|Year : 2016 | Volume
| Issue : 4 | Page : 114-119
Learning from Chennai floods to mitigate epidemic
Director, Institute of Community Medicine, Madras Medical College, Chennai, Tamil Nadu, India
|Date of Web Publication||27-Dec-2016|
T S Selvavinayagam
Director, Institute of Community Medicine, Madras Medical College, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Objective: The experience of Government of Tamil Nadu handling Chennai floods 2015 in preventing the occurrence of epidemic is critically analyzed and presented. This simple methodology in epidemic prevention is useful and replicable in needed situations. Materials and Methods: The mechanism of controlling the epidemic through organizing screening camps, vector control, monitoring of water supply, sanitation and surveillance mechanism, etc., is described in detail. Results: Based on the Integrated Disease Surveillance Programme reports, which is part of a monitoring mechanism, we could show that occurrence of major epidemic following the floods was prevented through our efforts. Conclusion: This simple model of epidemic mitigation, which we practiced in Chennai, is useful and replicable in any disasters even with limited resources in any part of the globe.
Keywords: Disaster, epidemic, flood
|How to cite this article:|
Selvavinayagam T S. Learning from Chennai floods to mitigate epidemic. Int J Health Syst Disaster Manage 2016;4:114-9
| Introduction|| |
The Chennai floods during November-December 2015 are of high magnitude and paralyzed the life of Chennai. It is feared that there is possibility of major epidemic outbreaks following this floods considering damage it caused. Following the efforts taken by the Government of Tamil Nadu, the epidemic was contained. The activities undertaken by the Health Department is commendable, and this knowledge will be useful in managing any epidemic and replicable in different settings and countries.
| Materials and Methods|| |
Disasters are sudden terrible damages with social, economical, and health consequences and many times need external agencies support to recover from the impacts.
Chennai, India's fourth-largest city,  which has borne the brunt of the disaster during November-December 2015 with a displacement of more than 11 lakh people, nearly 1.25 lakh lost their homes and are sheltered by corporation, 470 human lives lost with another 550 missing. Roughly 1.5 lakh tones garbage washed into the city. The details of Chennai floods are available in various sites including 2015 South Indian Floods  and Chennai Floods: Decoding The City's Worst Rains in 100 Years  which describes the impact and severity.
The rescue and relief measures were carried out with the active involvement of everyone including government, private institutions including individuals, nongovernmental organizations (NGOs), and volunteers.
Magnitude of damage in Chennai floods is understood through the Wall Street Journal's blog,  wherein it is stated that recent flooding in Chennai will cost India's economy an estimated $3 billion in losses, making it the worst disaster of its kind (i.e., flooding) this year in terms of damage to the economy. Overall, the Chennai flooding was the eighth-most expensive natural disaster in 2015 year.
The WHO  and other articles  list out the possible outbreaks along with technical inputs with risk factors and priorities. The diarrheas, acute respiratory infection (ARI), and vector-borne diseases are a common cause of epidemics and mortality following disasters. Measles and malnutrition contributing further damage to it. The waterborne infections such as diarrhea are many times combined with other infections such as hepatitis A and E and leptospirosis. ARIs are mostly due to overcrowding, particularly in the temporary settlements. Sometimes, it is complicated with the occurrence of meningitis and measles. Raising incidences of vector-borne diseases such as dengue, malaria, or any other vector-borne diseases which are locally endemic is commonly occur.
Lack of safe water and food, poor disposal of wastes, overcrowded shelters, infection of wounds, and breakdown of public system services, particularly preventive health services results in the occurrence of epidemics following the disasters.
Prevention of epidemic following disaster primarily depends on predisaster arrangements and activation of emergency response system immediately following disaster. Various review articles  provide recommendations to prevent communicable diseases and also establish the disease occurrence with floodings. 
Predisaster plan consists of ensuring sufficient supplies including backups and training the human resources to handle commonly expected epidemics. This plan should include epidemic surveillance systems and environmental health measures for disease control also.
Postdisaster plan usually includes activation of health system including private and volunteers to ensure the provision of emergency medical care close to the affected population. This must be supplemented by measures to ensure safe water supply, food, and sanitation including vector control measures.
Based on reports from various news agencies,  even after clarifications from the government  apprehensions continue to exist with public on impending epidemic. On the other side, there are evidence including public health registers report  from the UK, which states that health impacts are rare where public health practice is effective and public health guidance is followed.
| Results|| |
On December first immediately after floods, 24 × 7 control room for public health was established along with 104 services. It provides information, advice on epidemic control to general public, and also coordinates field epidemic control activities including report collection.
The study on the similar type of call center  established in Guinea for Ebola epidemic highlights the need to scale up the local response. To ensure timely response to the call alerts, various teams were formed with specific task and composition. The resources including health workers are mobilized from the districts not affected by flood. The districts are instructed to come prepared with sufficient medicines, equipment, and staffs along with financial support required for operating the team including fuel and food cost.
The response teams are elaborated in [Table 1].
Mobile medical unit (MMU) and rapid response team (RRT) were a huge success with visibility in providing medical care to the sick and disabled flood victims who are unable to access the health services due to logistic difficulties and damaged health-care facilities. The similar experiences are documented in Malaysian journals  also. Further, the importance of identification and tracking of disaster victims is emphasized scientifically. 
Further, we created six sentinel syndromic surveillance centers at Madras Medical College, Kilpauk Medical College, Institute of Child Health, Stanley Medical College, Sri Ramachandra Medical College, and at Mehta Hospital for outbreak detection and response similar to Pakistan experience. 
Inpatient and outpatient reports from these hospitals collected, consolidated, and analyzed along with the secondary data from death registers. In addition, ten private laboratories, six government hospitals, and thirty Primary Health Centers in and around the flood area were asked to report. Further reports from medical camps that are conducted by various agencies that are listed in [Table 2] are also supplementing this.
| Discussion and Conclusion|| |
We followed the syndromic approach and other surveillance measures as discussed in the World Bank documents.  The occurrence of episodes of any fever and diarrhea, etc., in the affected areas, is monitored so as to prevent the occurrence of epidemics. We use simple operational field definition for identification of cases. The Integrated Disease Surveillance Programme (IDSP) of  Government of India now uses similar definitions under presumptive diagnosis.
Episodes of three or more loose stools per day constitute acute diarrheal disease (ADD) and sudden onset of fever with or without rashes, jaundice, or hemorrhagic manifestations constitute acute febrile illness (AFI). This AFI definition will pick up most of the cases of ARIs in the community.
Based on the number of cases reported, high-risk areas are identified, and remedial measures are taken.
For ADD, high risk was considered when three ADD cases reported from the same area in inpatient or five ADD cases reported from the same area in outpatient or one ADD from shelter or 10% ADD cases in MMU/medical camp or five ADD cases reported by voluntary doctors.
For AFI, high risk was considered if three AFI cases reported from the same area in inpatient or five AFI cases in outpatient or one AFI case in shelter or 10% AFI cases in MMU/medical camps or five AFI cases reported by voluntary doctors.
Once the high-risk area is identified and ADD/AFI cases are confirming to epidemiological link, sufficient teams including RRT are put into service. The active search for additional cases, treating the cases and contacts, household and community level chlorination, and disinfection in and around the household of the cases are carried out with active support from the Chennai Corporation. Where ever-needed source reduction for vector control along with fogging is carried out and mop-up vaccination is given. Details reported to control room for follow-up.
When increased cases reported from the same area or mortality occurs additional RRT is put into service, and inpatient admissions are advised if needed. Additional RRT is directed to service depending on laboratory confirmation and further cases. Most of the times teams are deputed within 1 h of reporting and totally six high-risk areas are identified in the city.
Blood samples were lifted from the cluster of cases in the identified area, and positive cases are documented and tracked. Only after laboratory negative confirmation through repeat samples, the teams were withdrawn from that locality.
"Nilavembu kudineer," a siddha polyherbal formulation, is decoction concentrate widely used during Chennai floods. It has dual role, in prevention as immune enhancer and in treatment along with regular allopathic drugs. The antiviral properties of Nilavembu kudineer and its effect as prophylactic activity make it to be used as a public health measure to control outbreaks.
The active surveillance started at 10 zonal level since December 4 th , in 200 division level since December 7 th , in 1800 locality level since December 8 th , and in 27,000 street level since December 9 th . Finally, at household level started since December 10 th .
During the end of January 2016, when relief measures are getting closed, we scrutinized the IDSP surveillance reports, which will reflect the occurrence of epidemic. Although there is increased number of dengue, dysentery, enteric fever, leptospirosis, pneumonia, etc., it is well within the critical and manageable levels.
The IDSP reports for last 3 months (November, December, and January) are compared with previous 2 years (2013-2014 and 2014-2015 with 2015-2016) for commonly expected epidemic diseases. The reports are shown in [Table 3] (presumptive surveillance for 22 parameters) and [Table 4] (12 laboratory confirmation cases). This report proves the effectiveness of our control measures in preventing and limiting the epidemic following major disaster. For example, ADD was less on November 15 (433), December 15 (1052), and January 16 (772) compare to previous years in the same months. A similar trend is observed in most of the diseases. Even in the laboratory-confirmed cases reported in [Table 4] shows results with limited raise, not in epidemic propositions expected after such severe floods.
|Table 3: Presumptive surveillance - form - P under Integrated Disease Surveillance Programme for Chennai district, Tamil Nadu |
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|Table 4: Laboratory surveillance - form - L for Chennai district, Tamil Nadu |
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Although results are good, there are challenges such as:
Since climatic changes going to cause more floods in the future, health burden due to floods is going to increase. There is an urgent need to assess the effectiveness of various public health interventions to minimize the health effect of floods. With regard to Tamil Nadu is concern, there is an immediate need to establish separate state disaster response team with experts instead of depending only on Revenue Department and municipal corporation. Further, capacity building of community to manage and cope up with disaster to be increased. The simple methodology described here will be learning for many developing countries in handling disaster.
- Failure of communication network at least for first few days posed the difficulties in mobilizing relief measures including workforce
- Although volunteers and health-care team are willing to join surveillance measures from outside the city providing them, the minimum accommodation and support was a challenge
- Difficulties in reaching certain hotspots such as slums in view of extensive damage to the infrastructure
- Procuring certain essential medicines becomes challenge after exhaust of reserves. For example, simple things such as cough syrup/Whitfield ointment were an issue in many places. Further, people lost their chronic diseases' prescriptions for hypertension, diabetes, follow-up drugs for heart diseases, seizures, etc., and putting them on regular drugs challenge in the camps
- Sudden excess requirement of bleaching powder, lime, chlorine tablets, medicines, etc.
- Mobile medical team was not available in Chennai Corporation, and we need to mobilize teams from outside the city only. It took some time for them to understand the geography
- Mobilization of manpower at short notice, both medical and paramedical is an issue. All the CRRIs, PGs, and students from all the paramedical courses were also used to assist
- Transport difficulties to carry rice, dhal, etc., to Amma Unavagam which provided the food to affected victims till they are settled
- Hiring of extra vehicles for flood relief camp from the private in view of demand-supply gap
- The number of cases increased in outpatient and inpatient in the government hospitals because of less availability of private clinics and hospitals outside. The put stress on the system, wherein existing doctors and team are diverted to flood relief camps
- Private hospitals and doctors are willing to share their part, but it was a challenge in directing them to the place of actual requirement. As most of them want to follow their choice of place and timings close to their practice areas
- There is a need to practice disaster preparedness at all the levels that are practical, well-coordinated which will reduce morbidity and mortality as described by Kumar and Anuj. 
Thousands of health workers, volunteers, and health-care providers including PGs, NGOs, and individuals who rose on this situation to support the fellow citizens' needs acknowledgment here. The entire Health Department of Government of Tamil Nadu and the Municipal Corporation of Chennai under the dynamic leadership from the Hon-Health Minster and Health Secretary needs special mention. Special acknowledgment to my postgraduates who have done the important data collection from various departments.
Financial support and sponsorship
Conflicts of interest
There is no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]