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Prevent and Manage Infectious Disease Outbreak in Earthquake Stricken Areas
of Nepal with Incidence Command Systems (ICS)
By Dr. Sanjeeb Sapkota
Catastrophic natural calamities of the recent past such as the earthquake in
Turkey in 2000, the hurricane of 2005 in the USA, the tsunami in 2004 in Asia and
in 2011 in Japan, earthquake in Haiti in 2010 have shown us that outbreak of
diseases invariably occurs such devastating events.
Calamities forces people to live in close proximity under a tent, in a hall or
outside, be exposed to harsh elements and to unsanitary conditions. Further,
there is a disruption of public water and sewer supply. All these factors in
causing outbreak of diseases.
Diarrhea, cholera, influenza, pneumonia are among the common diseases that go out of control and
become outbreaks following such disasters. These disease not only disrupts the recovery efforts but
takes a heavy toll on human lives. We are just a week after the relentless earthquake in Nepal, but we
are already seeing indications that outbreak of these disease could potentially occur.
FIGURE: An Incidence Command Systems (ICS) to prevent outbreak of infectious diseases in areas
affected by earthquake in Nepal
However with an effective, appropriate and adequate measures, outbreaks following natural disasters
could be prevented. And if outbreak does happen then its effect could be minimized. One effective way
to prevent outbreak is with incidence command system or ICS. The United States and other countries
have used this systems to manage many outbreaks and public health emergencies like pandemic
influenza in 2009, earthquake in Haiti in 2010, tsunami in Japan in 2011.
As shown in the figure, ICS helps bring all in one center under one roof whose jobs are to directly or
indirectly to prevent and manage outbreak of disease: the authorities, agencies, players, stakeholders
and planners. ICS allows their effective interactions for a streamlined effort to get the maximum effect
in saving people lives and ensuring their health.
ICS is but nothing but an organogram of different officials and agencies whose roles are to look after
their area of responsibility to prevent and manage the outbreak. What ICS does is it tracks rapidly all the
necessary action to be done to effectively address in preventing or managing outbreak. For example, the
delivery of vaccines against cholera to a village is fast tracked with ICS and its challenges, progress are
well documented until the task is accomplished: the delivery of vaccines.
Take another example, disinfecting the water supply in a rural village. For the ICS tracks from the start to
the finish to make sure the job is done. It begins with the procurement of the water disinfectants and
the ends with the application of the disinfectants. ICS is able to do that, in a shortest possible time span.
As shown in the figure, planning, communications and finances are the backbone of ICS. With this
backbone, ICS primarily tracks the surveillances of diseases, mostly the infectious diseases and injury as
they are common after a disaster but also injuries (broken bones, large cuts, serious abrasions) and
chronic diseases, vaccines procurement, its supply, delivery and its administration.
Infectious diseases mentioned above (diarrhea, cholera, influenza, measles, pneumonia) need to be
heavily tracked as they have the tendency to spread out quickly following a disaster. If not managed
well, these diseases quickly begin decimating population, just as cholera did following the earthquake in
2010.
Surveillance is the heart of the ICS to prevent and manage outbreaks. Major role of a surveillance is to
identify and confirm the disease or symptoms with the help of a well-defined case definition. For
example the case definition of diarrhea is: three or more lose stool in one day. The case definition of
influenza is sudden onset of fever which is usually above 100 degree Fahrenheit, severe headache,
cough and weakness. Professional or lay persons are asked or assigned to report these symptoms
rapidly to the higher level through the channels of ICS. Once the symptoms are reported, then a rapid
assessment or intervention should occur to confirm that these symptoms really the symptoms of the
diseases that cause the outbreak.
People living with chronic disease like heart disease, diabetes, asthma are vulnerable during and a
disaster. They need special attention. They need to take their medications without interruptions and
they need to be monitored for any exacerbations of their symptoms. The ICS helps do that.
Water safety, waste and sewer management and the effective management of deceased individuals an
animals are critical in preventing or managing the outbreak and ICS heavily monitors that.
ICS could be different for different disaster. The ICS for managing influenza or Ebola outbreak could be
different from the ICS for preventing cholera outbreaks following earthquake or hurricane. But the
philosophy of outbreak remains the same for all: getting all the players, stakeholders and partners in
one centralized locations and facilitate their interactions to rapidly track actions that are aimed at
preventing or managing the disease in the shortest time possible.
The Incidence manager, as shown in the figure, oversees the entire ICS mechanisms but each
components of the ICS operates independently lead autonomously by its own respective manager. For
example, the managers of disease surveillance autonomously manages his area and so does the
manager for the vaccines. But each of these independent managers get together two or three times a
day to get sitrep (situation report) and to plan their actions ahead.
The communications department of ICS produces, edits and clears all the communications coming from
the concerned authority. For example an advisory meant for the public is prepared, circulated internally
for review by experts and disseminated, all by the communication department of the ICS.
The liaisons of the agency that is responsible for preventing the outbreak are integral parts of the ICS as
shown by the extreme right part of ICS in the figure. The liaisons for the health ministry are the
representatives from WHO country office, UNICEF country office, Red Cross, border and immigration
office, army and other partners whose jobs are also to prevent the outbreak and to minimize its effect if
it has already occurred.
During the disaster a fast track is expected in all the actions and in doing so there are chances of
overlooking legal matters, or further, in skipping or bypassing the legal process. This will have heavy cost
and consequences later. Legal branch of ICS monitors that and makes sure all actions are implemented
according to the law of the land.
The current earthquake in Nepal has taken an unprecedented toll of lives and have injured and
displaced thousands shaking the country and her countrymen to their core. It has left thousands
homeless and foodless making them vulnerable to diseases. The challenge we face now is how to save
the loss of further lives from the outbreak. ICS is one answer. With an effective ICS, a lot could be
achieved with less effort and less resources in a timely manner that help save lives, prevent disease and
manage outbreaks effectively.
(Dr. Sanjeeb Sapkota is a medical epidemiologist who has worked in various international
and national public health agencies including World Health Organization. He currently
lives in the United States and he can be reached at yessapkota@gmail.com)