization. Flooding and communicable disease fact sheet:
risk assessment and preventative measures. (Accessed January 13, 2005)
2. Post Disaster Needs Assesment Guidelines Vol. B Social Sector – Health 2014.
3. http//www.wpro.who.int/southpacific/mediacentre/releases/2014/nutrition-solomonsflashflood/en/.
4. http//www.who.int/hac/techguidance/ems/flood.cds/en/.
5. R. Nasir, A.Z. Zainah& R. Khairudin. (2012). Psychological Effects on Victims
http://dx.doi.
6. GFDRR, 2010. DaLA Guidance notes, Washington: GlobalFacility for Disaster Risk
Reduction (GFDRR).
7. Thai Flood 2011, Rapid Assessment for Resilient Recoveryand Reconstruction Planning.
8. UNDP, 2007. Review of Post Disaster Recovery NeedAssessment, New York: UNDP
31

ARTICLE 3
APPLYING MENTAL HEALTH COMPONENT IN
PSYCHOLOGICAL FIRST AID FOR THE FLOOD VICTIMS:
PAHANG EXPERIENCE 2014-2015
Fatimah AM 1 , A Zafri AB 2 , Noorazida ZM 2 ,
Balraj S 3 , NurAzian I 4
1. Pahang State Health Department
2. Department of Psychiatric HTAA
3. Department of Psychiatric HoSHAS
32

APPLYING MENTAL HEALTH COMPONENT IN PSYCHOLOGICAL FIRST AID FOR
THE FLOOD VICTIMS: PAHANG EXPERIENCE 2014-2015.
Fatimah AM 1 , A Zafri AB 2 , Noorazida ZM 2 , Balraj S 3 , NurAzian I 4
1. Pahang State Health Department
2. Department of Psychiatric HTAA
3. Department of Psychiatric HoSHAS
ABSTRACT
During Pahang’s Flood disaster 2014-2015, 12 Psychological First Aid (PFA) teams were
activated to cover mainly DRCs with more than 500 evacuees. A total of 41 centers during
flooding and 47 centers post flooding were visited by the PFA teams respectively. During
flooding periods, the activities done were assessing the mental state of the evacuees and
Flood Relief Providers. At the same time, psychosocial support for those needed was given.
DASS self-administered questionnaires were used to detect emotional distress.
Psychological and behavioural activities were carried out to lessen the distress experience
by the evacuees. A total of 58 evacuees and flood relief providers were noted to have
higher score on DASS questionnaires during the disaster. 47 of them were medical
personnel. They were referred for further assessment and management. For post flooding
period, activities were carried out only at the government hospitals and health clinics. A
total 1,132 medical personnel (either the evacuees or flood relief providers) were assessed.
19 of them were referred for further management.From the data, we noted that 2014-2015
flooding did cause psychological impact to the evacuees as well as the flood relief
providers. The impact was greater among medical personnel. This could be because they
were the victims and at the same time have to give their services at their working places.
Since there was no report yet from referral center on chronic impact of the disaster to the
effected medical personnel, no specific follow-up plan was done to those who were referred
for further management. The teams were unable to cover most of the centers due to
limited resources. In future, PFA training will be conducted locally as a preparation for any
disaster in the state.
33

1.0 INTRODUCTION
Psychological First Aid (PFA) is an evidence-informed approach that is built on the concept
of human resilience which aims to reduce stress symptoms and assist in a health recovery
following any traumatic events or natural disasters. Its goal is to create and sustain an
environment of safety, calm and comfort, connectedness, self-empowerment and hope
(MDH, 2013). PFA is part of mental health aspect of Psychosocial Disaster Programme.
PFA has it owns strength. It assumes that most victims will not develop long-term mental
health illness if immediate needs are met after a disaster. It caters for individual needs as
it uses a modular approach. PFA can be used for individual across the life-span with
different cultures and diverse populations. It only identifies victim’s strengths and does not
give diagnosis or treatment and PFA can also be delivered by non-professional mental
health providers. Hence it is economical as well as supportive to the professional mental
health providers (Shannon, 2015).
A systematic review confirms that there is sufficient evidence for PFA to be used during
disaster. It offers an acceptable intervention option to be provided by volunteers without
professional mental health training for people who have experienced a traumatic event.
PFA is a vital first step in ensuring basic care, comfort, and support. Volunteer providers
must be trained and reminded that PFA assists victims with their initial needs but is not a
treatment for their mental health problems, which is the responsibility of the disaster
mental health professional staff (Fox JH, et. al, 2012).
Acute distress following exposure to traumatic events or disasters is best managed
following the principles of psychological first aid which can be taught to both volunteers
and professionals. It is a potentially valuable skill that is easily applied in the wake of mass
disasters. Although its operation is basic compared to other types of psychotherapy, it is
important to recognize that competence in Group-PFA still requires specialized training. It
is important for them to recognize that community is a source of safety, support, and
recovery. This is possible with Group-PFA (Everly et. al, 2006).
Most studies show that debriefing has no added advantage to individuals who receive it
post disaster compared to those who do not receive debriefing. Recent recommendations
suggest that ‘psychological first aid’ is important in assessing victims’ needs and offering
support as necessary, without forcing them to disclose their personal thoughts and feelings
about the event. A part from that, it is also important to provide information about the
trauma and the consequences. Several controlled trials also suggest that certain cognitivebehavioral
therapy methods may reduce the incidence of PTSD among people exposed to
traumatic events, which are delivered weeks or months after the trauma. These methods
are more effective than either supportive counseling or no intervention (McNally RJ, Bryant
RA, Ehlers A. 2003).
In recent flood disaster in Pahang, the team members of psychosocial responders were
from trained medical personnel. Their responsibilities included early detection of mental
health problems among evacuees and other flood relieve personnel and referring them to
relevant authorities. Promotion of mental health education was also added as a component
of psychological interventions. Mental health screening using DASS questionnaire and
34

public mental health education with regard to the aftermath of disaster complications were
also emphasized, focusing in returning back to their normal social functioning. They were
also empowered to do early detection and recognising early symptoms of stress,
depression and mental health problems and getting appropriate treatments.
2.0 METHODOLOGY
Teams of PFA were consisted of psychiatrists, medical officers, nurses, assistant medical
officer, counsellors, social welfare officers and occupational therapists. There were all
together 12 PFA teams throughout Pahang during the disaster. They were divided
according to coverage area; 6 teams from psychiatric department of Tengku Ampuan Afzan
Hospital Kuantan (HTAA) covering the district of Pekan, Muadzam, Maran and Rompin; 3
teams from psychiatric department of Sultan Haji Ahmad Shah Hospital (HOSHAS) covering
Temerloh, Bera, Jengka and Jerantut; 2 teams from psychiatric department of Bentong
Hospital covering Raub and 1 team from psychiatric department of Kuala Lipis Hospital
covering Lipis area. These teams were allocated to visit identified Disaster Relief Centres
(DRC) to observe, screen and identify any mental health issues and refer accordingly either
to the static clinic at DRC or nearest health centres. DASS questionnaire was used for
mental health screening for depression, anxiety and stress. Mental health education talks,
breathing and relaxation therapy and supportive psychotherapy were also delivered.
Simple techniques of counselling for individual and group were performed for evacuees,
flood relief volunteers and medical teams’ staff at the centre. The teams also carried out
activities with children and adolescents such as art therapy (colouring and drawing), in
door games and origami.
Post flood activities were mainly focused on the mental health well being of our medical
staff who were directly or indirectly involved in the disaster through mental health
screening using DASS questionnaire and early intervention at respective health clinics or
early referral to psychiatric services if indicated.
35

3.0 RESULTS
During the disaster, there were 81,927 evacuees registered throughout the whole Pahang
with 403 DRCs were established by Disaster Operation Control Centre (DOCC).
Table 1: Distribution of Evacuees and DRC'sduring 2014/2015 flood by districts in Pahang
District
Number
of DRC
Number of
Families
Affected
Number of
Evacuees
Mean duration of
DRCs’ operation
(days)
Kuantan 61 6,326 23,549 4
Jerantut 59 1,161 4,418 10
Lipis 34 1,173 4,442 7
Pekan 85 3,912 15,298 12
Rompin 6 122 471 2
Maran 44 1,629 6,788 10
Temerloh 77 5,978 22,865 11
Bera 19 869 3,327 10
Raub 16 200 668 1
Bentong 2 20 101 1
Total Pahang 403 21,390 81,927 8
source: State Disaster Operation Control Centre (SDOCC)
A total of 41 centers were visited by the PFA teams during flooding period mostly at the
DRCs with static clinic. For post disaster activities, a total of 47 centers were visited
comprising of government hospitals and government health clinics.
As shown in table 2, a total number of 1,856 DASS screening was carried out in the
disaster. 724 were done during the flood event on evacuees and flood relief providers.
The remaining 1132 were carried out on health personnel who were either they themselves
were evacuees and service providers or they were only service providers.
36

Table2: Distributions of DASS Screening During And After Flood Disaster
DASS Screening Kuantan Temerloh K Lipis Bentong Total
During Flood 196 464 54 10 724
Post Flood 792 289 0 51 1132
Total 988 753 54 61 1,856
Table 3 showed total number of referrals based on the DASS screening. A total number of
77 referrals from static clinics or health clinics were made to either psychiatric clinic or
counsellor. 47 referrals from Temerloh were mainly from medical personnel of HoSHAS
stranded in the hospital during the floods.
Table 3: Distributions of Referrals Based on DASS Screening Questionnaires During And
After Floods Disaster
During
After
Referrals Kuantan Temerloh K Lipis Bentong Total
Psychiatry Clinic 6 5 0 0 11
Counsellor 0 47 0 0 47
Psychiatry Clinic 0 1 0 1 2
Counsellor 0 17 0 0 17
Activities done by the team were briefing on psychological disaster, mental health
education, breathing and relaxation therapy, supportive psychotherapy and counselling. A
total number of 1372 evacuees and clients were benefitted from the activities. 140 sets of
mental health pamphlet were also distributed as shown in table 4.
37

Table 4: Distributions of Activities Done During and After Flooding.
Activities Kuantan Temerloh K Lipis Bentong Total
Briefing On Psychosocial
Disaster
40 20 10 5 75
Mental Health Education 221 172 60 50 503
Breathing And Relaxation
Therapy
19 104 30 0 153
Supportive Psychotherapy 40 0 0 0 40
Counseling 173 351 49 28 601
Mental Health Pamphlet
Distributed
40 40 40 20 140
As for the children and adolescents, there were 3 main activities done for them, namely art
therapy, indoor games and origami and card therapy.
Table 5: Distributions of No of Children and Adolescents Participating In The Activities
During And After Flooding
Activities
Kuantan Temerloh K Lipis Bentong Total
Art Therapy
540 90 99 60 789
Indoor Games 65 20 30 0 115
Origami And Card
Therapy
15 0 20 0 35
38

4.0 DISCUSSION
The 2014-2015 floods episode in Pahang recorded total number 81,927 evacuees from 10
districts. It lasted for 28 days from 22 nd December 2014 till 18 th January 2015. In this
massive flood, the coordination of PFA team was from CPRC Pahang State Health
Department. The disaster response for the whole state of Pahang was activated on the
24 th of December 2014 following instruction from CPRC. The field implementation of the
psychosocial disaster response was carried out by the department of psychiatry HTAA,
HoSHAS, Bentong Hospital and Kuala Lipis Hospital.
Based on the number of evacuees, the coverage of PFA activities were very minimal
compared to the number of flood victims. Furthermore, the activities were only carried out
in DRC with more than 500 evacuees. Since the data collections were small, it does not
represent the real pictures of psychosocial problems faced by the evacuees.
Data collected also showed that the number of medical personnel being referred for further
psychological assessment were more than evacuees. This finding could be due to the fact
that flood was occurring almost every year and the evacuees are already conditioned to the
situation. We found that a large number of medical personnel in HoSHAS had higher DASS
score. Further interviews revealed that some of them were victims, stranded and
separated from the family or an increase of workload due to shortage of staff. So, it is
important for medical personnel especially front liners to take care for themselves in order
to serve others and immediate intervention has to be done if they are in distress.
Specific activities carried out for children and adolescents were meant to detect any
emotional distress among them so that early interventions can be instituted and further
management if needed. Fortunately none was detected.
The Health Education materials provided by the CPRC were also not enough to run
activities.
A pilot study done in students who were exposed to the Great Flood of Iowa in 2008 using
LPC, a form of Psychological First Aid delivered by school personnel, was found to be a
promising response strategy. With reduced resources available for school-based mental
health services, LPC is an efficient first-level of defense that identifies children in distress,
provides initial support from a trusted adult, and links those most in need of advanced
care. Listen Protect Connect (LPC), a school-based program of Psychological First Aid
delivered by non-mental health professionals, is intended to support trauma-exposed
children (Ramirez et. al, 2013).
Perhaps in future, school teachers can be trained to cater students who are exposed to any
disasters and PFA can provide easily accessible links for the teachers to help their students.
39

5.0 LIMITATION AND RECOMMENDATION
As we cannot predict on how bad any disaster can be, our preparedness will only be based
on our previous experiences. There will definitely be some weakness and limitations in our
service provisions.
The limitations encountered during the disaster were that the numbers of PFA teams were
not enough to cover all Disaster relief Centres (DRC) throughout the state. All PFA teams
were activated from hospitals because PFA teams were not established from Public Health
sector yet. There were no established system in referring and follow up victims from DRC
to Public Health Clinics, counsellors or Psychiatrics clinics. The number of medicals
personnel trained in PFA was limited. Therefore, most of the PFA teams member only
consisted of minimal personnel. PFA volunteers from other states or Non-Governmental
Organizations were not coordinated accordingly as they were not reporting to Pahang
District Relief Coordination Centre. At that moment, there was no specific allocated budget
for materials and activities during the disaster.
We hope that in the future, we are able to train and develop more PFA teams from Public
Health Sector in every district so that more DRCs can be covered, to involve the
participations of Family Medicine Specialist as coordinator in handling referral at Public
Health Centres, to conduct refresher course annually to ensure psychosocial responders are
updated with current knowledge, to develop comprehensive referral system from DRC to
referral centre and to develop Health Educations Pamphlets and posters in main languages
specifically on mental health to educate the victims
6.0 CONCLUSION
In trying to prevent long term psychosocial consequences after flood disaster, early
detection, proper referral, proper follow-up and adequate attention should be emphasized
by the health care providers (Anja JE Dirkzwagar et al 2006). Generally, the number of
PFA teams was not enough to cover all DRC. There were no specified allocations. So
materials needed to carry out activities were limited. Hopefully, Pahang State Health
Department will plan to do trainings on this matter and building networking with other
related agencies so that if any major disaster re-occur, PFA teams are ready to function
throughout the state.
40

REFERENCES
1. Anja J. E. Dirkzwager, Linda Grievink, Peter G. Van der Velden, C. Joris Yzermans
2. Risk factors for psychological and physical health problems after a man-made disaster:
Prospective study DOI: 10.1192/bjp.bp.105.017855 Published 31 July 2006
3. Minnesota Department of Health April 2013
4. Psychosocial First Aids (PFA)
5. Ramirez M. et al (2013) listen protect connect for traumatized school children: a pilot
study of psychological first aid BMC Psychology 1:26 doi:10.1186/2050-7283-1-26
6. Fox JH, et. al, (2012) The Effectiveness of Psychological First Aid as a Disaster
Intervention Tool: Research Analysis of Peer-Reviewed Literature From 1990-2010
Disaster Med and Public Health Preparedness. 2012;6:247-252
7. Everly et al, (2006) Introduction to and Overview of Group Psychological First Aid. Brief
Treatment and Crisis Intervention 6:130–136
8. McNally RJ, Bryant RA, Ehlers A. (2003) Does Early Psychological Intervention Promote
Recovery from Posttraumatic Stress? Psychological Science in the Public
Interest November vol. 4 no. 245-79 doi: 10.1111/1529-1006.01421
9. Shannon M.E.R, 2015. Early psychocosocial intervention after disaster: psychological first aid.
Health Emergency and Disaster Nursing (2015) 2, 3–6
10. Plaster G. 2014. Psychological first aid: as essential for providers as for their patients.
Emergency physicians international.
41

ARTICLE 4
HOSPITAL AS A DISASTER RELIEF CENTRE FOR STAFF AND
COMMUNITY IN A FLOOD DISASTER
Hospital Sultan Haji Ahmad Shah Experience (2014-2015)
Ngah, B.A; NyakAbdullah, N; Lim, F; Ahmad, A.
42

HOSPITAL AS A DISASTER RELIEF CENTRE FOR STAFF AND COMMUNITY IN A
FLOOD DISASTER
Hospital Sultan Haji Ahmad Shah Experience (2014-2015)
Ngah, B.A; NyakAbdullah, N; Lim, F; Ahmad, A.
ACKNOWLEDGEMENT
To all the staffs of Hospital Sultan Haji Ahmad Shah who works through the flood and
collect the data for this paper.
ABSTRACT
From the 25 th of December 2014 to the 4 th of January 2015, the District of Temerloh was
hit by a major flood which resulted in more than 20,000 flood evacuees. Hospital Sultan
Haji Ahmad Shah is located in the region. Although not directly flooded, its surrounding
area was submerged resulting in more than 6,450 people displaced. Hospital staffs were
also affected. Of the 730 staff involved, 383 had their houses flooded while 347 had their
houses surrounded by water. 128 staff used the hospital as their place of relocation
bringing with them 124 family members.
While the hospital services were stretched to it limit, the presence of these staff helped to
alleviate the shortage of healthcare personnel. In fact the hospital was able to function at
full resource capacity. Thus the hospital acted as a disaster relief centre for staff. The
hospital acted on 2 basic principles that is taking care of their basic needs and reducing
their stress level. By doing so, these staffs were able to perform.
Due to congestion of the designated relief centres, the public also used the hospital as well
as its facilities as a relief centre. This paper hence shows the need for a hospital to be
prepared for such an event and to not only focus on services deliveries.
43

1. PURPOSE OF THE STUDY
Hospitals situated in a flood disaster prone area are likely to be also involved as a disaster
victim. The staffs of the hospital and their families are likely to be severely affected.
Hospital Sultan Haji Ahmad Shah’s disaster plan was geared towards responding to the sick
and injured in the disaster hit areas but not as a relief centre. This paper will therefore
present the need for a hospital’s flood disaster response plan to not only include medical
relief but to also serve as a disaster relief centre, especially for staff and part of the
community.
2. INTRODUCTION
Hospital Sultan Haji Ahmad Shah (HoSHAS) is located in the state of Pahang in the district
of Temerloh. It has 550 beds with all the major clinical disciplines. It is hence the main
referral centre for 6 other districts which includes the districts of Jengka/Maran, Jerantut,
Bentong, Raub, Lipis and Bera. It was built on a hill, about 5 km from the major Pahang
River. The surrounding areas of the hospital are low laying areas and are prone to be hit in
major floods. Housing estates were built in this area of which many of the hospital staff
stayed. There are living quarters provided for 330 staff and families. The hospital
employed 2,050 staff of various categories. There were 5 schools designated as flood relief
facilities in this area.
Pahang River is 435km, the longest river in West Malaysia. The river starts from the
District of Lipis joining at the Kuala Tahan Tembeling River to form the Pahang River. It
flows toward the sea and join with the Semantan River at Temerloh town. The river drains
¾ of land water in the State of Pahang. When all the three river levels are high, major
flood will occur in the District of Temerloh and its downstream region. The worst flood
disaster recorded was in 1926, 1971 and 1988.
In recent years, there is rapid development in Temerloh town. This resulted in numerous
housing estates around the river bank. These housing areas are built on flood prone land
which is easily affected if major floods were to occur. Thus, the impact of flood at present
is more severe as the population effected is high due to high population density as
compare to previous floods.
3. THE STUDY
This is a retrospective study based on events documented during the recent major flood
that occurred on the 25 th of December to the 4 th of January 2015. Data are collected from
various authorities, from events recorded as well as via return to central agency.
44

4. RESULT
4.1. PAHANG RIVER WATER SITUATION
On the 22 nd of December 2014, Kuala Lipis town was hit by flood. Water levels reached
its town area. On the 23 rd of December 2014, Kuala Tahan reported that flooding has
occurred in its areas. The water level in Temerloh was still below its warning stage.
Table 1 shows the river water levels of three main contributors to Temerloh (Lubuk
Pasu) area.
Date/River
Tembeling
(Kuala
Tahan)
(meter)
Yap
(Jerantut)
(meter)
Lubuk Pasu
(Temerloh)
(meter)
Semantan
(Temerloh)
(meter)
Normal 60.00 44.00 26.00 49.00
Alert 64.00 48.00 29.00 51.00
Warning 66.00 50.00 31.00 52.00
Danger 68.00 52.00 33.00 53.00
24/12/2014 77.52 59.12 32.90 47.99
25 NA 55.40 35.80 48.49
26 NA 55.39 36.01 49.05
27 NA 55.09 37.92 50.54
28 NA 55.09 38.08 50.98
29 NA 55.40 37.91 62.55
30 NA 50.24 37.88 62.55
31 55.28 48.63 37.86 62.55
1/1/2015 49.86 48.23 38.02 62.52
2 NA 48.07 37.50 62.37
3 NA 47.94 35.50 62.19
4 NA 47.89 31.89 62.08
5 NA 47.83 29.61 62.04
6 NA 48.05 28.56 62.00
Table 1: Pahang river level from the 24 th of December 2014 to the 6 th of January 2015
(Source: Web Portal Department of Irrigation and Drainage Malaysia)
The Pahang River at Temerloh rose rapidly at about 1 meter/day from the 25th of
December 2014. This resulted in many of the population were caught unprepared.
From 25 th December 2014 to the 2 nd of January 2015, all major roads were affected
except for the old road from Temerloh to Kuala Lumpur, making most towns and villages
inaccessible by road.
The hospital flood committee sat on the 23 rd of December 2014 to review its flood
preparedness situation. Blood products, food, water, petrol and medication were at the
level stated in Standard Operating Procedure (SOP) for patient care. All elective
45

surgeries were cancelled. Three hospital quarters were designated for staff evacuees
with additional bed placed in the nursing hostel to cater for nurses.
4.2. COMMUNITY EVACUATION
HoSHAS is located in the Mukim of Perak II in the District of Temerloh. Table 2 shows
the number of disaster relief centres in the mukim and its capacity. The nearest disaster
relief centre to the hospital was at the Seberang Temerloh Secondary School. It has the
capacity to house 2,000 evacuees. The other 4 relief centres in the area were also
inaccessible by road leaving the Seberang Temerloh Secondary School as a relocation
site for the community surrounding the hospital area. During the flood, 3,000
communities were placed in the school leading to over congestion. Many of the
evacuees stayed in relatives or friends houses to avoid the congestion. 10 families were
evacuated to the hospital while many used the hospital facilities such as toilets and
power supply.
No. of Gazette No. % of
Mukim
DRC capacity Evacuee Displacement
Perak II 5 4,200 6,450 154%
Table 2: Disaster Relief Centre (DRC) in Mukim of Perak II (Source: Temerloh Disaster
Operation Control Centre)
A total of 21,226 people were displaced by the flood to relief centres in the District of
Temerloh.
46

4.3. HOSPITAL STAFF AFFECTED BY FLOOD
Graph 1 shows the number of hospital staff affected by the flood. Of the 730 staffs that
were affected, 128 moved into the hospital with 124 family members (Graph 2).
However 1,866 (90.8%) staffs were still able to come to the hospital via other
transportation. During the duration of the flood the hospital was able to maintain most
of its clinical staff. This enabled the hospital to operate in full human resource capacity.
NUMBER OF STAFF INVOLVED IN THE
FLOOD
TOTAL NUMBER OF STAFF AT HOSHAS = 2,054
390
383 (17%)
380
370
N
U
M
B
E
R
360
350
347 (15%)
340
330
320
rumah dinaiki air
rumah terkepung
CATEGORY
Graph 1: Number of HoSHAS staff affected by flood (Source: Hospital Census)
STAFF WHO STAYED AT THE
HOSTEL/QUARTERS DURING THE FLOODS
70
60
61
N
U
M
B
E
R
S
50
40
30
20
10
0
2
13
17
10
1
8
7
1
6
1 1
CATEGORY
NUMBER OF PEOPLE WHO STAYED AT THE HOSTEL/QUARTERS DURING THE FLOOD =
128 STAFF + 124 FAMILY MEMBERS
Graph 2: Number of staff moved to the hospital as evacuation centre (Source: Hospital
Census)
47

Categories
No. of
Staff
Staff
Reported To
Duty
% of
Attendance
Specialist 50 50 100.0%
Medical officer 216 212 98.3%
Nurses 820 808 98.6%
Medical
120 118 98.4%
assistant
Others 848 667 79.9%
Total 2,054 1,866 90.8%
Table 3: Overall staff attendance to work from the 25 th of December 2014 to the 5 th
January 2015 (Source: Hospital Census)
4.4. IMPACT ON HOSPITAL SERVICES
4.4.1. Hospital Bed Occupancy Rate
As the surrounding area was flooded, in accordance to the flood SOP, people who
that were bed ridden, pregnant ladies in their third trimester and end stage renal
patient were evacuated to the hospital (Graph 3). The hospital was also use for
evacuees from old folk homes. The total number of inpatient reached more than
100% BOR (Table 4). Two temporary wards were opened in order to meet this
need (Graph 4). Patients were also transferred to other accessible hospitals in the
west of Pahang as temporary measures to reduce congestion at HoSHAS.
Date No. of Inpatient BOR
25/12/2014 441 80.18%
26 434 78.90%
27 446 81.10%
28 472 85.80%
29 563 102.04%
30 573 104.10%
31 559 101.60%
1/1/2015 514 93.50%
2 439 79.80%
3 417 75.81%
Table 4: Number of inpatients and BOR of Hospital Sultan Haji Ahmad Shah from
the 25 th of December 2014 to the 3 rd of January 2015 (Source: Hospital Census)
48

PATIENTS ADMITTED DUE TO FLOODS (LODGER)
FROM THE 24.12.2014 - 05.01.2015
(ACCORDING TO WARDS)
Graph 3: Number of patients admitted or not discharges due to flood (Source:
Hospital Census)
Graph 4: Number of patients in 2 temporary wards from the 24 th of December 2014
to the 5 th of January 2015 (Source: Hospital Census)
49

Patients are usually evacuated with at least 1 family member, as it is the culture of
the community to fend for their sick relatives. With the failure of utility supply in
town and nearby districts, end stage renal patient was transfer to the hospital, thus
the need to keep maximum human resource especially nursing (Graph 5).
Patients discharged were also kept at minimal numbers as surrounding disaster relief
centres were congested and the roads were inaccessible to send patients back to
their homes. Newly delivered and infants were kept in the hospital in accordance to
the directive.
Graph 5: Number of renal patients admitted due to flood (Source: Hospital Census)
4.4.2. Outpatient Services and Emergency
Specialist outpatient services were cancelled. Emergency attendances were minimal
due to flooded roads and hence services were directed to communication and
dispatch operations with other flood relief agencies. This allowed resources to be
redirected to the wards and the formation of more medical team to help with the
flood relief evacuation centres.
50

4.4.3. Food and Medication
As standard flood preparation procedure, food and medication were available for
inpatient services for 3 months. However food was only stockpile for services. Staff
evacuees and relatives accompanying patients were not provided with food. The
hospital was not gazetted as a flood relief centre making supply from central
agencies unavailable to it. There was temporary shortage of food in the town
owning to electricity supply disruption in town and panic buying. However, electrical
and water supply to the hospital were uninterrupted.
4.5. HOSPITAL AS A DISASTER RELIEF FOR PERSONNEL LOGGING
During the flood there was shortage of medical personnel in the districts. The Ministry
of Health allowed volunteer from other unaffected states to help in providing services as
the number of health staff involved for sanitation and medical team were limited. The
hospital was used to house these personnel (Table 5).
State Numbers
Malacca 8
Raub 7
Selangor 20
Penang 11
Total 51
Table 5: Number of Ministry of Health volunteers that stayed in Hospital Sultan Haji
Ahmad Shah during the period from the 25 th December 2014 to the 3 rd of January 2015
(Source: Hospital Census)
5. DISCUSSION
5.1. THE NEED FOR HOSPITAL AS A RELIEF CENTRE
When disasters happen, members of the community look to the hospital as a safe haven.
Be it for the caring of the sick or disable or for a place of refuge, where basic amenities
are available. In time of war, hospitals are designated as a conflict free zone. After the
attack on the World Trade Centre on the 11 th of September 2001, St. Vincent Hospital
received 25,000 community members in it premises (4) .
The data showed that Hospital Sultan Haji Ahmad Shah was used to its capacity during
the flood. The bed occupancy rate reached more than 100%. Hospital services are high
51

human resource intensity. With availability of intensive care units in the hospital, the
number of nurses needed was high. Thus, there is a need to provide them with places
to evacuate in these circumstances. The hospital staff were also those who houses were
flooded leading to high loss of properties and difficulties in managing their personal life.
Working in a highly stressful environment of acute care and the additional stress of
being involved in the flood, the management of these personnel needs additional
attention.
As congestion of the designated Disaster Relief Centre (DRC) occurred, the community
turned to the hospital for shelter. Others used the hospital for the purpose such as
bathing, as the washing facilities in the DRC was over used. This creates sanitary and
cleaning problems for the hospital if no forward planning is done. Similarly hospital
security was an issue as the security services were also affected by human resource
availability.
A study of disaster plan of the hospital by the American Hospital Association on Hospital
Preparedness for Mass Casualty and WHO Hospital Emergency Response Checklist did
not address the use of hospitals as a relief centre for staff or for the community (5,6) . The
approach is still service oriented where communities are redirect to DRC. But in our case
the DRCs were already congested.
5.2. HOSPITAL SULTAN HAJI AHMAD SHAH EXPERIENCE
5.2.1. Staff and Ministry Volunteer
5.2.1.1. Basic Needs Provision of Staff
5.2.1.1.1. Housing for the Staff Evacuees and Volunteers
Fortunately Hospital Sultan Haji Ahmad Shah was newly built in 2004. Hence,
there were ample spaces to be converted to temporary bedding areas. Most
of the evacuees were female nurses thus the nurses’ hostels were used to
house them. Extra bedding were provided and bought using the Hospital’s
Social Society Fund. The 3 houses allocated were used to house families.
Some of the male staffs were allowed to use their working place, the single
rooms ward and the on call room to stay. Volunteers were housed in
converted seminar rooms.
52

5.2.1.1.2. Clothing
Some of the staffs were working while their houses were flooded. They were
left with only the clothes on their back. Donation drives were carried out
among staff to help them and some of the clothes were also donated to the
community evacuees.
5.2.1.1.3. Foods
The hospital’s disaster manual necessitates the availability of food supply for
inpatients. With the BOR reaching 100%, there were hardly enough for the
2,000 staffs and their families. The hospital was also not designated as a
flood relief centre and thus, was unable to source help from flood agencies.
Food was initially bought from nearby towns using emergency funds available.
5.2.1.2. Reducing Stress
5.2.1.2.1. Day Care Centre For Children
A day care service was set up using staff from the Medical Rehabilitation
Department. This was to enable staff to work without worrying about the
welfare of their children as it was an all private children minding facility.
5.2.1.2.2. Communal Cooking
Due to the flood, almost all diners near the hospital were close. To enhance
the feeling of hospital oneness, all daily meals were prepared and cooked
together. Staffs were ensured of at least one full meal a day.
53

5.2.1.2.3. Daily Trip to Nearby Town
The management also provided scheduled transportation for staff to visit
nearby towns daily. It enabled staff take a short break from the stressful
working environment.
5.2.1.2.4. Monitoring of Double Shifts
Double shifts were monitored so that the same staffs were not put in an
unbearable stressful situation. With the help of volunteers from other states,
no staffs were put on double duty during this period.
5.2.1.2.5. Monitoring of Stress Behaviour
The hospital had developed a stress protocol 2 years ago in order to detect
staff with stressful behaviour, especially in the emergency and critical care
area. It was developed with the Psychiatry and Psychology Department to
ensure staff with highly stress behaviour are detected and treated.
5.2.1.2.6. Daily Updates
The hospital briefed the staffs and head of departments daily on the flood
situation. Worst case scenarios, river water levels and recovery plans were
discussed. These daily briefings enabled staff to be updated as well as voice
their opinion and suggestions to the management.
54

5.2.2. Community
Ten displaced families used the hospital lobby as their temporary evacuation area.
The hospital allocated an area for their use and through its social club, four
temporary tents were set up for their use. The donation of food and clothing that
the hospital received was also distributed to these victims.
The hospital facilities were used to conduct Friday prayers as most of the
surrounding mosques were flooded. Designated washing facilities were allowed to
be used for the public. The hospital’s helipad was used not only for the transfer of
patients but also as a distribution despatch facility to transport supply to victims in
other flood relief centres.
5.3. THE RECOVERY
Four hospital voluntary groups were formed to help in the cleaning of staff, other health
facilities and community amenities (school and Mosques). With the help of the hospital’s
social club, high power water jets were purchased. The aim is to get the staff and
community return to normalcy as soon as possible, thus enabling the hospital to function
adequately as the number of post flood patients will be high.
55

6. CONCLUSION
Although the main function of the hospital is to provide treatment for the injured during the
time of disaster, there is a need for a hospital to be prepared as a relief centre. This is
especially so for the staff who are victims of the event as well. It enables the hospital to
utilise the personnel when shortness of staff is expected. Thus the ability to cope is greatly
enhanced. It creates a win-win situation and promotes better loyalty. Our action was
impromptu but with better planning, condition for staff and services can be greatly
improved. We missed the opportunity of helping staff to evacuate, thus enabling the
management to have a clear data on staffing availability before the flood occurred. In
conclusion, hospital disaster management plan should include staff evacuation to it facilities
and all the action needed thereof.
REFERENCES
1. Hospital Sultan Haji Ahmad Shah. Return and Statistic. 2015
2. River Water Level. Department of Irrigation and Drainage, Malaysia. 2015
3. Temerloh Disaster Operation Control Centre. Temerloh Municipal Council. 2015
4. Meyer, Susan. Disaster Preparedness: Hospitals Confront the Challenge. Trustee
Magazine. February 2006
5. Hospital Emergency Response Checklist: An all-hazard tool for hospital administrators
and emergency managers. WHO. Europe. 2011
6. Hospital Preparedness for Mass Casualties. Final Report. American Hospital
Association/U.S. Department of Health and Human Services. August 2000
56

ARTICLE 5
MAJOR FLOOD AFFECTING HAEMODIALYSIS SERVICE
JERANTUT HOSPITAL, PAHANG, MALAYSIA : CLINICAL
EFFECTS ON PATIENTS CARE.
Mohd Nor A, 1 Adam S, 1 Husain R, 1 Mat Deli H, 1 Theeban S, 1
Abdullah R 2
1. Jerantut Hospital, Pahang, Malaysia,
2. Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang
57

MAJOR FLOOD AFFECTING HAEMODIALYSIS SERVICE JERANTUT
HOSPITAL, PAHANG, MALAYSIA : CLINICAL EFFECTS ON PATIENTS
CARE.
Mohd Nor A, 1 Adam S, 1 Husain R, 1 Mat Deli H, 1 Theeban S, 1 Abdullah R 2
1.Jerantut Hospital, Pahang, Malaysia,
2.Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang*
ABSTRACT
Hospital Jerantut is a district hospital which began its operations in 1977. It has 77
beds with capabilities to extend to 96 beds. Its provides its services to approximately
a 100,000 population in the district of Jerantut, Pahang. Its services include an
emergency service unit, 4 inpatient ward, 12 specialist clinic which are run by
visiting specialist and a haemodialysis unit. The focus of this paper is to examine
clinical effects of the flood disaster on patients care. Various disaster preparedness
and response strategies were practiced before, during and after the flood disaster.
1. INTRODUCTION
1.1 OVERVIEW OF HEMODIALYSIS SERVICE IN HOSPITAL JERANTUT.
The hemodialysis unit in Hospital Jerantut runs 6 days per/week. It has 12
haemodialysis machine. Patients receive treatments based on a fixed schedule
within shifts. The unit caters for 42 patients whom are on regular dialysis, and 128
on pre-dialysis follow up. The strength of its staffing includes a Visiting Consultant
Nephrologist in charge, a medical officer in charge, a senior medical assistant, 2
medical assistant, one sister incharge, and 6 staff nurses. To run the dialysis service,
the unit uses up to 25,000 liter’s of water per day which is stored in a water tank
with capacity of storing up to 28,000 liter at any one time.
58

1.2 THE FLOOD CRISIS IN JERANTUT DISTRICT.
Flood disaster is a yearly occurrence which affects people and services in majority of
districts in the state of Pahang. In year 2014 however the severity and the impact of
the flood was worse than any other flood disaster we have encountered before. A
total of 98,345 people were evacuated which comprised of 23,205 families in the
state of Pahang. A total of 109 medical team and 90 health teams were despatched
to provide aid during the disaster and post flood activities 3 . This disaster impacted
continuity of care in healthcare services especially for patients on regular dialysis.
In the district of Jerantut the extent of the disaster impacted food supplies, electrical
supplies, water supplies and road access. This directly impacted Hospital Jerantut in
continuing its services. Without water supply the hospital encountered difficulties in
running its haemodialysis unit, performing cleansing and disinfection of wards and
personnel, preparing meals for patients and staff. In tandem with this the hospital
also faced obstacles in referring emergency cases to other healthcare facilities due
to inadequate road access. The nearest specialist hospital for referral is Hospital
Temerloh which is 57 km away. There are 3 road access to reach Hospital Temerloh,
which is Jalan Jerantut – K.Krau – Temerloh, Jalan Jerantut – Jengka – Temerloh
and Jalan Jerantut – Benta – Bentong – Temerloh which takes around 4 hours is the
furthest. During the events of the flood, the first road which was cut off was Jalan
Jerantut – K.Krau – Temerloh, followed by Jalan Jerantut – Jengka – Temerloh at
day 3.The only road which was accessible was Jalan Jerantut – Benta - Bentong –
Temerloh which was the furthest route to Hospital Temerloh however by end of day
6, this only route was inaccessible, immediate request were made by Jerantut
hospital director to the district Centre for flood relieve and rescue for the use of
helicopter’s and boat’s to transfer patients to other healthcare facilities.
2. OBJECTIVE
2.1 SPECIFIC OBJECTIVE.
- To examine the clinical effects of floods in patient care particularly for patient’s on
regular hemodialysis.
2.2 GENERAL OBJECTIVE.
- To develop a strategic plan in improving policies and procedures for disaster
preparedness for dialysis centre of Hospital Jerantut.
59

3. METHODS
This is a retrospective, observational single centre study, from 1st December 2014
until 31st March 2015. All patients on chronic HD programme were included. Blood
investigations prior (17th of Dec 2014) and after the floods (11th of March 2015)
were recorded. Chest radiographs performed on 15th of January 2015.
Demographic, clinical data were obtained and results were analysed using SPSS
version 20.
4. HOSPITAL MITIGATION STRATEGIES.
The 2005 hurricane season exposed deficiencies in the US’s disaster response. More
than 200,000 people with chronic medical conditions were displaced by Hurricane
Katrina, with Hurricanes Rita and Wilma wreaking similar havoc in subsequent
months, although on a lesser scale 1 . Patients with chronic kidney disease, especially
those who were receiving dialysis or had renal allografts, were particularly
vulnerable. A key lesson was learned: The kidney community was not prepared 1 .
The same could be said in regards to the Flood situation in district of Jerantut.
Various issue’s which cropped up had caught us off-guard due to the severity of the
flood in year 2014. Some of them were the breakdown of water plantations and
inadequate road access. These issues’ affected continuity of care especially for those
on regular dialysis.
An effective dialysis facility disaster preparedness program is goal-driven. Clear goals
create strong planning efforts and appropriate resource expenditures. Elements of a
successful program include methods to safeguard patients as well as the facility
(which in turn protects patients). Therefore, programs should include provisions for
patient safety and facility safety 2 . Patient safety aspect includes continuity of care.
Dialysis patients are critical because in chronic or end stage kidney failure, your
kidneys do not get better and you will need dialysis for the rest of your life 4 . Patient
safety goals include ensuring swift recovery for dialysis facilities and training of
patients in facilities to respond to disaster. Patient’s response to disaster includes
understanding and participating in disaster response strategies which includes
having an open communication between patient and doctor’s, participating in buddy
system’s which ensures dialysis centre’s to give kidney patients adequate
information on preparedness during disaster, encouraging early evacuation if
needed, early dialysis at least 60 hour before predicted disaster arrival to allow
patients evacuation ahead of the general population and evacuation of patients with
emergency box containing patient list and essential medical records. Meanwhile
facility safety includes management of hardcopy or electronic patient records, and
any damage to assets.
Looking at incidents of disaster in other countries etc. United States of America,
response to the 2005 disaster, a National level committee was formed named Kidney
60

community emergency response coalition (KCER) and composed of member’s from
various agencies. They have layer out a strategic plan and guide on addressing the
needs and requirements of patients with kidney disease during disaster periods.
These strategic plan included attending to the needs of the patients and facility
disaster mitigation and preparedness. The strategic plan encompasses a buddy
system between patient and clinician, and facility disaster preparedness. This
includes development of written policies and procedure in handling during
emergency disasters and enhancing effective communications between staff’s or
with patients. In an emergency situation the role of leader’s or supervisor are
enhanced. The responsibility in making timely and effective decision is critical. Every
written policies and procedure must be activated and respond to situations.
Effective line of communication should be maintained at all times between staff’s
and with patient’s to ensure every protocol’s to overcome the situations is taken and
followed. This also includes when sending patient’s over to other facilities for
dialysis temporarily. In the recovery phase it involves inspection of utility and testing
of equipment’s for use. Replacement of supplies and treating patient with posttraumatic
stress disorder (PTSD) are part of protocols in recovery phase.
5. DISASTER PREPAREDNESS IN HOSPITAL JERANTUT.
The catastrophic 2005 hurricane season alerted Americans to the need for a more
effective response to mass casualty incidents just as the events which occurred in
Jerantut, Pahang in December 2014. The hospital had prepared at the very
beginning in managing disaster situations. Standard operating procedures and
protocols were revised and updated. All this had been discussed at the hospital
disaster committee meetings. The important aspects of the preparation included:
- Elements of telecommunication and the use of alternate communication system
are available in the hospital which includes Government Integrated Radio
Network (GIRN).
- Identification of dialysis patients who live in flood risk area and preparing
evacuation and transport plan in an event of disaster. The high risk area’s which
were identified included The high risk areas which may be affected by the flash
floods were Kuala Krau, Sg tekam, Kota gelanggi, Kuala Tembling, Padang Piol,
and Sg rengkai
- Identification of locations within hospital compound which can be used as
temporary shelter areas for dialysis patient and next of kin.
- In situation where water supply was inadequate, a protocol was established to
ensure continuity of care. This includes reducing dialysis time from 4 hours to 3
hours. Ensuring adequate medical supplies beforehand which last up till 3
months.
61

- Finally in case of services comes to a halt, alternative dialysis centres were
identified to send patient for continuing their dialysis regime in this case Hospital
Temerloh, Hospital Kuala Lipis, Hospital Raub and Hospital Bentong.
6. RESPONSE STRATEGIES.
As the events of the flood went on for almost 13 days, various challenges was faced
by the dialysis center in Hospital Jerantut, this includes:
- Inadequate water supply.
- Limited routes to transfer out patients in case of emergency.
- Limited space for patients to room in to hospital wards, due to increase of bed
exchange rates (%BOR).
- Depleting food supplies.
- Telecommunication breakdown.
Various response strategies were taken for each challenges as it came this including
activation of all pre-planned the disaster response protocols. Telecommunications
breakdown became an issue since the very first day of the flood. This because all
telecommunication towers had been cut off electricity and running on generator
sets. Maintaining diesel supply during disaster events has also been a setback due
to lack of supplies as road access becomes limited. Therefore all telecommunication
between personal and hospital disaster response centre and team were through
GIRN.
During day 2 of events, the hospital and its dialysis centre experienced low water
pressure, which further investigations, lead us to find that the hospital’s water
supply had been cut off. This is the first time this issue had come up for Hospital
Jerantut which demonstrated the severity of the flood situation that year. Our main
available water tank to use had already reduced to more than 2/3. This information
was relayed to the district rescue and relieve centre. Suggestions were given for a
permanent static tanker to supply water to continue dialysis for patient. During this
period, dialysis time for patients was reduced to 3 hours instead of the normal 4
hours. The hospital also made emergency purchases of 4 static tanks to store water
each with a capacity of 150 gallons. 2 other static tanks with capacity of 400 gallons
were also provided by the state water agency (PAIP). Eventually at day 3 however
as one after another water pump stations in the districts malfunctioned, the hospital
administration weighting in on the possibility that water may become a district issue
and the limited routes available made a swift decision. A total of 18 dialysis patients
were sent to other early identified dialysis centre using a chartered bus service.
The remaining 12 patient’s which remained were continued to dialysed in Hospital
Jerantut till the end of the disaster, this was accomplished as the hospital received
on day 4 of event a permanent water tanker with capacity of 30,000 gallon for the
62

use of hospital. This tanker was provided by our concession company, Radicare
Sdn.Bhd which was brought from Kuala Lumpur.
7. RESULTS
Thirty-eight patients were included; 23(60.5%) were male, 15(39.5%) were female.
Twelve patients (31.6%) continued to dialyse in the facility; whilst 26 patients
(68.4%) had to move to another centre. An average of 18.05+1.18 hours of dialysis
was performed (5 HD sessions). There was no difference in Haemoglobin (Hb) level
before and after floods (10.59+1.85gm/dL and 10.23+1.59gm/dL, respectively,
p=0.362). Patients, who dialysed in other centres, had no Erythropoeitin
administered; however no significant difference in Hb observed (10.35+1.54gm/dL
and 10.25+1.56gm/dL respectively, p=0.77).
No difference in dialysis adequacy (Kt/V 1.78+0.4 and 1.81+0.43 respectively,
p=0.716), phosphate (1.71+0.51mmol/L and 1.61+0.4mmol/L respectively,
p=0.19), dry weight (59.5+13.77kg and 59.74+13.91kg respectively, p=0.183).
Serum albumin had significantly improved after the floods (39.87+3.97g/L and
45.26+4.38g/L respectively, n

REFERENCES
1. Kidney Patient Care in Disasters: Emergency Planning for Patients and Dialysis
Facilities Jeffrey B. Kopp,*
2. Jabatan Kesihatan Negeri Pahang
3. www.kidney.org/atoz/content/dialysisinfo
4. Disaster Preparedness: A Guide for Chronic Dialysis Facilities Second Edition, Center
for Medicaid and Medicare
5. Emergency Management for Dialysis Facilities
Aaron Battle -Patient Services Director ESRD Network of New York (NW2)
6. Disaster Preparedness for Dialysis Patients - Myra A. Kleinpeter
7. Emergency Preparedness Concepts for Dialysis Facilities: Reawakened after Hurricane
Katrina - Robert J. Kenney
64

ARTICLE 6
MANAGING VOLUNTEERS IN PAHANG FLOOD 2014-2015:
A LESSON LEARNT
Rosli I. , AR Kanagarajah , Norimah AG., Noor Faezah A. N. Fazilah,
Azmi ST., Nora, Leow Chee Cheng.
65

MANAGING VOLUNTEERS IN PAHANG FLOOD 2014-2015: A LESSON LEARNT
Rosli I. , AR Kanagarajah , Norimah AG., Noor Faezah A. N. Fazilah, Azmi ST.,
Nora, Leow Chee Cheng.
ACKNOWLEDGEMENTS
The author is grateful to the Pahang Health Director (Dr Zainal Ariffin Bin Omar), all Deputy
Director in Pahang state Health Department, District Health Office in Pahang state and all
staff at Pahang disaster relief coordination centre (PDRCC) for their direct and indirect
assistance in formulating this paper.
ABSTRACT
Flooding is one of the natural disaster where many jurisdictions have devised and
arrangements to deal with it. Pahang as a largest state of Peninsula Malaysia, had a worst
hit flood occurred in December 2014 till end of January 2015. It involved 81927 evacuees
which consists of 21390 families and 403 disaster relief centers throughout the state.
Bentong District Health Office of Pahang was chosen to facilitate as Pahang Disaster Relief
Coordination Center (PDRCC) and organize the distribution volunteers from Ministry of
Health and non-governmental organization (NGO) to the respective flood districts. This
paper focuses on the lesson learnt from all challenges related to managing volunteers
during flood through PDRCC.
KEY WORDS: flood disaster, Pahang Disaster Relief Coordination Center, guidelines.
INTRODUCTION
Flooding is a significant natural hazard. Kelantan, Terengganu and Pahang, the three States
in the east coast of Peninsular Malaysia were among the badly affected states during flood
in 2014. Pahang experienced the worst flood in 43 years with 81927 evacuees displaced to
Disaster Relief Centers (DRC) (1).
All districts in Pahang experienced the floods except in Cameron Highlands. The district of
Temerloh was worst hit with 22,865 evacuees placed in 77 other disaster relief centers.
The other 6 districts affected by the floods badly were Kuantan with 23549 evacuees
placed in 61 disaster relief centers, Pekan district had 15298 evacuees in 85 centers, Maran
district had 6788 evacuees in 44 centers, Jerantut district had 4418 evacuees in 59 centers,
Bera district had 3327 evacuees in 19 centers and the district of Kuala Lipis with 4442
evacuees in 34 centers. Rompin district had 471 evacuees in 6 centers and Raub district
had 668 evacuees in 16 centers. Bentong district had 101 evacuees and 2 centers. The
66

sudden occurrence of unexpected floods in Pahang created varying degrees of chaos to the
affected community (2).
From the health perspective, such events can result in immediate medical problems as well
as long term public health problems (3). Poor accessibility to the nearest health facility or
damaged health facilities deprived the families affected of their routine medical care. Some
of the paramedics and the health care providers themselves were affected which gave rise
to a need for volunteers from outside of Pahang state to be deployed to various districts
.The mobile medical team may work best during the flood disaster and bring health care to
the sick and needy in the disaster relief centers (4).
A volunteer is a person or a team of people who freely offer to work for an organization
without being paid. Volunteers can be from Ministry of Health (MOH) or nongovernmental
organization (NGO) from the same or different areas who take the initiative
to make a medical team with a primary objective of providing medical and humanitarian
assistance to flood victims at remote areas.
For the first time in Pahang, teams from other states were needed in flood management.
Bentong District Health Office was identified as the facility to facilitate Pahang Disaster
Relief Coordination Center (PDRCC) and organise the distribution of these volunteers to
these districts. This decision was solely based on the fact, Bentong being the entry point to
all other districts during the flood episode. Bentong is noted to be the least likely affected
district in Pahang. Crisis Preparedness Response Centre (CPRC) Pahang identified the
Health Office in the District of Bentong to function and facilitate to ask for help outside of
Pahang flood and distribute the teams to the designated districts. CPRC Pahang produced
standard operating procedure (SOP) (5) as a guideline for PDRCC Bentong to manage the
volunteers. Flow chart for activation of plan of action is shown in Figure 1.
67

Figure 1 : Plan of action for PDRCC.
Request for medical / health team
from health district office.
CPRC PAHANG evaluate the
need for help.
Not enough
Enough
Request fulfilled
by neighboring
district
PDRCC
END
No need help
Need help
PDRCC forward request to CPRC KKM and distribute
volunteer teams to the district in need.
PDRCC will register all the volunteer teams, arrange their
accommodation and arrange for briefing, before sending
volunteer teams to the district in need.
Reports send to
CPRC PAHANG
All the volunteer teams will check out at PDRCC and
received debriefing talk before going back home
68

OBSERVATION AND DISCUSSION
During the Pahang Flood 2014-2015, Crisis Preparedness Response Centre (CPRC) Pahang
has appointed Bentong District Health Office as a special unit called Pahang Disaster Relief
Coordination Centre (PDRCC) to facilitate volunteers within and outside Pahang following
Standard Operating Procedure (SOP) of PDRCC prepared by CPRC Pahang.
Functions of PDRCC are:
1. Represent CPRC Pahang in managing volunteers in Bentong.
2. To forward district requirement of volunteers to CPRC KKM.
3. To register all the volunteers in PDRCC Bentong.
4. To provide accommodation for the volunteers at the affected flood district.
5. To organize the distribution of the volunteers to the affected flood district.
6. To brief (briefing talk) about functions, safety to the volunteers, laces to stay, health
district offices to refer to if help needed.
7. To accommodate medical tools and health tools to the volunteers.
8. To accommodate transportation for the volunteers.
9. To debrief (debriefing talk) all the volunteers when they report back at PDRCC about
communicable disease which the volunteers can had while they were in Pahang,
about stress related complications and places and to whom to turn up to get help.
These volunteers were also given token as appreciation from Pahang Health State.
PERSONNEL
All District Health Office in Pahang have their preparedness plan for flood each year. All
these plans were coordinated by state. District Health Office prepared their local mobile
medical and health team volunteers. However, due to the unexpected worst hit of flood in
Pahang in December 2014 till January 2015, the volunteers outside the state were
required. All these volunteers that were registered and their numbers are showed as in
Table 1 (local Pahang volunteers), table 2 and 3 (outside Pahang volunteers).
All together, there are 116 volunteers for medical team and 98 volunteers for health team
within Pahang. A total of 104 medical volunteers, 56 nurses and 106 health volunteers
outside Pahang were registered in Bentong within those periods.
69

Table 1: Local Medical and health team from all district health office in Pahang
No. District Medical team Health team
1 Kuantan 24 13
2 Bera 13 6
3 Kuala Lipis 12 10
4 Maran 12 9
5 Pekan 11 12
6 Jerantut 11 9
7 Rompin 9 8
8 Temerloh 8 11
9 Raub 6 12
10 Bentong 6 4
11 Cameron highland 4 4
TOTAL 116 98
Table 2: Medical team and staff nurses outside Pahang health department
Negeri Medical team Nurses Team
Number
personnel
District
deployment
Number
personnel
District
deployment
Selangor 46 Temerloh,
Jerantut,
27 Jerantut,
Temerloh
Kuantan
Kedah 14 Temerloh, 0 -
Pekan
P.Pinang 30 PKD Temerloh, 13 Lipis, Temerloh
Melaka 0 16 Temerloh
W. Persekutuan 11 Temerloh 0 -
Putrajaya 2 Temerloh 0 -
N.Sembilan 1 Temerloh 0 -
TOTAL 104 56
70

Table 3 : Health team outside Pahang health department
Negeri
Health team
Number of personnel
District deployment
Kedah 32 Temerloh, Pekan
P.Pinang 56 Temerloh, Bera
W. Persekutuan 8 Temerloh
IMR 2 Pekan
Johor 8 Pekan
TOTAL 106
Table 4 : Number of personnel working at PDRCC
Category of personnel
Number of personnel
Medical Officer 3
Pharmacist 1
Food Technologist 1
Nursing supervisor 2
Assistant Medical Officer 2
Assistant Heatlh Environmental Officer 25
Public Health Assistant 27
Driver In Charge 1
TOTAL 62
PDRCC was started from 24.12.2014 till 21.1.2015. PDRCC opened for 16 hours a day (8
am – 12 midnight) continuously including public holiday. PDRCC has 3 work shifts. Each
shift was lead by Senior Assistant Health Environmental Officer together with Assistant
Health Environmental Officer and Public Health Assistant. Number of personnel working at
PDRCC for 28 days is as shown in table 4.
LOGISTIC
The number of transportation used by the volunteers during the major flood in Pahang is
shown in (table 5). Most teams are using 4WD as transport. Team from Selangor and
Melaka are the only team to travel by bus. Melaka does not require 4WD as only nurses are
brought to Hospital Sultan Haji Ahmad Shah, Temerloh and they are not required to
commute between the relief centre and the hospital.
71

Table 5: Transportation used by the volunteers
State
Type of transport used by the volunteers
Bus 4WD Van
Selangor 1 3 0
Kedah 0 19 0
Pulau Pinang 0 13 2
Melaka 1 0 0
W. Persekutuan 0 2 0
IMR 0 2 0
Putrajaya 0 0 0
N. Sembilan 0 0 0
Johor 0 2 0
TOTAL 2 41 2
Issues and challenges in logistic:
1. Medical team from Selangor travelled by bus, however, 4WD were required to reach
the affected areas, hence resulting in difficulty to shuttle mobile medical and health
team to the required destination.
2. Accessibility via roads was not possible. Boat is needed to reach most affected areas
however due to the high number of demand, most boats were unavailable.
3. Pahang Disaster Relief Coordination Centre (PDRCC) is required to prepare a map of
the accessible routes and hand over to each medical and health team to ease their
journey and ensure their safety.
PDRCC arranged accommodation for all volunteers involved in the program with the cooperation
of all districts that are involved. The provided accommodations are as listed in
table 6. The issues faced while arranging accommodation are also listed.
72

Table 6: Accommodation of volunteers
STATE PLACE DEPLOYED LIST OF ACCOMMODATION
Selangor
Kedah
Pulau Pinang
Hosp. Jerantut
PKD Temerloh
Hoshas
Kuantan
PKD Temerloh
PKD Pekan
H. Lipis
Kolej Kejururawatan Jerantut
Hoshas, Pusat Latihan Guru Sri Tualang
Hoshas
De Embessay, Kuantan
Kem PULARIS, Mentakab
Pusat Latihan JKNP, Pekan.
Asrama Jururawat
Asrama Jururawat
HOSHAS
Melaka HOSHAS Asrama jururawat
W. Persekutuan HOSHAS Asrama jururawat
IMR PKD Pekan Pusat Latihan JKNP, Pekan
Putrajaya HOSHAS Asrama jururawat
N. Sembilan HOSHAS Asrama jururawat
Johor PKD Pekan Pusat Latihan JKNP, Pekan
Issues and challenges in preparing accommodation:
1. Availability of accommodation for volunteers was limited due to all the available
accommodations were occupied with evacuees within the district and this had made
the preparation of accommodation for volunteers difficult.
2. Prior arrangement for accommodation was not identified by the Disaster Operation
Control Center(DOCC) other than hotels and home stay.
3. Volunteers had lacking basic necessities during such an emergency situations which
includes tent, sleeping bag, flashlights, portable communication set, etc.
4. There was no provision of time for PDRCC to provide bedding and a comfortable
shelter.
5. Due to shortage of power supply and environment was not conducive for the
volunteers. They are recommended to bring portable generators themselves.
Table 7: Medical equipment supplied to the volunteers in need
STATE PLACE DEPLOYED LIST OF MEDICAL EQUIPMENT
SUPPLIED
JKWPKL
Jerantut
Temerloh
BP Set, stethoscope, intravenous drip, a
set of medicine equipped box
PDRCC have provided the necessary medical equipment listed above for the use of aiding
the victims involved in the disaster flood in Pahang.
73

Issues and challenges in supplying medical equipments:
1. Teams should bring their own basic equipment and medical supplies at least for a
week so that they can work independently at the health district office or Disaster
Relief Center. PDRCC were facing difficulty to prepare large amount of the medical
equipment to all the volunteers.
COMMUNICATION
Purposes of disaster communication include preventing panic, promoting appropriate health
behaviors, coordinating response among stakeholders, advocating for affected populations,
and mobilizing resources (6).
Communication is a means of connecting people or places. Effective communication plays
an essential role in public health preparedness. Barriers to effective communication can
retard or distort the message and intention of the message being conveyed which may
result in failure of the communication process or an effect that is undesirable. These
include filtering, selective perception, information overload, emotions, language, silence,
communication apprehension, gender differences and political correctness (7).
Table 9: Request of medical (includes all nurses, pharmacist and psychotherapist) and
health team from the volunteers outside Pahang.
DISTRICT HEALTH
REQUEST
FULFILLED
OFFICE
MEDICAL HEALTH MEDICAL HEALTH
Kuantan 3 0 3 0
Pekan 3 4 1 2
Temerloh 15 20 18 18
Jerantut 5 7 5 2
Bera 0 6 0 6
TOTAL 26 37 24 28
The volunteers that registered at PDRCC consist of two team which is medical team and
health team. Medical team can be define as a team comprise of 1 Medical Officer, 1
Medical Assistant , 1 Staff Nurse and 1 driver or any paramedic who came in as a group
such as a group of nurses, a group of pharmacist and assistant pharmacist. Meanwhile
health team can be define as a team composed of 1 PPKP, 1 PKA, 1 PRA and 1 driver.
Table 9, it shows request for medical and health team from District Health Office in
Pahang. There were 5 districts that were actively requesting for volunteers. Kuantan and
Bera District Health Office requests were fulfilled accordingly. Temerloh District Health
Office request for 15 medical teams and 20 health teams but end up with 18 medical teams
and 18 health teams. Not as requested earlier due to miscommunication between PDRC
74

and Temerloh Health District Office. Pekan and Jerantut District health Office request were
fulfilled with local Pahang Volunteers.
Issues and challenges in communication:
1. A few of the District Health Offices in Pahang did not follow SOP upon requesting for
the volunteers. These District Health Offices request the volunteers directly to
PDRCC. Whereby in SOP, instruction to PDRCC only could be given by CPRC Pahang.
As a result, there will double request or fewer requests fulfilled by PDRCC to the
affected district.
2. Volunteers should registered at PDRCC, before entering the flooded district to insure
safety and short briefing on do and don’t by officer on duty at PDRCC. The first few
volunteers team did not register at PDRCC as they were not instructed so by CPRC
KKM. As a result PDRCC did not aware of their existing and these teams did not
receive appropriate briefing. There were also a few teams that did not checked out
at PDRCC, debriefing talk were not delivered to this teams too.
3. Duplication of instruction should be avoided. Team leader should be aware of any
changes made from the previous plan made by officer on duty at PDRCC. Term and
reference should be standardized to avoid miscommunication among PDRCC officers.
4. During the disaster there’s an IT and telecommunication breakdown and cut down of
power supply at Temerloh District. The Government Integrated Radio Network
(GIRN) is an alternative to solve the communications problems. Since not all been
trained to use it, there is an awkward sound from the radio. Additional
Communication equipment brought by volunteer’s team will be of benefit to the local
health authority.
5. Length of stay for the volunteer’s team should be determined by the PDRCC and not
by district health office. The outstanding instructions from the CPRCC KKM were the
minimum length of stay was one week. However there’s multiple direction given by
unauthorized person in a few Health District Office that the volunteers can check out
early and went back to their hometown. As a result a group volunteer’s overflow at
the door steps at PDRCC as early as 3 days after their stay at the respective District
Health Office that they were directed to before. Adding of length of stay should be
clearly stated in the SOP. All team in completion of the volunteers work should be
instructed to report back for debriefing in PDRCC and fill up the Depression Anxiety
Stress Scales (DASS). DASS is to isolate and identify aspects of emotional
disturbance.
It is important to reiterate the point that crises and disasters are inherently unpredictable,
chaotic events. Any effort to articulate a generalized set of standards should first
acknowledge that every crisis is a unique event that can be expected to evolve in
unexpected ways (8).
75

NON-GOVERNMENTAL ORGANIZATION
A non-governmental organization (NGO) was defined as any non-profit, voluntary citizens'
group which was organized on a local, national or international level. Task-oriented and
driven by people with a common interest, NGOs perform a variety of service and
humanitarian functions, bring citizen concerns to Governments, advocate and monitor
policies and encourage political participation through provision of information. Some are
organized around specific issues, such as human rights, environment or health. They
provide analysis and expertise, serve as early warning mechanisms and help monitor and
implement international agreements. Their relationship with offices and agencies of the
United Nations system differs depending on their goals, their venue and the mandate of a
particular institution (9).
NGO activities can be local, national or international. NGOs have contributed to the
development of communities around the world and are important partners of many
governments – while remaining independent from governments (10).
Table 10: Distribution of NGOs according to district deployment
DISTRICT NGOS PERSONNEL
Kuantan i-MEDIK Pahang 10
Pekan ST JOHN Cawangan Kuantan
Sukarelawan untuk keamanan
TEKUN Nasional
Amal Pekan
1
2
20
40
Temerloh
Bera
Maran
MIMPA
9
Haluan Malaysia
3
BESTA
1
Jelebu Club
2
St. John
8
IKRAM
15
Buddha Association
7
Yayasan Kebajikan Negara
17
Academy of Safety & Emergency Care
2
Cyberjaya College of Medical
9
4WD Bera
15
ADUN Guai
30
Unit AMAL Bera
15
MERCY Malaysia
16
Banjero Skuad Maran
10
UMNO Maran Supporters
20
4WD Bahau
3
4WD Jelebu
2
TOTAL 257
Table 10 shows distribution of NGOs according to district deployment. Temerloh district
received about 10 NGOs (73 people) helping in the flood disaster. Followed by Pekan
district with 4 NGOs (63 people), Bera with 3 NGOs (60 people), Maran with 5 NGOs (51
76

people) and Kuantan with 1 NGOs (10 people). Temerloh and Pekan, being the worst
affected areas, received the highest number of NGOs.
Issues And Challenges in handling NGO:
1. Enormous number of NGOs are available in Pahang but was not properly directed to
optimize their efforts. They should register at CPRCC KKM so that the PDRCC is
aware about the team.
2. Due to the fact that there was no briefing and debriefing given by PDRCC, the
existing SOP were also not brought to their attention. Safety and health issues of
NGO were not within PDRCC control because there was not any briefing and
debriefing given by PDRCC.
3. NGOs were not given the instruction to report to PDRCC. Monitoring of the NGOs
was not possible because there was no instruction stated in the existing SOP.
4. Mishandling of government assets while carrying out the work done by the
volunteers was posing major problems. All government assets or inventory that has
been damaged by the flood must be brought to the officers in charge attention
before they are to be disposed by the NGO because they are registered under
mySPA.
COST
Table 11: Cost consumed at PDRCC during managing Pahang flood 2014-2015
SERVICE TYPE
ESTIMATED COST (RM)
Accommodation for stay 2585.00
Food 9989.30
Stationary 1360.00
Dobby 170.00
Medical Supply 5250.00
Transportation 15 000.00
Staff allowances 19 088.00
TOTAL 53 442.30
77

Fund was one of the issues that PDRCC faced. During the Pahang flood 2014-2015, one of
PDRCC tasks was give optimize accommodation to the volunteers. These include giving
them briefing, to welcome them with refresher drink, providing place for them to stay at
night if needed, to provide petrol for transportation to arrange for local transportation
service if needed, laundry service and top up medications, medical tools and health tools to
volunteers. The cost of purchasing stationary to set up PDRCC also exists.
An estimated cost during that period is shown in table 11. Among the financial issues that
PDRCC faced were account for expenditure was closed early and minimal amount of budget
remained at PKD Bentong by the end of the year. However we manage to solve the
problem in our own way. We suggest the CPRCC Pahang has locked up the fund for flood
activities each year so that it can be used during any disaster especially flood disaster.
CONCLUSION
The state of Pahang experienced the worst floods in December 2014. CPRCC Pahang has
generated its own Standard Operating Procedure every year which is more or less the same
every year. It was a good new idea brought up by Pahang State director of health to set up
A PDRCC at Bentong District. Although health staff working at the PDRCC Bentong was not
properly trained, PDRCC was supervised directly by Pahang State director of Health himself
and Chief Assistant Director of Occupational and Environmental State Health Unit. Bentong
District Health Office manages to give the best effort to handle PDRCC even though lacking
of experience.
The PDRCC is committed to continuous improvement in its flood management activities.
PDRCC suggest the existing standard operating procedure (3) to be revised again according
to flood situation occurring in 2014-2015 which was beyond norm. PDRCC also suggest the
component of managing NGO which was not mentioned in the Standard Operating
Procedure (5) is added up in the function of PDRCC so that all the NGO will registered and
will be distribute accordingly to the needy so that there will be no pool of NGOs in certain
district. PDRCC also suggest the DASS screening for mental health status among volunteers
during pre-briefing and post-briefing is made compulsory inside the existing Standard
Operating Procedure (5).
In short, it has to be stressed that the importance of combine leadership, team work, and
effective collaboration in managing the PDRCC. Following and implementation of existing
guidelines is also importance to in order to have smooth PDRCC management.
78

REFERENCES
1. Rashidi Ahmad, Zainal Abidin Mohamad, Abu yazid Mohd Noh and et al. Health Major
incident : The experience of mobile medical team during major flood. MJOMS, vol.15,
no.2, April 2008(29-33).
2. Anonymous. Malaysia. Wikipedia :The Free Encyclopedia. Available at :
http://ms.wikipedia.org/wiki/Banjir di Malaysia 2014.
3. New South Wales Australia (2003). Managing Fl oods in a Volunteer Agency: some
Considerations Relating to Training, Planning and Response Activities in New South
Wales Australia, paper presented at the International Disaster and Emergency Readiness
(IDER) Conference, London, 2003.
4. Auf der Heide E. Disaster Response: The principles of preparation and coordination. St
Louis : CV Mosby 1989.
5. Garis panduan Pengurusan Bantuan Bencana Negeri Pahang : Unit KPAS JKN Pahang.
6. Preparing for effective communications during disasters: lessons from a World Health
Organization quality improvement project Laura N Medford-Davis and G Bobby Kapur)
International Journal of Emergency Medicine 2014 &:11).
7. Robbins, S., Judge, T., Millett, B., & Boyle, M. (2011). Organizational Behavior. 6th ed.
Pearson, French's Forest, NSW p315-317.
8. Matthew W. Seeger August 2006. Best Practices in Crisis Communication: An Expert
Panel Process. Journal of Applied Communication Research Vol. 34, No. 3, pp. 232-244).
9. The author acknowledges the helpful comments of Siti Haniza on the first draft of this
paper.
79

ARTICLE 7
COMMUNICABLE DISEASE DURING PAHANG FLOOD 2014:
WE MANAGED TO CONTROL
Sapian M, Sharifah Mahani SMA, Akmalina H, Shahidan H, Aznita
Iryany MN, Hafeez I
80

COMMUNICABLE DISEASE DURING PAHANG FLOOD 2014: WE
MANAGED TO CONTROL
Sapian M, Sharifah Mahani SMA, Akmalina H, Shahidan H,
Aznita Iryany MN, Hafeez I
ABSTRACT
Pahang, aneast coast state of Malaysia encountered the worst flood on 22 nd December 2014
until18 th January 2015. Medical and health teams were mobilized to carry out preventive
and control measures at Disaster Relief Centre and flood affected areas.The aims of the
study are to describe the pattern of communicable disease and preventive and control
measures taken during the flood period. Data from the Disaster Operation Room of Pahang
State Health Departmentand CDCIS E-Notification system were reviewed.Result showed
that 10 districts were affected by flood. A total number of 81,927 victims were involved in
the disaster of which 5,974 (7.3%) were detected to have communicable diseases. Five
most common diseases were ARI(64.9%), skin infection (16.3%), fever (11.9%), AGE
(4.4%) and conjunctivitis (0.8%). There were five food poisoning and one HFMD outbreak
reported. Overall, there was no significant increase in the number of notifiable
communicable disease related to flood except for leptospirosis, melioidosis and food
poisoning .However not all of the leptospirosis (5%) and melioidosis (56%) cases were
directly caused by flood. We managed to control the communicable disease because all
districts had succeeded in carrying out their preparedness plan effectively.
KEYWORDS: Pahang, Flood, Preparedness Plan, Communicable Disease, Preventive and
Control
1.0 INTRODUCTION
Flood is a yearly occurrence in the east coast of Malaysia which include the state of
Pahang. Flood phenomenon is due to climatological factors (temperature, rainfall,
evaporation, wind movement and the natural topography of the place). 1
The year 2014 flood in Pahang is the worst compared to the previous floods in 1926, 1971,
2001, 2007 and 2013 in terms of number of districts involved and infrastructure damage.
The recent flood started from the 22 nd December 2014 till 18 th January 2015 which involved
10 districts.
People affected by flood will be placed at the Disaster Relief Centre (DRC). These relief
centres are usually situated in the designated public places such as schools and community
halls. These facilities are equipped with basic amenities such as potable water supply,
electricity and sanitary latrines. However these places have environmental risk factors such
as overcrowding and improper food preparation facilities.Furthermore foods for the flood
victims are prepared by volunteers at the DRC.
81

Medical and health teams from District Health Offices (DHO) are responsible for monitoring
flood victims health status and health related activities at DRC’s and flood affected areas.
Medical teams which comprises of doctors and paramedics are taskedto provide medical
and psychological support to flood victims. Meanwhile, the health teams carry
outpreventive and control measures such as ensuring food safety, water quality, vector
control and proper refuse disposal.The medical and health teams are comprise ofstaff from
Pahang State Health Department (PSHD), assisted occasionally by health staff outside
Pahang and non-governmental organizations.
Flooding is associated with an increased risk of infection. Standing water caused by heavy
rainfall or overflow of rivers can act as breeding sites for mosquitoes, and therefore
enhance the potential for exposure of the disasteraffected population and rescuers to
infections.Because of overcrowding at the DRC, diseases such as acute respiratory
infections (ARI), skin infections and conjunctivitis are easily spread among the flood
victims. 2 In Malaysia, floods can potentially increase the transmission of food and waterborne
diseases (typhoid fever, cholera, hepatitis A, dysentry, food poisoning, acute
gastroenteritis), vector-borne (dengue, malaria), leptospirosis and melioidosis.
Since flood is a yearly event and usually occur at the end of the year in Pahang, all
government agencies at the states and districts level started their preparation early.The
Natural Disaster Management and Relief Committee (NDMRC) at the state and district level
are headed by State Secretary and District Officer respectively. Inter-agency collaboration
and communication are strengthened to ensure smooth and efficient execution of state and
district disaster preparedness plan. For the PSHD, DHO’s and hospitals has their own
preparedness plan which includes assisting the District Officer in identifying place forDRC to
ensure suitability and safety, logistics availability, adequate medical supplies andhuman
resource which includes medical and health teams. (refer to Annex 1 for Summary of The
State Preparedness Plan). Health education materials are also produced adequately to be
disseminated during all phases of flood to increase awareness among the public for them to
take necessary action towards prevention of diseases related to flood.
The objectives of the study are to describe the communicable diseases and outbreak
reported during flood, to describe the preventive and control measures taken and to
recommend remedial measures in managing communicable disease related to flood.
82

Annex 1: Summary of Preparedness Plan for Communicable Disease Surveillance, Control and Prevention in
Pahang
STATE
PRE FLOOD
CDC Preparedness Surveillance and trending of infectious disease
eg; ILI, sARI, AGE
Epidemiology of notifiable disease by e-
notification,e-measles, MyTB, e-wabak
Early warning signs (warning and epidemic
level) and response
Plan of action for disaster/flood available
Stock piling of supplies, operation room (Pahang
CPRC) standby
Rapid assessment team (RAT) and rapid
respond team (RRT)
Training of staffs and simulation exercise
DISTRICT
Surveillance of ILI, sARI, AGE, Dengue
Epidemiology of notifiable disease by e-
notification,e-measles, MyTB, e-Dengue, e-
wabak
Early warning signs (warning and epidemic level)
and response
Plan of action for disaster/flood available
Stock piling of supplies, operation room (Pahang
CPRC) standby
Rapid assessment team (RAT) and rapid respond
team (RRT)
Training of staffs and simulation exercise
Food quality and
safety
Data collection & monitoring
Food premises inspection, food sampling, food safety
briefing, vaccination of food handlers
Vector control Monitoring of E-Dengue
Epidemiology of notifiable disease (e-Dengue,
e-Vekpro)
Case notification and investigation, ACD/PCD, preventive
and control activities, management of Dengue outbreak
Water quality and
safety
Environment and
sanitation
Health Promotion
Inter-agencies
collaboration
Data collection & monitoring
Data collection & monitoring
List of identified DRC
Preparation and distribution of health education
materials
Inter-agencies meeting at state level
Water sampling & monitoring of water treatment plant
by PAIP (Pengurusan Air Pahang)
Provision of latrines, databases of the population
Inspection of identified DRC
Distribution of health education material to flood prone
areas
Meeting and update of communicable disease &
outbreak
83

STATE
DURING FLOOD
CDC Response Identify, mobilize, apply, and activate medical
and health resources. Resources include medical
and health personnel, equipment and supplies
required for state and district.
CPRC room activated
Surveillance activities enhanced and upgraded
Epidemiology of notifiable disease especially
diseases related to flood such as Typhoid,
Leptospirosis and Melioidosis
Early Warning And Response (EWAR)
Laboratory preparedness for testing of samples
for causative agent identification
DISTRICT
Identify, mobilize, apply, and activate medical
and health resources. Resources include medical
and health personnel, equipment and supplies
required for district.
Operation room activated
Data collection & Surveillance, Epidemiology of
notifiable diseases, lab surveillance, TBIS,
vector/Vekpro, clinic-based continue and
inclusive of evacuation centres & flood areas
Early Warning And Response (EWAR)
RRT activated/standby for any outbreak
verification, confirmation and data collection for
outbreak investigation.
Disease outbreak(medical & investigation) team
activated
ACD/PCD, isolation of cases, swab/samples
taking for lab testing for causative agent
identification
Food quality and
safety
Data collection & monitoring enhanced Typhoid vaccination given to all food handlers at
evacuation centres
Data collection & monitoring food premises
inspection, food sampling inclusive of evacuation
centres, holding samples
Vector control Data collection & monitoring enhanced ACD/PCD, source reduction inclusive of DRC,
investigation of cases,
Water quality and
safety
Data collection & monitoring enhanced
Water sampling & monitoring inclusive of DRC,
additional on-site testing besides the routine water
sampling points
Environment and Need assessment of resources including human Larvaciding, temporary toilets & mobile toilets provision
sanitation
Health Promotion
resource
Distribution of HE materials and media statements
focusing on topics related to flood
Distribution of HE material at DRC and flood affected
area
84

STATE
Inter-agencies Daily meeting at the state Disaster Operation
collaboration
Controlling Centre for problem solving, updates &
coordination of resources
POST FLOOD
CDC Response Surveillance (eg; ILI, sARI, AGE)
Epidemiology of notifiable disease (enotification,e-measles,
MyTB, e-wabak)
Weekly epidemiologic meeting focusing on
diseases related to flood
Early warning signs (warning and epidemic
level) and response
Rapid assessment team (RAT) and rapid
respond team (RRT)
Report writing
DISTRICT
Daily meetings at the district Disaster Operation
Controlling Centre
RRT activated/standby for any outbreak
verification, confirmation and data collection
Report writing & lessons learned
Food quality and
safety
Data collection & monitoring
Food sampling, Inspection of food premises that resume
services
Vector control Data collection & monitoring ACD/PCD, source reduction inclusive of DRC & flood
affected areas
Water quality and
safety
Data collection & monitoring of any violation
Water sampling & monitoring of any violation, inspection
& chlorination of wells
Environment and Need assessment
Inspection of latrine & rebuilding new ones
sanitation
Health Promotion Provision of health material on post flood diseases Health education continued
Inter-agencies
collaboration
Documentation, report writing & dissemination
Documentation , report writing & dissemination
85

2.0 METHODOLOGY
This is a retrospective review of communicable diseases data and activities
during 2014 Pahang flood. The flood period was divided into three phases, preflood
(23 rd November 2014 - 21 st December 2014), during flood (22 nd December
2014 - 18 th January 2015) and post-flood (19 th January 2015 - 18 th February
2015). For communicable diseases surveillance in Malaysia, epidemiological
week is used instead of normal calendar week. So in term of epidemiological
week (epid week), the period of study started from epid week 48/2014 untill
epid week 7/2015.
Data on flood victims, DRC’s, medical and health teams, prevalence of
communicable diseases at DRC, preventive and control activitiesat DRC’s and
flood affected areas were gathered from daily return from the PSHDDisaster
Operation Room (DOR). Some of the victims complained they only had fever
without other symptoms so data on fever alone were captured to differentiate it
from other diseases. Data on notifiable communicable diseases for the whole
state during the flood period were taken from web-basedCommunicable
Disease Control Information System (CDCIS) namely E-Notification and E-
Dengue.
Melioidosis is not a gazetted notifiable disease in Malaysia, however since 2015
it was made compulsoryto notify this disease administratively by Ministry of
Health (MOH), Malaysia. On the other hand, all medical practitioners in Pahang
were ordered to notify melioidosis administratively since year 2011 and the
information were captured in Pahang Melioidosis Registry. Additional
information onleptospirosis andmelioidosiswere also taken from daily returns
which were specifically collected during the flood period by the Pahang State
Communicable Disease Control (CDC) unit.
86

3.0 RESULTS
3.1 Flood Victims and Disaster Relief Centres (DRC)
Table 1: Flood victims and DRC'sduring 2014/2015 flood by districts in Pahang
District
Number of
DRC
Number of
Families
Affected
Number of
Flood
Victims
Mean duration
of DRCs’
operation
(days)
Kuantan 61 6,326 23,549 4
Jerantut 59 1,161 4,418 10
Lipis 34 1,173 4,442 7
Pekan 85 3,912 15,298 12
Rompin 6 122 471 2
Maran 44 1,629 6,788 10
Temerloh 77 5,978 22,865 11
Bera 19 869 3,327 10
Raub 16 200 668 1
Bentong 2 20 101 1
Total Pahang 403 21,390 81,927 8
Source: State Disaster Operation Control Centre (SDOCC)
Table 2:Medical and Health Team by districts in Pahang during 2014/2015 flood
District Pre-flood During flood
Medical Health Medical Health
Within
district
(team)
Within
district
(team)
Within
district
(team)
District
within
state
(team)
Outside
state,
MOH/
*MAF
(team)
Within
district
(team)
District
within
state
(team)
Outside
state, KKM
(team)
NGO/
other
agency
(person)
Kuantan 16 13 24 10 3 13 - - 10
Rompin 9 8 9 - - 8 - - -
Maran 12 9 12 - - 9 - - 51
Jerantut 11 9 11 2 6 9 1 2 12
Lipis 12 9 12 - - 10 1 - -
Pekan 8 12 11 13 3/2 12 6 6 -
Temerloh 8 11 8 5 20 11 13 21 73
Bera 13 6 13 1 - 6 1 6 60
Raub 6 12 6 - - 12 - - -
Bentong 6 4 6 - - 4 - - -
C.Highlands 4 4 4 - - 4 - - -
Total Pahang
105 97 112 31 34 98 22 35 206
MAF - Malaysian Armed Forces
87

3.2 Communicable Diseases And Outbreak Reported
Figure 1: Type of notifiable communicable diseases related to flood during
flood period by epid week in Pahang
Figure 2: Leptospirosis and melioidosis during flood period by epid week in
Pahang
88

Table 3: Type of communicable diseases at DRC’s by districts during flood period
District
Kuantan
AGE ARI Conjunc
-tivitis
Skin
Infection
Communicable Diseases
Fever
H
F
M
D
Typhoid
Food Leptospirosis
Chicken Dengue
Poisoning
Pox
Total
Cases
39 655 11 36 0 0 0 27 1 0 0 688
Jerantut 73 640 2 93 111 0 0 22 0 0 0 775
Lipis 7 285 4 120 0 0 0 0 0 1 0 369
Pekan 66 1384 24 321 272 0 0 0 0 5 0 1882
Rompin 1 38 0 10 5 0 0 0 0 0 0 47
Maran 24 123 1 270 224 3 0 0 0 2 1 643
Temerloh 26 107 5 100 62 0 0 39 0 0 0 339
Bera 24 643 2 26 38 0 0 0 0 0 0 628
Raub 0 1 0 0 1 0 0 0 0 0 0 2
Bentong 0 0 0 0 0 0 0 0 0 0 0 0
Total
Pahang
260 3876 49 976 713 3 0 88 1 8 1 5974
Figure 3: Distribution of communicable diseases among flood victimsat the DRC’s by
day.
89

Figure 4: Type of communicable diseases during flood period at DRC’s by day
Figure 5: Distribution of communicable diseases at the DRC’s by day.
90

Table 4: Outbreak of communicable diseases reported during flood period
Locality District Date Of
Outbreak
1. DRC Youth Complex
(Wisma Belia)
2. DRC Pahang Sport
Complex
(SUKPA)
3. DRC Advanced
Technology Training
Centre (ADTEC)
4. DRC National-type
Tamil Primary
School Mentakab
(SJKT Mentakab)
5. DRC Malaysia Civil
Defence
Department
(JPAM)
6. DRC UMNO Hall
Pekan Tajau
Kuantan 26.12.201
4
Kuantan 27.12.201
4
Jerantut 28.12.201
4
Temerloh 29.12.201
4
Temerloh 31.12.201
4
Type of
Disease
Outbreak
Food
Poisoning
Food
Poisoning
Food
Poisoning
Food
Poisoning
Food
Poisoning
Number
of Case
Comments
14 Outside food is
suspected
13 Outside food is
suspected
22 Outside food is
suspected
20 Food is
undercooked
19 Poor food
handling
Maran 5.1.2015 HFMD 2 Involved siblings
(contracted the
disease before
moving to DRC)
4.2 Prevention and Control Activities
Table 5: Dengue Control Activities at DRC’s and flood affected areas
During
flood
Postflood
No. of
DRC/ flood
area
inspected
No. of
DRC/ flood
area
positive
No. of
container
inspected
No. of
container
positive
Total pesticide used
(1/kg)
Larvicide
Adulticide
No. of
DRC/ flood
area
fogged
1225 11 20216 29 524.84 36.42 224
2482 7 8636 11 11.31 14.6 1286
Table 6: Flies Control Activities at DRC’s and flood affected areas
No. of locality
inspected for
No. of locality
positive for
No. of control activities
Maggot Adult Maggot Adult Larvicide Adulticide
No. of
premises
disinfected
During flood 3343 3116 133 1344 866 394 1628
Post- flood 1156 1308 0 10 340 218 1953
91

Table 7: Rats & Cockroaches Control Activities at DRC’s and flood affected
areas
No. of locality inspected
for
No. of locality positive for
No. of locality
disinfected
Rats Cockroaches Rats Cockroaches
During flood 2643 2538 4 7 1254
Post- flood 1064 1064 0 0 506
Table 8: Safe water supply monitoring activities at DRC's and flood affected
area
No. of
Sample
s
Pipe Water Supply
pH
violation
Chlorine
violation
NTU
violatio
n
E.coli
violation
(Colilert
test)
Well
No. of
Well
inspected
No. of
Well
Chlorina
-ted
During flood 840 0 81 59 0 13 13
Post- flood 120 0 0 0 0 96 96
Table 9: Environmental sanitation monitoring activities at flood affected area
Environmental Cleanliness
Sanitation
Villages
Inspecte
d houses
Unsatisfactory
houses
Unsatisfactory
toilets
Unsatisfac
- tory
water
sewerage
Unsatisfactory
solid
waste
disposal
Post- flood 108 2394 314 269 90 214
Table 10: Food Safety & Quality Activities for Food Handlers at DRC's
Briefing on Food Handling
Anti-typhoid vaccine
No. of Briefing
conducted
No. of Food Handlers
involved
given
Before Flood 14 574 329
During flood 815 5168 689
TOTAL 829 5742 1018
92

Table 11: Health Education Activities During Flood Period in Pahang
During
flood
Postflood
Lecture Individual
counseling
No. of health education session
Demo
n-
stratio
n
Small Public
group announ
discus- -
sion cement
Radio
annou
n-
cemen
t
Go
tongroyo
ng
Pa
m-
phl
et
No. of materials
distributed
Pos Bun
- -
ter ting
Ban
-
ner
523 1649
2
8585 2914 650 176 78 4619
7
3779 1024 105
1 3152 2514 205 0 0 15 1403 267 3 43
4.0 DISCUSSION
The 2014 flood was the worst episode in Pahang which involved81,927 victims
from 10 districts. It lasted for 28 days from 22 nd December 2014 till 18 th
January 2015. The victims and districts involved were higher compared to
previous flood disasters in Pahang.
4.1 COMMUNICABLE DISEASES INCIDENCE
Following disaster, overpopulation, population movement and displacement
economic and environmental devastation, poverty, lack of sanitary water, poor
waste management, lack of shelter, malnutrition as a consequence of food
shortages, and poor access to health care contributed to the increase in the
rates of communicable diseases. 3-7
The major causes of communicable disease in disasters can be categorized into
four areas: Infections due to contaminated food and water, respiratory
infections, vector and insectborne diseases, and infections due to wounds and
injuries. 8 The most common causes of morbidity and mortality in this situation
are diarrheal disease and acute respiratory infections. 9
There were 177 medical teams mobilized to 403 DRC’s to render medical aid to
flood victims. Only 7.3% (5,974) of the flood victims from DRC’s throughout
Pahang were detected to have communicable diseases. Five most common
diseases were ARI (3876 cases; 64.9%), skin infection (976cases; 16.3%),
fever (713cases; 11.9%), AGE (260 cases; 4.4%) and conjunctivitis (49cases;
0.8%). The pattern of communicable diseases seen during the flood disaster
was similar to Johore flood in 2006-2007 as reported by Badrul Hisham, A.S., et
al. (2009). 10 The risk of ARI increased due to overcrowding, poor ventilation and
poor nutritionat DRC during disaster. 11
93

Pekan district reported the highest number of communicable disease cases with
1,882 cases (31.5% of total case), of which 73.5% were ARI cases. This was
most probably due to Pekan was among the district that had highest number of
DRC and victims. On top of that, the mean duration of DRCs’ operation was 12
days, the longest among the districts.
Although Temerloh district was the worst hit district with the second highest
number of DRC’s, victims and mean duration of DRCs’ operation however the
number of communicable diseases reported from this district was only 5.7%
(339 cases). This was explained by the fact that medical and health activities
were temporarily paralyzed since many of the staffs were themselves affected
by flood. In addition, there were quite a number of DRC’s that were
inaccessible to the team for few days because of the flood.
The number of communicable diseases reported daily at the DRC correspond to
the number of flood victims present the centres. Only 91 cases (1.5%) of all
communicable diseases seen at DRC were notifiable, of which 88 cases were
food poisoning and 3 cases were Hand Foot And Mouth Disease (HFMD).
There were 6 outbreaks reported from DRC's during the flood period, 5 food
poisonings and 1 HFMD outbreak. All the outbreak were under control and all
patients were treated as outpatients. For food poisoning, 3 out of 5 episodes
were due to consuming food prepared outside the DRC in which the time of
food prepared and how it was prepared were not known. For the remaining 2
episodes, poor food handling by the food handlers at the DRC was identified as
the cause for the outbreak. Generally, food handlers at DRC were
volunteersand some of them were not pre-identified as a food handler prior to
the flood since flood were not predicted to occur at their areas. One hundred
and fifty five health teams were formed during the flood period throughout
Pahang. Among their task were to supervise and monitor the food preparation
at the DRC. However, these teams which were allocated to look after certain
DRC initially were unable to carry out the task as they also had to monitor few
other new DRC’s at the same time. The number of DRC during the recent flood
overwhelmed the number of health team especially during the peak period. The
formation of adequate health team was also hindered by the fact that the
health personnel were flood victims themselves especially in Temerloh district.
The situation improves after mobilization of additional 34 health teams from
outside the district and state.
The HFMD outbreak reported during the flood occurred in one family. The cases
developed HFMD symptoms at home prior to the evacuation to DRC. In the
DRC, the cases were isolated in a room to prevent transmission to other flood
victims.
Overall, there was no significant increase in the number of notifiable
communicable disease related to flood except for leptospirosis, melioidosis and
food poisoning during the flood period as compared to pre and post flood.
94

During flood, the incidence of leptospirosis and melioidosis were expected to
increase especially after heavy rainfall as it facilitates the spread of Leptospires 1
and Bulkholderia pseudomallei bacteria, agentscausing leptospirosis and
melioidosis. We noticed leptospirosis and melioidosis cases were higher during
the flood, however further investigations showed that not all leptospirosis (only
5% of cases) and melioidosis (56% of cases) were directly caused by flood. For
melioidosis and leptospirosis, cases reported during the flood was higher due to
increase awareness among medical practitioners in reporting these 2 disease
following instruction from the Crisis Preparedness and Response Centre (CPRC),
MOH to be on high alert for leptospirosis and melioidosis which are expected to
increase during flood.
4.2 PREVENTION AND CONTROL ACTIVITIES
The prevention and control activities were carried out by thestate and district
public health teams prior to the flood, during and post flood. Those activities
contributed to thelow occurrence of communicable diseases and outbreak
related to flood.
4.2.1 VECTOR CONTROL ACTIVITIES
Vector borne diseases was expected to increase during flood as a result
of increase potential breeding site and expansion in the number and
range of vector habitats. Standing water caused by heavy rainfall or
overflow of rivers can act as breeding sites for mosquitoes, and therefore
enhance the potential for exposure of the disaster-affected population to
infections such as dengue and malaria. Mosquito breeding sites were
initially flush out, but it comes back when the waters recede. 2 However,
in Pahang the expected increase in dengue cases in relation to flood was
not observed during the flood period. This was due to intensive and
integrated control activities done.
The vector prevention and control activities started prior to the flood.
Flood prone areas were visited whereby search and destroy activities are
carried out. Pamphlets and poster were distributed. During the flood, a
total of 1225 inspections were carried out at DRC of which only 11
(0.9%) were found to be positive for Aedes breeding. This was detected
at the early phase of flood period. Fogging and larviciding were done and
there was no breeding detected since then. The activities continued
during the post flood period.
Apart from mosquitoes, prevention and control activities for other pest
such as cockroaches, flies and rodents were also conducted at the DRC
95

and flood affected areas. More than 4000 localities were inspected for
the presence of maggots and flies. Larvaciding, adulticiding and
disinfection were also done accordingly at the premises.
4.2.2 DRINKING WATER QUALITY CONTROL (KMAM) AND
RURAL WATER SUPPLY & ENVIRONMENTAL SANITATION
(BAKAS) ACTIVITIES
Ensuring uninterrupted provision of safe drinking water is the most
important preventive measure to be implemented following flooding, in
order to reduce the risk of outbreaks of water-borne diseases. 2,12 During
the flood, 960 water samples were taken from the pipe water supplied
by the Pahang Water Authority (PAIP). The sampling points include
treatment plant outlet, reticulations and also DRC. Only 8.4% and 6.1%
violation on residual chlorine and turbidity were found respectively. All
violations were reported to PAIP and remedial measures were taken
immediately. There was no report of food water borne cases from the
area. A total of 109 wells werealso inspected and chlorinated.
In order to ensure environmental cleanliness,so as not to become source
of infection,2394 houses had been inspected. Out of that, 314 houses
were not satisfactory. During the inspection,it was also found that 269
latrines, 90 domestic water sewerage system and 214 solid waste
disposal systems were under substandard condition. Remedial actions
which include disinfections, gotong-royong activities and health
educationwere taken immediately by the health teams. A total of 60
mobile toilets were also dispatched to the areas which were badly
affected.
4.2.3 FOOD QUALITY AND SAFETY ACTIVITIES
Before the flood, briefings on hygienic and sanitary food handling at the
DRC’s were given to the volunteers. Anti-typhoid vaccinations were also
administered to 1018 food handlers. Not all food handlers were given
briefing and anti-typhoid vaccination since many of them were recruited
at the last minute due to the sudden occurrence of flood at the area in
which DRC and volunteers were not identified earlier. However these
DRC’s were inspected and food preparations were supervised for every
meal. Besides DRC’s, 397 food premises in flood affected area were also
inspected to ensure the quality and safety of the food sold. In addition to
that, 122 inspections were carried out at the point of sale such as
supermarkets, hypermarkets and sundry shops to ensure food that were
96

affected during flood were not sold to the public. During the operation,
food items worth RM 1,360,723.58 were sealed.
4.2.4 HEALTH EDUCATION ACTIVITIES
During the flood period, 35,305 health education sessions were carried
out. The three most frequent activities were individual counseling
(47.1%), demonstration on proper hand washing (24.5%) and small
group discussion (8.3%). A total of 52,821 educational materials on
various health topics related to flood were distributed during the flood.
The topics include hand hygiene, steps taken to avoid disease during
flood, food water borne diseases, vector borne diseases, leptospirosis,
melioidosis and cough etiquette.
These health education activities carried out during the flood period had
probably increased public awareness and empower them to take actions
which prevent them from contracting communicable diseases.
5.0 CONCLUSION
There was no increase in prevalence of communicable disease during the recent
flood, except for leptospirosis, melioidosis and food poisoning. However, the
increase in those diseases did not directly related to flood.
There were few factors which lead to the success in making communicable
diseases under control. Firstly, all districts had succeeded in carrying out their
preparedness plan (pre, during and post flood period). This was further
enhanced by good interagency collaboration observed during the flood period.
In addition, DRC were mostly equipped with basic amenities such as treated
water supply, sanitary latrines, uninterrupted electrical supply and supervised
food preparation. Moreover, population displacement and movement of victims
which usually leads to increase in prevalence of communicable diseases and
outbreak did not occur in Pahangsince the flood period was short in duration
and thus causing less impact on health.
6.0 RECOMMENDATION
To further improve the management of communicable diseases related to flood,
the preparedness plan has to be reviewed. Alternative plan has to be made
available to cater situations when the healthcare staffs themselves are affected
by the flood. Arrangement with neighbouring district within the state and
97

outside the states is made so as to make sure immediate and uninterrupted
response is in place to enable preventive and control activities runs smoothly.
In terms of preventing food poisoning outbreak during flood period, policy of
not allowing outside foods to be served to flood victims should be discussed in
NDMRC since all DRC is equipped with facilities and personnel to prepare the
food for flood victims and being supervised by health teams.
During the recent flood, Health Alert Card (HAC) was distributed to monitor the
health status of the MOH staffs and volunteers involved especially on Typhoid,
Leptospirosis and Melioidosis. However these HAC were distributed a bit late.
Some of the personnel involved has passed the incubation period for the
diseases. In future, this HAC should be make available early and distributed to
the exposed group when necessary.
98

7.0 REFERENCES
1. Balek, J. (1983). Hydrology and water resources in tropical regions.
Developments in water science. Vol.18
2. World Health Organization. Flooding and communicable diseases fact sheet:
Risk assessment and preventive measures (2005).(cited 7 April 2015).
Available from
http://www.who.int/diseasecontrol_emergencies/publications/who_cds_200
5.35/en/ OR www.who.int/hac/techguidance/ems/ flood_cds/en/
3. Connolly, M.A., Gayer, M., Ryan, M.J., Salama, P., Spiegel, P., Heymann,
D.L. (2004). Communicable diseases in complex emergencies: impact and
challenges. Lancet. 364(9449):1974–83. [PubMed: 15567014]
4. Jensen, P.K., Meyrowitsch, D.W., Konradsen, F. (2010).Water and
sanitation in disaster situations] Ugeskr Laeger. 172(2):109–12. [PubMed:
20074486]
5. Ivers, L.C., Ryan, E.T. (2006). Infectious diseases of severe weatherrelated
and flood-related natural disasters. Curr Opin Infect Dis. 19(5):408–
14. [PubMed: 16940862]
6. Wilder-Smith, A. (2005).Tsunami in South Asia: what is the risk of postdisaster
infectious disease outbreaks? Ann Acad Med Singapore.
34(10):625–31. [PubMed: 16382248]
7. Lashley, F.R. (2003) Factors contributing to the occurrence of emerging
infectious diseases. Biol Res Nurs. 4(4):258–67. [PubMed: 12698918]
8. Ligon, B.L.(2006). Infectious diseases that pose specific challenges after
natural disasters: a review. Semin Pediatr Infect Dis. 17(1):36–
45.[PubMed: 16522504]
9. Waring, .S.C., Brown, B.J. (2005). The threat of communicable diseases
following natural disasters: a public health response. Disaster Manage
Response. 3(2):41–7.[PubMed: 15829908]
10. Badrul Hisham, A.S., Shaharom Nor Azian, C.M.D. , Marzukhi, M.I., Norli,
R., Fatimah, O., Kee, K.F, Arbaiah, O., Mohd Yusof, M., Adam, A.M. (2009).
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Spectrum of flood-related diseases encountered during flood disaster in
Johore, Malaysia. Journal of Community Health,Vol.15,15-23
11. Isidore, K.K., Syed, A., Taro, K., Karen, H., Hitoshi, O. (2012). Infectious
diseases following natural diasasters: prevention and control measures.
Expert Rev. Anti Infect. Ther. 10(1), 95-104
12. Najmeh, J., Armindokht, S., Mehrdad, M. & Amir, L. (2011). Prevention
of communicable diseases after disaster: A review. Journal of Research in
Medical Sciences
100

ARTICLE 8
MEDICAL RELIEF DURING MAJOR FLOOD IN
PAHANG 2014: SHARING EXPERIENCES FROM FOUR
DISTRICTS:
BERA, JERANTUT, KUALA LIPIS AND MARAN
Suzana M.H., Rahimi H., Rosealaiza W.A.G., Rahim W.A
101

MEDICAL RELIEF DURING MAJOR FLOOD IN PAHANG 2014:
SHARING EXPERIENCES FROM FOUR DISTRICTS:
BERA, JERANTUT, KUALA LIPIS AND MARAN
Suzana M.H., Rahimi H., Rosealaiza W.A.G., Rahim W.A
ABSTRACT
Pahang experienced the worst floods in 43 years history in end of 2014 till late
January 2015. A total number of 98,345 evacuees were registered in various
relief centers across state of Pahang. During flood disaster, the evacuees were
predisposed to various types of illnesses for various reasons. The chaos in the
community summons an immediate medical attention and public health
obligatory. These posed challenges to the medical team response to deliver the
services. This paper is aiming to describe public health preparedness and
responses according to National Flood Management Plan. These include varying
degree of health problems among evacuees and issues encountered to provide
medical services in the Disaster Relief Center (DRC).
KEY WORDS: Pahang, Medical Relief and Major flood
INTRODUCTION
Flood is an overflow or an accumulation of an expense of water that submerges
land. Several major floods have been experienced in the last few decades. As
far back as 1886, a severe flood in Kelantan and in 1926 affected most of
Peninsular Malaysia. In 1967, disastrous floods surged across the Kelantan,
Terengganu and Perak river basins. A few years later in 1971, Pahang was
severely affected causing great economic losses, as well as mortality.
Most town in Pahang state received heavy rainfall in monsoon period, which
results in flood in low area especially near the flood plain area. The Sungai
Pahang begins to flow from Jelai River in the south east and south directions
and passing along Kuala Lipis, opened to Tembeling River near Jerantut and
Temerloh, midway on the river at its confluence with Sungai Semantan and
flow turning eastward at Bera in the central south, through Maran and finally
flowing through Pekan near the coast before discharging into the South China
Sea 6 .
On 22 nd December 2014, once again state of Pahang was hit by natural
catastrophic. 98,354 numbers of people were badly affected causing their
health in vulnerable state. Seven districts in Pahang state were seriously
102

flooded and victims were evacuated to designated and unsigned disaster relief
center. The objective of this study is to analyze the major flood impact to the
Health Care System and people at the study area. This paper is describing the
preparedness plan available in Pahang, together with medical responses due to
disrupted of routine healthcare services in 4 districts (Lipis, Jerantut, Maran and
Bera). The respective affected districts collected the primary data on
preparedness and medical responses for a period between 22 nd December 2014
and 11 th January 2015. The data is considered to be fairly reliable and verified
by state operational room team at Pahang State Health Department. It is used
for health disaster surveillance, mitigation and management activity of the
state.
PUBLIC HEALTH PREPAREDNESS
Flood Plan of Action Manual
As flood occurred almost every year in Pahang, it is a requirement for every
health district to have its own flood plan of action manual 1 . This plan of action
will be reviewed and updated every year. The content of the manual include
personnel involved in the dedicated medical teams and control teams,
dedicated vehicles, gazette DRC including in charge person, important contact
numbers, list of equipment ‘s and medications. A specific chapter on vulnerable
group information is also included in the manual. These group will be identified
and relevant health advise will be given to them prior to flood season 1,5,9 .
Mobile Medical Team (MMT)
A total of 158 government health care facilities are available at the 4 four
districts, 155 public health facilities, including 52 health clinics providing primary
care and 3 district hospitals. Bera district does not have any district hospital
and requires patient to be transferred to the nearest hospital at neighboring
district.
Forty-eight MMTs were formed in the public health and 9 others from hospital
giving rise to 57 MMTs standby for flood management. A total number of 447
identified health personnel including medical officers, paramedics and
supporting staff were dedicated for these 57 MMTs.
103

Vulnerable Group Identification
Vulnerable group is defined as a group of individual whom has medical
conditions or medical problems that require frequent or special attention
especially during any interruption of the existing health services such flood or
any other disaster at flood or disaster prone locality 5,9 . There were 7 common
vulnerable group identified namely antenatal mothers at period of amenorrhea,
POA of ≥36 weeks; antenatal mother with certain medical problem requiring
frequent or special medical attention; chronic medical illness person including
diabetes mellitus, hypertension and asthmatic patient, those with special needs
– including bedridden patients, disabled person; infant with medical problems;
post operative patient and other illness requiring special attention. These group
were identified and was given advise pertaining their health issues for example
to find alternative safer place before flood occurred, the need to evacuate
earlier if any sign or warning that flood will set in or have their medications as
an one of the important items to be brought along to DRC during evacuation.
During this flood event , 3,133 vulnerable individuals were identified at this four
district. Majority were those in the antenatal mothers at ≥36 weeks and
antenatal mothers with certain medical problem requiring frequent or special
medical attention group, with exception of Maran district, which had the highest
proportions of chronic medical illness group (54.8%)
Gazetted Disaster Relief Center (DRC)
A total of 197 DRCs were identified at this four district, which consist of 87
common or community halls, 69 schools and 41 mosques. Among important
criteria of DRC’s it must have proper space to occupy certain numbers of
people, enough and separate toilets for male and female, good ventilation, safe
water supply and electricity. All the DRCs were inspected by heath staff
together with local authorities in charge on flood management before
December 2014. This inspection was carried out to ensure the DRC in good
conditions before evacuees moves in 5,9 .
Meetings and discussions on flood management
For the preparedness on flood management, a minimum of 2 meetings and
discussions were conducted during June to November 2014. At health
departmental level, detail briefing on what need to be prepared and tasks of
medical were discussed in detail to all dedicated personnel identified for the
medical teams.
104

PUBLIC HEALTH RESPONSE
During the flood, there were 18 975 evacuees placed at 156 DRCs. The
evacuees comprised only 4.6% of total population from four districts. Among
these evacuees, 57.8% were adult, 30.1% children, 4.2% infant, 5.3% elderly
and 0.5% disabled.
Medical Mobile Team (MMT)
There were 48 MMTs from public health providing primary medical care services
during the period when DRCs were opened, which ranges from 14 days to 20
days. MMTs from hospital did not go to DRCs but were stationed or operating at
their own hospital instead. This measure was taken to ensure enough human
resources in the public health and hospital levels. Many health personnel at this
four district was affected by flood either cut off or became evacuees. Hospitals
were required to function as transit or holding area and need to serve the inpatients,
discharged patients, relatives or visitors whom were stranded there for
a period of time.
On the average, the coverage days of the MMTs was only 74.8% of the
required days they were supposed to visit DRCs. This is due to mainly of
logistic problems – not proper transportation, long waiting time for boats and
long journey time due to DRCs. Coverage by district of Lipis was the highest
(94.6%) followed by Maran (78.9%), Bera (74.0%) and the least was Jerantut
(51.6%)
Static Clinic
Static clinic is a 24 hours concept clinic being set up at DRCs. The aims was to
provide continuous primary medical care to the evacuees. Ten static clinics
were set up at the DRCs which had more than 500 evacuees, 5 were in Maran,
3 in Jerantut and 1 in Bera . Another 11 static clinics were set up at DRCs with
accessibility issues either road cut off due to raising water level or long distance
issues.
Health Problems at DRC
Health problems related to infectious illness were commonly seen by MMT 2,3 . A
total of 1622 evacuees presented with various infective illnesses namely Upper
Respiratory Tract Infection; URTIs (58.3%), Acute Gastroenteritis; AGE
including one episode of food poisoning in Jerantut (7.8%), conjunctivitis
(0.7%), skin infection (32.6%) and others like Hand Foot and Mouth Disease
HFMD, Chicken Pox and Dengue (0.6%). Bera, Jerantut and Lipis had URTI as
the highest proportion of infectious illness while Maran had skin infectious as
105

the highest burden of infectious illness. No other cluster or outbreak of
infectious disease occurrence at this four district during this flood event.
A total of 2,871 evacuees sought treatment for non-communicable diseases and
other non-specific symptoms like headache, minor injuries, musculoskeletal
problems and etc. Among the diseases registered were Hypertension (32.8%),
Diabetes Mellitus (24.8%), Asthma (5.8%), Gastritis (4.1%) and others
(32.5%).
Six hundred and eighty nine evacuees experienced non-specific symptoms i.e.
fever (338) and cough(351).
Two hundred and eighty seven patients were referred to the nearest hospital or
tertiary hospital for further management. Among those were 9 patients (7 from
Jerantut and 2 from Maran) requiring Mercy Flight services.
Figure 1 : Public Health Preparedness At District Bera, Jerantut, Lipis and
Maran, 2014
District
Bera Jerantut Lipis Maran Total
Health Facility
Health Clinic* 7 10 8 8 33
1 Malaysia Clinic* 1 1 1 2 5
Mobile Clinic 4 1 8 1 14
Community Clinic 16 25 23 38 102
Maternal & Child Health Clinic 0 0 1 0 1
Hospital 0 1 1 1 3
Total 29 38 42 50 158
Transportation
Ambulance 5 7 13 7 20
Four Wheel Drive 12 7 11 12 23
Boat 0 4 1 0 5
Other land transportation 9 9 21 11 32
Total 26 27 46 30 80
Medical Team
District Health Office 13 11 12 12 48
No. of staff 65 58 60 60 243
Hospital 0 3 3 3 9
No. of staff 0 15 15 15 45
Gazetted DRC 37 46 58 56 197
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Figure 2 : Vulnerable Group At District Bera, Jerantut, Lipis and Maran, 2014
Vulnerable Group
Bera Jerantut Lipis Maran
No. % No. % No. % No. %
AN mothers at POA 36/weeks 499 50.9 195 40.4 367 54.7 205 20.5
AN mothers with certain medical
problem
281 28.7 104 21.5 196 29.2 199 19.9
Chronic medical illness 86 8.8 69 14.3 31 4.6 547 54.8
Special needs 45 4.6 68 14.1 42 6.3 30 3.0
Infants with medical problems 7 0.7 3 0.6 9 1.3 12 1.2
Mental illness 43 4.4 32 6.6 24 3.6 6 0.6
Post operative 1 0.1 1 0.2 1 0.1 0 0.0
Others 18 1.8 11 2.3 1 0.1 0 0.0
Figure 3 : Public Health Response to Flood, Bera, Jerantut, Lipis and Maran
District, 2014
Population (x10 3 )
Evacuees
Population affected (%)
Evacuees
District
Total
Bera Lipis Jerantut Maran
108.7 92.7 94.4 117.3 413.1
3327 4418 4442 6788 18975
3.1 4.8 4.7 5.8 4.6
Adult (%) 1635 2432 2651 4638 11356 (59.8)
Children (%) 1226 1529 1228 1737 5720 (30.1)
Infant (%) 221 189 187 198 795 (4.2)
Elderly (%) 226 247 348 188 1009 (5.3)
Disabled (%) 19 21 28 27 95 (0.5)
Duration of flood (Days)
No. of DRC opened
No. of DRC with treatment room
DRC coverage by MMT (%)
19 17 14 20
19 58 35 44 156
1 5 13 10 29
74 94.6 51.6 78.9
No. of MMT
13 11 12 12 48
No. of Health Staff
Medical Team 65 66 46 50 227
Control Team 64 36 32 45 177
Operation Room 21 29 22 14 86
Static Clinic
> 500 evacuees 1 0 3 1 5
< 500 evacuees 0 3 2 6 11
107

Figure 4: Health Problems at DRC, Bera, Jerantut, Lipis and Maran
District 2014
District
Total
Bera Jerantut Lipis Maran
Infectious
URTI 271 419 171 84 945
AGE 21 64 8 34 127
Conjunctivitis 2 2 7 1 12
Skin Infection 22 97 118 292 529
Others 1 8 9
Total 316 582 305 419 1622
Symptoms
Cough 101 155 36 46 338
Fever 26 102 0 223 351
NCD
DM 52 169 29 220 690
HPT 90 293 159 371 913
Asthma 24 57 31 49 161
Gastritis 39 61 12 2 114
Others 133 72 332 366 903
Total 338 652 563 1008 2781
Referred patient from DRC *(by mercy flight) 53 196 *(7) 9 29 *(2) 287 *(9)
DISCUSSION
Flood occurrence at these four district at the end of 2014 was unusually bigger
in magnitude and longer duration as compared to previous year. Disruption of
normal health services and displaced evacuees at DRC requires MMT services
2,3,5,9 . During this flood event although there were 57 MMT’s standby (288
personnel) only 48 MMT’s (227 personnel) from public health were able to
provide primary health care services at 156 DRC’s opened. Nine MMT’s from
hospital need to be stationed in their respective hospitals as their services were
required there, to serve in-patients and stranded discharged patients, relatives
and visitors.
As many of health personnel were affected by flood there was shortage of
human resource to perform daily health activities during this period. Due to
longer duration of flood this time round, available human resources were
exhausted after the first week of flood. We are so thankful to receive assistance
from other state health department namely Penang and Selangor, other
agencies namely Malaysian Integrated Medical Professionals Association
(MIMPA) and Malaysian Medical Relief Society (MERCY Malaysia) and others.
In the disaster like flood, acute conditions are the most common reasons for
evacuees to seek medical attention 2,3,4 . It is normally followed by need of
primary health care services to be closer to the evacuees and likely to be more
burdens to the health care providers. As most of the land road had been cut off
108

y flood and lack of suitable transportations against strong water current , it
was not an easy task serving those requiring health need at DRC’s affecting the
medical coverage in all four district. The best coverage was by Lipis 94.6% and
the worst by Jerantut, only 51.6%.
Although the magnitude of flood is bigger than before , not all area were
affected and not all 197 DRC were opened. Most and worst affected area was
alongside Pahang river. Among 156 DRCs operationalized there was about 10
not gazetted DRCs set-up due to the needs. Among reasons to set-up was to
occupy for the stranded road user during road cut off. They did not have any
place to go except the nearest safe place, being it other people house or
mosque or squatting with other people temporary camp, until the road was safe
for them to continue their journey. Those suffering chronic illness on regular
medication had not enough supply or did not bring along their medications. As
most of the non- gazzeted DRC were not fully equipped, too remotes and
difficult to be reached by MMT or other agencies, couple with lack of regular
medications, worsen the health status of these evacuees.
The availability of outreach by MMT is particularly important following the
disaster and should be given high priority 2,3,4 . As most of the challenges were
focusing on the proper transportation to reach DRCs, the availability of suitable
and safe boats for MMT should be discussed. MMT also need to plan on how to
best manage or provide service to non gazetted DRC in future.
Disaster preparedness reduces future risk and vulnerability of the people.
Systematic assessment pre-disaster to vulnerable group of people enhance
capacity and promote for maximum efficiency in delivering the health care 7,8 .
During the flood, the vulnerable group of people was not easily managed as the
situations was no longer a proper and ideal situations. As an example those
requiring hemodialysis 3 times per week, it was difficult for the to get the
service as the usual means of transportation was interrupted. Some high cost
services like mercy flight may be the only means of transportation during this
time. In this flood episode there were 18 mercy flights made. We need to have
a proper plan and resources on how to initiate a high cost services like mercy
flight; earlier in the future.
CONCLUSION
This episode of major flood in Pahang, provide lots of new experience to our
MMT and health care service delivery. Ensuring better access to health care via
Mobile Medical Team especially to DRC was a great contribution and enhances
the well being among evacuees. Although all four districts had prepared for the
flood season, we noted lots more improvement required so as to smoothen and
provide better the service delivery during next episode of flood. Despite the
unusual magnitude of flood, we are able to provide appropriate health care
services to those people in needs
109

REFERENCES
1. National Security Council (amendment 2012). Dasar dan Mekanisme
Pengurusan Bencana Negara: arahan 20. Majlis Keselamatan Negara,
Jabatan Perdana Menteri, 2013.
2. C. Axelrod., P.P. Killam., M.H. Gatson., N. Stinson. Primary Health Care and
the Midwest Flood Disaster. Public Health Rep. 1994 Sep-Oct; 109(5): 601–
605.
3. Rashidi. A., et. Al. Health Major Incident: The Experiences of Mobile Medical
Team During Major Flood. Malaysian Journal of Medical Sciences, Vol. 15,
No.2, April 2008 (29-33).
4. Zhaong. S., Clark. M., Yu Hou. X., Zang. Y., FitzGerald. G. Progress and
Challenges of Disaster Health Management in China: a scoping review. Glob
Health Action.2014 Sep 10;7:24986. doi: 10.3402/gha.v7.24986. eCollection
2014.
5. Kementerian Kesihatan Malaysia. Pelan Tindakan Menghadapi Banjir.
Bahagian Kawalan Penyakit, Kementerian Kesihatan Malaysia, September
2007.
6. M.S. Khalid., Shazwani.S. Flood Disaster Management in Malaysia: An
Evaluation of the Effectiveness Flood Delivery System. International Journal
of Social Science and Humanity, Vol. 5, No. 4, April 2015
7. Minimal Standards in Health Actions. Humanitarian Charter and Minimum
Standards in Humanitarian Response. The Sphere Project Geneva, 2011
(p287-353).
8. Communicable diseases following natural Disasters: Risk assessment and
priority interventions. 2006.
www.who.int/diseasecontrol_emergencies/.../CD_Disasters_26_06.pdf
9. Kementerian Kesihatan Malaysia. Garis panduan Pengurusan Banjir
(Kesihatan). Bahagian Kawalan Penyakit, Kementerian Kesihatan Malaysia.
2008.
110

ARTICLE 9
CHALLENGES AND OBSTACLES INOVIDING MEDICAL
SERVICES DURING DISASTER RESPONSE:
ARE WE DOING ENOUGH?
Suzana M.H., Rahimi H., Rosealaiza W.A.G., Rahim W.A
111

CHALLENGES AND OBSTACLES IN PROVIDING MEDICAL
SERVICES DURING DISASTER RESPONSE:
ARE WE DOING ENOUGH?
Suzana M.H., Rahimi H., Rosealaiza W.A.G., Rahim W.A
ACKNOWLEDGEMENT
The author is grateful to the state director of JKN Pahang and other officers
especially Dr Nur Aiza Hj Zakaria, Dr Haminuddin Hassan and team members of
KPAS unit. This study also is strongly assisted by Assistant Environmental
Health Officer from Lipis, Jerantut, Bera and Maran Health Office.
ABSTRACT
The flood disaster in 2014 terrifying people across ten districts in Pahang.
Nearly 100,000 people were affected and evacuated during this 40 days of
event. Evacuees were exposed to various health issues and illnesses during
their stay in Disaster Relief Center (DRC). There were 202 localities affected by
flood requiring 156 DRC to be opened which accommodate 98,345 evacuees in
the district of Kuala Lipis, Jerantut, Bera and Maran. Impact of the disaster on
primary health care services were highlighted and discussed in terms of Mobile
Medical Team (MMT) coverage in DRC. MMT is an option for delivering medical
care services for evacuees and volunteers in emergency and post-emergency
phases. A total of 3,133 vulnerable individual has been identified and evacuated
during early phase of the disaster, in which40.4% constitute of antenatal
mother at 36 weeks of gestational and 59.6% were chronic cases such as
children with special needs, mentally ill and others. The aim of this paper is
focusing into issues and problems faced during delivering of the medical care,
the capacity of resources and the availability of support system. There was
discrepancy between the capability and capacity of the current MMT and
requirement needed by DRC evacuees.
KEYWORDS: Medical Mobile Team, Major Flood, and Disaster Relief Center
112

INTRODUCTION
Flood occurrences seem to be getting more frequent in recent years. In
December 2014, East Coast of Peninsular Malaysia experienced serious flooding
which had a negative impact on the economy and to society in general. Flood
disaster management in Malaysia is based on the National Security Council
(NSC) Directive No.20 and Fixed Operating Regulations (PTO). This machinery
was established with the objective of co-ordinating relief operations at the
district levels so that assistance can be provided to flood victims in an orderly
and effective manner. Ministry of Health is the leading agency responding to
public health and medical care needs during the disaster.
When flood is first set in, accidents or emergencies are the common reasons for
people to seek health care in the Disaster Relief Center (DRC). During this time,
there is usually a decrease in visits to health center and the needs in DRC are
escalating drastically. After initial emergency phase, the need for primary
health care services is slowly come in order. Mobile Medical Teams (MMT) serve
both phases at their DRC due to disruption of care in the clinic and provide
accessibility to the evacuees and volunteers.
HEALTH CARE PROVIDER
Main health care provider at these four districts is Ministry of Health Malaysia.
There are 14 existing operational Mobile Medical Teams, currently functioning
at these 4 districts. Role and function of the existing MMTs are to provide
outreach primary care services to localities with accessibility problems or
specific group requiring special attentions e.g. Orang Asli (Aborigine Group).
There are 38 primary care clinics and 3 hospitals providing secondary care.
There are 105 community and maternal and child health clinics focusing on
maternal and child health care, some community clinics do provide very basic
primary care and health population screening.
Another 57 Mobile Medical Teams specific (which will be addresses as MMT
subsequently) for flood season were formed at this four district, 48 teams from
public health and 9 teams from hospital. The role and function of these MMTs
are to provide primary care services at Disaster Relief Centers, DRCs.
Overall ratio MMTs and DRCs are 1 MMC to 3 DRC. Bera had almost 1 MMC per
1 DRC, Jerantut 1 MMC per 3 DRC, Maran 1MMC per 4 DRC and Lipis 1 MMC
per 5 DRC.
A vehicle was also designated to each team. Majority of the vehicles are
suitable for land transportation and only 5 boats available for water
transportation in Jerantut and Lipis district.
113

IMPACT FLOOD TO HEALTH SYSTEM
At this four district, 18 health facilities were flooded involving 3 health clinics
and 15 community clinics. None of 3 hospitals were flooded. A total of 33 health
facilities were cut off during flood. A number of 119 staff were affected by
flood, 22 from Bera District, 32 from Jerantut District, 21 from Lipis District and
44 from Maran District.
DISASTER RELIEF CENTERS (DRC)
Out of 197 gazetted DRCs at this four district, 156 (79%) DRCs were opened
which placed 18,975 evacuees (4.6% of total populations). Only 29 DRCs has
separate treatment rooms. None of this treatment room had medications or
medical equipment in-situ.
Majority of DRCs (123, 79%) were cut off during flood and main transportation
suitable was only using boat. A total of 62 (40%) DRCs had safe water supply
interruption, 48 (31%) had no electricity supply and 57 (37%) had
communications problems i.e. static telephone or hand phone or e-mail.
Static Clinics
Sixteen static clinic were set up at 12 DRCs. Five of the DRCs had more than
500 evacuees and 11 other static clinic were set up at DRCs with accessibility
issues i.e. due to distance, MMTs not able to come daily or transportation
reasons.
Medical equipment’s and medications
Medical equipment’s and medications for MMTs were prepared as stated in
Garis Panduan Pengurusan Banjir (Kesihatan), Ministry of Health Malaysia,
2008 9 . Although the preparation was as minimum as required, it must be noted
that it was still a heavy load for the MMTs to take all these medical equipment’s
and medication daily from their health clinic to DRCs. Common medications was
not available in the list for example Chloramphenicol eye drops for conjunctivis,
subcutaneous insulin for hyperglycaemia and emergency drug to bring down
blood pressure. It was also observed that nebulizer and small oxygen gas tank
was essential at DRCs. (Figure 2).
114

OBSTACLES AND CHALLENGES
Health department at this four district had prepared basic requirement of
medical services, namely MMTs, transportation, medication, medical equipment
to provide primary care needs for evacuees at DRCs. Gazetted DRCs were
identified and inspected before flood season to ensure the DRCs had health
basic necessities, safe and suitable for evacuees to be placed there.
We feel that the number of MMTs functioning during major flood at the end of
year 2014 was not enough to cater for health needs of 18,975 evacuees.
Although the ratio between MMT and DRC were small and seems manageable,
it was still not sufficient to give better primary care services to the evacuees.
There were only 18.6% of all DRCs were equiped with a treatment room.
(Figure 1). Contact time between health staff and evacuees was limited due to
numbers of DRC need to be visited and longer time required to reach each
DRCs. This is also taking into consideration the disrupted means of ways of
usual transportation and communication plus we did not have proper vehicles
to be used during flood. Boats were only available at Jerantut and Lipis district.
As for Maran and Bera district they had to rely on Fire and Rescue Department
boats which also serve as common transportation for every department and
public transport too.
It also noted that medications prepared were not adequate for the common
illness at DRCs. Common medications was not available in the list for example
Chloramphenicol eye drops for conjunctivis, subcutaneous insulin to for
hyperglycaemia and emergency drug to bring down blood pressure. Nebulizers
and small oxygen gas tank was essential at DRCs. Some medication and
medical equipment was essential to stabilized patient before transferring them
to nearest hospitals and lifesaving too.
Although medications preparation was as minimum as required, it must be
noted that it was still a heavy load for the MMTs to take all these medical
equipment’s and medication daily from their health clinic to DRCs, without
proper transportation too. It would be better if some medications and medical
equipment’s were stored at some DRCs before hand, which had history of being
opened during each flood season or had logistic issues.
ARE WE DOING ENOUGH?
MMT coverage during flood at four district mentioned was able to provide basic
primacy care services to the evacuees, although no district achieved 100%
MMT coverage. These was due to lack of proper vehicles i.e. boats for MMT to
reach DRCs. Long waiting time to get boats and long journey time caused MMT
only able to visit few DRCs per day only. Number of evacuees and medical
115

problem faced by them also affect the duration of each MMT spend at DRC and
subsequently affect the number of DRC can be visited by MMT per day.
About 7% of health staff affected by flood, causing shortage of health staff
especially during the initial phase of flood. These situations had caused not
enough man power to provide services at the health facility and to participate in
MMT.
The number of four wheel drive available was also not enough as the travel
conditions were more difficult during flood season. Furthermore the drivers
experience handling the vehicle during difficult road conditions play an
important role too. Not all drivers have the experience on how to drive four
wheel vehicle and driving on bad situation of the road or what to do when
facing unexpected raise water level on the road.
There was not enough boats available during flood. Each district had different
flood situations requiring different boat capacity and suitability according the
water level and water current. Boats to be used crossing Pahang River (for Bera
dan Maran) is different from boat to used at Tembeling River or cut off locality
due to raising water level.
Current DRC set up with no proper treatment room and medications medical or
equipment’s made MMT services difficult. Heavy load of medications and
medical equipment’s of MMT were not practical during flood season. Some of
the MMT staff had to walk long distance through muddy and wet soil, travelling
in boats on fast current water flowing, long journey which can be dangerous
sometimes. Review of medications and medical equipments required so as to
make MMT services better.
RECOMMENDATIONS FOR IMPROVEMENT
1. Vehicle : Proper vehicles as boats and four wheel drive should be made
available for district prone area. Proper boat and boatman or drivers
trained on handling boats are also required.
2. Mobile Medical Team: Medications and medical equipments for MMT
need to be revised. Water resistant and light weight bag or storage
should be supplied. Medications for common illness and emergency
situation and life saving drug should be made available.
3. Health Staff: During major flood assistance from non flood area is
required to ensure continuity of health services
4. Diasater Relief Centers: Gazette DRC should have proper treatment room
equipment with basic and common medication and medical equipments.
116

Some DRCs need to be stock with common medication and medical
equipments before flood season especially if static clinic is likely to be set
up there. Proper arrangement and monitoring will be required between
health department and DRC in-charge personnel or agencies to ensure
safety of medication and medical equipments.
5. Communication: Proper communication tools should be made available
for health facility prone to be cut off during flood.
Figure 1: Resource Availability During Flood at District Bera, Jerantut,
Kuala Lipis, Maran
DRC
Bera Jerantut Lipis Maran Total
DRC opened 19 58 35 44 156
DRC gazeted opened 14 45 34 31 124
DRC non gazetted 5 13 1 13 32
DRC with treatment room 1 5 13 10 29
DRC with water interruption 5 41 11 5 62
DRC with no electricity 3 31 3 11 48
DRC with no communication 2 43 6 6 57
DRC cutoff 14 56 9 40 119
Numbers of evacuees 3327 4418 4442 6788 18975
Transportation
Health Department
Ambulance 5 7 13 7 32
Four Wheel Drive 12 7 11 12 42
Boats 0 4 1 0 5
Other land transportation 9 9 21 11 50
26 27 46 30 129
Boats
Fire Engine Department 3 4 2 3 12
Police 3 4 7 1 15
Civil Defence 2 2 2 1 7
Army 2 0 2 0 4
District Office 0 1 0 0 1
Total 10 11 13 5 39
Mobile Medical Team Functioning 13 11 12 12 48
Health staff involved 65 66 46 50 227
All figures are in numbers
117

Figure 2 : Medications and Medical Equipment as in Garis Panduan Pengurusan Banjir
(2008) 9
Medical Equipments
Blood Pressure Set
Stethoscope
Torch light
Thermometer
TongueDepressors Airways
Spints
Medications (injections)
Adrenaline
Aminophyline
Hydrcortisone
Distilled Water
Morphine
Dextrose 5%
Pethidine
Dextrose Saline
Normal Saline
Cream
OMS
Betnovate
Ung Whitfield
Nystatin
Hydrocortisone
Lotion
Flavine
Eusol
Calamine
KMNO4
Inhaler
Salbutamol
Becotide
Minor Surgery Set
1/5 Dextrose Needle Holder
Tooth Dissecting Forceps
Medications (tablet and capsule)
Artery Forceps
Doxycycline
Gallipots
Amoxycillin Black Silk 3/0
Indocid
Nylon
Mefenamic Acid Plain Catgut 3/0
Gelusi Suture Needle Cutting Edge Size 16
Papase Injection Lignocaine 2%
Paracetamol
Ethyl Chloride Spray
Buscopan
Bark Parker Spray
Lomotil
Scapel Blade
Piriton
Salbutamol
Dressing/Others
Stemetil
Gauze
Ascorbic Acid
Cotton Wool
Bactrim
Zinc Oxide Plaster
Erythromycin
Micropore
Cotton Bandages 1" , 3"
Medications (syrup)
Crepe Bandages
Benadryl (adult/infant)
Safety Pins
Paracetamol Hibitane Solutions 1:1000
Buscopan
Lotion Flavine
Piriton
Disposable syringes 2 cc, 5cc, 10cc
ORS
Triangular Bandage
Lotion Cetavelon
118

REFERENCES
1. National Security Council (amendment 2012). Dasar dan Mekanisme
Pengurusan Bencana Negara: arahan 20. Majlis Keselamatan Negara, Jabatan
Perdana Menteri, Kuala Lumpur.
2. C. Axelrod., P.P. Killam., M.H. Gatson., N. Stinson (1994). Primary Health Care
and the Midwest Flood Disaster. Public Health Reports, 109(5), 601–605.
3. Rashidi. A., Zainalabidin. M., Abu Yazid. M.D., Nasir. M., et. al. (2008). Health
Major Incident: The Experiences of Mobile Medical Team During Major Flood.
Malaysian Journal of Medical Sciences, 15(2), 29-33.
4. Zhaong. S., Clark. M., Yu Hou. X., Zang. Y., FitzGerald. G. (2014). Progress and
Challenges of Disaster Health Management in China: a scoping review. Global
Health Action. 10(7), 24986.
5. Ministry of Health Malaysia (2007). Pelan Tindakan Menghadapi Banjir.
Bahagian Kawalan Penyakit, Kementerian Kesihatan Malaysia, Putrajaya.
6. M.S. Khalid., Shazwani. S. (2015). Flood Disaster Management in Malaysia: An
Evaluation of the Effectiveness Flood Delivery System. International Journal of
Social Science and Humanity, 5(4), 398-402.
7. Mesfin, T. (2001). Minimum Standards in Health Actions. Humanitarian Charter
and Minimum Standards in Humanitarian Response. The Sphere Project
Geneva. Southamptom: Hobbs the Printer; p. 287-353.
8. World health Organization. Communicable diseases following natural Disasters:
Risk assessment and priority interventions (2006).
www.who.int/diseasecontrol_emergencies/.../CD_Disasters_26_06.pdf
9. Kementerian Kesihatan Malaysia (2008). Garis Panduan Pengurusan Banjir
(Kesihatan). Bahagian Kawalan Penyakit, Kementerian Kesihatan Malaysia,
Putrajaya.
10. Ochi. S., Hodgson. S., Landeg. O., Mayner. L., Murray. V. (2014). Medication
supply for people evacuated during disaster. Journal of Evidence-Based
Medicine. 8, 39-41.
119

ARTICLE 10
WORST HIT DISTRICT IN PAHANG :
HOW WE SURVIVED ?
Rafidah AL 1 , Zainal AO 2 , Rohaya AR 2 , M.Zainie 1
1. Temerloh District Health Office
2. Pahang State Health Department
120

WORST HIT DISTRICT IN PAHANG : HOW WE SURVIVED ?
Rafidah AL 1 , Zainal AO 2 , Rohaya AR 2 , M.Zainie 1
1. Temerloh District Health Office
2. Pahang State Health Department
ACKNOWLEDGEMENTS
We would like to thank the Director and Deputy Director of Pahang Health
Department for their support in ensuring prevention and control activities
during and post flood phase. Thank you also to all staff of district health office
and other state health departments from Kedah, Selangor, Melaka for giving all
their efforts and overwhelming support to Temerloh district.
Our appreciation also goes to all government agencies, the NGOs, private
companies and other parties and individuals who directly or indirectly
contributed to the success of managing the worst flood in Temerloh, Pahang.
ABSTRACT
Introduction: Past major flooding events of Temerloh, Pahang were
documented in 1971. However the worst flood that occurred in December 2014
till January 2015, displacing 21,773 people involving 5,902 families to 79 DRCs.
Affected main administrative centre of Temerloh resulting in disruption of
administrative and commercial activities as well as public utilities and basic
amenities includes electrical, water supply and telecommunication system.
Remarkable number of medical and health team were arranged to execute
control and preventive activities in avoiding potential outbreak.
Objective: To share experience and challengers faced by District Health Office
Temerloh in managing worst ever floods during Disember 2014 till January
2015.
Methodology: Personal experience of authors managed the flood through
active participation, observation and discussion with other providers involved
during the flood period. Using official reports and records collected during the
disaster period.
Finding and Discussions: Tremendous challenges faces by Temerloh District
Health Offices managing initial phase of the flood. Lack of leadership leads to
poor coordination of activities during flood resulting in ineffective disaster
management. Unable to mobilised health personnel to affected area and DRCs
due to limited appropriate transport to access submerged road. Disruption of
121

electricity and telecommunication cause delayed in disseminate directive and
executes services to DRCs. Poor coordination of volunteers and additional
health and medical team from other state in order to maximise their
capabilities. Overcrowding of DRCs with presents of high risk victims, chronic
disease and person with special needs, inadequate facilities and scarcity of
resources contributes to psychological stress among evacuees and health
personnel. Several strategies and decision making were made to ensure district
survive throughout the flood.
Conclusion: Reinforcement disaster preparedness would enhance
management skills, improve knowledge and capacity in planning, organising
and implementation of strategies in managing flood.Closed cooperation and
collaboration at district level in order to maximising scarcity of resources.
Keywords:
Worst flood,scarcity of resources, disaster preparedness
INTRODUCTION
Flood is considered as the most significant natural disaster affecting
Malaysia. Flood had damaged properties, public utilities, agriculture, loss of
lives and caused deterrent to social and economic activities lead to financial
impacts to the country 1 . Flooding also has severe consequences on human
health before, during and after the onset of flood 2 . Temerloh is a town in
Central Pahang , second largest town after Kuantan and one of the flood
prone areas identified in Pahang. It is located about 130 kilometres from
Kuala Lumpur along the Kuantan-Kuala Lumpur trunk road. Temerloh is
situated at the junction of the Pahang River and the Semantan River 3 . Temerloh
has a total area of 2,251 km 2 consist of 234 taditional villages, 6 new chinese villages,
4 felda settlement and 15 aborigens villages. Temerloh district is bordered by
Maran on the east, Bentong on the west, Jerantut on the north, and Bera on
the south. Temerloh has 10 mukim or subdistricts namely Jenderak, Semantan,
Perak, Kerdau, Mentakab, Sanggang, Lebak, Lipat Kajang, Bangau and
Songsang.
Temerloh District has population of 165,451 people comprising of 71.4 %
Malays, 15.8 % Chinese, 7.8 %, India and 5% others 4 . Temerloh has 6 Health
Clinics, 27 Community clinics, 2 Klinik 1 Malaysia, 3 alternative birthing centres,
23 general practitioner clinic, 2 army clinic, 3 haemodialysis centre. Total of 79
designated DRC were made up of schools, community halls and mosques.
122

Figure 1: Map of Pahang by District
Figure 2: Map of Temerloh District
Floods hit Malaysia from 15 December 2014 – 3 January 2015. More
than 200,000 people affected while 21 killed during the floods. This flood have
been described as the worst floods in decades. Pahang was one of the state
that was severely affected by the flood in which Temerloh was declared as
worst flood affected district. It was observed that Pahang River rapidly rose
123

from normal level of 26 metres to 38.09 metres within two days of heavy rain,
affected much larger areas and huge number of victims. Flood affected 86
villages out of 234 villages (37 %), 85 residential areas, public facilities such as
school and mosque, public transport services and other public areas such as
the football stadium, fast food outlet, banks, and shops as compared to flood in
the previous years. The number of victims evacuated were 21,773 which is 22
percent of the total flood victims placed in DRCs in the state of Pahang (98,345
victims) and it involved 5,902 families. Duration of flood was 24 days started
from 24 December 2014 to 16 January 2015 and 79 DRCswere set up.First time
in history flood affected the main administrative centre, where Temerloh town
were submerged. It resulted in disruption of administrative and commercial
activities as well as basic amenities, electrical and water supply and
telecommunication system. Furthermore to make it worst, all major roads
including the East Highway (LPT) connecting Temerloh town to nearby district
(Kuantan, Maran, Bera, and Jerantut) were closed to all traffic after it was
inundated with flood and Temerloh town became an island for about 2 weeks.
Substantial number of medical and health personnel were deployed from
other district in Pahang and other states. Total of 35 medical teams comprising
of 173 health personnel provide first hand primary health care at the DRCs and
46 health team with 184 personnel executed and monitored environmental
health services such as vector control, personnel hygiene, food preparation and
food premises examination, water supply, sanitation and waste disposal.
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Picture 1: Submerged health centre ( KD Kuala Tekal, KK Kuala Krau and KK
Temerloh)
125

Picture 2: Flood in Temerloh District involving shops, roads and stadium.
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OBJECTIVE:
The objective of this article is to share experience and challengers faced by
District Health Office Temerloh in managing worst ever floods during
December 2014 till January 2015.
METHODOLOGY
Personal experience of authors managed the flood through active
participation, observation and discussion with other providers involved during
the flood period. Using official reports and records collected during the
disaster period.
FINDINGS
Challengers faced during disaster in Temerloh:
1. Poor coordination in implementing and monitoring of disaster
and services
In any disaster, the function of Disaster Operation Room (DOR) in Health
District is very critical and important. However during the critical period of
flood, the DOR in Temerloh Health District was not fully function, poorly
coordinated resulting in ineffective disaster management. Poor Leadership,
chaotic line of command, inadequate equipments, shortage of HCW,
disruption of electric supply and telecommunication together with
transportation problems were among the contributing factors affecting
management of the disaster.
2. Restoring and establishment of Health Care Services
Submerged of the facilities and equipments resulting in disruption of health
care services for the population in Temerloh. Total of 10 health centres
involving 3 Health Clinic, 6 Community Clinic and 1 Klinik 1 Malaysia (K1M)
whereas other 13 health clinics and community clinics were inaccessible by
road transport. Nevertheless health services was continued by shifting the
services to nearby health facilities.
At the same time, we also have to provide health care services in the DRCs.
As stated in Pahang Plan of Action for Disaster Management, district health
127

office need to provide basic mobile health service at the all DRCs and have to
set up a static health clinic in DRCs with more than 500 evacuees.
Challengers faced were:
i. Many HCWs were affected by flood which poses problems to mobilise them
in order to provide continuation of service at respective clinic. Some of HCWs
were unable to come to work place due to connecting roads in the affected
areas were cut off.
ii. Unable to reach DRCs via road and no appropriate transport to cross the
flood water.
iii. Due unexpected large area affected, the community had to set up their own
DRC which was not designated by the DOCC (District Disaster Operation
Control Center), making the DHO unable to locate the undesignated DRC and
to mobilised extra HCWs
iv. As the flood occurred at the end of the year, the financial allocation was a
big headache to the organisation because money are needed served meals
for HCWs volunteers on duty, pay for staffs overtime works, payment for
accommodation of volunteers as well as to replaced some of the destroyed
critical medical equipments.
3. Failure of telecommunication systems, transportation services,
disruption in water and electrical supply.
i. A numbers of roads were closed to light and heavy vehicles creating difficulty
for victims to get assed to many private and government agencies including
health facilities and hospital.
ii. DHO do not have appropriate water transport vehicles to commutes HCWs as
well equipment to the affected areas and some DRCs to provide health
services.
iii. Unable to get helps from other agencies due to large scale disaster, DDOCC
do not have adequate number of appropriate water transport vehicles.
4. Poor management of volunteers
Volunteers plays an important roles in helping the DHO to provide optimal
health services to affected populations. During the flood disaster in Temerloh
we also get helps from volunteers comprises of HCWs from other districts
and states as well as from NGOs. At the beginning, we failed to maximise
their roles because of no proper guidelines in managing and coordinating the
volunteers during disaster resulting in mal distribution of volunteers at the
affected areas. Some volunteers were not reporting to DOR before they
pursued their services. Furthermore some of volunteers are poorly equipped,
not trained and have inadequate knowledge of the location of DRC. Other
issues were the safety of volunteers, logistic needs including accommodation,
transport, meals also aroused which needs to be addressed immediately by
the MOH Temerloh.
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5. Managing the DRC
Disaster management at national level in Malaysia is the responsibility of
the Natural Disaster Management and Relief Committee (NDMRC) which
involves all related agencies with its own responsibilities. One of the
responsibility are to delineate the DRCs as well to provide necessary needs
of the victims in the DRCs. Most of DRCs are located in the schools,
community halls and mosques or place of worship. Issues related to DRCs
includes:
i. Overcrowding, inappropriate facility for elderly, small children and
women, disable or victims with special needs.
ii. Lack of privacy for individual and family members resulting in
psychosocial stress.
iii. Inadequate basic amenities and poor sanitation.
iv. In the early stage of flood, Health services were not be able to reach the
undesignated DRCs set up by local communities due to inability of DHO
to locate them.
v. Control and prevention of vector borne, food and water borne as well of
infectious diseases. There were huge number of designated and
undesignated DRCs as well as huge number of victims and affected
areas in the district, DHO have a lots of problem in addressing this
issues. Make worst with difficulties in mobilization of health team to
implement the prevention and control activities. Fortunately there was
no other communicable disease outbreak reported at DRCs except for
food poisoning.
vi. At DRCs food for victims were prepared by the elected committee among
the evacuees. Most of them were not trained in food safety this situation
together with inadequate safe water supply, poor hygienic practices and
poor supervision in food preparation may cause outbreak of food water
borne disease especially food poisoning. Limited choice of menus may
impose deterioration of health for victims with special needs and suffering
from chronic diseases including person with Diabetes Mellitus,
hypertension, renal failure, elderly, pregnant ladies and children.
6. Psychological stress among victims, evacuees at DRC and health
care workers
Due do abrupt displacement from their usual environment and daily life
activities for long period of time leads to psychosocial stress among the
victims. Psychosocial stress also were observed among HCWs who needs to
continue their service at DRC with limited resources and long duration of
working hours. Scarcity of individual capable in managing the stress during
disaster worsening the situation.
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7. Managing the high risk patient at DRC
High risk patient should be manage in the hospital but due to logistic issues
and overloading of patient in the hospital as well as the refusal of the
victims to be admitted for further management, poses challenges to the
HCWs in managing the situation at DRC without observation areas or acute
critical case management. Due to stressful conditions, some of victims with
chronic diseases such as Diabetes Mellitus and hypertension become
unstable and need for observation for stabilization.
8. Prevention of Vector, Food and Water Borne disease in the affected
areas
The risk of outbreaks of disease is associated with size, health status, and
living condition of people displace from its nature. Overcrowding,
inadequate water and sanitation, and poor access to health services often
characteristic of sudden population displacement, increase the risk of
communicable disease transmission. During flood disaster in Temerloh there
were only two food poisoning outbreak occurred at DRCs involving 35
evacuees taken meals which was prepared by the committee among the
victims.
HOW WE SURVIVED?
1. Coordination of services
Coordination and collaboration of government, private sector, NGO,
volunteers and the community is the most important factors to achieve a
successful flood delivery system in the district. Apart from success in the
management of disaster it will helps in reducing the impact of disaster on
the affected communities. The State Health Director have to call a special
meeting to coordinates the services on day one of crisis. Among measures
taken were:
i. Medical Officer of Health of Temerloh have to establish the proper and
well equip DOR as soon as possible
ii. Improvement of command system by appointing Public Health Specialists
(seniors officers) from the state health office to work together with MOH
iii. All supervisor of each services were appointed to manage and report
daily on progress of tasks given to them.
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2. Restoring and establishment of Health Care Services
Providing Health care services during disaster is challenging to the health
authority and a prime need of the affected to community. In establishing
the health care services for the community around the health clinics and
community health clinics which were submerged by flood, the services
were relocated to nearby clinic or by setting up a clinic in other
appropriate building nearby such as in community halls as well as
schools. HCWs needed to run the new clinic was mobilised from the clinic
itself or from nearby clinics as well as HCWs from other district and other
state. The clinic opened daily from 8.00 am till 5.30 pm.
To expedite services recovery in the affected health facilities, a recovery
task force was established and the team members were Public Health
Specialist and Engineering personal from state health department and
supervisors from unaffected clinics. Portable Generator set donated by
private company were provided to facilities with disruption of electrical
supply.
As for health services in the DRCs, the clinic were set up within the DRC
areas and the services were provided in two modalities. DRCs with more
than 500 evacuees, a static clinic are set up and the services will be for
24 hours and, the HCWs have to work in shift while in DRC with less
than 500 evacuees, there are mobile services run on daily basis and the
HCWs have to go to more than one DRCs in a day.
Budget allocation plays very importance roles in providing a better health
care services and Emergency budget for purchasing of medical and
administrative equipments and other necessities were approved by the
higher authority in Ministry of Health.
3. Transportation
Coordination at district level requires close cooperation and
understanding among various agencies in order to be efficient and
successful in rescuing the victims 5 , providing resources supply, mobilising
the health team to the DRC especially when both road transport and
telecommunications are disrupted and electricity supply is short-circuited
at the start of the flood. Basically the flood emergency response to
rescue the victims is led by Army and Public Defense. During disaster,
Marine Department State of Pahang delivered three boats to Temerloh to
facilitate mobilization of Health care team reaching the DRC situated
near the riverside. State Department of Pahang make an iniative move to
purchase 4 light boats in which two were located at Temerloh. Several
corporate body such as BESTA and Jelebu Club contributes four wheel
drive vehicles and two Jet Ski from Academy of Safety and Emergency.
In addition of the helicopter services by the Ministry of Defence, Fire and
131

Rescue Department, Ministry of Health provides extra helicopter by
outsourcing the services to a private company.
4. Management of volunteers
MOH Bentong was appointed as volunteers’ coordinator to organizes and
facilitate the distribution of volunteers from other state. All volunteers
were registered at DOR in DHO and were briefed by respected program
supervisor before they carry their duties in the affected areas or DRCs.
Accommodation and meals were provided by DOH.
5. Managing the DRC
Actions taken to overcome or minimises issues at DRCs are:
i. Establishment of special tasks force to pursue prevention and control
activities to prevent disease outbreak including close supervision of food
preparation at the DRC.
ii. Diligence control measure were enforced together with provision of
mobile toilets and special water tank with filter for washing especially in
the overcrowding DRC.
iii. In undesignated DRC with communication problems, a static clinic were
also set up by utilizing HCW who are the evacuees at the DRC or
mobilising of HCW from other centre. To minimised logistic problems
they were placed there for longer duration.
iv. In managing the high risk patient at DRC, a volunteers from Yayasan
Kebajikan Negara comprising of specialist, medical officers and trained
nurses and Assistant Medical Officers were assigned to provide treatment
as well as temporary observation ward in the DRC at Sekolah Menengah
Seberang Temerloh.
6. Psychosocial stress among flood victims at DRCs and health care
workers
The Public Health Specialist of non communicable disease control
program from state health office was appointed to coordinate and
facilitate the Psychosocial First Aids (PFA) services for the victims
especially at DRCs. The service were provided by the HCWs from
Psychiatric Department in HTAA and HoSHAS. The aims service was to
detect and treat any psychosocial problem among the victims.
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7. Prevention of Vector, Food and Water Borne disease in all affected
areas
Supervisors of the Vector, Food and Water Borne Disease Control and Food
Safety programs has to develop a work plans to run the activities in order to
prevent outbreak of Vector, Food and Water Borne disease as well as other
infectious diseases. Registry of diseases encounter at the DRCs and Health
centres during the flood period were developed. Monitoring was done and
discussed in the daily meeting of the DOC chaired by MOH.
CONCLUSION AND RECOMMENDATION
It was observed that the Implementation of the Plan Of Action For Disaster
Management were not fully implemented during the early and critical phase of
flood and need to be stress out to the all managers of the district in order to
improve overall management of flood in the future. Among the
recommendations to be considered are:
1. Strengthening of pre disaster activities which include training of all related
HCWs including simulation exercise to enhance management skills, improve
knowledge and capacity in planning, assessment of health needs,
preparedness for all hazards disasters and risk reduction 6 .
2. Improves coordination and collaboration intra and extra agencies and NGOs
in the district
3. Financial allocation needs to be addressed seriously by higher authorities.
4. Own helicopter services should be provided by Ministry of Health
5. Purchasing of water transport vehicles such as boat to commute HCWs in
providing health services at affected areas.
6. Establishment of observation ward in DRC with high number of high risk
victims
7. Tele communication system have to be improved including providing
amateur radio, high end walkie talkie and Government Integrated Radio
System (GIRN).
8. In preparation to future unexpected disaster in the district, designated DOC
that is fully equips should be established at District Health Offices.
133

REFERENCES
1. Mohammad Muqtada Ali Khan, Nor Ashikin Binti Shaari, Arham Muchtar
Achmad Bahar, Md. Azizul Baten et al. Flood Impact Assessment in Kota
Bahru, Malaysia: A statistical analysis.World Applied Sciences Journal 32
(4):626-634,2014.
2. Jacqueline Torti. Floods in Southeast Asia: A health priority. Journal Glob
Health. 2012 Dec; 2(2): 020304.
3. Wikipedia. Temerloh District. Available at:
http://en.wikipedia.org/wiki/Temerloh. Accessed 29 April 2015.
4. Department of Statistics Malaysia. Key Statistics. Available at:
http://www.statistics.gov.my. Accessed 30 April 2015.
5. Mohamad Sukeri Bin Khalid and Shazwani Binti Shafiai. Flood Disaster
Management in Malaysia : An Evaluation of the Effectiveness Flood
Delivery System. International Journal of Science and Humanity, Vol. 5,
No.4, April 2015.
6. Hisayoshi Kondo MD, Norimas Seo MD Tadashi Yasudaa MD et al, Post
Flood epidemics of infectious diseases in Morzambique. Prehospital and
Disaster Medicine. http://pdm.medicine.wisc.eduVol 17, No 3.
7. Badrul Hisham, A.S, Marzukhi, M.I, Daud, A.R. The worst flood in 100
years : Johore experience. Malaysian Journal of Community Health Vol
15, S, 2009.( Pg 1-14).
8. Arbaiah O, Daud A.R, Surinah A, Noorhaida U et al. Public Health
Preparedness and Response in Flood Disaster in Johore, Malaysia:
Strengths and Lessons Learned. Malaysian Journal of Community Health
Vol 15, S, , 2009 (Pg 126-131).
9. Arbaiah O, Badrul, H.A.S, Marzukhi, M.I, Mohd Yusof et al. Outbreak
management during the worst flood disaster of 2006-2007 in Johore,
Malaysia. Malaysian Journal of Community Health Vol 15, S, 2009.( Pg
111-118).
10. Laporan Bencana Banjir di Temerloh 2014-2015, Unpublished.
134

Abbreviatives:
1. CPRC Crisis Preparedness Response Plan
2. DDOCC District Disaster Operation Control Centre (PKOB)
3. DRC Disaster Relief Centre
4. NDMRC Natural Disaster Management and Relief Committee
5. NSC National Security Council
6. PDRCC Pahang District Relief Coordination Centre (PKOB Daerah)
7. PFA Psychosocial First Aids
8. DOR Disaster Operation Room
9. HCW Health Care Worker
10. DMOH District Medical Officer of Health
11. PFA Psychosocial First Aids
135

ARTICLE 11
FLOOD MANAGEMENT (DIS 2014~JAN 2015)
IN PAHANG:
FROM FOOD SAFETY ASPECTS
Nor Khamisah Abdul Rahman@Tahir 1 , Mohammad
JefriCrossley 2 , NorBahiyah Bakar 3 , Cheng Lai Ping 4 ,
Fatimah Md Salleh 5 , NorisulianaIshak 2 , Isnizam Sapuan 2
136

FLOOD MANAGEMENT (DIS 2014~JAN 2015) IN PAHANG:
FROM FOOD SAFETY ASPECTS
Nor Khamisah Abdul Rahman@Tahir 1 , Mohammad JefriCrossley 2 ,Nor Bahiyah Bakar 3 ,
Cheng Lai Ping 4 , Fatimah Md Salleh 5 , NorisulianaIshak 2 , Isnizam Sapuan 2
1. Makmal Keselamatan & Kualiti Makanan Negeri Pahang, JKNP,
2. Bahagian Keselamatan & Kualiti Makanan, JKNP,
3. PKD Jerantut,
4. PKD Temerloh,
5. PKD Pekan
ACKNOWLEDGEMENT
Highly appreciation to the Food Safety and Quality Division, the Health
Department of Pahang in cooperation with the data collection. Thanks are also
given to staffs of Occupational Health Unit(KPAS), State Health Department,
Jerantut District Health Office, Temerloh District Health Office, Pekan District
Health Office and the Social Welfare Department of the State and to individuals
who are involved directly or indirectly in the success of this article.
ABSTRACT
Floods phenomenon that often happens in this country every year due to the
climate change, do leave impacts on humans and the environment which is also
closely related to food safety. Knowing how to determine if food is safe to eat
will help to reduce the risk of foodborne illness. When floods occur, evacuees
will be transferred to evacuation centers in which not all places equipped with
basic facilities such as sanitation, potable water and appropriate food
preparation. This article will discuss the relevant issues and food safety
measures before, during and after floods. The methodology used is through the
collection and analysis of data before and during floods, such as food security
trends at the storage depot, the number of flood evacuation centres (PPB), the
status of food handlers, food poisoning investigation and also compliance with
PPB. Meanwhile, for the after-flood measures, few data such as scoring (rating)
of food premises and safety of food products in the premise/food outlet were
collected and analyzed. It is found that even if a health team has identified
some problems regarding PBB before the flood, the facility is still enacted as
PPB by the relevant authorities. In addition to the problem of inappropriate
facilities, control of the reception prepared food or raw materials from third
parties that are not fully controlled also increase the risk of food poisoning in
137

the PPB. Therefore, proposals such as improving our facilities in place in the
PPB food preparation and implementation of the module "Food Safety
Awareness" for all members and victims affected by the flood can control the
level of food safety during flood disaster occur.
Keywords: Food safety, storage depot, flood evacuation centers, food
poisoning, foodsafety awareness
1.0 INTRODUCTION
Floods has occurred as a result of climate change occurs in Malaysia. Floods
usually occur during the monsoon season especially in East coast of Peninsular
Malaysia. In addition, the floods also occur as a result of changes in the
monsoon by environmental factors, uncontrolled development of infrastructure
as well as unexpected rainfall at one time (Muhammad BarzaniGasim et. al,
2010).
In 1923, a major flood occurred in Pahang. The floods have destroyed
vast land areas in the District of Lipis, Temerloh, Kuantan and Pekan. Floods
had continued until 1924 that broke up the connection between Pekan and
other districts. At the end of 1926, the worst floods recorded in the country
called the ‘Great Flood of 1926’. In 1971, the state of emergency had been
declared caused by the severe flooding that hit the country, including the state
of Pahang after almost all of the whole country was submerged by water due to
non-stop heavy rainfall for almost a week (Nan Zul, 2013). According to Prof
Kay Kim, floods in 1926 and 1971 occurred because of the weakness of the
drainage infrastructure which could not cope with massive quantity of rainfall
(e-utusan, 2007). By the year 2014, flood disaster in Pahang started on 18
November 2014 that involved the district of Kuantan. The second wave on 18
December 2014 involved all districts in Pahang except for Cameron Highlands,
involving 23,205 families with the total of 98,345 people victims (KPAS Unit,
2015).
According the 2014 flood disaster, flood management has been
implemented to help victims affected by this incident, which included the
economic management, public health, food safety and cleansing the area
helped by local authorities. In Food Safety aspect, the flood disaster
management was carried out in accordance with the procedures outlined which
could help, check and complete the facilities available such as sanitation, clean
water supply and food preparation as well as a kitchen appliance for proper
cooking during floods to reduce the risk of the occurrence of incidents of food
poisoning and disease-food borne and water.
The main objective of this article is to describe the monitoring of food
safety in flood-hit areas by stages before, during and after the flood. It also
seeks to identify interventional measures of safe food-handling and to explain
the ways to overcome food poisoning episodes during floods.
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2.0 MATERIALS AND METHODS
Following the floods (December 2014 ~ January 2015) in the state of Pahang,
the Food Safety and Quality Division, Department of Health Pahang (BKKM,
JKNP) has provided some procedures and carry out the collection of data to
address the food safety issues that will occur during the great flood. A
collection of data shows the trend in the Food Safety Monitoring activities as
below.
Food Safety in Storage Depot
In accordance with the directions of the National Security Council (NSC),
Welfare Community Department (JKM) as the agency responsible for the
management of evacuation centres have had commissioned throughout the
State that are identified are storage depot, Halls, Community Centres and
schools. NSC also established a Disaster Needs Storage Depot to save stocks of
food products and disaster relief goods to the area foreseen of flooding.
Therefore, the health team from the District Health Office also monitoring the
suitability of the storage of food stocks to ensure it is in a clean and safe from
pollution particularly pests.
Data Flood Evacuation Centres (PPB)
Each PPB has been monitored on safety and hygiene and cooking utensils used
during flood disaster. Following the flooding that has occurred, collecting flood
relief centers have been obtained for each area as well as the collection number
of victims who have been involved in this flood.
Status of Food Handlers
Prior to flooding, Food Safety & Quality Division (FSQD) has identified a number
of food handlers who will be involved during the flood. The food handlers have
given training in handling foods during the flood to avoid food poisoning.
During flood disaster, there is increase in number of food operators due to
over-crowded number of victims. Thus, the data collection for food handlers
before and during floods also has been compiled to ensure they are aware of
clean and safe food-handling.
Food Safety in Flood Evacuation (PPB) and Food Premises
A total of PPB has been identified by FSQD, State Health Department. Based on
the information obtained, Assistant Environmental Health Officer (PPKP) will
carry out an inspection in PPB to identify hazards in food preparation premises
in PPB. Inspection methods and strike directly against the non-compliance
found in the premises is carried out by adopting a special form by Assistant
Environmental Health Officer (PPKP) before and during the flood by using Form
22 and Form Examination of PPB.
Subsequent monitoring of the level of food safety in the preparation and sale of
food premises, inspection observations conducted on all categories of food
139

premises as post-flood activities. It carried out inspection to ensure that the
food premises not conduct sale of food products or foods that are at risk
ofhazard due to flooding with the use of tools such as thermometer for
monitoring cold storage temperature and UV light to detect the presence of rat
urine.
Food Product Safety Compliance On-Premises/Food Outlet Inspection
Post Flood was conducted to ensure the safety of food products sold in the
premises or in the food outlets that have been affected by flooding. The
inspections on the premises/food outlets must be carried out to ensure food
products that have been affected by floods are not been sold in rampant due to
lack of awareness of food safety.
Investigation of food poisoning Episode
The FSQD has issued a special procedure to carry out investigations in the
event of food poisoning at the PPB. The investigators will conduct investigation
of food poisoning by using the form Investigation of Food Poisoning during
Flood.
3.0 RESULTS
Food Safety Trend in Storage Depot
Chart 3.1: The Data Base Of The Storage Depot Inspected
Source: KPAS,JKNP (2015)
Based on Chart 3.1 above, all districts in the State have carried out inspections
at the storage depot during the flood disaster occurred. Based on the
inspection, there were a total of 79 of the storage depot in the State stipulated
by JKM. Only 7 districts that have the storage depot that complies with the
specifications prescribed district of Kuantan, Pekan, Maran, Bera, Bentong,
Raub, Jerantut. For Temerloh district, a total of 12 (15%) of the storage depot
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and 2 of them have a pest problem. For Lipis district, there are 3 (4%) of the
storage depot and the entire three storage depot have a pest problem. For the
District of Rompin, there are 8 of the storage depot, 5 of which could not be
examined due to the constraint of vehicle and weather conditions.
Data on the Status of Flood Evacuation Centres (PPB)
Table 3.1 Data Flood Evacuation centres, the number of flood victims and the
families that are involved
District Date PPB Victims Families
Kuantan 17/12/14 - 19/12/14 8 1,678 426
21/12/14 - 12/01/15 53 21,871 5,900
Temerloh 23/12/14 - 16/01/15 77 39,283 7,793
Pekan 23/12/14 - 14/01/15 85 15,298 3,912
Maran 23/12/14 - 12/01/15 44 6,788 1,629
Lipis 22/12/14 - 05/01/15 34 4,442 1,173
Jerantut 22/12/14 - 08/01/15 59 4,418 1,161
Bera 24/12/14 - 12/01/15 19 3,327 869
Raub 26/12/14 - 28/12/14 16 668 200
Rompin 23/12/14 - 11/01/15 6 471 122
Bentong 10/01/15 - 12/01/15 2 101 20
Cameron
- 0 0 0
Highlands
Total 403 98,345 23,205
Source: KPAS, JKNP (2015)
Table 3.1 shows the data Flood Evacuation Centres, the number of flood victims
and families affected by flooding (Dec 2014 ~ Jan 2015) in the entire district of
Pahang. The number of victims in the District of Kuantan is higher as the result
of the first wave (1678 victims) and the second wave (21871 victims) flooding.
The number of victims in Temerloh district recorded the highest of 39,283
victims and 7,793 family involved with flooding.
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Data on The Status Of Food Handlers
Table 3.2 Data Status of food handlers who attended training and get
vaccination of anti typhoid
District
Food Handlers
Who Attended
Training
Pre Flooding
(Oct.-
Nov.2014)
Vaccination
During
Flooding
The Total of
food
handlers
who get
Vaccination
Kuantan 112 95 38 133
Temerloh 60 0 392 392
Pekan 217 191 23 214
Maran 35 0 71 71
Lipis 23 5 0 5
Jerantut 10 0 52 52
Bera 30 30 69 99
Raub 0 0 0 0
Rompin 0 13 28 41
Bentong 117 7 16 23
Cameron
0 18 0 18
Highlands
Total 604 359 689 1048
Source: BKKM, JKNP (2015)
A total of 604 food handlers who have attended the training of food safety
during floods and the amount present only 359 of food handlers who have
obtained a vaccination of anti typhoid during October – November 2014 and the
remainder have got vaccination of typhoid previous year.
The Trend Of Food Safety In Flood Evacuation (PPB) And Food
Premises
A total of 403 flood evacuation centre was inspected by focusing on the
suitability of the food preparation area in the PPB. Inspection shows 50%
(201) PPB who inspected and does not have a suitable cooking area. All the
413 of food preparation area in PPB were inspected on a daily basis during the
flood. Results showed 69% (285) food preparation area is in satisfactory
hygiene and cleanliness with a score of 70% to 95%. All of 413 PPB requires
immediate corrective action and no food contamination complaints received
during the period of inspection.
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Table 3.3: The Level OfCleanliness In Food Preparation Areas, Evacuation Of
Flood Centre During The Flood
No No Food
Cleanliness
PPB Preparation
area in ppb
Satisfactory Require
Immediate
Corrective
Action
Food
Complaint
403 413 285 413 0
Source: BKKM, JKNP (2015)
Safety
In view of the post flood activity, a total of 122 hypermarket/super markets,
183-premises restaurants/eateries, 119 food stalls and 88 canteen/kitchen
school hostel and 7 manufacturing establishment have inspected (Refer Table
3.4). The results show a 40% (205) of the premises involved in the flood
operation without undergoing the process of adequate sanitation. A total of 3
factories operate with marks ranging from 79.55% to 89.40%, with 3 were not
yet in operation and 1 were forced to closed down due to unhygienic practices.
Table 3.4: Number of Food Premises Inspected in Post Flood Activities
District
Restaurants/
Eateries
Food
Stalls
School
Canteens
/ Kitchen
Hostel
Super
Market/Hypermarket
Kuantan 74 63 0 41
Temerloh 59 37 18 14
Pekan 25 0 5 4
Maran 13 14 3 21
Lipis 6 1 5 4
Jerantut 3 2 50 29
Bera 3 0 7 9
Raub - - - -
Rompin 0 2 0 0
Bentong - - - -
Cameron - - - -
Highlands
JUMLAH 183 119 88 122
Source: BKKM, JKNP (2015)
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The Trend of Food Product Safety Compliance on-Food Premises/Food
Outlet
Table 3.5 Status of Food Premises Inspection
District Food Service Outlet
Remarks
Inspected
Kuantan 41 4 premises selling products that are
drowned out by flood water, dents,
rusty and damaged
Temerloh 14 7 premises selling products that are
drowned out by flood water, dents,
rusty and damaged
Maran 21 1 premises selling products that are
drowned out by flood water, dents,
rusty and damaged
Lipis 4 Satisfactory
Jerantut 29 13 premises selling products that
are drowned out by flood water,
dents, rusty and damaged
Bera 9 All premises selling products that
are drowned out by flood water,
dents, rusty and damaged
Based on Table 3.5 above, a total of 7 districts were affected by floods,
inspection on the premises of the supermarket were done. From the inspection
of 10% supermarkets in Kuantan, 30% supermarkets in Jerantut, 100%
supermarkets in Bera, 5% Maran's supermarket and 50% supermarket in
Temerloh sell products that are drowned out by flood water, dents, rusty and
damaged. For the District of Lipis and Pekan, there is non-compliance found.
Investigation of Food Poisoning Episode
There are a total of 5 episodes of food poisoning occurred in flood evacuation in
2014/2015 with two cases in the District of Kuantan, one case in Jerantut, and
2 cases in Temerloh district. The major cause of the food poisoning is the
unhygienic food handling practices, lack of food safety awareness and also
cross-contamination of food occurs from equipment, food handler and the
environment. The suspected food caused food poisoning are not available from
flood evacuation but supplied from public.
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4.0 DISCUSSION
Inspection of the storage depot were carried out by health team of the District
Health Office in their respective districts prior to the event of flood disaster
based on data obtained from Welfare Department. Based on the inspection, by
17% storage depot in Temerloh district have pest control problems and 100%
storage depot in the District of Lipis encountered pest control problem. Pests
that are found are as cockroaches, flies and rats. The presence of pests can
cause contamination of the food stored in the place. Foods that have been
contaminated should not be distributed to flood evacuation centre as can cause
food poisoning if ingested.
Around 63% of the storage depot in the District of Rompin cannot be inspected
due to vehicle and weather problems. The selection of the storage depot should
take into consideration the safety of the food stored and the suitability of the
place for the assessment of health team.
A total of 403 that have been declared as a Flood Evacuation Center throughout
the State of Pahang and 413 again is the food preparation area for flood
victims. Some PPB is not gazetted by the NSC and JKM, as at the mosque which
accommodated flood victims. Food handlers are persons who carry out the
preparation of food from raw materials to the final food products. The main
requirements must have the food safety awareness training and vaccination
with anti-typhoid in order to avoid the occurrence of food poisoning. Therefore,
before the flood occurs every PPB has identified individuals who will be involved
to handle food have been briefed about food safety and anti-typhoid
vaccination prior to flooding. A total of 604 people who have attended the
training and 359 people food handlers who have vaccinated throughout the
months of October-November 2014 and the rest of the operators have received
vaccination in the previous year. Increase number in food handler were due to
several factors, namely food handlers who were present before the floods were
unlikely to be able to carry out food preparation as they were the flood victim
as well.
The most basic aspect of lacking was the absence of special raw material
storage, cooking utensils has not been fully equipped and garbage disposal
facilities that have not been prepare by the local authorities. This article shows
the flood preparedness in terms of food safety less taken weight and show the
cause of pollution or damage to the food is expected to occur during the flood
hit.
The status of food safety in the PPB which is assessed on a daily basis
expressed in scoring basis that takes into account the elements of food quality,
food handlers, equipment, water supply, waste management, pest infestation,
hand washing facilities and toilet facilities.
Availability of preparation and sale of food premises operating without
completely sanitized demonstrate food operators are only concerned itself
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merely profit without caring the safety of consumers. Mindful of this status, the
health authorities have taken appropriate action in making referrals corrective
action and close to the owner of the premises to protect people from
experiencing harm as a result of food contamination.
A total of 7 districts in the State that were affected by flooding, inspection on
the premises of the supermarket were done accordingly. From the inspection,
30% supermarkets from 5 districts namelyKuantan, Jerantut, Temerloh, Maran
andBera, sell food products flooded, dents, rusty and damaged. For the District
of Lipis and Pekan, there is non-compliance found. For Bera, all the
supermarkets inspected selling unsafe food products. Supermarkets were found
selling food products unsafe for consumption have been directed to move such
food products from the shelves and dispose immediately.
Some food products damaged could not be identified by health personnel
during the inspection as the product have been washed and cleaned. Huge
number of supermarkets affected cannot be inspected effectively due to the
lack of health personnel. Some supermarkets also refused to give cooperation
to the health personnel during inspections due to the loss arise.
Investigation of food poisoning Episode
1) Outbreak of food poisoning has occurred on 26 Dec 2014 @ 6.30 pm at
WismaBelia, Kuantan, where the suspected food is porridge, which is suspected
not prepare from the relief centre but supplied by the public. Suspected
organisms Bacillus cereus toxin diarrheal type due to long incubation period,
signs and symptoms of lower GIT. A total of 14 cases were registered suffering
from vomiting and diarrhoea. The cause maybe due to long holding time as
some victims was found taken meal after more than 4 hours without heating
the food in advance.
2) Food poisoning outbreaks also occurred on 27 Dec 2014@9.30 am at the
SUKPA, Kuantan flood evacuation. The suspected food is Milo drink which is
again not been prepares from the PPB. The supplied of Milo drink by the public
may have prepared in advance before distributed to the flood victims. Not all
flood victims affected as the limited supply of Milo drink. The suspected
organisms Bacillus cereus emetic type toxin due to a short incubation period,
signs and symptoms of upper GIT. Most cases said that the Milo turned stale. A
total of 13 cases were registered suffering from vomiting.
3) Incidence of food poisoning occurred in flood evacuation centre Advance
Technology Training Centre (ADTEC), Jerantut was caused by Bacillus cereus
"diarrheal type" based on the main sign and the incubation period. A total of 22
cases with 4% attack rate involving adults have been registered as suffering
from abdominal pain, diarrheal, vomiting, nausea and fever. The onset time is
between 5-6 hours after eating fried vermicelli from SMK Temin. The suspected
food had more than 4 hours holding time after cooked.
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4) Food poisoning incident involving 20 people flood victims in the evacuation
center at SRJK Tamil Mentakab with attack rate of 3.15% after taking dinner on
29 Dec 2014. All the flood victims who are suffering from symptoms and signs
such as vomiting and/or diarrhoea and/or abdominal pain, after taking a meal
in the Flood Evacuation SRJK Tamil Mentakab. Suspected etiology agent Bacillus
Cereus emetic toxin that has been polluted the fried rice. The fried rice was
suspected undercooked as it cooked in bulk in limited resources like cooking
utensil and stove.
5) Food poisoning incident involving 19 people flood victims in JPAM Temerloh
with the attacks rate of 19% after taking dinner on 31 Dec 2014. The suspected
agent Staphylococcus aureus infections that have been polluted canned sardine
during serving time. The possibility occurs due to unhygienic practice of the
rescue team taken the meal without proper hand washing practices after
carrying out rescue operations flood victims, causing cross contamination
occurred.
The challenges of Flooding (Dec 2014 ~ Jan 2015)
Flooding Management (Dec 2014 ~ Jan 2015) especially in the aspect of food
safety face several challenges and limitations in carrying out its duties in the
field. Before the flood, the health team inspected on PPB selected and taking
into consideration food safety element to be in place in cooking preparation,
water supply and cross-contamination factor that can occur and to suggest
improvements and yet the decision are under the local authority. During the
flooding, there is a flood evacuation centre that is not enacted before the flood
and is used as a food preparation Centre with the lack of facilities such as water
supply, and equipment.
In addition, the Welfare Department was found less cooperate with the
Secretariat PPB in controlling the receiving of ready to eat food or raw material
donated by NGO. This makes it difficult for the process of food traceability in
the event of identify food hazard during food poisoning occurs. During the
preparation of food, volunteers involved with cooking are not competent to
cook in bulk resulting in undercooked food.
The leftover food is always brought to the next menu and food eaten after 4
hours contributed to factors of food poisoning. In addition, low awareness of
flood victims in practicing good personal hygiene before meals led to the risk of
cross-contamination occurred. In addition, the lack of human resources in the
health team during the floods makes it difficult for monitoring food safety in
PPB due to flood. For inspection of food preparation premises after flood, the
main challenge is the trader who initiates the operation although the
sanitization job not yet fully in place. There is also an incident whereby the
usage of damaged or spoilt raw materials from some irresponsible outlets
owner to reduce the loss after flood.
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5.0 CONCLUSION
Following the floods experienced in December 2014 to January 2015, it has
inspiring to the health department to continually improvement in flood
management. Although, flood management has been implemented to help the
victims involved in this incident, but the team will continue to improve the
existing systems, especially in terms of food safety. Before the floods, health
personnel in particular in Food Safety And Quality Division collecting data base
on conducted inspection of storage depot to ensure the food product to be kept
safe from pests.
While flooding has not occurred, all district health offices have taken the
initiative in collecting data on food operatorsas well as conducted briefing on
food safety issues and vaccination of anti typhoid. The health team has worked
hard during the floods in checking food preparation area in PPB to ensure food
safety is in place. The health team also conducts inspections of food premises
affected by the flooding. This is because there are more than 100 food
premises and food outlets affected by the floods. During the recent floods,
there are five (5) episodes of food poisoning throughout the state. Low level of
food safety awareness among flood victims and traceabilityof raw material and
ready to eat food is yet to be implemented. There are a few suggestions to be
improvednamely coordination of issues arising in relation to food safety during
the meeting inter- agencies such as National Security Council, Social Welfare
Department and the Local Authority. Preparation of high risk food menu in PPB
without proper cold storage facilities exist due to lack of electricity. For food
preparation, cooking area size is not in line with the capacity residing PPB. Food
donations by NGOS are not monitored by the Coordinator/secretariat of the PPB
(Zulhafiz et. al, 2013).
In addition, waste management was found ineffective due to negligence of
Alam Flora. During the inspection in food preparation, food handler difficult to
be advised as the disaster happening with limited recourses. In view of
KOSPEN program, module ‘Food Safety Awareness’ was suggested to be
absorbed to provide precautionduringand after flooding to the community.
Health education shall be disseminated to the general public through
broadcasting radio, television, newspaper, billboard and banner needs to be
carried out before the flooding and in accordance with the Malaysian
Meteorological Department.
148

REFERENCES
1. Arahan Majlis Keselamatan Negara (MKN) No. 20.
http://portalbencana.mkn.gov.my/FileRepository/Portal/20150109-
16012516.pdf
2. Artikel Langkah-langkah Keselamatan dan Kesihatan.
http://www.moh.gov.my/autodownload/LANGKAH-LANGKAHKESELAMATAN
DAN KESIHATAN .pdf
3. Bahagian Keselamatan dan Kualiti Makanan, Jabatan Kesihatan Negeri Pahang.
Reten-Reten Pemeriksaan PPB, Status Pengendal iMakanan, Premis Makanan
dan Outlet Makanan
4. Daud Abdul Rahim, Thayalan Ramadas, Farhatun Najmi. (2007) Food Safety
Issues in Recent Flood 2006-2007
5. Mohd Zulhafiz Said, Salfarina Abdul Gapor, Mohd Nazri Samian, Abd Malik Abd
Aziz.(2013). Konflik di pusat pemindahan banjir: Kajian Kes di Daerah Padang
Terap, Kedah. Journal of Society and Space 9 issue 1 (61 - 69) 61
6. Muhd. Barzani Gasim, Salmijah Surif, Mazlin Mokhtar Mohd Ekhwan Hj
Toriman, Sahibin Abd. Rahim, Chong Huei Bee (2010) Analisis banjir Disember
2006: Tumpuan di Kawasan Bandar Segamat, Johor. Sains Malaysiana39(3),
353-361.
7. Nan Zul. Artikel Banjir Besar di Pahang (Tradisi Persejarahan Pahang Daru
lMakmur 1800-1930) http://lipis-zaini.blogspot.com/2013/12/banjir-besar-dipahang.html.
8 Disember 2013.
8. Nizam Yatim. Artikel Mengimbau Banjir Besar 1927 & 197,
(http://ww1.utusan.com.my/utusan/info.asp. 15/01/2007)
9. Pengurusan Bantuan dan Bencana oleh JKM
http://www.jkm.gov.my/content.php?pagename=pengurusan_bantuan_dan_b
encana_jkm&lang=bm
10. Unit Kesihatan dan Pekerjaan (KPAS), Jabatan Kesihatan Negeri Pahang. Reten
– Reten Banjir 2014-2015
149

ARTICLE 12
REVISED AND UPDATED DISASTER PREPAREDNESS
PLAN FOR PREVENTION OF FOOD AND WATER
BORNE DISEASE IN FLOOD RELIEF CENTRES
‘KUANTAN MASSIVE FLOOD 2014’:
LESSONS LEARNED
Shahdattul Dewi Nur Khairitza, T., Poornima, K., Mariah, A.,
Noor Azurah, W.C., Ahmad Zulfadli, M.N., Amirullah, A.
150

REVISED AND UPDATED DISASTER PREPAREDNESS PLAN
FOR PREVENTION OF FOOD AND WATER BORNE DISEASE
IN FLOOD RELIEF CENTRES- ‘KUANTAN MASSIVE FLOOD
2014’ LESSONS LEARNED
Shahdattul Dewi Nur Khairitza, T., Poornima, K., Mariah, A., Noor
Azurah, W.C., Ahmad Zulfadli, M.N., Amirullah, A.
ACKNOWLEDGEMENT
We would like to express our gratitude to Pahang State Health Director for the
support of this research. We also like to thank all the staff in Kuantan District
Health Office for their support, cooperation and encouragement.
ABSTRACT
Introduction:
Foodborne disease is defined as conditions that are commonly transmitted
through ingested food caused by enteric pathogens, parasites, chemical
contaminants and bio toxins. Kuantan district had seasonal flood every year due
to north-east monsoon. Immediately after flood, action plan for prevention of
foodborne and water borne diseases is the upmost important
Purposed:
The objective of this paper is to describe the updated and revised plan on
prevention of foodborne diseases by Kuantan District Health Office, lesson
learned after the occurrences of two outbreaks of food poisoning at flood relief
centres at the end of last year
Methodology:
Formulation of new plan of action was carried out based on three phases.
Phase one is to identified the predisposing factors contributed to the outbreak
occurrences. Second phase is to study the available plan in order to detect the
limitations and weaknesses. Third phase is to come out with a revised and
updated plan of action that able to anticipate the problems identified.
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Findings:
From the three phases brainstorming sessions, it was decided that the plan of
action to anticipate this problems will concentrate on three elements; strict
supervision on all foods and beverages contributed by third parties,
strengthening the education and practise on restriction of food holding time and
introduction of the module on ‘Lihat (See), Hidu (Smell) dan Rasa (Taste)’ for
all occupants at the flood relief centres.
Conclusions:
This revised and updated plan of actions is a guide for us to develop new
strategy and implement a wide range of actions and interventions for
prevention of foodborne disease post flood. These actions and interventions will
be evaluated later to assess the impact of these activities and helped us to
shape for a better strategy.
Keywords: foodborne disease, outbreak, flood, action plan, review articles,
flood relief center.
INTRODUCTION
Foodborne disease is defined by the World Health Organization (WHO)
as conditions that are commonly transmitted through ingested food caused by
enteric pathogens, parasites, chemical contaminants and biotoxins 1 . Foodborne
disease is a serious and global problem. Even though the majority of cases are
mild, it resulted in absences from the education or the workplace. However,
most foodborne disease go undiagnosed and unreported, either because the ill
person does not see a doctor, or the doctor does not make a specific
diagnosis 2 .
Foodborne disease place significant demand and imposes a significant
burden on affected individuals and the economy. Occasionally, it can lead to
serious or long term conditions or even death. The WHO estimates that
worldwide foodborne and waterborne diarrhoeal diseases taken together
causing about 2.2 million mortality per year and 1.9 million of them were
children 3. Outbreaks of foodborne disease caused devastating health and
economic consequences in both developed and developing countries. It could
hamper the achievement of Millennium Development Goals 1 which is to
eradicate extreme poverty and hunger, and Millennium Development Goals 4
which is to reduce child mortality 4 .
Foodborne disease can originate from a wide variety of different foods
and be caused by many different pathogens. The food can be contaminated by
pathogens at different points in the food production and food preparation
process, between farm and fork. Raw foods of animal origin are the most
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frequently associated with foodborne illness. These include meat, fish,
poultryraw eggs, unpasteurized milk and raw shellfish 2 .
Natural disasters can occur in any country. Sometimes it is not the event
itself but the aftermath that harms more lives. Frequent fallouts of flood are
food, water and vector borne diseases.
Immediately after flood, action plan for prevention of foodborne and
water borne diseases is the upmost important. Flood water can be
contaminated with sewage, animal waste and other waste from drains or the
surrounding area. It could be contaminated with harmful bacteria or chemicals.
Poor sanitation, lack of safe water, improper toilet facilities and mass cooking
carried out at flood relief centres all can contribute to mass outbreak of
foodborne disease 5 . It is vital to detect food borne disease outbreaks as early
as possible in order to limit their spread.
The strategy for reducing food borne diseases at the flood relief centres
is by promoting a hazard analysis-based approach to food safety management.
This will provide guidance for producers, retailers, caterers and the general
public. This is the upmost important for prevention of outbreaks of food borne
disease.
In the end of year 2013, Kuantan had massive flood due to heavy rain
from the annual north-east monsoon falling continuously for few days and
worsened by the rise of sea level. This massive flood began to hit multiple
states which Pahang, Kelantan, Johor and Terengganu were mainly affected.
Pahang was the most affected state with some of its peripheral regions such as
Kuantan and Rompin were heavily inundated by flood water. However, since
the flooding is a seasonal issue, the Pahang State Health Department and
Kuantan District Health Office, is all ever ready. The Action Plan for Flood
Management was all prepared. The plan was generally divided into three
categories; pre-flood, during flood and post flood management. In term of
foodborne diseases, it was a victory. Through all actions planned and
implemented pre, during and post flood, no food disease outbreak was reported
during this time.
However, in the end of year 2014, Kuantan had another episode of
seasonal flood. This time, it affected all the three states in East Coast. Kelantan
was the most affected. For Pahang, again it caused massive flood in Kuantan.
Even though in term of magnitude of severity, it was less massive as compared
to 2013. But the suffering and the lost was all equivalent.
However, what followed immediately after these events was unexpected.
Despite of aggressive effort to curb foodborne diseases in flood affected areas
and in the flood relief centres, unexpectedly it occurred. This time, it happened
in two flood relief centres.
The first food outbreak happened in Wisma Belia, one of the flood relief
centres that occupied 652 flood victims. This outbreak involved 14 victims that
experienced vomiting, abdominal pain and diarrhoea. All victims were children
aged five to twelve years old. All were treated as outpatients.
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The second food outbreak happened in SUKPA (Sukan Pahang) Stadium,
one of the flood relief centres that occupied 1972 flood victims. This outbreak
involved 13 victims that experienced vomiting. The victims involved were six
children aged below 12 years old and seven adults. All were treated as
outpatients. Based on the symptoms and incubation period, it was postulated
that the pathogenic organism involved was Bacillus cereus ‘emetic type’.
For the first outbreak, investigation revealed that the contributor had
sent about 100 packs of rice porridge with crab-meat. They distributed the
porridge to 100 families, when each family received one pack. The priority to
distribute this porridge was for children. That explained why all the victims were
children. However we cannot conclude accurately about total number of those
that consumed and total number of those that falling sick. This was because
most of the occupants already went back to their home when this outbreak was
investigated.
From the investigations for the second outbreak, we’ve discovered that
during the outbreak, the contributor had sent two containers of chocolate malt
drink. Fortunately, not everybody in the relief centres consumed it because it
was very limited. Again, we cannot captured the total number of people who
had consumed it since when people started having symptoms, most the
occupants at the relief centres went back to their home already. However, most
of the victims admitted that they noticed that the drink tasted awful.
The first food outbreak caused by consumption of rice porridge. While
the second outbreak caused by consumption of chocolate malt drink. Even
though it was not supported neither by any laboratory findings nor statistical
investigations, the presumption was made based on thefindings that among
those symptomatic, all had history of consuming the suspected food and drink.
In an ideal situation, a case control or cohort study will be carried out if
the exposed and non exposed population can be identified. Following a
statistical test, a presumption can be made about the most likely food item
causing an outbreak. This will be supported by laboratory findings on food
sample analysis, history from those exposed and investigation findings on food
handlers.
These two outbreaks, both shared similar history when the culprit
(affected food and drink) actually were prepared by the third parties. The third
parties here were the NGOs and other contributors.
The objective of this paper is to describe the updated and revised plan
on prevention of food borne diseases by Kuantan District Health Office, lesson
learned after the occurrences of two outbreak of food poisoning at flood relief
centres at the end of last year.
METHODOLOGY
Formulation of new plan of action for prevention of foodborne diseases
in flood relief centres was carried out based on few steps. A committee was
established and lead by District Health Officer. Those involved included Health
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Epidemiologist Officer, Food Technology Officer, Inspectorate Officers and
Health Education Officer. Only few people related to this matter were involved
to ensure that this committee had content planning meetings. All members
understand their collective purpose to ensure the objectives can be obtained.
A few meetings were conducted. It can be divided into few phases. First
phase is a post mortem phase. The objective of this phase is to identified the
predisposing factors contributed to the outbreak occurrences. Second phase is
to study the available plan in order to detect the limitations and weaknesses.
Third phase is to come out with a revised and updated plan of action that able
to anticipate the problems identified.
The first phase was conducted through initial meeting to identified
factors predisposed to the occurrences of outbreak at flood relief centres. All
possible predisposing factors were listed. For each predisposing factor, we
matched with the possible intervention in the initial plan of action that can be
used to prevent it. Based on this findings, we decided what was lacked in the
initial plan.
The predisposing factors for this outbreak can be divided into four: Flood
victims, Food handlers, Health Personnel and Third parties or the NGOs.
Possible Predisposing Factors
Flood Victims
1. Lack of knowledge, attitude &
practise
Food handlers
1. Lack of knowledge, attitude &
practise
Food materials
Health Personnel
NGOs
1. Lack of training
2. Lack of equipment
3. Inavailability of guidelines
4. Lack of Enforcement Activities
Possible Intervention Available in The Initial
Disaster Preparedness Plan For Prevention of
Food and water borne Disease
Promotion on food safety pre, during and post
flood through mass media, buntings, banners,
posters and pamphlets.
Food safety briefings, anti typhoid
vaccinations.
Food suppliers inspection
Update & refresher course, availability of
inspection equipment, Availability of guidelines
and Standard Operative Procedures (SOP),
Enforcement Activities pre-, during and post
flood.
Not available
1. Lack of knowledge, attitude &
practise
For the second phase, the initialDisaster Preparedness Plan For
Prevention of Food and water borne Disease was studied. Listed below were
intensive and integrated control activities and food hygiene surveillance being
carried out by Kuantan District Health Office to minimize the impact of flood for
food borne diseases in flood related areas and in flood relief centres.
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Table 1: The Initial Disaster Preparedness Plan For Prevention of Food and
water borne Disease In Flood Relief Centers In Kuantan
No.
A
Plan of Actions
Pre flood
1. Promotion Activities on Food Safety
Health education to public through radio, television, newspaper, billboard
and banner.
Creating pictorial posters and buntings to educate public on food hygiene
and food safety.
Educating public on ‘3 langkah kenali makanan: Lihat (See), Hidu (Smell),
Rasa (Taste)’.
2 Food handlers at flood relief centres
To update data on number food handlers already attended briefing on
food safety.
To update data on number of food handlers received anti-typhoid
vaccine.
Data verification on food handlers from other agencies and volunteers.
To conduct training activities on food safety and anti typhoid vaccination
for food handlers from agencies.
To conduct routine inspection at flood relief centres and list of premises
that being gazetted by the Welfare Department as food supplier for flood
relief centres eg. groceries shops, caterers.
3 To update and refresh health team on knowledge in food safety and plan of
action
To conduct refreshment training on food safety including ‘Health Risk
Assessment Method in Food Preparation Area in Flood Relief Centres’.
To provide inspection kit for health team.
4 To ensure availability of proper equipment for food safety assessment.
To check the availability of equipment for the inspection kit eg.
thermometer (infrared/probe), torch light and camera.
To purchase the inadequate equipment
To coordinate the distribution of the inspection kit.
B. During flood
1 To conduct inspection and supervision activities on cleanliness and safety of the
place, equipment and food handlers.
Inspection among food handlers for health status, anti typhoid
vaccination and hygiene practises.
Inspection on food preparation areas and equipment.
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To obtained menu for each meal and to ensure that holding time does
not exceed 4 hours.
To act immediately on all sub standards detected during inspection and
supervision.
To act immediately on all complaints received about food safety.
Inspection of stocks on food supply eg. expiry date, physical appearance
and evidence of ‘LILATI’ (Lipas, Lalat dan Tikus @ Coakroaches, Flies and
Rats).
Monitoring of domestic waste disposal.
To ensure no direct flow of domestic waste and wastewater to the drain.
2. Health education to occupants at flood relief centres
Health education to occupants at flood relief centres on food hygiene and
food safety.
Distribution of posters and pamphlets on food safety.
3. Monitoring on the occurrence of communicable diseases in flood relief centres
To investigate all Acute Gastroenteritis and food poisoning cases.
4. Supervision on all food premises in flood affected areas
To identify and supervise all food premises exist temporarily during flood.
To conduct health risk assessment to all food premises that still operating
during flood especially factory and food stalls.
C. Post flood
1 To enforce the compliance on law and regulations
Inspection on food factories and food premises.
To conduct re-inspection on all food premises with first rating less than
65%.
Inspection on hypermarket, mini market and grocery shops.
2. To ensure all food premises affected flood conducting all necessaries steps
before restarting operation.
To distribute fliers and pamphlets on procedures on how to clean food
premises and how to clean all food preparation equipment in all flood
affected premises.
To provide consultancy services on food safety for flood affected
premises.
Health promotion through fliers and radio announcement on
management of food affected flood (canned food, food in refrigerators
with disruption of power supply and food that has flooded).
3. To ensure the safety of ready-cooked food in food premises.
To conduct random sampling for ready-cooked food in food premises
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affected flood.
To ensure all food premises in flood affected area use safe water supply.
4. To ensure the occurrence of Acute Gastroenteritis is beyond control.
To investigate and to analyze all AGE cases.
To conduct food premises inspection and rating.
5. Complain Management
To conduct investigation for every complaint received on food hygiene
and food safety.
6. Post Mortem
To conduct post-flood post mortem to identify weaknesses and problems
All committee members had content brainstorming session by thoroughly
reviewed the initial plan, detected all the shortfalls and made wise decisions
about the possible interventions to anticipate this problems.
For the third phase, few guidelines and SOP were studied and reviewed
as a guidance such as from the World Health Organization (WHO), Pan
American Health Organization (PAHO), United States Centers of Disease Control
and Prevention (U.S. CDC) and few scholar articles. Following these few
meetings, we had revised our plan of action in the management of prevention
of food borne diseases following flood. Using a strategic, organized and forward
thinking, the committee came out with few resolutions to this matter.
FINDINGS
Listed below is the updated, intensive and integrated action plan to curb
foodborne disease in flood relief centres by PKD Kuantan specifically to cater
the above problems identified.
Table 2: Revised and Updated Disaster Preparedness Plan For Prevention of
Food and water borne Disease
No.
A
Plan of Actions
Pre flood
1. Creating promotion kit on food safety specifically on module ‘Lihat (See), Hidu
(Smell) dan Rasa (Taste)’.
2. Public announcement on food safety including the ‘3 langkah kenali makanan:
Lihat, Hidu, Rasa’ through radio, television, newspaper and billboard.
3. Creating pictorial posters and buntings to educate public on food safety
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especially on ‘3 langkah kenali makanan: Lihat, Hidu, Rasa’.
B
During flood
1. Supervision on all food and beverages contributed by third parties
2. Supervision on occupants at the relief centres regarding holding time for each
food and beverages received.
3. Re-strengthened on the usage of technique on ‘3 langkah kenali makanan: Lihat,
Hidu, Rasa’ for all occupants at the flood relief centres especially children.
4. To distribute pamphlets and bunting on food hygiene and safety especially on ‘3
langkah kenali makanan: Lihat, Hidu, Rasa’ to all flood relief centres.
The revised and updated plans of actionare concentrating on three major
elements. The first element is to supervise and monitor all foods and beverages
contributed by third parties. The second element is to anticipate longer ‘holding
time’ before foods and beverages are consumed. The third element is using the
module ‘Lihat, Hidu dan Rasa’.
The first and second elements in the revised and updated plan are very
familiar to us. For the third element, it is an added value to the basic concept
that being practise before.
DISCUSSION
Even though the occurrence of these two outbreaks had very minimal
impact since only 27 people involved, all had mild symptoms and were treated
as outpatients. However, it is an an indication that something needs to be
improved in the food safety system in the flood relief centres.
The objective of the investigations carried out by PKD Kuantan was to
control the outbreak and also to learn how similar outbreaks can be prevented
in the future. Initially, emergency action is needed to keep the immediate
danger from spreading. Next, a detailed objective scientific investigation is
needed to learn what went wrong, so that future similar events can be
prevented. Later, is to revise and update the available action plan to strengthen
all the weaknesses identified.
When all the food preparation at the food relief centres were closely
being supervised and monitored, there was one aspect in prevention on food
borne disease in flood relief centres was missed. The monitoring of food and
drinks contributed by third parties or NGOs.
Even though, the experienced of having two outbreaks in two flood relief
centres within 24 hours was the most frustrating after all efforts concerted
159

towards prevention of food borne diseases. There was ‘pain’, but it followed by
‘gain’. Again, the lesson learned.
The revised and updated plans of actionare concentrating on three major
elements. The first element is to supervise and monitor all foods and beverages
contributed by third parties. A specific guidelines on monitoring foods and
beverages contributed by third parties is the most important aspect for the first
element. A registration system will be developedto record all food and
beverages received from the third parties or NGOs. This registration system will
act as a gatekeeper to ensure all the food and beverages distributed to the
people in the flood relief centres are in good condition. This registration system
also can facilitate investigation of outbreak if it happened. All the third parties
and NGOs will be train regarding food safety practices.
The second element is to anticipate longer ‘holding time’ before foods
and beverages are consumed. All staffs who inchargedof food distribution at the
flood relief centres should be given training on food safety practices and
general requirement. They must have knowledge to identify potentially
hazardous foods that have a higher probability forrapid growth of diseasecausing
bacteria and lead to foodborne illnesses.
The third element is using the module ‘Lihat (See), Hidu (smell) dan
Rasa (Taste)’. It is a basic concept that should be taught to all occupants in the
flood relief centres. This module had already been widely spread previously
especially among students, nevertheless the awareness of importance of this
concept is still lack among Malaysian citizen. The main objective for this module
is to educate people especially children on the 3 steps in order to recognize
food that had been contaminated. Those steps include the 3 main senses, eyes
for observing (lihat), nose for smelling (hidu) and tongue for tasting (rasa).
The first step is to observe. The occupants should be taught to observe
their food carefully before consuming it. Firstly, look if there are any changes in
the colour or texture of the foods. For canned or processed food, the expiry
date must be observe first. Any defect of the can or plastic wrapper itself such
as any tear, or distorted can must be identified.
Not just the foods per se, the hygiene status of the food handlers or
contributors should be well observed by the occupants. We also should
educate them to observe the relief centres they occupied. They have to ensure
the places are free from any sources of infections or vectors such as rats,
cockroaches or flies and the foods are properly covered. Even though we have
dedicated team from district health office to monitor the relief centres, to get
them involve is important.
The next step is to smell. Foods that smell awful or bad should not be
consumed by the victims because that may also indicated the food had already
been contaminated.
The last step, to taste is also vital. Detect if there are any changes in the
taste of the foods. Awful foods should be discarded straight away.
160

CONCLUSION
Following this revised and updated plan of actions, we will develop new
strategy and implement a wide range of actions and interventions. However, to
ensure the successfulness of this action plan, it needs continuous close
communication and collaboration with stakeholders as well as other relevant
agencies and NGO’s. Since flood is an annual seasonal issue in Kuantan district,
meticulous plan of action is mandatory to prevent food borne disease post
flood. Later, this wide range of actions and interventions will be evaluated to
assess the impact of these activities and helped us to shape for a better
strategy.
REFERENCES
1. World Health Organization (2007). WHO Initiative to Estimate the Global
Burden of Foodborne Diseases. First formal meeting of the Foodborne
Disease Burden Epidemiology Reference Group (FERG) 2007. Geneva.
2. Communicable Disease Centre. Food borne Illness, Foodborne Disease.
(2014).(cited 2 Mei 2015). Available from:
http://www.cdc.gov/foodsafety/facts.html.
3. World Health Organization (2010). Food Safety Report by The
Secretariat.
4. United Nations. Millenium Development Goals and Beyond 2015 (2015).
(cited : 1 Mei 2015). Available from : www.un.org.
5. International Food Safety Authorities Network . Food Safety In Natural
Disasters 2005 (2015)( cited : 1 Mei 2015). Available from
www.paho.org.
161

ARTICLE 13
READY FOR FLOODS IN PEKAN 2014-2015:
SHARING OF EXPERIENCES
Siti Zubaidah AR 1 , Mohd Rahim S 2 , Daud O 3 , FadillaNorli M 4 ,
Faridah J 5 .
162

Ready for floods in Pekan 2014-2015:
Sharing of experiences
SitiZubaidah AR 1 , Mohd Rahim S 2 , Daud O 3 , FadillaNorli M 4 ,
Faridah J 5 .
Pekan District Health Department
Acknowledgement
We would like to thank the Director of Pahang Health State Department,
Director of Pekan Hospital, staffs from Pekan Health District Office and all
agencies who have been directly or indirectly involved in this study.
Abstract
Background: Flood is an annual awaited event in Pekan due to its unique
geographical location at the estuary of Pahang River and the fact that it is 100
percent wetlands. Owing to that, Pekan was recognized for its vigilance and
quick response in the disaster which evidently led toalmost zero interruption in
the delivery of services neither in the hospital nor at the community clinics. This
paper is aimed to share our valuable experiences in preparing for floods at our
vicinity; commonly triggered by Northeast monsoon which occurs from
November to March each year.
Method: This is a descriptive review using both quantitative and qualitative
approaches. These include direct observation, focus group discussion among
organizations involved during the floods, key informants and data gathered
both from hospital and health district office. Literature reviewsusing
established data and published reports were also used to support the study.
Results: Main findings from our observational study are:
i) The importance of setting up a functional networking system to
ensure effective communication during disaster (committee/ flood
operation room/ systems)
ii)
iii)
Role of medical and health teams as front liner in delivering services
Haemodialysis service: a highlight on the importance of early problem
recognition and prompt action during floods
Conclusion: Experience over the years has benefited Pekan in many ways.
Despite the adverse situation, good planning and cohesive team work has
shown that quality health services could still be successfully delivered to the
163

needy. In conclusion it is vital for us to be prepared, structured and proactive in
handling disasters to ensure minimized losses and to optimize the services
given.
Keywords: Flood, Rapid Response Team, Preparedness, Pekan District
Introduction
Pekan is a well-known royal town in Pahang, Malaysia. It is located
about 45 km from the capital of Kuantan, near the South China Sea and the
south bank of Pahang River. Pekan covers an area of 3846.14 square
kilometers equal to 385,135 acres. It has 11 sub-districts (mukim) which
areBebar, Temai, Lepar, Kuala Pahang, Langgar, Ganchong Pahang Tua, Pulau
Manis, PulauRusa and Penyor. Bandar Pekan is situated on the banks of Pahang
River; the longest river in peninsular Malaysia which stretches to 477.97km in
length. There is also Parit Sungai and Sungai Air Hitam at the left and right of
the Pekan Baharu area. In general, natural and geological conditions of the
town and surrounding lands are plain that lie flat along Pahang River. The
capacity of the population was approximately 145,000 people consist of
majority Malay followed by Chinese, Indian, Orang Asli and others [1].
Floods are the most common natural disaster in Malaysia and has
affected many areas since 1971, because of that, the government established
the Natural Disaster Management and Relief Committee (NDMRC) in 1972 [2], it
was given the task of coordinating flood relief operations at every stage of
national, state and district level with the combined aims of reducing flood
damage and to preventing loss of human as the main part and role of health
team preparedness in flood management. The directive of the committee also
describes the purpose of responsibilities and determining how the various
agencies should be involved in disaster management.
Flooding takes many forms; from slow onset riverine floods, rapidonset
flash floods, accumulation of rainwater in poorly drained environments,
and coastal floods caused by weather extremes such as cyclones [3]. Floods
which commonly hit Pekan, Pahang are mainly divided into 2 phases; flash
floods and monsoon floods. Flash floods occur due to sudden surge of water
volume following prolonged rain to more than 3 days. It usually subsides within
a short period of time as occured in Sungai Miang and Merchong, areas
southern to Pekan town. The second phase is due to monsoon flooding also
occurred within the specific Northeast monsoon season from November to
March and the Southwest monsoon season that normally begins in May until
August [4]. Among the states affected by the monsoon rains are the east coast
states of Kelantan, Terengganu, Pahang, Sabah and Sarawak. Figure 1 below
outlines areas most commonly affected by floods in the district of Pekan, which
situated alongside the banks of Pahang River.
164

STATISTIC
Figure 1
Affected
Locations
Overflow
of
Sungai
Pahang
Overflow
of creeks
(Anak
Sungai)
Low
Land
(Tanah
Rendah)
63 Localities
12 Localities
10 Localities
Preparedness is defined by United States Department of Homeland Security/
Federal Emergency Management Agency (DHS/ FEMA) as a continuous cycle of
planning, organizing, training, equipping, exercising, evaluating, and taking
corrective action in an effort to ensure effective coordination during incident
response[5]. Disaster preparedness is an initiative that is intended to increase
165

eadiness and knowledge among the various stakeholders regarding the risks,
related agencies, preventive measures and other disaster related information. It
seeks to improve the overall preparedness towards a disaster or at least the
type of disasters that is likely to happen at a particular locality. The phases of
disaster management cycle are described as follows [6]:
Table 1: Phases of Disaster Management Cycle
Pre
disaster
stage
During
disaster
stage
Post
disaster
stage
Methods:
Mitigation
Risk reduction
Prevention
Preparedness
Response
Recovery
Any activity that reduces either the chance of
hazard taking place or a hazard turning into
disaster
Anticipatory measures and actions that seek to
avoid future risks as a result of a disaster
Avoiding a disaster even at the eleventh hour
Plans/ preparations made to save lives or
properties and help the response and rescue
service operations. This phase covers
implementation/ operation, early warning systems
and capacity building so the population will react
appropriately when an early warning is issued
Includes actions taken to save lives and prevent
property damage, and to preserve the
environment during disasters. The response
phase is the implementation of action plans
Includes actions that assist a community to return
to a sense of normalcy after a disaster
The aim of this paper is to share experiences in healthcare management during
floods in Pekan. Among the aspects covered in the study are:
i) The importance of setting up a functional networking system to
ensure effective communication during disaster (committee/ flood
operation room/ systems)
ii)
iii)
Role of medical and health teams as front liner in delivering services
Haemodialysis service: a highlight on the importance of early problem
recognition and prompt action during floods
This is a descriptive review using both quantitative and qualitative approaches.
These include direct observation, focus group discussion among organizations
involved during the floods, key informants and data gathered both from
hospital and health district office. Literature reviews using established data and
published reports were also used to support our study.
166

Results:
The importance of setting up a functional networking system to ensure effective
communication during disaster
Disaster management in Malaysia has three levels and each committee
has its own responsibilities. In level I, the committee ensure coordinated
actions, with sufficient asset and human resources, in relation to the media.
Level II, must provide to the District assistance such as financial aid, assets and
human resources. For the third level, the committee must determine the
national disaster management policy, finance, assets and human resources. The
three levels are shown below in Figure 2 [7]:
Figure 2: Disaster Management Level/ Executive Committee
Level 1 Disaster
District Disaster Management and Relief
Committee (DDMRC)
Level 2 Disaster
State Disaster Management and Relief
Committee (SDMRC)
Level 3 Disaster
Central Disaster Management and Relief
Committee (CDMRC)
Source: National Security Council (2011)
In Pekan, as in Level 1 of disaster management, leadership was assumed
by the Health District Office, the strongest and most prepared government
sector. A disaster plan of action was established and improved based on
previous experience during worst flood in 2007. The plan of action was divided
into pre flood, during flood and post flood as a guideline for all health activities
that needed to be carried out. Among the services delivered were disease
surveillance and control, clean water and sanitation inspection, environmental
health monitoring, health promotion and education. Two Rapid Response
Teams had been established to act as the first responders should any disasters
announced. The teams include Medical Officer, Matron, Senior Assistant Medical
Officer, Senior Assistant Health Environment Officer and a secretariat; whom
are put on standby to deliver immediate health services to the flood victims in
the relief centre.
167

In terms of data management, a dedicated team was assigned to
coordinate the process daily from raw data collection to handing in full report to
health state department. Among the data recorded were current situation of
health facilities, usage of drugs, chemical and vaccine and number of staffs
involved in delivering services. Hence, an efficient data management during
disaster was crucial as it acted as a tool for need assessment as well as risk
reduction control.
Flood operation room of Pekan District Health Office played a pivotal role
in organizing and coordinating relief teams during flood. On daily basis map of
areas affected by flood, numbers of relief centres and health facilities involved
were updated. The operation room also acted as a medium of relaying
information either to or from State Health Department and by receiving
updated information regarding water levels from the District Operation Room.
Weekly schedules of person in charge with their respective contact numbers
were made available to ensure effective communication between staffs in
delivering services to flood victims.
Role of medical and health teams as front liners in delivering services
In comparison to 2013 flood which hit Pekan, 2014/2015 flood showed a
marked increase in the total number of victims resulting in significant increase
in demand of services from the health care teams.
Table 2: The difference between the number of victims and relief centres for
2013 and 2014
Year
Flood
Evacuation
Centers
No. Of
Families
Total Of Victims
2013
(16 Days)
2014/2015
(22 Days)
50 1829 7421
54 4303 17332
Table 3: Facilities involved as relief centres in Pekan District
School University
Statistical facilities in 2014/2015
Hall
Town
hall
Flood
Evacuation
Centers
Mosque
Total
54
23 3 9 17 1 1
168

12 health teams and 10 medical teams from Pekan District Health Office have
been assigned to deliver first hand services to victims at relief centres. Besides
providing primary care services, a thorough screening for infectious diseases
(i.e: food or water borne diseases as well as other communicable diseases) was
also performed by medical teams at relief centres. With the growing number of
victims at relief centres, a total of 8 static clinics were opened which required
staffs to be on call for 24 hours and divided into 3 working shifts. Henceforth,
more staffs were deployed from other districts and states who were involved in
various activities to ensure a smooth delivery of healthcare services to those in
need. The number of workforce made up to total of 22 medical teams and 21
health teams which involved 195 staffs altogether (as shown in table 3). The
efficient and timely deployment of workforce was coordinated by Pahang
Disaster Relief Coordination Centre (PDRCC) based at Bentong Health District
Office.
Table 4: Total of Medical and Health Personnel in flood management in
2014/2015
Health and Medical Personnel
Team
No of
Teams
No of
Personnel
Remarks
Health 21 84 9 reinforcements (2Rompin District Health Office, 2 Bentong, 2
Kedah Health Department, C.Highland 1, 2 Johor)
Medical 22 110 10 reinforcements (1 Bentong District Health Office, Hospital
Muadzam 2, 2 Rompin Hospital, 2 of Malaysian Royal Arm
Forces, 1 Kuantan District Health Office, 2 Kedah Health
Department)
Excellent service was delivered by the medical and health teams from Pekan
district Health Office resulted in no major outbreaks of communicable diseases
or complications from chronic non-communicable diseases. From 4088 cases
reviewed, 2035 were cases of non-communicable diseases and 786 were cases
of communicable diseases (as shown in table 4).
169

Table 5: Total of Non-communicable and communicable diseases detected in
comparison to cases reviewed during flood in 2014/2015
Total Cases Review: 4088
Total Case of Non-Communicable Diseases
Diabetes Mellitus 99
Hypertension 270
Asthma 49
Others 1617
TOTAL 2035
Total case of Communicable Diseases
Acute Gastroenteritis 66
Acute respiratory illness 55
Conjunctivitis 26
Skin infections 365
Fever (with no other symptoms) 270
Chicken pox 4
TOTAL 786
Table 6: Total inpatient admission among flood victims
Adult male 33
Adult female 77
Children 18
Total 128
For health teams, among the services provided were health education activities,
fly, mice and cockroach control activities, dengue control activities as well as
ensuring safe and quality food and drinking water. The table below shows
results from all activities performed during 2014/2015 flood:
Table 7: Health education activities
Lecture Individual
Advice
No. of Sessions
Demo
Group
discus.
Public
announcement
No. of media used
Pamphlet Poster Bunting Banner
335 8316 4147 1027 4 6514 1825 341 24
170

Table 8: Fly Control Activities
No. Of Positive No. Action Control No of Total Poison Used
Location
premises
Maggot Adult Larvicide Adulticide inspected Larvicide Adulticide
25 135 409 93 748
12L 10L
(Gokilath) (Gokilath)
Table 9: Dengue Control Activities at Relief Centres
No of relief
centres
positive
No of former
No. of forms
be examined
positive
0 3755 0
Total poison used (1/kg)
Larvicide
3.0kg (Abate
500E)
Adulticide
3.0kg
(Gokilath)
No of relief
centres
fogged
7
Table 10: Mice and Cockroach Control Activities
No of premises inspected
No of Premises positive
Mice Cockroaches Mice Cockroaches
492 509 2 8
Table 11: Drinking Water Supply Safety activities at relief centres
Water Supply Safety
No of samples Wrong pH Wrong Chlorine Wrong NTU
280 1 76 64
Table 12: Food Safety and Quality activities at relief centres
Catering place
No of premises visited
Satisfy (Yes / No)
54 54 (Yes)
Food complaints
No
171

Haemodialysis service: a highlight on the importance of early problem
recognition and prompt action during floods
Haemodialysis unit is located at the heart of Pekan town, which is usually
submerged by flood every year. It serves end stage renal failure patients in
Pekan district as far as Chini (90 km away) and even from neighbouring district
of Rompin. HospitalMuadzam Shah on the other hand, is located on a hilly area
in the middle of Muadzam Shah town in Rompin district. The distance from
Pekan to Muadzam Shah is about 100km via land transportation. The hospital
was never directly affected by flood and managed to operate as usual despite
the road system linking Kuantan to Segamat being submerged in water during
major floods.
During 2014/2015 flood which has affected almost all major districts in
Pahang, it was feared that Pekan would be affected even worse than before.
Hence, a preliminary measure was taken to transfer haemodialysis patients
from Pekan to Hospital Muadzam Shah and the procedure was made possible
with the assistance from Medical Corps of Malaysian Royal Army. The transfer
procedure involved two batches of patients with the use of 2 army trucks via
Kuantan-Gambang-Muadzam Shah route as Pekan-PalohHinai-Muadzam Shah
route was not accessible to any means of land transportation. The total number
of patients being transferred was 45 comprising of 27 females and 18 males.
On top of receiving 45 patients from Pekan, Hospital Muadzam Shah also
received another 3 patients from district of Temerloh, in addition to the existing
61 dialysis patients at the centre. With total of 109 patients, haemodialysis had
to be done in 4 shifts which extended the operating hour to 12 midnight daily.
This was made possible with the use of 13 existing haemodialysis machines and
the addition of another 6 units from Hospital Pekan and 1 unit of portable
reverse osmosis machine from Hospital TengkuAmpuanAfzan, Kuantan.
Table 13: Number of hemodialysis patients based on infectious screening status
at Hospital Muadzam Shah during 2014/2015 flood
Negative Hepatitis B Hepatitis C Total Grand
total
Male Female Male Female Male Female Male Female
Muadzam 28 27 1 3 1 1 30 31 61
Pekan 24 17 1 1 2 0 27 18 45
Mentakab 1 1 0 0 0 0 1 1 2
HOSHASTeme 0 1 0 0 0 0 0 1 1
rloh
53 46 2 4 3 1 58 51 109
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Table 14: Number of hemodialysis machines at Hospital Muadzam Shah during
2014/2015 flood
Muadzam Pekan Total
Negative 10 6 16
Hepatitis B 2 0 2
Hepatitis C 1 0 1
Total 13 6 19
With the increased workload at haemodialysis unit, Hospital Muadzam Shah
staff deployment was deemed imperative. There were 9 existing staffs at the
unit comprising of 5 staff nurses, 1 assistant medical officer and 3 hospital
attendants. 11 more staffs from 4 districts were deployed to assist the
haemodialysis unit during the disaster; in which the details are shown below.
Table 15: Number of staffs at hemodialysis unit Hospital Muadzam Shah during
2014/2015 flood
Sisters Assistant Medical Staff Hospital Total
Officers nurses attendants
Muadzam 1 1 4 3 9
Pekan 0 1 4 1 6
Kuala Lipis 0 0 2 0 2
Bentong 0 1 0 0 1
Rompin 0 0 0 2 2
1 3 10 6 20
Discussion & Conclusion
Experience over the years has benefited Pekan in many ways. We
learned that preparedness is crucial in order for us to be able to react or
response accordingly during and post disaster.The extraordinary flood has
enormously challenged the spirit, strength, patience and willpower of all staffs
but perserverance has made everybody rose to the occassion. Despite the
adverse situation, the team work was excellently cohesive and health services
were successfully delivered to the needy. Undeniably, a good working
relationship with all stakeholders and an effective communication is of utmost
priority. In conclusion it is vital for us to be prepared, structured and proactive
in handling disasters to ensure minimized losses and to optimize the services
given.
173

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Delivery System, International Journal of Social Science and Humanity,
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change: a strategic review, cat no. 68, Tyndall Centre for Climate
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Toriman, Sahibin Abd. Rahim and Pan Ia Lun, 2012. Analysis of Thirty
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Earth Sciences, 5: 25-35
5. Plan and Prepare For Disaster, US Department Of Homeland
Security,December 27, 2013
6. United Nations Development Programme. (2007). Asia-
PacificDevelopment Information Programme (UNDP-APDIP) Asian and
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174